Dynamics of Physical Abuse, Sexual Abuse, and Neglect

1. Dynamics of Physical Abuse, Sexual Abuse, and Neglect Created by the Harborview Center for Sexual Assault and Traumatic Stress www.hcsats.org

2. Child Abuse and Neglect Washington State Categories: Sexual Abuse Physical Abuse Neglect Defined in: • RCW 26.44.020 & WAC 388-15-009

3. WA State CPS Referrals (FY2011) • 77,882 referrals received • 37,992 screened for investigation • 63% cased involved neglect • 27% PA • 5% SA • Children birth to 3 were at highest risk for fatalities or near fatalities resulting from CA/N or suspected CA/N

4. National CPS Referrals • ¾ of all cases involved neglect • 18% PA • 9% SA • Victim gender was evenly divided • Highest CA/N: Children birth – 3 • 18% referrals are made by neighbors, friends or relatives • 72% referrals are made by mandated reporters FY 2011 NCANDS

5. Adverse Childhood Events Felitte VJ, Anda RF et al Am J Preventive Med 1998.14:245-258

6. CA/N Incidence Trends • SA has shown the largest and most consistent decline over the past 20 years • PA there has been an overall decline but findings are less conclusive • Increase admissions for PA related injuries • Increase in abuse related head trauma • Neglect has variable data from increase to decrease in incidents • Identification of substance abuse in active cases can offset declines New Directions in Child Abuse and Neglect Research 2013.

7. CA/N Incidence Trends (NCANDS) Child Fatalities: • Child fatalities report a 46% increase between 1993- 2007, while child homicide rates fell • 80% of victims less than 4 year’s old • Deaths - higher boys than girls • 70% fatalities attributed to neglect exclusively or in combination with another types of abuse • Nearly 50% fatalities involve PA • In WA State during FY2012, there were 30 fatalities or near fatalities. Of the 30 children, 21 were age birth to 3. New Directions in Child Abuse and Neglect Research 2013.

8. CA/N Incidence Trends (NCANDS) Perpetrator Relationship • Four-fifths (81.2%) of victims were maltreated by a parent either acting alone or with someone else. • Nearly two-fifths (36.8%) of victims were maltreated by their mother acting alone. • One-fifth (19.0%) of victims were maltreated by their father acting alone. • Thirteen percent (12.8%) of victims were maltreated by a perpetrator who was not a parent of the child.

9. National CPS Referrals Disproportionality: • Nationally, African American and Native American children are overrepresented in child welfare. • In WA State, African American and Native American children are referred to CPS at disproportionality higher rates than Caucasian children. Once in system: African American disproportionality is reduced in each stage of involvement, with the exception of time in care, which remains higher. • Native American children are disproportionately higher at each stage of the child welfare process.

10. WA State Race/Ethnicity Stats • Asian 7.2% • Black 3.6% • Caucasian 77.3% • Native American 1.5% • Pacific Islander .6% • Other 5.2% • 2 + races 4.7%

11. WA State Race/EthnicityInvolvement in CA Compared to White children: • Native American children are three times more likely to be referred, African American children are twice as likely to be referred • Native American children are more likely to have a high risk tag at intake, are more likely to be removed from the home, are less likely to reunify with parents within two years, and less likely to be adopted within two years • African American children are more likely to have an accepted intake, are more likely to be assessed high-risk at intake, are as likely to reunify with parents within two years, and are less likely to be adopted within two years

12. Check for Understanding • Nationally and locally, most CPS referrals involve: • Sexual Abuse • Neglect • Physical Abuse • True of false: Children birth to 3 are at the highest risk for CA/N, including fatality resulting from CA/N

13. Check for Understanding • Nationally and locally, most CPS referrals involve: • Sexual Abuse • *Neglect • Physical Abuse • *True of false: Children birth to 3 are at the highest risk for CA/N, including fatality resulting from CA/N

14. Check for Understanding • Which type of CA/N has shown the largest and most consistent decline over the past 20 year?: • Sexual Abuse • Neglect • Physical Abuse • In WA State, which racial/ethnic group is consistently disproportionately represented throughout each stage of the child welfare system • African Americans • Latinos • Native Americans

15. Check for Understanding • Which type of CA/N has shown the largest and most consistent decline over the past 20 year?: • *Sexual Abuse • Neglect • Physical Abuse • In WA State, which racial/ethnic group is consistently disproportionately represented throughout each stage of the child welfare system • African Americans • Latinos • *Native Americans

