Florida Department of Health
Child Maltreatment: An
Overview for Professionals in
the Field
Child Protection Team Training
To protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.
It's a New Day in Public Health
Child Maltreatment Course Guide Child Protection Team Training
It's a New Day in Public Health
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Table of Contents
SLIDE NUMBER - TITLE PAGE
Slide 1 – Child Maltreatment: An Overview for Professionals in the Field – Title Page 1
Slide 2 – Child Maltreatment: Objectives 1
Slide 3 – History of Child Abuse: “Everywhere, All the Time, Rarely Noted” 2
Slide 4 – Child Abuse: Recent History in Medical Literature 4
Slide 5 – Child Abuse: Statistics – “The Bad News – It’s Common” 5
Slide 6 – Child Maltreatment in Florida: Statistics Close to Home 6
Slide 7 – Child Maltreatment: Statistics – Types of Abuse 6
Slide 8 – Deaths Due to Abuse and Neglect: Florida Death Review Program, 2005- 7 2009
Slide 9 – Florida Law: Definition of Child Abuse 8
Slide 10 – Neglect: Legal Definition (Florida Statutes, Chapter 39.01) 9
Slide 11 – Recognizing Child Abuse: The Challenge 10
Slide 12 – Recognizing Child Abuse: A Process Similar to Making Other Medical 11 Diagnoses
Slide 13 – Recognizing Child Abuse: Types of Discrepancies Between History and 12 Injury
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Slide 14 – Recognizing Child Abuse: Types of Discrepancies Between History and 12 Injury (continued)
Slide 15 – The Abuse Cycle: “It Can Be Broken” 13
Slide 16 – The Abuse Cycle: Interacting Factors of Varying Weight 14
Slide 17 – Perpetrators: Relationship to Child 15
Slide 18 – Perpetrator Risk Factors: Florida Child Abuse and Neglect Deaths 16
Slide 19 – Cause of Abuse and Neglect Deaths: Role of Substance Abuse 16
Slide 20 – Prior Involvement with DCF 17
Slide 21 – Prior Involvement with DCF: “You Often Have Only One Chance” 17
Slide 22 – The Abuse Cycle: Interacting Factors of Varying Weight 17
Slide 23 – Characteristics of the Child 18
Slide 24 – Abuse and Neglect Deaths 18
Slide 25 – Child Risk Factors: “Some Can Be Addressed” 19
Slide 26 – The Abuse Cycle: Interacting Factors of Varying Weight 19
Slide 27 – Infant Crying: Common Cause of Abusive Head Injury 19
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Slide 28 – Hand-Slap Bruises to Face: Identify Children at High Risk for Future Injury 20
Slide 29 – Hand-Slap Bruises to Face: Identify Children at High Risk for Future Injury 20 (continued)
Slide 30 – Fractures: Twisted Arms and Legs 21
Slide 31 – Chip Fractures in the Arms and Legs: “Classic Metaphyseal Lesions” 21
Slide 32 – Posterior Rib Fractures: Highly Specific for Abuse 21
Slide 33 – Abusive Head Trauma: Devastating Brain Injuries from Shaking and 22 Slamming
Slide 34 – Normal Crying 22
Slide 35 – Coping with Normal Crying: Advice for Stressed Parents 23
Slide 36 – Exploratory Behavior 23
Slide 37 – Bruises from Spanking: Angry Over-Reactions to Normal Exploring 24
Slide 38 – Abusive Injuries: Angry Over-Reactions to Normal Exploring 24
Slide 39 – Hot Water Immersion Burns: Often the Result of Touching Things 24
Slide 40 – Abusive Fractures: From Normal Exploratory Behavior 25
Slide 41 – Abdominal Injuries: Serious and Frequently Life-Threatening 25
Slide 42 – Family Circus (Comic Strip) 25
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Slide 43 – Discipline for Creepers, Cruisers and Crawlers: An Important Precedent 26
Slide 44 – The Playpen: Many Uses Other Than Play 27
Slide 45 – The Negative Two-Year-Old 27
Slide 46 – The Negative Two-Year-Old (Part 2) 28
Slide 47 – Bruises Are Injuries: Blood in Tissues from Torn Vessels 28
Slide 48 – Bruises from Belts and Cords: Identify Children at High Risk for Future 28 Injury
Slide 49 – Bruises from Belts and Cords: Identify Children at High Risk for Future 29 Injury (continued)
Slide 50 – Discipline for the Negative Two-Year-Old 29
Slide 51 – Being Smarter Than a Two-Year-Old 30
Slide 52 – Using Time-Out: Most Effective Technique for Pre-Schoolers 31
Slide 53 – Toilet Training 31
Slide 54 – Toilet Training: Can Be Lethal (News Article) 32
Slide 55 – Toilet Training: Reasonable Expectations 32
Slide 56 – Toilet Training: A Developmental Accomplishment of the Child 33
Slide 57 – Bed-Wetting Alarms: Cheapest, Safest and Most Effective Treatment 34
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Slide 58 – School-Aged Children: Talking Back, Not Doing Chores, Bad Report Cards 34
Slide 59 – Spanking: Problems with its Use 35
Slide 60 – Discipline for Pre-School and School-Aged Children 36
Slide 61 – Discipline and Adolescents 36
Slide 62 – Beating with Belts and Cords: Useless in Older Children and Teens 37
Slide 63 – Beating with Belts and Cords: Useless in Older Children and Teens 37 (continued)
Slide 64 – Discipline and Adolescents: “It’s Payback Time!” 37
Slide 65 – Intervening in Child Abuse: Address the Underlying Issues 38
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Slide 1 Hello, I'm Dr. Bruce McIntosh, Co- Child Maltreatment: Interim Statewide Medical Director of An Overview for the Child Protection Team system. Professionals in the Field Welcome to this presentation on Child Maltreatment. This presentation is
Bruce J. McIntosh, M.D. going to be an overview of the field. For Child Protection Team Co-Interim Statewide Medical Director those of you who are new to the area this will give you a good large view of the problem of child abuse, how we go about making the diagnosis and how we identify it and begin to intervene on behalf of children who have been hurt. For those of you who've been already working in the field, I'm hopeful that I'll still have some new ideas to share with you.
Slide 2 Child Maltreatment Our objectives are going to be to review Objectives first the history of our society's
. Review the history of awareness of child awareness of child abuse as a problem abuse as a societal problem which is a relatively recent awareness. . Review national and Florida child maltreatment statistics We'll talk about national and local . Discuss strategies for differentiating abusive from accidental injuries statistics related to child maltreatment. . Review the age-related risks for child We'll talk about how we go about, as maltreatment and strategies for prevention and intervention medical professionals, distinguishing between abusive injuries and accidental injuries which can also be useful for child protective investigators and others who deal with this issue, and finally we'll spend a good bit of time talking about those things that children do at different ages that develop the cause, well, developmental norms that often cause parents to lose their temper and injure them.
