Thursday, May 29, 2014

Child Abuse, Neglect, and Stress In the First and Third World. Its Long and Short Term Effects.

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Recently, I attended an eye opening series of lectures, held by the Medical Students Aid Project at the University of New South Wales on the issue of Child Abuse in Australia, given by preeminent pediatrician Dr Elisabeth Murphy and inspirational, war-site venturing trauma expert, Dr Jennifer Dawson .
It gave me an insight into the emotional and physical effects of child abuse - something that I never had before, something I probably won't be exposed to in much detail in medical school - and it's made me realise how wrong those who say "they should just get over it" really are.
It's made me understand that a child's development isn't just restricted by things like physical and sexual abuse and starvation (though these factors contribute to a huge amount of developmental issues), but also by things such as a stressful environment to grow in and a lack of a loving caregiver.
It's made me see how it affects people beyond just their childhood and how hard it must be for people to come out of it.
And it's made me wonder, if these issues are so much more prevalent than I thought in Australia, a relatively well off country, imagine how it must be to grow up as a refugee, in a warzone, or while being malnourished...

I'll begin by introducing the concepts and trends of child abuse and neglect, in both developed and developing countries, then continue on to the long term neurological, physical and psychological effects of this issue and finish with how it's currently being dealt with, and how that can improve. Click on the headings below if you wanna skip to a particular section.


Contents:

1) The Patterns of Child Abuse and Neglect
ia) What constitutes child abuse or neglect?
ib) What are the patterns of abuse in the developed world?

ic) What are the main causes of child abuse in the developing world?
2) The mechanisms behind the physical, psychological effects of abuse and neglect, and its long lasting effects.
iia) The importance of childhood (and teen) development, and the important role adults play in normal developement.
iib) The mechanisms behind stress hormone induced changes to the body.
iic) The effects of stresses on the brain; The effects of severe abuse and neglect on Roman Orphansit
iid) The mechanisms behind lowered brain volume, trauma and malnutrition, and psychological changes with abuse/neglect.
iie) How it affects physical and mental health in adult survivors.
3) Dealing With Child Abuse
iiia) Identifying child abuse victims
iiiax) Physical signs of abuse and neglect; when you need to suspect and report child abuse.
iiib) Coping mechanisms in children and adults
iiic) The system for how we deal with child abuse in the developed world (an ideal setting)
iiid) What are the problems in this system? How do we resolve them and improve the system?
iiie) What are the goals of psychological therapy, for children
iiiex) For adults
iiif) How to reduce the occurrence and impacts of abuse/neglect in the third world; (improving economic structure, restoring culture, dealing with trauma)
iiig) What YOU can do about it.
Summary - YOU CAN MAKE A DIFFERENCE.
Comment anything you want to add.

Different countries have differing patterns of child abuse, not only because of the differences in econimics and geopolitical stability, but also because of different paradigms and definitions of what child abuse entails. Environmental and economic factors play a huge role in child development; the decisions a struggling, sustenance farmer in hugely conflicted Somalia would be forced to make to survive would be tantamount to neglect in Australia, for instance. 
In the third world in particular (though it's relevant all over the world) "rates of abuse and neglect can be thought of as indicators of the quality of life for families, and maltreatment can be viewed as a symptom, rather than a cause, of difficulties in family and individual functioning." [15] 
By analysing the physical and psychological impacts of child abuse in more privileged countries, we can begin to grasp the impacts of global disasters, conflict and poverty on children all around the world. 

What does Child Abuse Entail?

Child abuse patterns in Australia. Remember - this is a developed country, and statistics vary from country to country,  with issue to issue and from what different countries categorise neglect under. Hence Australia, a developed country was used for this model.


As seen above, child abuse can cover a range of features. In the US, due to definitional differences and possibly because of greater inequality, neglect makes up almost 80% of child abuse. And exposure to stressful events and a lack of a loving environment can be enough to harm regular development, and cause issues for life. How each of these aspects affect brain development and how it affects people their whole lives, I'll talk about later, but suffice to say, childhood abuse, neglect and stress definitely has longstanding physical and psychological impacts. 


Things that can cause long lasting effects that impair development of children:

  • Sexual Abuse
  • Physical abuse/torture
  • Mental/emotional abuse
  • Exposure to domestic violence
  • Substance abuse (or exposure to this)
  • Physical Illness
  • Difficulty with school work/maintainence of expectations
  • Lack of attention from parents
  • Post Partum depression (occurs in 5 - 25% of women and causes a less loving enviornment)
  • Too much work or expectation.

