Assessing Changes in Child Abuse and Neglect As a Result of COVID

Assessing Changes in Child Abuse and Neglect as a Result of COVID

Desmond K. Runyan, MD, DrPH The Kempe Center Topics in today’s talk

.ISPCAN’s ICAST instruments- origin and intent .Has the epidemic increased or decreased child maltreatment? .(POLL) .Why we need parental and self-report data .Requirements for a study .Candidate instruments . ICAST-p and ICAST-C . MICS Child discipline module . VACS instruments .Other study considerations World Report on Violence and Health in 2002

.Limitations of current international knowledge . Mixture of incidence & prevalence estimates . Data compromised by disparate measures & definitions . Some studies mix school & home while others consider only home events . Some scholars limited focus to specific populations or avoided specific forms such as sexual abuse . Participants limited by age, gender, religion, & school enrollment, among other criteria ISPCAN’s Contribution to Secretary General’s Study of Violence Against Children Develop instruments to measure extent of child maltreatment: • Rights based • Reliable & valid • Globally useful • Culturally sensitive & easily translated Tension between need to be standardized for comparison of data, yet flexible enough to allow for subject comfort, cultural & individual factors. Background: Child Abuse & Environmental Stress

Increased child abuse noted with financial stress Child abuse in the US has declined since 1993 • Expansion of jobs and income in 90’s with changes in welfare • Decreased teen pregnancy • Dramatic reduction in intimate partner violence • Expansion of paid parental leave • Increased minimum wage 2008 recession in US linked to increased abusive head trauma Increase in abusive head trauma also seen in natural disasters But COVID 19 and Quarantine may be different

Families at home in quarantine • Less opportunity for sexual abuse as multiple people are in close quarters? • Less neglect as parents are at home? • More physical abuse as tensions rise with discipline, restrictions, and activity in conflict? Poll of Audience

What do you expect to have happened with COVID & Child Abuse and Neglect?

(POLL)

7 So how could we actually know about changes in CA&N rates related to COVID19?

Official statistics will be insensitive • Teachers and other reporters won’t see children • Reduction in taking children to doctors and telemedicine results in less physical scrutiny of children • Calls to hotlines appear to be up but for other services • Surveys of adults about their childhood will take years to answer questions. Surveys such as the Multiple Indicator Cluster Survey (MICS) & 2 of the ISPCAN Child Abuse Screening Tools (ICAST) may be the most sensitive way to assess changes related to COVID and quarantine Requirements for a study of the Impact of COVID on CA&N

•Baseline data by parent or child •Population-based survey using the same instrument before & after •A well-executed population survey of parents or children • Sampling with clusters may facilitate access. •A rapid study requires either parent or older child report •A retrospective survey (ICAST-R or the young adult VACS) is less useful. •Child perspective may not describe young children’s experiences- those most vulnerable to neglect and physical abuse

9 Candidate instruments that have been widely used and could be used for a new study surveying parents

•Parent-Child Conflict Tactics Scale (Strauss, et al) (parent-completed)

•The Multiple Indicator Cluster Survey Child Discipline Module (UNICEF) (parent-completed)

•The ISPCAN Child Abuse Screening Tools – (specifically the parent or the child questionnaire (ISPCAN)

•VACS Survey data for children 13-18 years of age

10 The Multiple Indicator Cluster Survey (MICS) Child Discipline Module Survey questions, from the UN, to assess current populations & needs. The third wave (2006) added a UNICEF-developed child discipline module. The 4th and 5th waves repeated this module. The MICS-4 used a multistage stratified cluster sampling strategy to obtain representative samples & calculate national prevalence. Waves 4 & 5, completed prior to COVID, provide best baseline estimates of abuse.

11 MICS Discipline Module

12 Countries Completing the Child Discipline Module, Multiple Indicator Cluster Survey- 4 (MICS-4), 2010-2013 Country Sample Data Year Belarus 3334 2012 Bosnia & Herzegovina 2582 2011-12 Kazakhstan 6782 2010-2011 Macedonia 1729 2011 Moldova 3122 2012 Serbia 3093 2010 Ukraine 4404 2012 Papua 1931 2011 Indonesia 1865 2011 Lao People’s Dem. Rep. 14547 2011-12 Mongolia 5686 2010 Vietnam 6424 2010-11

13 The MICS -4 Samples Country Sample Data Year Madagascar 2352 2012 Somalia 4046 2011 NE Somalia 4059 2011 Also Swaziland 2846 2010 Algeria, Iraq, Palestine, Argentina 14938 2011-12 Tunisia, Afghanistan, Nepal, Barbados 901 2012 Central African Republic, Belize 2467 2011 Chad, Dem. Rep. Congo, Costa Rica 3065 2011 Ghana, Mauritania, Nigeria, Jamaica 2661 2011 Sierra Leone, Togo St. Lucia 595 2012 Suriname 3865 2010 Uruguay 2043 2012-13

14 The ICAST Instruments (ISPCAN Child Abuse Screening Tools) Oak Foundation supported a meeting following the ISPCAN Congress in Brisbane in 2004 40 Researchers, Clinicians, & representatives of NGO’s met to develop an instrument to measure child abuse Evolved to three measures: • Parent-completed form • Youth retrospective form • Child completed form

15 Development of ICAST

Two rounds of Delphi review of ICAST by a total of 120 reviewers, mostly social scientists. • Reviewers preferentially recruited from low & middle-income countries (authors published in CA&N) After use by many investigators with BECAN and around the globe, revisions made to questions, response set, and instructions. Revised instruments released by ISPCAN in 2014. EpiInfo data entry system developed by ISPCAN and made available in 2016