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Slide 3 History of Child Abuse The lives of children have sadly been Everywhere, All the Time, Rarely Noted very cheap over the ages. In ancient
. Ancient Times: times it was not uncommon for “Exposure” to unwanted infants unwanted children or children born with . Massacres of the Innocents deformities to be exposed to the . Industrial Revolution: Children as chattel elements to die and be eaten by animals. . Abroise Tardieu (France 1818-79) This was the story of Romulus and . The Mary Ellen Case (New York 1874) Remus, the mythological founders of the city of Rome who were exposed and adopted by a wolf. Subsequently it's been not uncommon for the mass murders of children to occur as described in the Bible at the time of the birth of Moses and later at the time of Jesus. Again, the lives of children in ancient times were very, very cheap. Over the intervening 1800 years, children continue to be treated as chattel, which is to say properties of their parents, who could be sold into slavery or abused in any way that parents found to be useful to them. During the time of the industrial revolution for instance, children were often leased to factories where they would work 18 hour days, sometimes literally changed to machines, suffering high rates of industrial injuries. This is a picture of a child being as the saying goes, being 'given the dickens' because the situations under which children lived in those times were so graphically described by the author Charles Dickens. And around this same time, Dr. Ambroise Tardieu who was a public health officer in Paris did autopsies on many, many children and described in French medical literature pretty much everything we know about child abuse today. He described the fractures, the internal injuries, injuries to the eyes, the brain hemorrhages, pretty much what we know about child injuries from 2
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abuse today he described in his writings, but being and writing in French and being in the late 1800'sit did not really catch on and get a lot of attention around the world. More locally here in the United States, the Mary Ellen case which occurred in 1874 brought more attention to the problem of child abuse. Mary Ellen was an adopted child who was being systematically abused by her adopted mother. She was kept in a darkened room, she was beaten, not fed, and not allowed out into the yard. She was beaten for instance, with these scissors inflicting the kind of injuries that you can see on her legs there. Some people became aware of her plight and went to court and had her removed and placed with another family where she grew up to live a long, happy life and did not in fact, pass away until 1956, but an example of a successful intervention and the kind of thing that we need to use as a role model for working to help children. As far as a child abuse in the way that we now deal with it though, it's really a very recent development. Up until very recently, it was known that some terrible, terrible people might hurt their child, but the idea that that nice family up the road would hurt their child and then provide some false story to explain it; that really seems not to have occurred to people.
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Slide 4 Child Abuse In 1946, Dr. John Caffey pictured here, Recent History in Medical Literature who is the father of Pediatric Radiology in fact, published an article entitled 1946 Caffey “Multiple Fractures of the Long Bones in Infants Suffering From Subdural Hematoma” "Multiple Fractures of the Long Bones “It is difficult to avoid the over-all conclusion that skeletal1953 Silverman lesions having“The the Roentgenappearance Manifestations of fractures - of in Infants Suffering from Subdural regardless of history forUnrecognized injury or the Skeletalpresence Trauma or in absence of intracranialInfants” bleeding - are due to Hematoma." It's said that Dr. Caffey undesirable vectors of force.” 1955 Wolley “The Significance of Skeletal Lesions in InfantsWoolley Resembling - 1955 thought that these were inflicted injuries Those of Traumatic Origin” 1962 Kempe “The Battered Child Syndrome” but the editor of the pediatric journal would not let him say that. It was just too outlandish of an idea, so what he ended up presenting was simply a clinical association. He said that if you saw a child with multiple fractures you should look for head injury. If you saw child with a head injury should look for multiple fractures. It's fascinating to read this article in hindsight because these are children who would go home from the hospital for Christmas leave and come back with new injuries but again, there was no speculation as to what caused those injuries. After this article was published, because many of the fractures described were metaphyseal chip fractures, which we will talk more about later, people started speculating on new diseases. They talked about a thing called ‘Metaphyseal Fragility Syndrome’ thinking well maybe there's some disease that makes these children's bones break and makes them bleed into their head. But in 1953 Dr. Silverman published an article titled "The Roentgen (or X-ray) Manifestations of Unrecognized Skeletal Trauma in Infants." And what he was saying, 'No, this isn't a disease that looks like a fracture. It's a fracture. It's skeletal trauma.' Then in 1955 Dr. Wolley published an article entitled "The Significance of Skeletal Lesions in Infants Resembling Those of Traumatic Origin." Notice the way he careful 4
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couches his words here. The significance he said, well, and let me use a quote here. This is from the last paragraph of his article. He says "It is difficult to avoid the over-all conclusion that skeletal lesions having the appearance of fractures - regardless of history of injury or the presence or absence of intracranial bleeding - are due to undesirable vectors of force." Now just look at that language, - Undesirable vectors of force - That's as far as anyone would go. It's as close as anyone could come in 1955 to saying, 'someone broke these babies.' And then it was finally, in 1962, that Henry Kempe published his landmark article, "The Battered Child Syndrome" making society aware that yes in fact, that nice couple down the street would hurt their child and make up some false excuse. So that's why we are all now working in this field as a result of this development over a relatively recent time of our understanding of the prevalence of child abuse.
Slide 5 Child Abuse: Statistics It is in fact, quite prevalent including in The Bad News – It’s Common this data from the National Child Abuse . According to the National Child Abuse and Neglect Data and Neglect Data System. In 2005 there System, in 2005 there were an estimated 3.3 million referrals for child abuse or neglect were over 3 million children who were . Of these, 899,000 children were confirmed to be victims of abuse or neglect referred for possible abuse of whom . Thus 12 out of every 1,000 children (1.2%) up to age 18 in the United States were found to be victims of 899,000 were confirmed as being maltreatment in 2005
. Approximately 1,300 deaths from abuse and neglect in 2005 victims of abuse or neglect. That gives in the United States us an incidence of 1.2 percent which is www.americanhumane.org the number that's been true for many, many years. Approximately 1,300 deaths per year occur due to child abuse and I think most people in the field believe that this is a gross underestimate due to children that are killed and written off as accidents or natural causes due to inadequate investigations. 1300 would be the minimum. 5
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Slide 6 Child Maltreatment in Florida Right here in Florida it's estimated that Statistics Close to Home in 2010 and I'll be referring frequently
. In Florida it is estimated that in 2010 there were about 51,920 to the data from 2010 because we have children who were victims of child abuse or neglect. . 13% of the victims were less than one year old; a really good data that was really well . 38% of the victims were less than four years old; . Racial Distribution . 47.2% of the victims of child abuse were White analyzed from that year. There were . 29.4% were African-American . 17.2% were Hispanic about 51,000 children who were victims . 74% of the victims were maltreated by their parents . Fatal Abuse: 133 children died as a result of child abuse and of abuse or neglect. Overall, 13 percent neglect
Child Maltreatment 2012, U.S. Department of Health and Human Services, of these were less than a year old and Administration on Children, Youth and Families, Children's Bureau. 38% less than 4. Now let me point out that this is data for all children who are abused. Later we will be looking at children who were killed. In those children that were killed, the age distribution is much lower. It's the younger children who are much likely to be killed. The racial distribution as you can see is about half white and about a third African-American. The most common abuser is the child's own parent; 74 percent of the time and in Florida in that particular year about 133 children were established as having died of child abuse or neglect and that's the number that goes up and down year to year but it's always somewhere around that number.
