Child Maltreatment Medical Curriculum

1. Child Maltreatment Medical Curriculum Editors: Aaron J. Miller, MD, MPA & Marilyn Kaufhold, MD

2. ISPCAN Mission To support individuals and organizations working to protect children from all forms of abuse and neglect worldwide. History ISPCAN was founded in 1977 by Dr. C. Henry Kempe and is still the only multidisciplinary organization bringing together professionals worldwide to work towards the prevention of child abuse, neglect and exploitation globally.

3. ISPCAN has 1,000 members around the world – from more than 100 countries. www.ispcan.org

4. Curriculum Outline • Child Maltreatment Overview • The Social and Developmental Impact of Child Maltreatment • Taking Medical History in Child Maltreatment • Child Physical Abuse • Child Sexual Abuse • Psychological Maltreatment • Child Neglect • Human Trafficking • Multidisciplinary Identification and Management of Child Maltreatment • Testifying in Court

5. Child Maltreatment Overview Susan Bennett, MB ChB FRCP Aaron J. Miller, MD, MPA, FAAP

6. Learning Objectives

7. Why we address child maltreatment • Children have rights (deontologic ethics) • UN Convention on the Rights of the Child • Local laws and policies • It is the right thing to do – it helps the child, the family and the society (teleologic ethics) • Large body of research supports the wide consequences of child maltreatment and the benefits of treatment and prevention

8. Cost of Non-Fatal Maltreatmentper maltreated child (USD in 2010) (Fang 2012)

9. Total Lifetime Costs for All Children Abused in a Given Year Canada: $16 Billion (1998) Australia: $13 Billion (2007) United States: $124 Billion (2008) United Kingdom: $1.1 Billion/year (1996)

10. A Child Rights Approach to Child Protection

11. To learn about the United Nations Convention on the Rights of the Child and the General Comment on Article 19 and their use as advocacy tools To highlight the opportunity to transform child protection through a child rights approach

12. "Mankind owes to the child the best that it has to give." 1924: “Declaration of the Rights of the Child” - the League of Nations

13. The 9 Core UN Human Rights Treaties • International Covenant on Civil and Political Rights (1966) • International Covenant on Social, Economic and Cultural Rights (1966) • International Convention on the Elimination of All Forms of Racial Discrimination (1966) • Convention on the Elimination of All Forms of Discrimination Against Women (1979) • Convention against Torture, and Other Cruel, Inhuman and Degrading Treatment (1984)

14. The 9 Core UN Human Rights Treaties • Convention on Rights of the Child (1989) • International Convention on the Protection of the Rights of all Migrant Workers (2003) • Convention on the Rights of Persons with Disabilities (2008) • International Convention for Protection of all Persons from Enforced Disappearance (2010)

15. United Nations Convention on the Rights of the Child (1989-2012) 1

16. UN Convention on the Rights of the Child • Adopted by UN GA on November 20, 1989 • Entered into force September 2, 1990 • 193 ratifications (excluding US and Somalia) • Contains 54 articles setting international minimum standards and aspirations for proper care & treatment of all children everywhere • First international instrument covering economic, social, cultural, civil and political rights, including special protection measures • For everyone under the age 18 • Children previously seen as passive victims of charity vs. active rights holders with responsibilities

17. Three Optional Protocols to CRC • On Children in Armed Conflict (2000) • On the Sale of Children, Child Prostitution and Child Pornography (2000) • On a Communications Procedure (2011)

18. Convention’s Four Guiding Principles • Right to life, survival and development (Article 6) • Best interests of the child (Article 3.1) • Non discrimination (Article 2) • Participation (Article 12)

19. Three categories of rights in the Convention • Protection - rights to protection from all forms of harm, violence & maltreatment • Provision – rights for optimal well-being & access to essential services: the right to live and to develop to their fullest potential & right to health care & education and play • Participation – rights that protect the liberties and advance the participation of young people: right to participate in decisions affecting them according to their age and level of maturity, rights to freedom of thought, expression and information, conscience, religion & freedom of association

20. Article 19 of the UN CRC 1. States Parties shall take all appropriate legislative, administrative, social and educationalmeasures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child. 2. Such protective measures should, as appropriate, include effective procedures for the establishment of social programmes to provide necessary support for the child and for those who have the care of the child, as well as for other forms of prevention and for identification, reporting, referral, investigation, treatment and follow-up of instances of child maltreatment described heretofore, and, as appropriate, for judicial involvement.

