National Family Safety Program, NGHA January 28 th and 29 th 2013 Presentation 3. Step 1 of the Public Health Approach

1. National Family Safety Program, NGHA January 28th and 29th 2013 Presentation 3. Step 1 of the Public Health Approach to Child Maltreatment Prevention: The Magnitude and Distribution of Child Maltreatment Presented by Alaa Sebeh, MD Ph.D. Independent International Consultant, Child Protection & Disability. alaa1234@gmail.com

2. Objectives The core learning objective of this module is to provide a basic understanding of the second part of step 1 of the public health model as applied to child maltreatment prevention by focusing on data on the magnitude and distribution of child maltreatment and sources for, and problems with, these data.

3. Outline • Data Sources for Estimating the Magnitude and Distribution of Child Maltreatment and Difficulties Collecting Data • Existing Data on the Global Burden of Child Maltreatment and Gaps within These Data • Presenting Data to Convince Policy-Makers • Summary and Conclusion

4. Data Sources for Estimating the Magnitude and Distribution of Child Maltreatment and Difficulties Collecting Data

5. Main Sources of Data The main sources of data for estimating the magnitude of child maltreatment and its distribution can be divided into two main types: • Epidemiological information • Case-based information

6. Epidemiological Information Epidemiology is the study of how often diseases occur in different groups of people and why. Incidence – Measures the number of new cases arising in a defined population within a specified time period. Prevalence – Measures all cases within a defined population occurring at a point or period in time.

7. Worldwide Epidemiological Information In many parts of the world, epidemiological information about child maltreatment is lacking. Consequently, decision-makers and the general public often refuse to accept that child maltreatment is a serious issue in their society.

8. Epidemiological Information on Child Maltreatment and Its Consequences Epidemiological information can contribute directly to preventing the phenomenon by: • Providing a quantitative definition of the problem • Providing ongoing and systematic data on the incidence and prevalence, causes and consequences of child maltreatment at local, regional and national levels • Enabling the early identification of emerging trends and problem areas in child maltreatment • Suggesting priorities for prevention among those at high risk of either experiencing or perpetrating child maltreatment • Providing a means to evaluate the impact of prevention efforts • Monitoring seasonal and longitudinal changes in the prevalence and characteristics of child maltreatment and its associated risk factors • Giving an overview of the geographic distribution of child maltreatment cases

9. Sampling Strategies Few cases of child maltreatment are reported; therefore, it is essential to conduct population-based surveys using representative samples to get an accurate estimate of the size of problem. Probability sampling – Some form of random selection is used in choosing the elements, and each element in the population has an equal and independent chance of being selected. Non-probability sampling – The elements that make up the sample are selected by non-random methods.

10. Ethical Considerations Surveys that question children and adults about events in the present and recent past should be considered only where there are adequate resources to guarantee a resolution of the situation or to bring it to the attention of the relevant authorities. Surveys should in every case be conducted in such a way that a respondent’s situation is not made worse by answering the questionnaire. The design of studies, therefore, should always be reviewed by an ethics committee.

11. Case-Based Information Only a small proportion of all child maltreatment cases ever come to the attention of service providers. Case information refers to the information collected from individuals and families where maltreatment has already occurred and who are currently receiving services to deal with the effects of maltreatment. Case-based information collected can never be used to measure the overall extent of the problem of non-fatal child maltreatment. Despite these limitations, facility-based information does serve two important purposes: 1. Helps ensure a continuity of information about individual cases over time and between the different agencies involved in case management 2. Helps plan the provision of services, such as what the peak demand times are, what staff are required, or where the users come from

12. Cased-Based Information and Surveillance of Reported Cases Surveillance of reported cases of child maltreatment can point to trends in service provision and service utilization, but it cannot give a proper overview of the problem. Routine data collection on child maltreatment must be based on accepted, standardized definitions so that categories are uniform and sets of data can be effectively compared. Surveillance systems should build on existing systems where possible and, ideally, coordinate existing systems used by various sectors if they are independent of each other.

13. Reporting Child Maltreatment Countries have taken different approaches to the issue of reporting suspected child maltreatment, including: • Mandatory reporting • Confidential reporting • Reporting as the accepted norm Many countries however have no system for reporting or responding to suspected or actual child maltreatment.

14. Mandatory vs. Voluntary Reporting of Child Maltreatment Cases There are advantages and disadvantages to mandatory and voluntary reporting of child maltreatment cases. Mandated reporting creates an adversarial relationship between families and child protection authorities. The fear of reporting and its consequences can be a powerful deterrent for families. There is extensive evidence that the public as well as professionals are reluctant to act on knowledge or suspicions of maltreatment. Without reporting laws, children in need of protection may not be identified ,and systems will not be put in place to prevent further maltreatment. Whichever approach is chosen, it should be founded in a public health and social support context rather than being primarily punitive.

15. Suspected Child Maltreatment Children at risk of experiencing maltreatment, and the parents and other family members of those children, frequently interact with a number of service agencies. Each of these interactions provides an opportunity to detect maltreatment and to intervene. Whenever a family or child encounters a service agency and child maltreatment is either confirmed or suspected, basic information on the case should be documented.

16. Complete Understanding of Child Maltreatment in a Particular Location For non-fatal maltreatment: • Population-based epidemiological surveys • Case information on individual cases and communication about the cases within and between agencies • Routine data collection of cases seen by emergency medical care facilities, child protection services, and other services For fatal maltreatment: • Systems for the medico-legal investigation of all known and suspected deaths from external causes and all unexpected deaths in young children

17. Gathering Information about Deaths from Child Maltreatment Fatal cases of child maltreatment cannot be easily measured through population-based surveys or service-based case systems that record information. Accurate information about deaths from child maltreatment can be obtained only in settings where: • There is a legal obligation to report such deaths. • This obligation is enforced. • Systems exist for the medico-legal examination of all known and suspected deaths from injuries or external causes.