16. Risk Factors: Child Abuse and Neglect Perception of increased risk for CA/N: Fact: Strong but not conclusive findings to support Strong correlation; also linked to lower socio economic level and use of harsher parenting Depression, substance abuse and antisocial personality disorder factor for maternal CA/N. ASPD factor for paternal neglect • Parental history of CA/N • Early childbearing mother(18 and younger at time of first birth) • Parental MH problems

17. Risk Factors: Child Abuse and Neglect Individual level-child: • Children with developmental, physical or mental disabilitiesare at higher risk, specifically children with significant behavioral and emotional problems • Younger children/infants = higher risk; greater vulnerability

18. Risk Factors: Child Abuse and Neglect Family Characteristics: • Living with 2 biological parents decreases risk (protective factor) • Families with CA/N move twice as often as non-abusing families • Poor parenting skills increase risk of CA/N • Intimate partner violence increases risk: • Mothers who experience DV have higher incidence of physically abusing their children. • DV perpetrators have increased risk of physically abusing their children • Social isolation increases risk for neglect

19. Risk Factors: Child Abuse and Neglect Contextual factors: • Poverty, unemployment and low socioeconomic status: • May reduce parent capacity to nurture, monitor and provide consistent parenting and needed resources • Risk factor strongest for neglect, then PA

20. Protective Factors: Child Abuse and Neglect Caregiver/Family: • Social support in the form of secure and supportive relationships • Maternal value of “familism” – strong sense of family • Ability to make positive changes within the family Resilience and temperament of child: • Personality traits (easy going, adaptive, likability factor) • Strong cognitive abilities and coping strategies • Positive social skills and ability to connect

21. Potential Consequences • Attention: Higher rates of ADHD; impulsivity and inattention than non abused children • Academic achievement: Overall lower reading and IQ scores; academic underachievement; higher rates of special education • Attachment: More likely to have disorganized attachment. Leads to increased behavior and parent/child problems

22. Potential Consequences • Emotion Regulation: • Trouble managing emotions • identification to expression. • Increased problems with depression/Suicide Ideation • PTSD symptoms and other MH problems • Interpersonal Problems: • Problematic interactions with peers, siblings and adults

23. Potential Consequences Externalizing Problems: • Behavioral problems that can classified as Oppositional Defiant Disorder or Conduct Disorder • Increased aggressive behaviors and/or social withdrawal • Delinquency and violence • Alcohol and substance abuse • Suicide attempts or self harm behaviors • Risky sexual behaviors

24. Check for Understanding • Which of the following has not been found to be a risk factor for CA/N • Parental history of depression or severe mental illness • Child with disabilities including significant behavioral or emotional problems • Child being raised in a biological 2-parent household • True or false? Abuse and neglect negatively impact a child’s ability to effectively self regulate, leading to potential problems handling current and future stressors

25. Check for Understanding • Which of the following has not been found to be a risk factor for CA/N • Parental history of depression or severe mental illness • Child with disabilities including significant behavioral or emotional problems • *Child being raised in a biological 2-parent household • True* or false? Abuse and neglect negatively impact a child’s ability to effectively self regulate, leading to potential problems handling current and future stressors

26. Check for Understanding • List three potential protective factors for CA/N:

27. Check for Understanding • List three potential protective factors for CA/N: • *Social support for caregivers form of secure and supportive relationships • *Maternal value of “familism” – strong sense of family • *Ability to make positive changes within the family • *Child personality traits (easy going, adaptive, likability factor) • *Strong cognitive abilities and coping strategies of child • *Child has positive social skills and ability to connect

28. Neglect

29. Assessing Neglect • Do the conditions or circumstances indicate that basic needs are unmet? • What harm or threat of harm may have resulted from the conditions/circumstances? Neglect is a significant risk factor for child physical and sexual abuse. Increasing safety and active supervision of children is a protective factor . Important to do thorough assessment

30. Assessing Neglect Unmet basic needs: • Inadequate or delayed healthcare • Inadequate nutrition or limited access to food • Inadequate clothing or inappropriate clothing for weather • Unsafe and/or unsanitary household conditions that present hazards to child’s safety and wellbeing • Highly unstable living conditions: living in car; frequent evictions; leaving child unattended for long periods of time • Inadequate supervision/abandonment • School/special ed needs routinely unmet