Patterns of Child Abuse in Australia:
A Representation of Child Abuse in Developed Nations:

In Australia, children aged less than 1 year were the most likely to be the subject of abuse or neglect (with 13.2 incidents per 1,000 children), followed by children aged 1–4 years (8.4 per 1,000 children). This seems staggering as it is - apparently 1 in every 100 children weren't taken care of properly after birth - but it's important to note that neglect is included in this figure. Just as important though is that the effects of neglect are often just as bad as physical and sexual abuse. 
Unfortunately, Aboriginal Australians were almost 8 times more likely to be a subject of this abuse.
40,000 kids were in out of home care last year. That's 1/40 of all kids in Australia. 95% were in foster care or living with relatives, but 5% were in institutions of some kind. And the total number of notifications of possible abuse was very high as well, as seen below. [1] sources from many studies, and government statistics were compiled in this factsheet.


The total number of notifications have been increasing over time, possibly because people  have became more aware of the issue of child abuse. The decrease from 2008-09 can be attributed to the system no longer counting multiple notifications per child as separate notifications. As seen above though, the total number of children in out of home care (final column) has steadily increased, showing intervention is happening more and more. [2]

Possibly because of media attention, perpetuated by large scale investigations like the Royal Commission into Institutional Reponses to Child Abuse, people have the impression that child abuse occurs through institutions or from deranged psychopaths. But in reality, most incidences of child abuse in Australia, in fact 80% of them, were perpretated by family members (63% of those were by immediate family members). [3] And most cases weren't single incidences, rather, prolongued, repeated, more complex traumas. Here are some sources for the rates of child abuse in other countries, such as the US, the UK and Europe (pages 8 - 25). 


What About Child Abuse/Deprivation in the Developing World?

The prevalence and rates of child abuse Australia is shocking. But we're one of the privileged ones. In the developing world, factors such as poverty and war makes child abuse much more prevalent, concerning and harder to deal with than it is here.  

Malnutrition:

Though not under the umbrella of abuse in most circumstances (it may just fall under the banner of neglect though), the impact of lack of nutrition in childhood results in stunted physical and psychological development later in life, and impairs the ability of adults to function at their full capacity long into the future. 
The World Health Organisation found that in 2010, 171million children between 0 and 5 years of age alone were stunted in development. This age group is the most important for proper development, and any stunting at this stage will lead to lifelong defects in physical and mental health. Africa reported the highest rates of this stunting, and will continue to do so in the future, with a stagnating rate of 40% of children stunted in development. Asia reported the greatest decline, from 49% in 1990 to 28% in 2010, and Latin America showed rates of 7 - 12%. The trend is declining, projected to "only" be 142 million by 2020, which, though still high, is encouraging. [14]
The immediate and longstanding physical and developmental manifestations of this issue I'll delve into in the next section, but the eery sounds of the street, indicating a world passing by, uncaring; coupled with the bleak, blank  intonation of the child in this video highlights the desolate, impairing nature of both malnutrition and child labour. 


Depressing. This child sees no point in life. I can't see much hope for him either. If you don't appreciate it already, you'll understand the severe, utter lack of power that a person, yet alone a child, constantly in survival mode has to endure. It's impossible to think beyond the next meal. This child is one of many. I've seen hundreds of such kids with my own eyes on visits to India. And this issue occurs all over the world.

Child Labour:

211million children worldwide - that's 18% of all 5 - 14 year olds - are economically active. 60% of these children are in Asia, and 23% in Sub-Saharan Africa, and most children who do work do so in the agriculture industry, though with even further urbanisation, and the continuing exponential growth of Megacities and other urban developments, that number may be fast rising.[4] Child labour, especially in manufacturing and agricultural industries, is bad not only for the harsh working environments, which contributes to 2.5million children a year suffering a disability, 32,000 dying and many more being exposed to toxins and infections, but also because children who work have lesser access to education. This can be quantified, with children not forced to work in Latin America performing 28% better in mathematics and 19% better in language tests [5] The issue of child labour is obviously caused by bad educational and labour systems, and unfortunately often occurs in cycles; with fathers who had been forced to work, til disability from an early age unable to provide later on, leading to their own children being forced to work. 


Sexual Abuse/Prostitution and Slavery

This issue is of concern in some western countries too, but in third world countries, this problem is endemic. In a study of 21 countries (most of them developing nations), it was found that 7 - 36% of women and 3 - 29% of men reported sexual victimisation during childhood years [6]. This number rises substantially in conflict regions, and in refugee camps too [7].

