Howard Dubowitz, MD, MS University of Maryland School of Medicine ISPCAN Councilor

1. Child protection Around the World Similarities and Differences Advances and Challenges25th Annual San Diego International Conference on Child and Family MaltreatmentJanuary 2011 Howard Dubowitz, MD, MS University of Maryland School of Medicine ISPCAN Councilor

2. Child Maltreatment – A Global Problem • A common problem, in all countries • Definitions, rates, circumstances vary • Comparison across countries is tricky • Apples and oranges and peaches ….. • Variation within countries, across cultures • This overview does not cover all countries

3. Nova Science Publishers New York

4. Data on Child Maltreatment Incidence and Prevalence • Reported cases • Canadian Incidence Study (CIS) of Reported Child Abuse and Neglect • US National Child Abuse and Neglect Data System (NCANDS) • Limitations • Community surveys • US National Incidence Study (NIS) of Child Abuse & Neglect • Center for Research on Crimes Against Children (USA) • Limitations

5. Lifetime Prevalence of Contact Sexual Abuse15 - 17 Year Olds

6. Lifetime Prevalence:Physical Abuse by Caregiver15 - 17 Year Olds Finkelhor et al, 2010

7. Percent of University Students Reporting Past Neglect Straus & Savage, Child Maltreatment, 2005; 10:124

8. Defining Child Abuse and Neglect Much variation

9. Corporal Punishment vs. Abuse • Most countries permit corporal punishment considered as “reasonable” • Canada considers it abuse if: • Child <2 or >12 • Use of objects or blows to the head • Use of force on child incapable of learning from it (eg, disabled child) • Force stems from parent’s frustration, loss of temper, or abusive personality • Degrading, inhuman or harmful conduct

10. Physical Abuse Definitions • Any injury lasting 24 hours – Maryland, USA • Severe injuries – fracture, burn, death Sexual Abuse Definitions • Victim must have been a virgin • Voyeurism, exhibitionism

11. Exposure to Intimate Partner (or Domestic) Violence

12. Different Measures of Child Maltreatment • Infant mortality, malnutrition • Female genital mutilation (FGM) • Street children • Child labor • Children kept out of school • Children without health insurance • ……………………………..

13. Societal Neglect or Abuseor Structural Violence

14. Legal Issues

15. Legal Issues • Varying legal definitions • of child abuse and neglect • of age of children covered by child welfare • Evolving laws • Egypt: new focus on children’s rights, guided by the UN Convention on the Rights of the Child (CRC); the new Child Law discourages corporal punishment

16. UN Convention on the Rights of the Child (CRC) - 1989 • A valuable blueprint for developing laws to help ensure children’s health, development and safety; work on Article 19 • Has influenced laws, policies and practice in many countries • Huge gap between the CRC and children’s conditions - in many countries

17. Limitations of Legal Definitions • Not clearly guided by what’s known about children’s health, development and safety • Laws are necessarily broad and cannot cover all situations. Open to interpretation • Need agencies to operationalize and implement the laws; these agencies may be weak or nonexistent • Mandatory reporting laws, but no means to enforce them

18. Still, laws are essential for developing strategies and systems to protect children

19. Mandatory Reporting ??? • Pro • Needed to protect as many children as possible • Conveys state’s seriousness about CM, educates the public • Places a legal and ethical responsibility on the state • Against • Unnecessary and rigid burden on professionals • Concern for professional immunity • Preference for a less adversarial approach (Belgium) • Immunity for professionals? • USA: yes Israel: no • Investigate all reports? • USA: no Israel: yes

20. Reporting Issues • Variation in who must report • Notable exclusions • Lawyers (Canada) • Priests (USA) • Little feedback to reporting professionals • Confidentiality ?

21. Policy Issues

22. Political and Economic Realities • Decentralizedsystems with varying policies and practice (Canada) vs. mostlycentralizedsystems with common policies • Rich countries, better resources • Poor countries, poorresources • Not always true, other factors

23. Social Safety Net for Children • Huge variation across countries • Relatively comprehensive eg, “Building a Europe for and with children” • Much variation even in “good” countries eg, First Nations people in N. Canada

24. Child welfare embedded within a larger social services agency- ideal?

25. The Need for a Child Welfare System • Many low income countries have little or no child welfare system • Patchwork of local services, NGOs • Value of a lead agency (eg, hospitals in Pakistan, Phillipines) • Need for associated services. eg, mental health • Most middle-high income countries have a child welfare system, but they vary greatly, and …….. advocates point to many weaknesses