16 Validation Studies

Initial studies: small samples (limited by financial support) of about 120 parents or children • India, Egypt, Colombia, Congo, Malaysia, Russia, Iceland • “ICAST P & C performed with little difficulty in pilot testing” Chinese ICAST-C validation concluded instrument was valid in Mandarin Brazil validated all three versions in Portuguese Siri Lanka version of ICAST-R also validated

17 More than 300 Investigators have requested the ICAST from ISPCAN Published ICAST Studies- 27 countries and counting

19 Validation Studies

20 >27 Known Translations To Date

Albanian, Arabic, Bulgarian, Bosna and Herzegovina, Croatian, English, French, Greek, Hindi, Icelandic, Korean, Macedonian, Mandarin, Marathi, Persian, Portuguese, Romanian, Russian, Serbian, Sinhala, Spanish, Swahili, Thai, Turkish, Urdu, Vietnamese

21 ICAST Citations on Web of Science

• ICAST-P: 25 publications • Cited 179 times in 142 articles • ICAST-C: 53 publications • Cited 254 times in 233 articles • ICAST-R: 27 publications • Cited 536 times in 514 papers

22 Version 3 of ICAST-P, -C, & -R

 Began with BECAN version modifications  Added back questions dropped from ICAST P and added ICAST-C(sexual abuse) and ICAST-P(neglect) questions to ICAST-R  Modified list of perpetrators  Reworded several questions  Modified response options The ICAST-P  Ample evidence that parents will reveal sensitive information by interview  Parents can understand informed consent  Parents were present  Can be asked about behaviors in context of child rearing Background- 10 demographic questions Discipline – 36 questions Neglect and Sexual abuse – 8 questions Attitude about corporal punishment – 1 questions Parent Demographics- 5 questions Developing the ICAST-C  Child abuse is often a private act  Child rights perspective - respect for children  Research ethics: informed consent & respect for persons US conference recommended not asking children less than 10 years  Multi- year experience asking children directly: found children understand & reveal more events than parents  Child well-being best predicted by child report ICAST-C Revised response options Developing the ICAST-C Child abuse is often a private act Child rights perspective - respect for children Research ethics: informed consent & respect for persons • US conference recommended not asking children less than 10 years Multi- year experience asking children directly: found children understood & reveal more events than parents Child well-being best predicted by child report ICAST-C Revised response options Epi Info Revisions

Revised Manual developed to clarify how additions or deletions are made by section and translation & ethics standards ICAST copyrighted by ISPCAN. 2018: Data Entry templates developed with Epi Info to facilitate data entry and analysis Epi Info is free software developed by CDC for building questionnaires and analyzing them. • Includes building questionnaires and facilitating data entry • Epi Info can do basic statistical analyses • Data can be exported to other statistical programs including SAS, SPSS, Systat, and Stata. • Epi Info available in multiple languages Epi Info The Form Designer module of Epi Info™ allows users to create questionnaires & data entry forms in Epi Info™. The Enter module of Epi Info™ automatically creates the database from the questionnaire in Form Designer. Users enter data, modify existing data, or search for records. Check Code validates the data or performs any automatic calculations that were specified in Form Designer. The Analysis module will read and analyze data including statistics, tables, graphs, and maps are produced with simple commands. The Epi Map module displays geographic maps with data from Epi Info.

30 ICAST-P data entry form – can be edited to change language leaving scoring and data entry intact

31 ICAST-C

32 Violence Against Children Surveys

.Cross-sectional surveys of females & males 13-24 years of age asking last year & ever violence exposure. .Designed to produce nationally representative data .Examines health consequences & risk / protective factors .Surveys completed in 22 countries (Botswanna, Cambodia, El Salvador, Haiti, Honduras, Kenya, Laos, Malawi, Nigeria, Rwanda, SwaZiland, TanZania, Uganda, Zambia, & Zimbabwe .VACS surveys planned or underway in Colombia, Cote d’Ivoire, Guatemala, Lesotho, Moldova, MoZambique, Namibia, and the Philippines

33 Back to COVID- Love The Data You Have

If MICS data are available, a new random population survey with the child discipline module can be help. If prior ICAST data are available, a new random survey of parents may be linked to the prior data. • Additional instruments or questions needed to characterize isolation, quarantine, family finances, and function. If VACS data are available, restricting to the past year and looking only at children will assess COVID impact on older children. Parent provided data may be better than child data across ages

34 Designing new studies

Attention will be needed to sampling and access in a time of limited contact: • Telephone or computer-based data may be needed • Mail surveys are again in fashion and may have better response rates • Difficult to interpret new ICAST, VACS, or MICS data if no prior data exist for your country. • A second wave of data collection after COVID has waned may allow interpretations of current data

35 Other considerations New surveys using the MICS discipline module or the VACS work are likely to have great power as baseline samples were large. New surveys following up on the ICAST will have greater ability to distinguish perpetrators and acts as the instrument is more detailed. Funding for these studies are likely to be available from Oak, local foundations, CDC, and national or local health research sources.

36 Access All ICAST instruments, and field guides and data entry system, are available at ISPCAN.ORG The VACS instruments and Epi Info are free at CDC.gov https://www.cdc.gov/epiinfo/pc.html Tutorials for Epi Info on You Tube and at CDC.gov Discussion?

Des Runyan can be contacted at [email protected] or at [email protected]