In terms of prostitution, 1million children are forced into prostitution every year, with 10million estimated child prostitutes in the world at present. Most of these young girls and boys are conscripted to do so by adults above them, but in areas high in orphans, some girls in particular are forced to make that choice. Child prostitutes have significantly higher risks of being infected with STDs, with infection with HIV occurring in 17% of Thai child prostitutes, and STD rates of 36% within child sex workers in Cambodia [9]. Physical assault and rape is also rampant in the childhood prostitute industry, with 73% of children reporting being physically assaulted, and 62% reporting being raped. [9] When asking who fuels this trade though, we need look no further than ourselves as developed nations. Thailand, Malaiysia and the Phillipines, where sexual tourism is suspected of being responsible for between 2 - 14% of their economy [10] are frequent destinations for rich, male clients seeking deranged pleasures. 
I'll delve into the mechanisms of psychological impacts of sexual abuse in the next section, but said impact is severe, with 41% of pregnant assaulted women in the US, a well off nation, considering suicide in the year after impregnation [9]. Short term impacts of severe anxiety and depression peak at around 3 weeks after abuse, but can continue for a year afterwards, and long term effects such as post traumatic stress disorder and low self esteem occur in a large portion of women affected [11].
Child slavery is also a problem, with a lot of it being linked to sexual slavery. It is much more under the covers, and little data exists to support it, but don't be fooled, it still exists in the third world to this day. It's estimated 200,000 children are implicated in the carpet industry worldwide, majority of those in India [12]. Haiti is another child slavery hub, with 150 - 500,000 implicated in domestic slavery within the country alone. [13] As it's an international slavery hub and destination, this number is probably only a minor representation of a larger problem. Abuse, neglect, lack of education and impaired development are some of the many impacts of slavery.


War and Conflict:

All these issues talked about above culminate and fester in the melting pot of war and conflict. And one of the biggest side effects of war, talked about in detail again in the next section, is trauma after the incidents stop occurring.
It's hard to quantify the various abuses that occur, whether it be to children or adults in times of war, but the fact that they exist, and do so at much higher rates than even normally present is indisputable. It's some of the worst affected areas that one of the lecturers who inspired this response, (Dr Jennifer Dawson) travels regularly - places like Congo, Uganda, Sudan and more recently Palestine. Long lasting struggle is present in each of these countries, but the atrocities and effects of war, especially on children, are very similar, especially in the former 3 countries.
Malnutrition, parasites and infections, both sexually transferred (rape rates are incredibly high) and those endemic to regions with little access to vaccinations and basic sanitation, are only the tip of the iceberg when talking about the suffering of kids in war-torn areas.
Trauma - especially that at a very young age - has even bigger impacts on children, who are still developing emotionally, than it does adults. The things she described that many kids, not just the occasional few, go through at some point in their lives were truly horrific. Horrified cannot even capture a tenth of what I felt when I heard of them. Some children are forced to watch their parents be burned, and then ground up in bowls designed to grind wheat, others are forced to kill or even rape their own parents, and walkways to schools are sometimes purposefully littered with strewn body parts, or skulls on stakes to incite fear in children. Child soldiers are abducted away at younger, more impressionable ages of between 7 and 10 purposefully, to ensure that they will go on to become more efficient killers. And they know nothing else beyond that. Women, and men, by the roomful, take Dr Dawson's rape counselling sessions.
The effects of war aren't just on seen on the individual level. In nations where war has lasted generations, culture is lost, leading to a lack of knowledge of anything but war. Non governmental organisations, which are responsible for a lot of humanitarian aid in these regions, do good work in initial management of crisis situations, but fail to help communities recover in the long run. The targets of these NGO aid projects are usually vulnerable children, and the whole societal balance is ruined, as men are no longer providers. This leads to growing rates of alcoholism which further fuels violence and abuse in the region. The huge numbers of orphans after war, who often have no-one to guide them emotionally and provide for them physically, suffer even more. These effects, and how Dr Dawson helps by intervening at a community level I'll talk about further down as well. 

Emotional Abuse/Stress: 

Something I haven't talked about thus far, but definitely has just as impact as any other form of child abuse, is the issue of stress and emotional abuse. The Child Welfare Information Gateway suggests that more children suffer from neglect and emotional abuse than physical and sexual abuse combined [16]
In itself, stress of the primary caregiver, which can be felt and experienced by children even as babies and toddlers, is also something that can't be helped. It's when it occurs for a sustained period of time that it becomes an issue. In a warzone, during tough economic times, periods of domestic violence and in women with post partum depression, that stress can't be helped. Efforts to manage it, or hide it from the baby should be taken, but awareness of this issue and knowledge of how to manage stress isn't easily available. 

Emotional abuse, however, is something that isn't as easily quantifiable in many regions, but definitely existant. Psychological maltreatment can be further broken down into 5 components; rejection - the abandonment or refusal of showing affection toward a child, isolation - preventing children from engaging in normal social activities; terrorising - with intense punishments; ignoring and corrupting - the purposeful development of false, dubious social values  [17]. Emotional abuse is prevalent all over the world, and rates of trauma due to it are similar, despite huge disparities in causes between developed and developing world children. Personal neurophysical problems and emotional abuse suffered by the parent makes them more likely to be emotionally abusive to their kids, but  there is an aspect of societal pressure, applied by both the parents and by children toward themselves which constitute and lead to emotional abuse too. And the effects of this are palpable, with emotional abuse being a major contributing factor to maladaptive, unsocial being later in life [44]. This video below shows the power of words in truest form, and describes a growing problem in many nations of high expectations on kids, especially in Asian nations; India for instance, has the second highest rate of suicides in the world, and the major contributors are those ages 15 - 24 [18].