Slide 7 Child Maltreatment: Statistics When we look at national statistics we Types of Abuse see this distribution of various types of
. Neglect - 62.8% maltreatment. Neglect in every survey . Physical abuse - 16.6% is the most common form of child . Sexual abuse - 9.3% maltreatment. I'm going to be talking . Emotional and/or psychological abuse - 7.1% today primarily about abuse but there . Medical neglect - 2.0% will be another presentation in this . Other - 14.3% series focusing on neglect which again www.americanhumane.org (2005 Statistics) is a major, major problem. It causes more deaths than abuse. Physical abuse at 16 percent, sexual abuse, emotional abuse, medical neglect and other forms of abuse like exposure to drugs, and Munchausen Syndrome by Proxy.
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Slide 8 Deaths Due to Abuse and Neglect Here in Florida, looking at data from a Florida Death Review Program, 2005-2009 few years past again I just want you to
Year Abuse Neglect Total see that when you look at the deaths due 2005 32 62 94
2006 55 115 170 to neglect each year, they are usually 2007 45 118 163 about twice the number of abuse. This 2008 60 138 198 is held true right into more recent times. 2009 52 140 192
Total 244 573 817 You can see again the numbers, 130 -
Source: Florida Child Abuse Death Review Committee 140 per year. Most years children dying Annual Reports from neglect in the United States - in Florida, I should say.
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Slide 9 Florida Law Let's look at the definition of abuse as Definition of Child Abuse indicated by Florida Statute. Abuse “Abuse” means refers to a willful act, a threatened act a) Any willful act or threatened act that results in any physical, mental, or sexual injury or harm . . . that results in physical, mental or sexual b) Includes acts or omissions c) Corporal discipline of a child for injury or harm; so willful act to cause disciplinary purposes does not in itself constitute abuse when it does not result in harm to the child. injury or harm. An example that would “Willful” refers to the intent to perform an action, not to the intent to achieve a result or to cause an injury. be, for instance holding a lighted cigarette to a child inflicting a burn. Florida Statutes 39.01 That's really an intentional burn because there's nothing else that's going to happen there. But what about this case? This is a child who has loop-marks on her face and the parent is going to tell you that 'I was trying to discipline her because she brought home a bad report card and she had talked back to her teacher and she wouldn't hold still and I accidentally hit her in the face.' The parent is going to present this to you as an accident. Well, part of the definition of willful in the statute is that willful refers to the intent to perform an action, not the intent to achieve results or cause an injury. So if the caretaker meant to be swinging the belt then they are responsible for the consequences. The swinging of the belt was intentional act that resulted in the injury to the child. This is an important fundamental thing that we have to understand because parents will tell you, 'Yes I twisted his arm, [but] I didn't mean to break it. Yes, I slapped him in the face, I didn't mean to injure his eye.' If they meant to do a thing, they are responsible. Let me also draw your attention to the fact that corporal punishment, Paragraph C there, corporal punishment for the purpose of discipline does not constitute child abuse if it doesn't result in injury to the child. Once it causes an injury, then it's crossed the line and does become abusive.
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Slide 10 Neglect: Legal Definition Neglect refers to when a child, [excuse Florida Statutes, Chapter 39.01 me] when a parent or other person
“Neglect” of a child means: responsible for taking care of the child
1. The parent or other person responsible for the child’s welfare fails to supply the child with adequate food, clothing, shelter, or health care . . . fails to supply adequate food, clothing, 2. Exposes a child to a controlled substance or alcohol. shelter, health care, exposed the child to 3. Engages in violent behavior that demonstrates a wonton disregard for the presence of the child and could reasonably result in serious injury to the child some illicit substance or alcohol, 4. Negligently fails to protect a child in his or her care from inflicted physical, mental or sexual injury caused by the acts of another. engages in violent behavior in the
“Harm” includes leaving a child without adult supervision appropriate for the child’s age or mental or physical condition presence of the child that indicates a want and disregard for the child that in other words, and this is a very good thing about Florida Law, engaging in domestic violence in the presence of a child constitutes neglect. Also negligently failing to protect. It often happens that one person will abuse the child. The other person in the family will not let anyone know about it, will not protect the child, will try to cover it up, then that second person buys some of the responsibility for the child's condition. Harm includes injuries that result from inadequate supervision. That actually, to my mind, that's neglect but it’s included actually, in the physical abuse section of the statute.
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Slide 11 Recognizing Child Abuse So how do we go about recognizing The Challenge child abuse? The challenge is that
. Parents who abuse their children people who abuse their children would will lie to you about it. usually lie to you about it and lie very . Most will be smart enough to be nice to you. convincingly. They know that there are . The parent you’re talking to may really not going to be legal consequences; they know what happened. might go to jail, they might lose custody . You can not tell who has abused a child by how they look or the way they act. of their children so they are not going to tell you the truth about it. More often than not, they will make up some false story. They'll usually be smart enough to be nice to you. They will figure that if I act nice to the investigator, the doctor or the nurse, the child protective investigator, the case coordinator, they will think that if I am nice to them they won't think I'm the kind of person who would abuse my child. It's also helpful to remember that the person you're talking to you may not know what happened to the child. It's very common for one person to abuse the child, the other parent or caretaker notices the child is injured and takes them to the hospital. They really don't know what happened so sometimes, and that's one reason we should always keep an open mind and not get accusatory when we're talking with people. The person you're talking to may in fact, not really know what happened. And finally and very importantly we must understand that we cannot tell who's abused the child by the way they look or how they act. That includes their age, their demeanor, their gender, their race. Nothing of that will tell you whether or not they have abused the child. An innocent person, someone whose child was actually injured accidentally might be nervous when you start asking them questions about the child's injury. They might be nervous because they think "Oh he thinks I hurt my child. They're going to 10
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take them away." An innocent person may get nervous and act that way, whereas a sociopath, someone who has no conscience who has hurt their child will look you in the eye and lie very convincingly when they tell you that they have not hurt their child so never think that you can tell by the way someone acts whether they have hurt their child or not.