26. Current Scope of Child Welfare • Narrow focus on protection, after maltreatment is suspected (most countries) • Broad focus – includes prevention, youth justice, mental health • Primary prevention (rarely, funding constraints) • Exposure to intimate partner violence • An emerging concern for child welfare (USA, Canada)

27. Future Scope of Child Welfare? • Goal: A broad concern with children’s health, development & safety • More resources, and ….. • More science, better applied • Competent professionals • More collaboration among agencies, professionals • A focus on prevention

28. Law enforcement Judicial system Responding to Child Maltreatment - USA CPS Child Protective Services Community Resources

29. Alternative Response Systems • “Less serious” reported cases referred to community agencies • Evaluation vs. investigation • Address needs vs. find fault • Flexibility to direct cases back to CPS • Preliminary findings: somewhat encouraging

30. Alternative Response Systems Kohl et al. Time to leave substantiation behind: findings from a national probability study. Child Maltreatment. 2009;14(1):17-26.

31. Need for Greater Resources • Resources rarely adequate to meet needs eg, USA: limited mental health services • Impact of poverty on children eg, Philippines: 22% report regularly experiencing “moderate to severe hunger” • Impact of poverty on families, parents • Poverty compounded by HIV/AIDS • Need to address underlying systemic issues that contribute to CM (Belgium as a model)

32. Poverty and Neglect • Clearly connected • Poverty - a form of societal neglect • Child welfare systems focus on situations where parents held responsible for neglect • USA: 12 states exclude poverty in legal definition • Child welfare can offer a way to obtain services (USA) • Addressing poverty – a problem mostly beyond current child welfare systems

33. Children’s Advocates • Independent from child protection services • Semi-independent from the government • Goals: • advocate for children in the child welfare system • Advocate for improvements in the system

34. Needed ?An international effort to establish core principles, policies and practice for child welfare Adaptation to meet local circumstances will naturally be necessary

35. Practice Issues

36. Core Principles • Main goal: protect child from harm • Best interests of child must be considered • Views of children should be considered • Continuity of care is important for children • State respects family autonomy and parents’ primary responsibility for child rearing • Cultural heritage should be respected

37. Varying Principles and Practice • Sanctity of family vs. need to protect • How to be minimally intrusive • Belgium: working with incestuous families, while trying to avoid the judicial system • Argentina: removes perpetrator, not abused child • USA: child placed in alternative care

38. Minority Groups • Oppressed, marginalized, abused, neglected • Ongoing problems – discrimination, poverty, health and mental health problems • Challenges for child welfare • How best to address complex and multiple needs in a culturally sensitive way? • Separate system, self-government? • Immigrants • Eg, female genital mutilation (abuse in USA, Canada)

39. How should we consider the role of different cultural values in considering neglect?

40. Cross-cultural Issues • In common: UN CRC, sanctity of the family, high threshold for removing children • Should lead to efforts to support family and protect child • Varying approaches • Parental rights more often terminated than restricted • USA: kinship care • Institutional or foster care

41. Cross-cultural Issues • Attention to children’s rights – France • In some countries, a child’s death does not trigger an investigation - India • Involving children in child welfare policies and practice – Lebanon • Cultural differences within countries • In a global world, professionals need to know how to approach families from different cultures

42. NEEDED Cultural competency to advance our field and the wellbeing of children

43. There is hope UN Convention on the Rights of the Child

44. Need to Enhance Professional Capabilities – of all Involved • The work is very difficult, and requires well trained and supported child welfare staff • Requires training other professionals involved in children’s lives • A challenge for most countries • This issue is central to ISPCAN’s mission • Curricula project

45. Prevention • UN CRC provides a legal and moral impetus • Limited resources often prioritized for responding over preventing CM • Some countries have well developed “safety nets” • Some countries have low thresholds for involving child welfare • Some countries have broad approaches to child protection (tertiary prevention) • Role of private agencies, NGOs – important, but limited. Cannot tackle underlying systemic problems

46. Much remains to be learned about the effectiveness of different approachesAnd, this may vary across countries and cultures

47. Evidence-informed Practice • Emerging recognition of the need • Need more evidence • Link policy-makers, researchers and clinicians

48. Research Issues

49. Need for Data on Child Abuse and Neglect • Data shows extent of the problem • Crucial for building public and political support • Guides the development of the response • Helps track progress • Need clear definitions – eg, WHO (2002) • Definitions will likely vary across countries • eg, broad definition of psychological abuse in Brazil

50. Need for Research • Child welfare policies and practice often guided by philosophical, political and personal preferences and practice experience • Need for research and evidence eg, home visiting programs eg, evaluation of children in kinship care • England: a good model where monitoring and evaluation of services are built into the system • Research costs - worth learning what works