An inspiring project designed to raise awareness of the impact of emotional abuse in children, in part caused by the pressure to perform.
https://www.youtube.com/watch?v=n5b7Tb7bci0

2) HOW Does Abuse, Neglect and Stress Affect Physical and Emotional Development?

The effects of child abuse aren't something that can be easily altered. We've all heard the phrase "what doesn't kill you makes you stronger"; that's true for some cases - I know I'm "stronger" for how I dealt with cancer. But in the instance of abuse at a young age, where people are still developing physically and emotionally, the impacts of abuse are long lasting and sustained. And they aren't restricted to psychological trauma either - there are direct linkages between childhood stress/abuse and poorer lifestyle choices leading to poorer physical health too. In this section I'll establish the importance of early development, the mechanisms by which child abuse disrupts that growth and a few eye-opening papers which give solid backing to the long term effects of childhood abuse. In the next one, I'll discuss ways of fixing them. 

Why is Early Development Important?

At birth, your brain is 25% the size of your adult brain. By 3, it's at 80%. But just as, if not more important than the mass of brain tissue present is the connections, or synapses, that form in the brain during this time frame. This synaptic development continues on til adolescence, but as seen below, the first 3 years is where major physical brain development occurs. If it occurs properly at this time, full development occurs, but any factors stopping or delaying the development can cause long lasting effects. These synapses not only affect the functioning of the senses and muscles, but also higher order thinking, and so both physical and psychological impairments (which can lead to physical impairments by the way) can cause lasting damage that can't be easily reversed. 



  












As seen above, the first 3 years of life features huge amounts of brain development, with both neurons (brain cells) being formed and synapses (linkages between neurons) being establlished. The senses are developed and refined in the first few years of life, with sight developing to almost adult levels in the first 3 - 6 months of life and touch and hearing developing further from what it was in the womb by 3 years of age. The senses, as well as finer motor and muscular control, speech centers and various other functions continue to be refined over the entirety of childhood. And just as important as the physical components of brain development is the development of emotions and responses to the world. Child abuse and neglect can impair, inhibit or slant the development of these as well to shape how somebody turns out.


The Importance of Teenage development: 

The second image isn't showing that 14 year olds are dumber than 3 and 6 year olds, but rather shows the process of optimisation of brain signalling pathways and pruning of unnecessary synaptic connections to make the brain more efficient - something that occurs during adolescence. In particular, the frontal lobe, responsible for a lot of higher order thinking and risk taking behaviour develops in adolescence, making those abused or neglected at those ages less likely to be well adjusted in later life. The teens are are also a time of learning, and figuring out one's place in the world, and social interactions (which can be interfered with by abuse), are just as impactful as physicat and emotional abuse at this stage of development. 


What Causes Disruptions In This Development?

The brain pathways shown above require proper environmental stimulation to develop. In the first few years of life in particular, (though this theme of relying on adult mentors continues throughout development) this development is modulated by a primary caregiver as a child learns through them and their reactions how to respond to the world. 

Thus, the lack of a reliable, healthy caregiver, or adult role model/mentor can be just as abrasive to a child's development as a stressful environment. 

Examples of Situations which cause impaired development include [19]:
  • Sexual Abuse
  • Physical abuse/torture
  • Mental/emotional abuse
  • Exposure to domestic violence
  • Substance abuse
  • Substance/drug abuse
  • Physical Illness
  • Difficulty with school work/maintainence of expectations
  • Lack of attention from parents
  • Post Partum depression (occurs in 5 - 25% of women and causes a less loving enviornment)
  • Too much work or expectation.
As you can see above, a lot of the causes of stress above will apply to families just going through strife; hence family crises play just an important role in childhood maltreatment. 

Child abuse occurs in younger people more often than older ones too and have more severe implications for younger people; of the 1760 fatalities in the US due to child abuse, 3/4 of the children were under the age of 4 [69]. Remember, these issues are even more prevalent in the developing world.

In the words of Doctor Dawson, who works with trauma victims in both Australia and various parts of war torn Africa and the Middle East, the trauma victims in Australia suffer similar levels of trauma, despite having been subject to seemingly lesser abuse, maybe because unlike in Africa, they're isolated and alone.

Mechanisms of Abuse Impacting Development:
How Stress Impairs Development

Stress is a natural occurrence, and certainly can't be avoided completely. Mild, low levels of stress in childhood is good, and allows children to develop and react to the world; what we call positive stress. Some unavoidable stresses, or periods of stress can be lumped into what we call tolerable stress. However, when stress continues for a long time, or when stress occurs in high doses or continues to remain high after an event, the levels of stress, and the major pituitary-adrenal hormone released during it, cortisone, become toxic to the body. The brain is more vulnerable to the effects of cortisol as unlike adrenaline (epinephrine for US readers) it can pass the blood brain barrier and cause changes to the central nervous system.