Slide 12 Recognizing Child Abuse So how do you tell? Well, we medical A Process Similar to Making Other Medical Diagnoses people do this in the way we make any . Gather information other medical diagnose but with a twist. . History
. Physical examination We begin by gathering information we . Laboratory studies get the history, the detailed story of . Normally in the practice of medicine, the history, physical what happened, we do a physical and laboratory studies will all point in the same direction examination looking both at the injured . In child abuse there will be significant discrepancies -the obviously injured area and at the whole child for other injuries that might be present elsewhere, and in many cases we get laboratory studies. Now, normally in the practice of medicine, that works out very nicely. The history, the physical, and laboratory studies are all point in the same direction that lead you straight to the diagnosis. What we're looking for in child abuse typically is some kind of discrepancy because typically there is some discrepancy between the story that's offered and the injury that we document with our physical exam and laboratory studies.
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Slide 13 Recognizing Abuse What kinds of discrepancies? Well, Types of Discrepancies Between History and Injury there are eight common discrepancies.
. The history does not The first and most common is that the explain the injury found . Multiple injuries of various history that they give simply doesn't types or ages explain the injury that we see. We may . Delay in seeing medical attention for an injury which is obviously serious see multiple injuries of various types . No history offered to like bruises and burns, burns and broken explain an injury which is serious or typical of abuse bones. Often there's a delay in seeking (Continued) medical attention for serious injuries or injuries that any reasonable parent would know should be brought for care, or sometimes no history is offered for a typical abusive injury or an injury that is very serious.
Slide 14 Recognizing Abuse Sometimes the history will change over Types of Discrepancies Between History and Injury time as the caretaker looks for a story
. History changes over time or that doesn't cause people to raise their different caretakers give different stories eyebrows and look at them . Child is developmentally incapable of having acted as suspiciously. They will just keep described . Child would not reasonably tweaking that story, or different be expected to have acted as described caretakers will give different stories. . Serious injury blamed on another child Sometimes they'll give a story that the child is just not developmentally capable of doing. We know a child that age can't do that. Or common sense says the child would not reasonably do what they said that he did. And then sometimes they will blame serious injuries on other children. That's really uncommon. Kids will give each other bumps and bruises sometimes, but not serious injuries of the kinds that we are typically seeing.
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Slide 15 The Abuse Cycle One reason why it's important for us to It Can Be Broken work on child abuse is that it's an inter- Abused Child generational problem that often recurs Anger and Poor Parental from year to year to year. What happens Frustration Role Models is that if you begin at any point with an abused child which we'll take as a
Unrealistic Poor Parenting starting point here, that child is growing Expectations Skills up with poor parental role models. They Unmet Emotional Needs don't learn good behavior modification techniques. They don't learn patience. They grow up not knowing how to be good parents so they grow up with poor parenting skills themselves. They often have unmet emotional needs because their parents had not loved them and given them support in the way that they should have. And when they had then, their own children they have unrealistic expectations. They have unrealistic expectations of their behavior. They may think for instance, that a two-year- old should stop and come when he's called, when he's playing with his toys. Well maybe, maybe not. They may expect that child to meet their unmet emotional needs. Now you will have young mothers say that 'my parents never loved me so I had a baby so I would have someone to love me.' While those of you who have had babies know that it's a long time before you get any emotional feedback from them. When they're born they're little, bottomless pits of physical and emotional needs. So, not having those unrealistic expectations met, the parent in anger and frustration acts out and abuses their child in a cycle that then repeats from 13
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generation to generation. And the hope is that if we can break this cycle that we can break, that we can stop that cycle from continuing from generation to generation. And the hope is that if we can break this cycle that we can break, that we can stop that cycle from continuing from generation to generation.
Slide 16 The Abuse Cycle Now when we look at the actual event Interacting Factors of Varying Weight of abuse, it usually grows out of the interaction of three different factors that Caretaker we're going to spend some time analyzing. There's the caretaker of the child in the crisis, and one point I'd like to make to start is that you can weight
Child Crisis any one of the three corners of this triangle in such a way as to have abuse become likely to occur. The caretaker may be a parent who has a low frustration tolerance, problems with anger management, one of the parents like we talked about who was raised in an abusive family and doesn't have good parenting skills. It may be the child. It may be a normal child or it may be a child who is in some ways special, a child with developmental delays, a child who has spent a lot of time in the NICU and the parents didn't have the time to bond with effectively, maybe a child that's a boy --they wanted a girl, or a child who reminds a young mother of the man who got her pregnant and left. There may be something about the child makes him a target or he may be just an ordinary everyday child. And then there's some event, some crisis that precipitates the injury. Now, if the parent has a low frustration tolerance than any little thing like a spilled glass of milk might enough to set off an 14
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instance of abuse, but let me just present another possible scenario for you. You may have a perfectly normal parent, a perfectly normal child but some set of circumstances, that maybe the father is gone. There's no money in the house. They're about to be evicted. There's no food. The mother doesn't know what's going to happen next and the child does some little thing and it's just more than the mother can tolerate and she over reacts and injuries the child. I always keep this in mind when I'm working with families because it helps me remember that 'There but for the grace of God go I.' There but for some set of bad circumstances, that could be, could have happened to me. So we do need to be understanding when we work with these people because they're not all bad people. They're are often good people who have simply been pushed beyond their ability to cope with the situation. Let's look at a few more characteristics of the caretaker as drawn from Florida statistics.
Slide 17 Perpetrators The most common abuser in this, we're Relationship to Child looking now at deaths, not all abuse, but . 76 (44%) were Mothers/Stepmothers at deaths was the mother or stepmother. . 60 (34%) were Fathers/Stepfathers . 12 (7%) were Other Relatives That surprises a lot of people because I . 8 (5%) were Other non-relatives think most people think that men are the . 5 (3%) were Day care workers . Four were licensed facilities more common causes. Some years they . One was an unlicensed home day care . 3 (2%) were Male and Female Paramours are but in this particular year 2010, as . 1 (0.5%) was a Foster Mother reviewed in 2011 report it was the Florida Child Abuse Death Review Committee Report, 2011. women. 7% are by other relatives, 5% by non-relative caretakers, some by daycare workers, and in this particular year only 2% were by paramours. Again that's not what we expect, I'm used to thinking of boyfriends and girlfriends as being common causes of abuse. Other years it is more common but it's not the 15
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predominant number. One death (.5%), was caused by a foster mother. That happens pretty much every year so that's a reminder that foster care itself is not always as benign as we would like it to be.