31. Assessing Neglect Inadequate supervision: • Child left unattended. Consider: • Age of child (under 8?) (Between 8 and 12?) • Length of time child is alone • Time of day child is left alone • Frequency of parental absences • Place child is left

32. Assessing Neglect Inadequate supervision: Child left in care of inadequate substitute caregiver: • Young sibling too young for responsibility • Stranger or slight acquaintance • Known child abuser or active drug addict/user • Left with substitute caregiver without a plan of return or doesn't return when arranged • Substitute supervisor does not adequately supervise • Substitute supervisor allow or encourages child to engage in harmful behavior

33. Assessing Neglect Inadequate supervision: Additional Considerations: • What are the child’s personal resources? Personality, maturity, competence, ability to handle emergencies? • What are the conditions where the child is? (home, neighborhood, level of crime in community, more isolated or near neighbors) • Are there adequate/reliable adults nearby or that child has access to? (next door, call on cell phone)

34. Child Physical Abuse

35. County Protocols • For child physical and sexual abuse investigations

36. Medical Assessment: FAQ • Babies who don’t cruise shouldn’t bruise • Bruises cannot be dated • Unexplained serious injuries need explanations • Non-Accidental Trauma (NAT) work-ups take time • Occult injuries (traumatic injuries that are not obvious on initial presentation) OFTEN have no, few or non-specific clinical signs (pain, bruise, deformity) • Delays or failures in diagnosis of occult injuries might result in serious medical complications or continuation of abuse

37. Is this Abuse or Neglect? Assessment depends on: • History • Nature of the injury/symptoms • Action to obtain care • Associated findings (other injuries) • Consultation with experts/collateral information • Witnesses

38. Coining

39. Mongolian Spots

40. Importance of Medical Evaluations of CA/N Physical Abuse • Assess cause of physical injuries – accident or result of PA? • Can look for patterns/history • Helps because of varying reports/age of child Sexual Abuse • Children who experience SA rarely have any medical findings (4%) • Even with findings, most are non-specific/inconclusive • Helpful to allay child’s/parents fears; provide information, support and early engagement in treatment

41. Physical Sexual Abuse vs Physical Abuse Sexual The child’s history IS the story Delayed disclosure is common Exams are mostly normal Non-offending caregiver most often supports child The exam IS the story Findings are commonly close to the events Exams are usually abnormal Non-offending caregiver most often supports partner offender

42. “History” = Verbal information

43. Problems Getting the History Children Non-verbal Delayed Developmentally young Fearful/guarded Caregivers Non-offending parent – may not have been present Partial history No history Unwillingness to report Fearful/guarded

44. Scenario • 3 month old Steve brought in for well child care • Small bruise on abdomen noted • Exam and behavior otherwise normal • Thought to be due to ‘tight diaper’

45. Outcome • Steve returns 1 week later with acute spiral femur fracture • Head CT is negative • DV within home is noted by family physician • Steve lives with mother, bio father and maternal grandmother

46. Assessing Problem/Cause:Exercise Doctor makes a report to CPS based on the spiral femur fracture. • What do you need to consider in terms of actions and next steps? • Who are suspects? Could there be other potential suspects? • What do you think of that abdominal bruise now? • Would you consider a consultation with a Medical Child Abuse Expert at this time or do you feel confident in the findings of the PCP? Why?

47. Small but SENTINAL injuries • Sentinel injury is seen as a previous injury, that was suspicious for abuse either because the infant was not yet crawling, able to pull to a stand, or walking - or -because the caregivers' explanation for injury was implausible. • Sentinel injuries occur during early infancy: 66% at younger than 3 months of age and 95% by the time they had reached 7 months of age. • Detection of sentinel injuries with appropriate interventions could prevent further abuse.

48. What caused this? • Bruises on the ears, neck and face for all children • Also, bruises on torso, ear or neck in a child < or equal to 4 years • Or ANY bruise in infant <4 months Pierce, et al. Pediatrics 2009

49. Random unusual injuries Other small but SENTINAL injuries Oral injuries

50. Abdominal injuries • Accidents are almost always witnessed • Auto passenger, pedestrian/auto • Handlebar • Spleen, liver laceration • Pancreatic or duodenal trauma • 30-40% mortality is related to delay in seeking medical care