During early development, particularly in the first year of life, a child's natural stress circadian rhythms (daily rhythms, if you will) are beginning to develop. Natural production of these corticosteroid binding globulins (CSGs), proteins which bind to free cortisone in the blood and reduce the impacts of it, are not fully established, meaning that increases in stress last longer and have much more severe effects on the brain [19]

The Direct Effects on the Brain:


Development of the natural responses to stresses also develops substantially in the first few years of life. Children exposed to excessive stress during this time can develop a hyperactive fight or flight response, and a hyperactive HPA (hypothalmic pituitary-adrenal axis), induces further neuro-endocrine hormone releases that enhance the effects of cortisol on both the body and mind. Prolonged stress, particularly at young ages, leads to a mind and body exposed to chronically high levels of stress, furthering the issues that arise from it.

Cortical regions (the outer parts of the brain), those used in higher order thinking, are stimulated less in periods of stress due to a combination of it being a slower overall process (time can't be afforded in pressure, or pressure-like situations) and a lower amount of MR receptors (a type of cortisol/corticosteroid receptor), and hence lower total cortisol receptors in that region of the brain [22]. The hippocampal volume also decreases due to overproduction of stress hormones. The hippocampus is responsible for relaying information from the body and brainstem to higher order centers in the outer brain for a more thought out, less reflexive response to a stimulus. Areas overstimulated in periods of high stress regions include the the brainstem, responsible for reactive and survival instincts and the relay of responses, and the limbic brain system, which, when over-stimulated by high levels of cortisone causes disorders in memory and emotion (in more severe cases causing severe PTSD and reliving experiences)[20]

In children experiencing positive, or tolerable levels of stress, their levels of cortisol return to normal, but in those suffering persistent, toxic stress, cortisol levels remain higher than usual after the stressful event or stimuli is taken away [21], showing that those children who have been abused or neglected are more likely to go into a more toxic, hyper-aroused mode. The lack of a strong, supporting nurturing environment, and caregiver, only makes this worse.

Furthermore, many studies have implicated chronic, higher production of cortisol and other early stress hormones in children who've been subjected to abuse or neglect [26 - 28]Chronic overproduction of cortisol production leads to severe physical manifestations, such as severely compromised immune systems (which leads to further illness; this is worse in developing countries where communicable diseases are prevalent and access to treatment is not), lowered bone density, insulin resistance (which can lead to diabetes and obesity), impaired kidney function and electrolyte (salt) homeostasis, amongst other effects. It also leads to increased use of the limbic brain system, which as discussed above, leads to a more survival focused, stressed mindset.    


Unfortunately, there is a lot of information and data to show the effects of abuse and neglect during child development. The horrible physical and sexual abuse, undernourishment and neglect suffered by Romanian Orphans, following the fall of their communistic government in 1989, provides much of the physical evidence of deprivation and abuse at early ages in humans. Of import is the aspect of neglect, and lack of a mother/father figure in these circumstances. Something that all of these children faced.
It's unethical, evil, to test the effects of separation from parents directly on children, though it has been observed (more on that in the Romanian Orphans section below) in Rhesus monkeys. It was found that separation from a parental figure induced higher levels of cortisol in 2 year old and 5 year old monkeys [73]. The effects of separation from parental figures is long lasting. A study on humans who had been separated from their parents for more than a year in WW2 found that their daily wakening levels of cortisol were greater, and also less likely to change during the day [74] and these effects were observed up to 60 years post separation. 

This is crucial in terms of treatment, as it shows that reintroduction of a parental figure or adult role model soon after loss of that connection is vital to a child's short AND long term health. 


Some manifestations of excessive stress shown above. Lower brain volume on the outside, cortical regions is obvious, and is due to lower recruitment and hence development of neurons at a critical growing point. A smaller corpus collosum, the region connecting the 2 hemispheres of the brain, shows less interaction and connection between the 2 sides of the brain. A smaller hippocampic volume, identifiable by very large ventricles, or gaps, indicates lower communication occurring between the brainstem and higher order thinking centres.

Temporal lobe activity in a healthy (left) and abused (right) brain. The temporal lobes of the right aren't accessed, or able to be accessed as easily when stimuli are shown to children, showing decreased use of higher order thinking when reacting. Also notice the increased use of the brainstem region (in the middle, on the lower, as opposed to upper side of the temporal lobes) in the abused brain.