Slide 18 Perpetrator Risk Factors When you look at risk factors among Florida Child Abuse and Neglect Deaths perpetrators, you can see that the most predominant one is substance abuse or alcohol use. This tends to decrease people's tolerance, it disinhibits them so that they are less likely to be able to control their anger when a child does something. Prior history with DCF, Florida Child Abuse Death Review Committee Report, 2011 criminal history, domestic violence, and mental health issues; these are risk factors that we can identify in perpetrators of children who have been killed.
Slide 19 Causes of Abuse and Neglect Deaths When we look at what happens to Role of Substance Abuse children who have died in the care of people who are using substances, what we can see is that the most common form of death is physical injury, that's child abuse again by a disinhibited adult. But you also see unsafe sleep is
State of Florida Abuse Death Review Committee. Annual Report, very, very common as is drowning. December 2011, page 13. Drowning occurs of course because they're drinking and using drugs and not looking after the kids, unsafe sleep is because the mother washes down a couple of Lortabs with a couple of beers and takes the baby to bed to breastfeed so unsafe sleep is a very, very common cause of death in children whose parents are abusing substances.
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Slide 20 Prior Involvement with DCF As to prior involvement with DCF we PresentAbsent in in 95 41 of of 136 136 Deaths Deaths (70%) (30%) can see here that in this particular year, 41 cases or 30 percent of the deaths had prior involvement with the Department of Children Families, and DCF gets a lot of flak for that, but I think it's worth pointing out that in 70 percent of child
State of Florida Abuse Death Review Committee. Annual Report, abuse and neglect deaths, there was no December 2011, page 14. prior interaction with DCF. So, many of these kids who die, it's the first time that anybody notice anything has happened that they are killed.
Slide 21 Prior Involvement with DCF If you look at the cases that do have a You Often Have Only One Chance history with DCF though, I think this slide makes a really important point. You can see that most of them had only one prior contact with DCF so there's an important lesson here, for all us who work with the Department of Children
State of Florida Abuse Death Review Committee. Annual Report, Families and our other community December 2011, page 14. partners, we often have only one chance to get it right; we've got to get it right the first time because the next time may be too late, so we need to work closely with our community partners to get it right the first time.
Slide 22 The Abuse Cycle So we talked about the caretaker, let's Interacting Factors of Varying Weight talk about the child. What are some characteristics of child victims? And Caretaker again, we're looking at death's,
Child Crisis
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Slide 23 Characteristics of the Child 70% were male, 30% were female and Race and Gender pretty much everything that you look at • Gender of Child about mortality, male children have • 92 (70%) were male children • 44 (30%) were female children higher numbers. They just tend to be • Race/Ethnicity of Child • 62 (46%) were White more active get into to stuff more. And • 39 (29%) were Black
• 11 (8%) were Hispanic
• 10 (7%) were Multi-racial you can see that racial distributions
• 9 (7%) were Haitian • 3 (2%) were Asian Pacific there largely reflecting the distribution • 2 (1%) were Middle Eastern State of Florida Abuse Death Review Committee. Annual Report, of our community largely also reflecting December 2011, page 11. the distribution around the country.
Slide 24 Abuse and Neglect Deaths Now when we look at deaths, it's 119 of 136 Deaths (88%) Less Than 5 important to note that 88% and this is true year in, year out, 88% of the children who are actually killed are less than five years old. The first two years are the greatest risk, the older children make up a significant number of kids
State of Florida Abuse Death Review Committee. Annual Report, reviewed, but it's harder to kill an older December 2011, page 10. child. Young children are more vulnerable to be killed for several reasons, for one they are simply smaller, weaker, easier to hurt and kids in this age group tend to do things that, we'll talk about those things later, things that irritate and anger adults and these young children are out of the sight of the larger community; people don't see them, people don't know when they're being injured until often it's too late. So remember, it's important to remember, that the vast majority of children who died from abuse and neglect are less than five years old.
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Slide 25 Child Risk Factors When we look at risk factors in the Some Can Be Addressed child, that it can easily be identified, some of these can be fixed and some can't. I want to draw your attention particularly to the issue of visibility in the community when we're coming up with a plan to protect children who have been reported for abuse or neglect, one Florida Child Abuse Death Review Committee Report, 2011 of the most important valuable things we can do is to get them into some kind of day care get them out into the community so that other people, it gives the parents a respite, but also puts other eyes on the child so that if they are injured intervention can be conducted before something worse happens.
Slide 26 The Abuse Cycle So we've talked about the caretaker and Interacting Factors of Varying Weight the child, now let's talk about the crisis. Now, I say crisis but it can be simply an Caretaker event, something that the child does. Some years ago, Dr. Barton Schmitt published an article called 'Seven Deadly Sins of Childhood' in which he
Child Crisis outlined the developmental stages that children go through and how at each of those stages it can be challenging to adults who have a low frustration tolerance and can result in abuse.
Slide 27 Infant Crying So let's look at some of those things; Common Cause of Abusive Head Injury what do you think is the first behavioral challenge that comes up with regard to infants? If you said crying, yes that's it. Crying is the first thing that babies tend to do that causes a lot of child abuse including most of our most serious cases, the head injury cases. The baby's crying, the caretaker tries to make them better, the caretaker tries to figure out 19
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what's wrong, tries to meet their need, but the child just continues to cry until finally in anger and frustration the caretaker takes out their anger and frustration in some physical way against the baby.
Slide 28 Hand-Slap Bruises to Face Sometimes it's a hand slap like this Identify Children at High Risk for Future Injury which leaves a hand print on the cheek, where the blood is squeezed out of the blood vessels where the fingers land and overloads the capillaries between the fingers so that you get this kind of negative imprint.
Slide 29 Hand-Slap Bruises to Face Here's another case in the same, you can Identify Children at High Risk for Future Injury see here we have parallel linear bruises on the child's cheek, there's a little hemorrhage in the corner of the eye here, the parent is going to tell you that the baby did this banging his face against the crib rails, never believe that. That's a death sentence to the baby, someone who will lose their temper and slap a baby this young that way will do something worse later.
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Slide 30 Fractures Sometimes they will twist their arms or Twisted Arms and Legs legs causing obvious fractures of the femur or humerus like this,
Slide 31 Chip Fractures in the Arms and Legs …but more often they will jerk them by “Classic Metaphyseal Lesions” their arms or legs, and they'll get what are called Metaphyseal chip fractures where we have just little chips of bone off down here. These don't happen in falls, these are highly specific for abuse and when you see that again that's a child that's going to be in danger.
