Child Protection

Elizabeth Park

Child Abuse
There are different forms of child abuse
Neglect Physical abuse Emotional abuse Sexual abuse

Neglect
Defined by Children First Guidelines An omission, where a child suffers significant harm or impairment of development, by being deprived of
Food Clothing Warmth Hygiene Intellectual Stimulation Supervision and safety Attachment to, and affection from, adult Medical care

Neglect
Generally becomes apparent over a period of time, rather than a specific time point Eg- child suffers series of minor injuries (supervision and safety) Child is failing to thrive- may be being deprived of adequate nutrition Child consistently misses school- deprived of intellectual stimulation

 Threshold of significant harm- childs needs are neglected to the extent that his or her well being and/or development are severely affected.

Signs
Abandonment and children left at home repeatedly without adequate supervision Malnourishment, lack of warmth, lack of adequate clothing Lack of protection and exposure to danger Failure to attend school

Emotional Abuse
Normally to be found in the relationship between a caregiver and a child (as opposed to specific event or pattern of events) Childs needs for affection, approval, consistency, security not met Rarely manifested in terms of physical symptoms

Emotional Abuse examples

Persistent criticism, sarcasm, hostility, blaming Conditional parenting- level of care shown to a child is made contingent on his or her behaviours or actions Emotional unavailability by parent/carer Unresponsiveness; inconsistent or inappropriate expectations of a child Premature imposition of responsibility on child

 Unrealistic or inappropriate expectations of a childs capacity to understand something or to behave and control himself in a certain way Over or under protection of the child Failure to show interest in or provide age appropriate opportunities for childs cognitive and emotional development Use of unreasonable or over harsh disciplinery measures Exposure to domestic violence

 Emotional abuse demonstrated by childs 1)behaviour- excessive clinginess or avoidance of parent/ carer 2)emotional state (low self esteem, unhappiness) 3)development (non organic failure to thrive) Threshold of significant harm reached when abusive interactions become typical of the relationship between the child and the parent

Physical Abuse
Any form of non accidental injury that causes significant harm to a child
Shaking Use of excessive force when handling Deliberate poisoning Suffocation Munchausens syndrome by proxy Allowing or creating a substantial risk of significant harm to the child

Possible indications of Physical Abuse

Inconsistent or unconvincing explanations for: Bruising or injuries, burns Refusal to discuss injuries Delay in time reporting injuries Repeated poisonings- alcohol/prescribed drugs Failure to thrive Limbs kept covered in hot weather, refusal to go swimming, P.E. Etc Aggression toward others Unconsciousness/ coma

Sexual Abuse
Sexual abuse is probably the most emotive and is currently topical due to the recent Ryan report outlining abuse in Church run settings A recent survey in the USA using a nationally representative group of parents and children found that 82 of 1000 children had been sexually victimised in the previous year Difficulty in reporting exact numbers, as very young children or children with learning disability may not be able to communicate

What constitutes CSA?

Definition by Children First, Irish guidelines, states Sexual abuse occurs when a child is used by another person for his or her gratification or sexual arousal They give examples of
Exposure of the sexual organs or any sexual act intentionally performed in the presence of the child Intentional touching or molesting of the body of a child whether by a person or object for the purpose of sexual arousal or gratification

Examples ctd
Masturbation in the presence of a child or involvement of the child in the act of masturbation Sexual intercourse with the child, whether oral, vaginal or anal Sexual exploitation of a child Consensual sexual activity between an adult and a child under 17 years

Recognising Child Sexual Abuse

Index of suspicion Not always readily apparent, as usually no overt injuries, as occur in physical abuse, when you see the signs that raise alarm bells eg fractured ribs, inconsistent histories etc. Distress without obvious reason Unusual behavioural problems eg sexualised behaviour May be fearful, but also bear in mind that the child may have a strong bond with the perpetrator, as it may be their main care giver

Signs of child abuse

Academic performance poor Anxiety Behavioural or psychological problems Depression Dissociation Distress Emotional problems HIV or other STI Homelessness or runaway Hopelessness Hostility Neuroendocrine dysfunction Obsessive compulsive behaviour Paranoid ideation Pregnancy in adolescence Psychotic behaviour PTSD Sexualised behaviour Somatic problems Substance abuse Suicide or suicide attempts

Signs of child abuse in adult survivors

Adjustment problems Anxiety Attachment disorder Binge eating Borderline personality disorder Children more likely to be sexually abused Coerced intercourse Conversion disorder Depression Dissociation Divorce Irritable bowel syndrome Marital conflict Maternal functional problems Medical symptoms Less likely to have cervical smear tests Paternity in teen pregnancy Paedophilia Pelvic pain Premenstrual distress Prenatal weight gain, inadequate or excessive Post traumatic stress disorder Rape reports Sexual abuse offence Sexual dysfunction Sexually transmitted disease incl HIV Substance abuse Suicide or suicide attempt