The Specific Mechanisms of How Child Abuse Causes Impaired Development:

The Increased likelihood of Poor Learning and Future Lifestyle Choices
Caused by Decreased Cortical Stimulation at Young Ages:

Lowered development of cortical regions of the brain (which can be seen even better in the image below) and an increased reliance on the limbic system can lead to the capacity to learn and problem solve being decreased later on in life. 
Hyperarousal, caused by increased stresses and increased sensitivity to stress, will lead to more short term memory and thought processes being accessed rather than problem solving areas. Children exposed to higher levels of stress are less likely to engage in higher order thinking, meaning they will be less likely to develop those synaptic pathways, and the resultant adults are more likely to be impulsive, more likely to be suffering from cognitive impairments than [23] and more likely to make poor lifestyle choices later on in life [29]

Trauma; How It Develops From Abuse:


The amygdala, responsible for processing emotions, is less immune to the effects of cortisol and other stress hormones, but is still activated before higher order brain functions get the cue, and is hence implicated in many emotional responses to stimuli. When emotionally charged cues, especially those associated with danger (loud explosions or vivid images associated with traumatic experiences for example) are first encountered, the amygdala primes them to be more likely to be made long term memories [25].  Re-experiencing these cues, or triggers, causes the amygdala to release hormones to induce a fight, flight or freeze response, which is how vivid reliving experiences from certain traumatic triggers come about in post traumatic stress disorder [24]. A decreased hippocampal volume, also caused by increased levels of sterss and lower recruitment of outer, higher order centres of the brain early in life leads to lessened declarative, or deliberate, long term recall memory. The lower the hippocampic volume, the higher the chance of being susceptible to post traumatic stress disorder.

Personality Disorders and Emotional Damage

Underdevelopment of the corpus callosum (CC), the neuronal pathway between the two hemispheres of the brain is more likely caused by neglect or other emotional damage than physical abuse or malnutrition (as it isn't starvation or excessive hormones, so much as impaired pathways as a result of previous disturbances that cause this) [31], as evidenced by a 24 - 42% reduction in CC mass in neglected males, but significantly lower rates for those undergoing sexual abuse. The Mclean's hopsital 2000 study [28] theorised that the greater shifting of the 2 hemispheres observed in patients with smaller corpus callosi was what caused the higher rates of personality disorders and dramatic mood shifts, though a direct pathway couldn't be established. The same study also found a lowering in mass and development of the left brain, and theorised that this contributed to higher rates of depression and language difficulties in children abused, but again no link could be drawn. 
Neuroendocrine imbalances in child abuse, caused by the overactivation of the limbic brain system and the subsequent overactivation of the HPA axis (discussed above) are also responsible for long term emotional imbalances. The alteration of the levels of various neurotransmitters such as seratonin, dopamine and noradrenaline can cause a variety of neurological problems, such as major depressive disorder, chronic fatigue syndrome, bipolar disorder, post traumatic stress disorder and alcoholism to mention only a few [32]. These are only the tip of the iceberg, as chronic imbalance of these neurotransmitters can manifest in non-disease states, and simply result in bad, overly aggressive decision making which leads to poor lifestyle and health outcomes.

Biological deficiencies cannot describe all aspects of the effects of child abuse, especially the emotional effects. The attachment theory can be used to describe an array of social problems that many children and adults impacted by child abuse seem to have. Children who were well nurtured and cared for develop secure attachments, and feel relationships with themselves and others that are loving and effective. Ambivalent attachment describes those who were subjected to neglectful, or unreliable parenting, resulting in jealous, clinging, obsessive, self-sacrificing individuals who feel relationships and love to be a series of highs and lows. Avoidant attachment describes parenting that is hostile, cold or controlling in nature, and results in detached, sometimes overly self reliant, closed off people unwilling to trust in others. Disorganised attachments indicate parents who tend to be frightened or anxious in their interactions with their child, and disorganised children see themselves as a problem, as weak and suffer from depression and self-esteem issues. [33]
Children of child abuse can fall into any of the last 3 theories of attachment, and it can be a combination of all of these. But suffice to say, all of these, combined with the huge negative stigma and shame associated with it in developed countries, where occurrences are rarer and society is arguably less open, can create immense social difficulty. With social connection a major way of getting past child abuse [34] something I'll discuss more in the next section, this can lead to a vicious cycle of further problems. 

Malnutrition   

The mechanism of of malnutrition on growth seems almost self explanatory, but the effects of this should still be mentioned, as it is by far one of the most prevalent of all of these issues (as stated above, some 170 million children worldwide are stunted due to lack of funding. The major effect of it, the major way in which is kills people isn't starvation however, it's the severe depletion of the immune system which puts children at risk of thousands of diseases. 62 million people died due to infections attributable to nothing else but lack of nourishment alone last year - most of them children [35]. The effects on malnutrition early in life are again, hard to recover from mentally. From a biological standpoint alone, severe loss of neurons, glial cells (the immune cells of the brain) and increased ventricular, or empty spaces [36] (due to lowered cortical/hippocampal brain matter) makes it very hard to recover from. But it's not all disheartening, with IQ restorations from 36 - 120 being documented [36]. This shows the need for early intervention, and providing a nurturing environment, especially in this cause of impaired childhood development. Though malnutrition is (barring exceptions for extreme cases of outright neglect) not technically a product of child abuse and neglect, but often something that can't be helped, it goes hand in hand with a lot of other kinds of abuse, and with everything that is discussed in this post. 