Slide 32 Posterior Rib Fractures Sometimes instead of squeezing them Highly Specific for Abuse by the arm or leg they will take them by the chest sometimes that a part of shaking them, sometimes they simply squeeze until they feel ribs pop, that can give you posterior rib fractures like this. Again, a type of fracture that's highly specific for abuse.
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Slide 33 Abusive Head Trauma And then, the most devastating head Devastating Brain Injuries from Shaking and Slamming injuries occur again typically as a response to crying and someone will angrily, violently, shake a baby or slam the baby's head against some surface causing serious brain injury and often death. So all of this can be a result of the baby's crying.
Slide 34 Parents get frustrated because they don't Normal Crying know how much it's normal for babies to cry this was a survey done again by Dr. Schmitt some years ago, in which he outlined normal baby crying. He had mothers keep calendars of what their babies were doing each day in 15 minute increments and what you can see here is that at the age of six weeks, the crying peaks at about a little less than three hours; some babies cry less, some babies cry more, but if you add up all the crying a baby does during the course of a day that's a couple of hours. Young parents, inexperienced parents they don't expect that, they don't know that, they think the baby, if he's not dirty or hungry he ought to be quiet. But it's just a normal thing for babies to cry, so one thing that parents can learn is better, safer ways of dealing with crying.
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Slide 35 Coping with Normal Crying This is the kind of thing that can be Advice for Stressed Parents taught in parenting classes or in classes that educate them on normal childhood . Know what’s normal development. One thing we need to . Don’t take it personally encourage parents to do is to not take it . It’s okay to hold a crying baby personally. The inexperienced young . It’s okay to let them cry parent will think "the baby doesn't like . When all else fails, leave the room me, they're crying because they think I'm a bad mother." Babies don't have opinions, people just need to learn to accept that, it's just, crying is part of their job description; it's what they do. It's ok to hold babies when they're crying, you won't spoil them at a young age. It's okay to let them cry, it won't hurt them to cry. And when all else fails, the bottom line message for parents is that, when you've done everything you can for the baby and they're still crying, just leave the room. Because again, losing your temper with a crying baby can be disastrous both for the baby and for the parent.
Slide 36 But the child makes it through that Exploratory Behavior developmental stage, the next thing that happens is that around nine months typically they start creeping, cruising, crawling, pulling up, getting around, and getting into stuff. The creeper, cruiser, crawler baby is driven to investigate the environment. It's a normal healthy thing to explore, if they can reach something they're going to pull it down, if they can pull it down they're going to put it in their mouth, they're going to see if it breaks by dropping it, they're going to see if it tears by pulling on it, they're going to test everything in their environment.
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Slide 37 Bruises from Spanking Now some parents will respond to this Angry Over-Reactions to Normal Exploring in anger and frustration, this is a child who's been spanked forcefully on the bottom causing bruises there. It's not necessary to do this, what they will tell you is that the baby is learning to walk and sits down hard, but their little butts are only a few inches off the floor they don't fall far enough to bruise themselves. But getting into things is a common cause of excessive spanking…
Slide 38 Abusive Injuries …or they will use objects like belts, Angry Over-Reactions to Normal Exploring electrical cords,
Slide 39 Hot Water Immersion Burns they will sometimes, if the child's been Often the Result of Touching Things handling things, they will hold the child's hands in scalding hot water causing immersion burns like we see here, with that clearly defined upper limit of demarcation on that swollen hand with the blister on the back, common result of abusing children who have been touching things. This is a child who has both an immersion burn on the hand and you'll notice down here and slap mark on the cheek. So again, multiple injuries of various types.
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Slide 40 Abusive Fractures They will jerk and twist kids’ arms or From Normal Exploratory Behavior legs causing fractures like this.
Slide 41 Abdominal Injuries Toddlers are especially prone to Serious and Frequently Life-Threatening abdominal injuries too, as they walk around, they are at a convenient height to be kicked or punched in the abdomen which can cause injuries to the liver which is the most common injury that occurs in abusive abdominal trauma or other abdominal injuries like the intestines and spleen, or again, they can be shaken and slammed causing brain injury so that again curiosity getting into things can cause children to be killed in this age group.
Slide 42 Again, parents who know or who have good grandparents who can teach them, know that you begin to deal with this age of exploration by putting things up out of reach. Here's the grandmother who has cleaned off all the lower shelves and the experienced parent knows this, but a lot of our young parents don't and when the child pulls something down and breaks it, they're mad at the child for doing something that's completely normal.
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Slide 43 Discipline for Creepers, Cruisers and In my own practice when I talk to Crawlers: An Important Precedent young parents, and this is a talk I typically have at nine months, I talk Step 0 Childproof the house about this is the time that we introduce Step 1 “No” with a firm voice and a frown the concept of discipline to the child Step 2 Pick up, move to another location and distract with another activity which is the concept of teaching him Step 3 Confine to playpen how to behave. You begin at step 0, because it's a safety matter to childproof the house, then step 1 is well, there's always something you can't move. There's a T.V., a stereo, a fish tank, there's something that you can't move; you don't want to put it away or can't put it away. When the child goes to that thing step 1, in the discipline at this age is to say no, firmly with a frown, some kids will stop, our first child, if we told him no he would just sit back and start to cry, he was that sensitive. Other kids will just go straight ahead to it. Step 2, if they continue to move towards the no-no, is to pick the child up, no need to shake him, no need to spank him, set him down somewhere else in another location and give him something else to do. Give him pots and pans to play with, we call that distraction give him something else. Some kids will take that, other kids will get up and go straight back to the no-no. Step 3 then, is to pick him up and again you don't just sit on the couch and shout at him, you don't need to shake him, you don't need to spank him; you pick him up and put him in the playpen. The playpen is perfect for teaching children that there's a consequence to ignoring you.
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Slide 44 This is a good cartoon in which Marvin The Playpen Many Uses Other Than Play says "this is not a playpen it's a holding cell with a good public relations agent." Playpens are not about play, playpens are about keeping kids safe when you're cooking or whatever or cleaning house or doing something that we can't have eyes on immediately and it also teaches them that if they if they keep going to that no-no they're going to end up in the playpen and they soon learn that mother is serious when she says no and they want to avoid being put in the playpen and that's how we teach them to behave which is what discipline is.
Slide 45 Next challenge the negative two-year- The Negative Two-Year-Old old as children get a little bit older they start to develop minds of their own and they start to understand that they can to some extent influence what goes on in the world around them. We call it the "terrible twos" but in my experience it's really more the second year of life when the child becomes somewhat verbal and mobile and starts presenting more challenges.