18. Main Difficulties Related to Collecting Data on Child Maltreatment Some of the main difficulties include: • Existence of many different potential data sources generating different estimates • Availability and quality of data • Ethical problems • Taboo and shameful nature of child maltreatment and the belief that it is "a private affair” Despite the difficulties of collecting data on child maltreatment, enough is known to confirm that child maltreatment affects substantial numbers of children around the world.

19. Existing Data on the Global Burden of Child Maltreatment and Gaps within These Data

20. Child Maltreatment and the Global Burden of Disease and Injury WHO’s Global Burden of Disease (GBD) project is a consistent and comparative description of the burden of diseases and injuries. The GBD project quantifies the health effects of more than 100 diseases and injuries for eight regions of the world. Data on child maltreatment within the GBD project are however quite limited.

21. Child Maltreatment Mortality Rates (Ages 0–9) by WHO Region and Country Income Level, 2004 Source of data: Global burden of disease database: 2004 update. WHO, 2008

22. Misclassification of Child Homicides It is possible for child deaths due to maltreatment to be missed, and for this reason, these estimates underestimate the true number of deaths from child maltreatment. Many child deaths are not routinely investigated and post-mortem examinations are not carried out. In 2004, there were an estimated 22,320 deaths attributed to homicide among children under 10 years of age and an estimated 31,000 among children under 15 years of age.

23. Global Child Homicide Risks Infants and pre-school children are at the greatest risk of fatal maltreatment as a result of their dependency, vulnerability, and relative social invisibility. The risk of fatal abuse is two to three times higher in low- and middle-income countries than it is in high income countries. It is also greater in societies with large economic inequalities than in those where wealth is more evenly distributed. The most common cause of death is head injury, followed by abdominal injuries and intentional suffocation.

24. Homicide Rates per 100,000 Population among 0-4 Year Olds by Region and Sex, 2002

25. Global Burden of Child Maltreatment Studies suggest that members of the family are responsible for the majority of homicides in children aged 0–14 years. Deaths represent only a small fraction of the problem of child maltreatment. Every year millions of children are victims of non-fatal abuse and neglect. Some international studies have shown that, depending on the country, between a quarter and a half of all children report physical abuse.

26. Sexual Abuse of Children Worldwide The reluctance of many cultures to openly discuss sexuality in general and sexual abuse in particular, renders it extremely difficult to quantify this form of child maltreatment. WHO estimates that 20% of women and 5%–10% of men report being sexually abused as children. Approximately 150 million girls and 73 million boys under the age of 18 experienced sexual violence, including rape, during 2002.

27. Lifetime Prevalence of Child Sexual Abuse in High Mortality Developing Regions of the World Source of data: Andrews et al., Child sexual abuse, WHO, 2004

28. Child Maltreatment Trends in the US, 1990-2004

29. Explanations of Child Sexual Abuse Reduction in the US, 1990s The 40% decline in CSA in the 1990s in the United States is due to four main explanations consistent with the timing and breadth of the trends: 1. The economic boom, job growth, and economic optimism of the 1990s 2. An increase in the number of police, child protection workers, and other agents of social intervention 3. Enhanced efforts to identify, arrest, prosecute, and incarcerate offenders 4. The widespread diffusion of new psychopharmacology, starting in the early 1990s, to deal with depression, anxiety, hyperactivity, and aggressive behaviour in both children and adults

30. Presenting Data to Convince Policy-Makers

31. Child Maltreatment Data Determining Policy It is vital that data on child maltreatment are presented in reports dealing exclusively with the problem. Reports should use simple language and clear charts and tables so the issue can be clearly visible for policy-makers and others. Dedicated reports on child maltreatment should also be made readily available to the media and civil society organizations. To protect the anonymity of individuals, all data presented in these reports must be stripped of the case identification numbers and any other information that could possibly allow individuals to be identified.

32. Using Data to Inform Policy For policy-makers to be convinced of the need for strong action on child maltreatment, the analysis and reporting of data should include three important elements: 1. The size of the problem in relation to other issues. The scale of child maltreatment in the given country can be highlighted by comparing it with: • The magnitude of other public health threats • The scale of child maltreatment in other countries • The human cost of disasters and collective tragedies covered in the media 2. The relationships between child maltreatment and socioeconomic and environmental factors. 3. The possibility of preventing maltreatment. Showing the considerable gains that good prevention programmes can achieve is important for convincing policymakers

33. Summary and Conclusion

34. Summary and conclusion This module reviewed: • Data sources for estimating the magnitude and distribution of child maltreatment and difficulties collecting data • Existing data on the global burden of child maltreatment and gaps within these data • Presenting data to convince policy-makers   Despite the difficult nature of collecting reliable data on child maltreatment, enough is known to confirm that child maltreatment affects substantial numbers of children around the world.

35. References Andrews, G. Corry, J. Slade, T. Issakidis, C. Swanston, H. (2004). Child Sexual Abuse. In Ezzati, M Lopez, A. Rodgers, A. Murray C. (Eds.), Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors Volume 1. (pp. 1851-1940). Geneva, World Health Organization. Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teach-vip.edc.org/course/view.php?id=23 Finkelhor, D. Jones, L. (2006). Why Have Child Maltreatment and Child Victimization Declined? Journal of Social Issues. 62(4), 685--716 Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14. Global burden of disease database: 2004 update. (2008), Geneva, World Health Organization. The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 3-21. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.

36. Activity: Reviewing Child Maltreatment Data In small groups review the data provided and discuss implications and trends this information may indicate, including: • The strengths and weaknesses of the data from different sources • The differences between one-year and lifetime prevalences • The regional factors which may influence these findings