Poor Lifestyle Choices and Adult Health as a Result of Child Abuse:

Many studies have drawn links between various types of child abuse and poorer health outcomes in later life, but none more comprehensive and all encompassing than this wide ranging questionnaire on the physical and mental health of older people who were abused as children. Those who were abused, either physically or sexually as children were 35% more likely to have physical health problems and 89% more likely to have mental health problems, with those experiencing both jumping to 60% and 140% more likely respectively[29]. This in itself indicates a severe problem.

This survey, ascertaining the prevalence of various forms of child abuse/neglect factors made links between broader classifications of abuse and worse health outcomes highlights the impact of child abuse later in life.  
It found that 25% of people lived with a problem drinker or drug abuser, 22% were sexually abused in some way, 18% lived with a mentally ill person, 12.5% had experienced domestic violence growing up, 11% were emotionally abused, 10% physically so and 3.5% of respondents had a parent incarcerated at some point of their childhood.
The results shown below show the relative risk of those exposed to 4 or more of any of those 7 factors above of developing a variety of physical health problems.

A linkage between the two indicates a serious problem. In countries where child abuse is a rare occurrence, this is concerning. In areas where they are prevalent, exponentially more so. Source [30]


These are a few of many studies linking child abuse and neglect with poorer physical health outcomes for adult survivors. It is a culmination of the variety of mechanisms discussed above that these problems exist.


Furthermore, abuse has been linked in many studies to lower attainment of education in many studies [37 - 41] which partly explains why many child abuse survivors don't reach high socio-economic status. Crime rates, and drug abuse are also increased in instances of child abuse, or exposure to violence as children as well [42 - 43]. And it's unfair to put full blame on children, and adults who've come out of traumatic experiences, for being brought up in such a way. There are many studies showing the linkage between childhood traumas and poor social adaptability too. And the fact is that this all results in a vicious cycle, with links between lower economic statuses and child abuse and neglect [45] and future generations are affected too. 

Child abuse and maltreatment has a variety of effects, that works through many mechanisms to cause effects long-lasting effects on the survivors of these events. 

The question now is; How do we fix it?


3) How To Stop Child Abuse

I'll discuss this part in 2 sections. "Identifying Child Abuse"; and then "Dealing with it". I'll talk about how we deal with the issue in developed countries first, and then ways we are trying to tackle the much more prevalent, global issue later, but will incorporate ways YOU can make a difference throughout the piece. 


Identifying Child Abuse Victims


Catching signs of child abuse early is of vital import. As I talked about in the previous section, early childhood development is of crucial to proper development, and so identifying and intervening at an early age is hugely beneficial to children. But just as important (and harder to do) is the issue of catching and treating adult sufferers of childhood maltreatment. The picking up of "coping mechanisms", which is the more appropriate term for "symptoms" of child abuse (as symptoms implies short term or physical effects) is key in dealing with both children and adult sufferers of child abuse.

Identifying Child Abuse in Children

Doctors and healthcare staff, in fact all professionals, whether it be GPs/primary care physicians, psychologists, nurses; any kind of healthcare worker really are of vital import to the identification of child abuse victims, whether it be children currently going through some form of it or previous sufferers. They show consistently higher rates of substantiated notifications of child abuse compared to non professionals (11% higher for reports of sexual abuse, and 26% higher for reports of neglect compared with nonprofessionals, 14.4% of non professional notifications are substantiated compared to 27.4% for professionals), as they usually see physical, palpable, later presentations of child abuse and maltreatment and are better trained to detect them [60]. But that isn't to say that ordinary people don't play a role in early identification of child abuse. Early notification of child abuse is vital to reducing its occurrence and the severity of the impacts later on in life.

Exactly what constitutes child abuse or neglect, and what warrants attention is a difficult question to answer. It varies from state to state and country to country, and again, we'll look at mainly developed countries', who have better child protection services and systems (and are better able to man them) set up, first before delving into the hard task of controlling third world child abuse, neglect, the effects of conflict, disasters and war, and malnourishment patterns.

In Australia alone, there are many definitions. Mandatory reporting is emphasised in many countries like Australia and America, but even that becomes unclear when looked at under the radar, as seen in the graphic below. 


Highlighting the conflicting, confusing reporting guidelines that many countries have in place. However - the cliche "better safe than sorry" is no less true because it's said a lot. Which side would you rather err on?Soure: http://www.aifs.gov.au/cfca/pubs/factsheets/a141787/

Signs of A Child Being Abused:  


There are many physical and psychological signs of child abuse that can be caught by healthcare workers and a great paper, outlining recognisable signs of abuse, and when to suspect it as a cause of these issues due to various presentations is here[46]I've compiled the signs of physical and sexual abuse into easy to browse tables, which you can peruse at the bottom of the post. 