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Slide 46 'No' becomes almost an automatic The Negative Two-Year -Old response here is the child, no she doesn't want to take a bath, no she doesn't want to get out of the bath, this is common. Parents who don't know that this is a common normal developmental stage will see this as a challenge to their parental authority. That's giving it really too much weight, this is just a child testing limits seeing who's in charge. And there are safe and effective ways of dealing with it, not including spanking.
Slide 47 Bruises Are Injuries Spanking results from—when spanking Blood in Tissues from Torn Vessels is done with excessive force, it can tear blood vessels allowing blood to leak into the skin causing again this kind of a patterned bruising, a hand-print on this child's rear end from being spanked with excessive force.
Slide 48 Bruises from Belts and Cords Sometimes people use belts, ropes, and Identify Children at High Risk for Future Injury chords…
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Slide 49 Bruises from Belts and Cords …that can cause significant injuries but Identify Children at High Risk for Future Injury sometimes result in scarring that, the white areas here are areas that were shallow cuts that will be scars on this child for the rest of his life.
Slide 50 Discipline for the Negative That's not necessary, there are safe and Two-Year Old effective ways to discipline and deal
. See independence as a healthy development with negative two-year-olds this is the . Pick your battles - and win the battles you pick kind of thing that again, can be taught in . Offer choices whenever possible parenting classes and in childhood . Don’t offer choices when they don’t exist . Notice and reward good behavior development classes. We won't go into . Use Time Out as primary negative reinforcer detail about this, but just say that you McIntosh BJ. The Spoiled Child Syndrome. Pediatrics 83:108, 1989. pick your battles but you plan to pick all the battles that you pick. It's critically important that children that you notice, that parents notice when children are being good. We call that 'catch them being good.' Children would rather be punished, then ignored. That's an important point, so that if parents are busy, preoccupied, not paying any attention to the child, the child will find some way to get their attention that is probably going to be a misbehavior, so parents need to learn how important it is to always notice when the child is being good and cooperative. Time out is the most effective way of dealing with that.
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Slide 51 Here's one way of dealing with the Being Smarter Than a Two-Year -Old negativism of two-year-olds, you don't offer two year olds choices when there's really no choice. You don't for instance, ask a child "do you want to go to bed now?" No, he doesn't want to go to bed, you tell him it's time to go to bed now and you give him choices, "which pajamas do you want, do you want the lights on or off, do you want a glass of water?" You give them choices, but them going to bed is not negotiable. And so here we see that the mother is giving the child, that needs to get dressed to go outdoors, she doesn't ask her "do you want to get dressed," give some choices, "what sweater do you want to wear, what cap do you want to wear, what scarf do you want to wear, so the child is able to exercise that autonomy within the limits that are acceptable to the parent.
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Slide 52 Using Time-Out Time-out, again we won't go into the Most Effective Technique for Pre-Schoolers details but this is the kind of thing that
. Select Time-Out area is safe, effective, it can be used as many . Explain procedure to child times a day as necessary, and can be . Implement with brief explanation . Hold in place if necessary taught in parenting classes. When . Use timer to keep track . Release with word of encouragement parents tell you that they've tried time- . Repeat as often as needed out and it hasn't worked, it's because . Stay calm and be realistic . Expect child to test the system they haven't really tried it consistently. Kids don't like time-out so they will what we call 'testing the system', they will say "mom has tried something like this before and when I continue to disobey she gave up on it so I want this to go away so I'll continue to disobey, I'll try to show her that it doesn't matter to me." Well if you're consistent, if they stick with it over time it will work. Kids don't learn misbehaviors overnight, they're not going to learn to behave overnight, it takes persistence and again it can be taught in parenting classes.
Slide 53 Toilet Training The next challenge that comes along is toilet training, this is a big developmental stage for children and a challenge often for parents who can't wait to get their children out of diapers, often comparing their progress with the neighbor's child who seems to have done it so much more quickly and so much more easily.
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Slide 54 Toilet Training There are many cases of children Can Be Lethal who've been seriously injured or killed in the process of being potty trained. These are two local Jacksonville cases here which made, actually I take it back that one was from Bartow, but these are cases some of which have actually resulted in legislative initiatives because they were so extreme. Now you notice that one of these children was 21 months old and the other was two years old; these children were killed for something, for having not accomplish something that many children haven't accomplished at that age.
Slide 55 Toilet Training This is an article that looked at Reasonable Expectations frequency of success with toilet training and what you can see is that it wasn't until say, four years of age that you had a vast majority of children being successful; now you do have your early achievers back here, but many kids don't really master toilet training until they're up around four years of age. Now this particular article showed kids getting bowel control earlier than bladder control. We raised three boys, they all achieved bladder control long before bowel control, but the point here is that it takes a long time and people who think that "my child is 12 months old now," it used to be that the potty chair was a typical birthday gift from the grandmother to the mother at 12 months indicating that it's time to get on it, but 2 years old is a better time for most people, but it really depends on the individual child and you have to be patient because it's a process, it's not a one weekend deal. One thing I want to draw your attention to because we'll be addressing it in a minute, is that complete bladder control at night, that is 32
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not wetting the bed, isn't something that-- it's not until 72 months or 6 years of age that 90% of children are successful so pediatricians in general, don't consider bed-wetting a problem until you get to be 6 years of age.
Slide 56 Toilet Training So toilet training should be seen as a A Developmental Accomplishment of the Child developmental accomplishment of the
. Wait for signs of readiness child, people think of it as something . Emphasize “grown up” aspects they do to the child, really it's a . Encourage to begin using toilet developmental accomplishment. They . Reward success are at the right time, when they're ready, . Ignore lapses . Expect regressions it'll be a fairly easy thing to do. When . No corporal punishment they're not ready, it's impossible, when they're ready, it's much easier and these are the steps that we do. I should comment, this is a picture of my granddaughter and the stickers that they put on the wall as she had successes, she has now started off to college and would probably be appalled see this picture but I don't have her face so you can't really tell that it is she. One important thing about child abuse though and toilet training is that toilet training should not involve corporal punishment. We don't spank children to teach them to walk and talk. We shouldn't teach them to learn to use the toilet because it is a developmental accomplishment.