21. 13 General Comments to the CRC • Role of independent national HR institutions • Aims of education • HIV/AIDS • Adolescent health • General measures of implementation • Separated children outside their country of origin • Early childhood • Protection from corporal punishment & other cruel or degrading forms of punishment

22. 13 General Comments to the CRC (cont.) • Children with disabilities • Juvenile justice • Indigenous children • Right to be heard • Right to freedom from all forms of violence

23. General Comment 13 on CRC Article 19: the right of the child to freedom from all forms of violence was adopted by the UN Committee on the Rights of the Child, Feb 2011 http://www2.ohchr.org/english/bodies/crc/comments.htm

24. General Comment 13 Overview • No violence against children is justifiable; all violence against children is preventable • A child rights approach to care & protection • Importance of concept of dignity, empowerment & participation of children and best interests of the child • Primary prevention through public health and other approaches

25. General Comment 13 Overview • Outlines negative impact of violence on children, their families and society as a whole • Highlights resources for implementation and need for international cooperation • Emphasizes need for a national coordinating framework on violence against children

26. Implementation of General Comment 13

27. All “measures” (paragraph 1 of Article 19) need to be applied to all “stages of intervention” (paragraph 2 of Article 19) ) through a comprehensive coordinating framework on violence against children Overall approach to implementation of Article 19

28. Dissemination Resource Program Education and Training Accountability Advocacy GC 13 Implementation Strategy

29. UN Committee on the Rights of the Child • Monitors how well States are meeting their obligations under the Convention • Facilitates State Party implementation • States must report initially 2 years after joining and then every 5 years thereafter • Parallel/Alternative reports from NGOs, UN Agencies, other intergovernmental organizations, academic institutionsand children themselves • 18 members with 4 year mandate • Committee publishes its concerns and recommendations in “Concluding Observations” .

30. Scope of Child Abuse and Neglect is minimized • Child abuse typically occurs in secret • Children, parents, and others are reluctant to disclose abuse because of familial, social, and legal consequences • Many professionals are not trained to identify cases • No ongoing public health effort to chart trends in the incidence and nature of CAN.

31. Prevalence of Child Abuse & Neglect • Definition • Conceptual, legal, research definitions • International definitions: WHO, other countries • Specific to country • Cultural influences • Common parenting and care-giving practices • Religious dictates • Conflicts between definitions

32. UN Secretary General’s Study on Violence Against Children (VAC) 2003 - 2006 3

33. UN Secretary-General’s Study on Violence against Children • Commissioned by OHCHR, UNICEF & WHO • Nature, extent, causes and consequences of violence in 5 main settings (family, schools, institutions, work and communities ) • 9 regional consultations with govts, ngos, professionals, public & child participation • Final report & recommendations to GA October 2006

34. Paulo Sergio Pinheiro (leader of the study) “I have been struck by the fact that violence against children in all settings and contexts is very prevalent and knows no boundaries of geography, class, politics, race or culture.”

35. UNICEF State of the World’s Children Annual statistics per country on: • Basic Indicators    • Health   • Education   • Demographic Indicators • Economic Indicators • Child Protection • The Rate of Progress of Millenium Development Goals • Nutrition • HIV/AIDS • Women

36. UNICEF Child Protection • Birth Registration • Child Labor • Child marriage • Female Genital Mutilation/Cutting • Violent Discipline • Attitudes towards wife-beating Source: http://www.unicef.org/protection/57929_57977.html

37. A Child Rights Approach to Child Protection • Major paradigm shift in core values & practices • Respect and promotion of human dignity and physical and psychological integrity of children as rights bearing individuals rather than primarily as “victims” • Historically has been a narrow corrective emphasis on child’s bodily survival with fear of imminent harm & loss of life • Investment of full social ecology to foster “bottom-up” and “top-down” initiatives and involves international cooperation

38. A Child Rights Approach to Child Protection • Child participation: employing child’s present and future contributions • Children have a right to be heard and to have their views taken seriously & must be respected systematically in all decision-making processes and their empowerment and participation should be central to child protection strategies and programs • Very compatible with a public health, ecological, injury prevention and economic approach

40. A Child Rights Goal or “Prize” • The protection and promotion of the child’s survival, physical, psychological, social, moral, spiritual health & well-being & development, dignity and personal security as well as all of the child’s rights.

41. PROTECTIONof child from maltreatment to PROTECTION & PROMOTIONof child survival, physical, mental, social, moral and spiritual health, well being, development, personal security, dignity, and indeed all their rights.

42. Children have rights and it’s the right thing to do.

43. Effects of Abuse & Neglect on a Child

44. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.Felitti VJ, Anda RFAm J Prev Med. 1998 May;14(4):245-58.

46. Adverse Childhood Experiences Study (ACE) www.acestudy.org • 17,421 members of the Kaiser Health Plan in San Diego County • ongoing collaboration between the U.S. Center for Disease Control • Analyses relationship between adverse childhood experiences (ACEs) to later health & behavioral problems

47. Adverse Childhood Experiences (ACE) Categories • Contact sexual abuse • Recurrent psychological abuse • Recurrent physical abuse • Psychological neglect • Physical neglect • Alcohol/drug abuse in household • Incarcerated household member • Household mental illness • Mother treated violently • Parents divorced or separated 1 point for each type of trauma. Add up all your points to get your ACE score.

48. Adverse Childhood Experiences Study Results • Compared to persons with ACE score of 0, those with score 4+ • x 2 smokers • x 12 attempted suicide • x 7 alcoholic • x 10 injected street drugs • Stress associated with cardiovascular disease, hypertension, hyperlipidemia, asthma, metabolic disorders, obesity, infection ..

49. Adverse Child Experiences Study Conclusions • The number of categories of ACE exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. • Persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. • There was a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

50. By: Gerison Lansdowne