 Behavioural effects are influenced by the childs age, development, physical acts performed, threats and bribes, fear of retribution, fear of culpability, chronicity of acts, childs resiliance and relationship with the perpetrator, and effective treatment

Physical consequences
A careful or experienced perpetrator will be unlikely to perform acts that will result in his or her detection Immediate suspicion is more likely if the child has severe pain, bleeding, tissue injury, unless the perpetrator can prevent this from being noticed, eg by keeping child home from school Findings after penetration include hymen fossa, tears, or transection in girls; neisseria gonorrhoea, or deep lacerations to the anal

Duty of Care if Abuse is suspected

Primary care physician may often be first contact for disclosure of sexual abuse In Ireland, the Protections for Persons reporting child abuse act, 1998 provides immunity from civil liability to persons who report child abuse reasonably and in good faith to designated officers of health boards List of designated officers includes social workers, child care workers, NCHD, consultants, psychiatrists etc.. The list is long

When the child starts to tell

DO NOT Promise confidentiality Criticise or correct choice of words or language used Interrogate or suggest answers to the child, or ask leading questions Probe or press for details, especially those the child is unwilling to give

 DO NOT Display shock or disapproval of the childs alleged abuser, a parent, or the situation Make promises to the child about how the situation will work out Make promises you cannot keep

DO Listen Find an appropriate place Use the childs language Express belief that the child is telling the truth Stay in control of your emotions

 DO Reassure child it is not his or her fault, he or she did nothing to deserve this, he or she is not bad Assess child immediate need for safety Let child know you will do your best to protect/ support Record in chart

Your Duty of Care

Any person who suspects that a child is being abused, or is at risk of being abused has a responsibility to report their concerns to the health board. A duty social worker is always on call to talk to or write to If social worker is not available, a report can be made to An Garda Suiochana

 Investigating allegations of child abuse is NOT your duty.. It is your duty to report all cases where there is a suspicion of child abuse, or discuss with the duty social worker if you are unsure. It is also NOT your duty, nor is it advisable, to delve into details about the abuse, an experienced social worker will have more skill in this area

Information needed for report

Name, address of child, parents, any other children Name, address of person alleged to be causing harm Full account about the current concern about childs safety or welfare Source of any information being discussed with the health board Dates of incidents being reported Circumstances in which the incident or concern arose Any explantion offered to account for risk, injury or concern The childs own statement if relevant Any other information about the family and any difficulties Any supportive factors relating to the family Name of childs school and GP Repporters own involvement with child and parents Details of any action already taken Name and address of any agencies or key person involved with family

Legislation in Ireland
Child Care Act 1991
Dealing with children in need of care and protection

UN Convention on the Rights of the Child

Ratified 192 Right to protection

Children First Guidelines

1999 Parents/carers duty to protect children Society a duty of care to report Report to Health Board to designated officer or garda in emergency Protections for Persons Reporting Child Abuse Act, 1998

Risk Factors for perpetrators of abuse

Risk factors for perpetration of child abuse were reviewed in a recent meta analysis by Whitaker et al 89 studies were reviewed Risk factors were classified into 6 broad categories
Family factors (hx of abuse/parent child relationship/attachment difficulties/ discipline) Externalising behaviours (violence/ delinquency) Internalising behaviours (depression/ low self esteem/ poor coping mechanisms) Social deficits (social skills/ empathy/ lonliness) Sexual problems (sexual interest in children/ deviant sexual fantasies) Attitudes/ Beliefs (attitude toward rape/ rationalizations) They found that family factors were strongly linked to childhood sexual abuse, in offenders compared to non offenders

Statistics in USA
Father only or other relative: 21.5%, 19.4% Parents: 45.3% of child abuse cases Day care in 2.7% of cases

Prevention
Education in childhood, continuing through school Efforts must not focus on child, as child may have difficulties with size difference, trust, training to obey adults, naievety about sex Child victims and perpetrators should receive treatment and risk assessment Screening for family history of child abuse Physicians should be particularly aware of children with learning difficulties, behavioural problems, medical problems, who may be at increased risk of abuse

Case Studies
Please break into groups of 4 Discuss your management of the following cases:

 1) A 12 year old boy has presented to you (the GP) with his mother. He has not been eating well. He has become withdrawn. He is refusing to go to school for the last two weeks. He has also been going missing from home for long periods. His mother thinks he is being bullied at school, and leaves him on his own with you as she feels he will talk easier. Sean shows you some marks on his back, and says that he has something that is not easy to tell you. He

 1) How would you make it easier for Sean to talk? 2) Sean reveals that his father has been hitting him with a belt. This has been going on for some time, but has been much worse recently, as his father lost his job, and seems to be in a bad mood all the time. 3) What is your next step?