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Slide 57 Bed-Wetting Alarms We mentioned bed-wetting; a problem Cheapest, Safest and Most Effective Treatment for families who are struggling with
. Work on the basis of conditioned response bed-wetting and you may get involved
. Cost: One-time purchase price of $45-60 with cases where children have been . Effectiveness: Over 70%, abused or shamed because of bed- with relapse rate of only 10% . Education of parent and wetting, the best treatment for this child in appropriate use of device is important to success which should be done with the advice of
. No corporal punishment or shaming for bed-wetting accidents a pediatrician or family doctor is a bed- wetting alarm of the small, clothing- worn type, this is the safest, most effective, and cheapest treatment in medicine. It is not often that you get safe, cheap, and effective in the same package but this is the best way to go when children who are over 6 are still wetting the bed. I want to emphasize that again there's no corporal punishment, no shaming for bed- wetting accidents because it's not a misbehavior. Parents misunderstand, they think this is something that a child does willfully. They're asleep, they're not doing it on purpose, they would like not to. In terms of just one other point about bed-wetting alarms, you want the small clothing-worn alarms not the mattress pad. To make one of these work, the child has to soak through his underwear or through his pajamas to the pad, too little too late. These don't work, they're more expensive too so do not go with the mattress pad type alarm.
Slide 58 School-Aged Children Once kids get into school, the problems Talking Back, Not Doing Chores, Bad Report Cards that caused them to be abused are talking back, not doing their chores, bringing home bad report cards or bad notes from teachers, and again parents tend to lash out with quote chords and belts causing injuries in these cases.
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Slide 59 Spanking: Problems with its Use Spanking, again, it's not against the law But 80 - 90% of Parents Approve as long as you don't cause an injury, but
. Risk of injury it's still just a bad idea, it should never . May increase oppositional be parents’ number one approach to behavior in some children or fearfulness in others discipline. It does cause the risk of . Short term effectiveness injury because if the child continues to discourages learning better alternatives misbehave; if the only discipline . Power eventually runs out technique a parent has is to spank, then when a child continues to misbehave the only alternative he/she has is to hit again and hit harder and eventually something's going to go wrong. Kids who are stubborn will get very resistant, I've had parents who spank a lot tell me that when they spank their child he just laughs at them and that will happen, the more you spank the less good it's going to do. One of the biggest problems with spanking however, is the fact that it works over the short time for some kids, will discourage parents from learning better, safer, more constructive techniques for teaching their children how to behave. If spanking works with the two-year-old, they might continue to try to do it with their six-year-old, well that's not going to work so well, because the power to spank eventually runs out and its effectiveness burns out. So we need to help parents to learn safer, better, more effective ways of disciplining their children.
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Slide 60 Discipline for Pre-School and This is the kind of thing again that can School-Aged Children be taught in child development classes . Many techniques more effective and in parenting classes. There are a lot than spanking
. Clearly and consistent limits of different techniques that we won't go . Family rules into now that can teach parents how to . Natural consequences
. Restriction of privileges help children behave more . “When…then…” choices appropriately but don't run the risk of . Notice and reward good behaviors injuring the child. One thing parents need to be cautious of is, it's indicated here, making some threat that you aren't really willing to carry out. For instance, if you take away a child's bike for a month, then you've lost that handle on the child for a month. And there's a good chance that before the month is out the parent's resolve will melt in the face of the child's nagging and they'll let the child have it back. It's better to take the child's bike away for two days, you'll feel that deprivation and then in two days you have that handle to use on the child again as a safe, effective, non- physical form of discipline.
Slide 61 Then, as children get into adolescence Discipline and Adolescents they find new and altogether different ways of challenging us. Again they try to work their way, more or less effectively, into it adulthood. There are a whole different range of misbehaviors that I don't need to go into that adolescents can use to challenge us.
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Slide 62 Beating with Belts and Cords Again, physical punishment; if you've Useless in Older Children and Teens built your child rearing and discipline on physical corporal punishment that power is now running out and that's just not going to work. Hitting older kids with belts and chords just does not work to change their behavior,
Slide 63 Beating with Belts and Cords …this is useless, it's damaging, it means Useless in Older Children and Teens that you really are not being successful as a parent's if you're still striking children in this age range.
Slide 64 Discipline and Adolescents It's never a good idea at this age, it's just It’s Payback Time! really, really useless. This is when, if
. Discipline built on the positive you've been building a positive relationship that has been built over time constructive relationship with your . Parents must be realistic and accept some limits to their child over time built on mutual respect control . Some flexibility and negotiating and appropriate treatment, this is when are appropriate . Restrictions of carefully you start reaping the benefits or the selected privileges most useful technique burdens of not having done that well. Parents have to be realistic and accepting that there are some limits to how much they can control their teenagers, you can't control the 16 year old in the same way that you control the six-year-old it's just a different world and this is where having done it right early pays off and a strong emphasis on corporal punishment early on doesn't pay off well at this point. Restrictions of privileges are the best, use of the car, going out, bedtime, TV, those are the things that work better with teenagers.
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Slide 65 Intervening in Child Abuse We're drawing to a close now and this is Address the Underlying Issues where we kind of bring all this back
. Education on normal childhood development together. We've talked about the history . Education on behavior modification techniques of child abuse, we've talked about how . Impulse control/anger management training . Mental health services we go about recognizing it, we've talked . Substance abuse treatment
. Domestic violence interventions about risk factors for it, and we've . Day care for child talked about the interaction the three . Other services as needed . Sheltering in an alternative safe, nurturing environment different factors; the caretaker, the child, and the crisis or event. But understanding how all those things interact can help us then formulate a plan for intervention to prevent (initial abuse) and prevent repeated abuse. If the problem is that the parent doesn't know what's normal for a child at a given age to do, education and normal childhood development can help. Education on effective behavior modification techniques; like use of time-out, restriction of privileges, those non-physical ways that are safe and effective can be taught. Some families need impulse control and anger management training, their big problem isn't anything else, it's that they just can't control it when they get mad, they don't have that, they don't know how to draw that line between being mad and striking out. We need to learn that those are two different issues. Some parents have mental health issues and you won't really make the situation for the child better until you get them treated for that or for their substance abuse treatment problem. Their substance abuse problem, those are so widespread in the families with which we deal, but if that's an issue it's got to be addressed or again you're going to fail at successfully protecting the child. If domestic violence is going on in the home, that needs to be addressed. Again as I mentioned earlier, with young children in particular, getting a child who has 38
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been abused into daycare so that the parents have a respite from him and that he is in the public eye; that can be a very valuable service. And then, whatever other services that if the case investigation that's conducted by the Child Protection Team and the Department of Children and Families, whatever other services turn out to be needed can be provided. And then when all else has failed, we've got to accept that there are some parents, some families that are so dysfunctional because of mental health issues, because of pervasive substance abuse problems, there are some families that just can't be rendered immediately safe for the child and some children do need to be placed in safe, alternative, nurturing environments. I hope that this presentation has been helpful to you in coming to understand more about what child abuse is, how it comes about, and some of the strategies that we can use for addressing it. I hope this will be useful to you in your career and I thank you for your involvement and your willingness to work in this challenging, but truly rewarding field. Thank you.
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Child Maltreatment Course Guide Child Protection Team Training
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