If you, whether you be a doctor, medical student, nurse or anyone who knows a child, notice any of these signs, do consider notifying authorities about these issues.

Other, non physical signs of child abuse and neglect, include repeated presentation to doctors/hospitals with different or untreated medical issues and non-compliance with medical treatments. The UK considers non compliance with vaccination regimes as child abuse and rightly so (here's why). 
If children appear not well adjusted, or shows marked dissociation from the expected behavioral or emotional state, or show or talk about signs and symptoms of repeated stress, such as recurrent nightmares, extreme distress, withdrawal of communication, body rocking, aggression, it may indicate some occurrence of child abuse, though it's often hard to tell. States of over-clinginess, controlling/coercive behaviour, attention seeking habits and other signs of delayed or faulty interpersonal communications may also indicate some sort of child abuse, but again, it's hard to say. 
More leading signs that point toward child maltreatment or over-stress include showing dissociation, trauma symptoms, if the child doesn't present regularly to school or daily activities, if they behave unexpectedly in examinations and overreactions to minor stresses. 

The physically visible symptoms, and when to alert authorities are at the bottom of the post:
The signs and presentations of actual abuse when they happen are rarely easily visible. The way children and adults cope in response to abuse and neglect can elicit possible avenues of questioning and investigation by regular people and healthcare staff alike. 

Childhood Coping Strategies: 

Children who undergo stress are likely to respond in two ways. Either the hyper-arousal continuum, where they show vigilence, resistence, agression or the dissociative continuum. The younger the individual, and the more sustained stress and development they're exposed to, the more likely they are to pick the dissociative path [47]. 

Children cope by a variety of mechanisms. The first is dissociating from experiences, effectively reducing the emotional connections to memories and children who demonstrate there feel like they're "watching a movie they were in" or going to a "different place" when remembering traumatic events. Splitting is when, after traumatic experiences or exposure to a stress, children perceive the world as black or white, or good and bad based off those. Fragmentation of Personality occurs with chronic abuse, with little persona left behind afterwards. Denial and Forgetting is also common, especially when they're unable to process what's happened, and can lie dormant until the child is ready to face them [48]

Children who have been abused or neglected will attempt to reframe their experiences to make sense of them. Common ways they do this include Rationalising the abuse they faced; that is, feeling like they deserved to be punished or abused, that their worth is dependent on it. Children will preserve faith in parents/caregivers so they can continue to stay attached to them, even if they're the perpetrators of the violence. Minimilisation, or trivialising their abuse is also common when denial doesn't work for these children, with children saying things like "I've been through much worse" to adapt. Please or Appease strategies, where children try and prove their compliance and loyalty to the perpetrators of the abuse, to reduce their suffering is also employed. And seeking affection of those who abuse them is also common. [48]

These responses may seem weird, something you may insist that you wouldn't do, but if you put yourself in their shoes, you'll see that you're only a child, you're probably unable to make sense of the world, have little power over your circumstances and still need a mentor or adult to learn off. Hence these coping strategies. 

Adult Coping Strategies:

Long term survivors of child abuse also develop coping strategies to deal with the trauma and stresses they'd been exposed to in the past. Many adult coping strategies are continuations of childhood coping strategies, and they affect adults way past the initial abuse [50], and the adult survivor of these becomes "the fighter, accommodator, the escape artist, the victim, the denier, the over-achiever and the pleaser"[50]

Adult survivors generally develop coping mechanisms of repression, emotional insulations such as withdrawal, and avoidance of painful stimuli or relationships and rationalisation to make do. And signs of this may be evident in their personalities. 

This all describes how a child abuse or neglect victim looks like the developed world. In the developing world, these issues and many more obvious examples of childhood suffering exist, as I discussed above. But the question now goes to how are we, and how do we deal with this?

Dealing With Child Abuse:  

Recognition of child abuse is the first step of it occurring. In developed countries, there are established protocols for reporting, investigating and dealing with child abuse victims.

How Child Abuse Notifications Are Dealt With:

I'm giving a brief outline of the model, it varies from country to country and policy from policy, but the basic gist of a lot of developed country's response in intervening in child abuse is below: 

A basic model of how childhood intervention strategies work. Taken from the Western Australian Government [51]. Contrary to popular opinion, there are many steps taken before children are stripped away from family, including the assessment of the information, substantiation of any claims, and then working with the family to prevent further outcomes, with voluntary programs, therapy and counselling and supervision programs in the case of neglect and other features. However, when abuse has already occurred and there is a risk of further incidences, the last resort, stripped parenting rights is taken up to protect the child. 

This model governs how child abuse notifications are dealt with. However, due to a variety of reasons (including overload of staff, too many notifications and instances of abuse, time taken to get processes through and burnout of workers), this model mostly takes action after incidences of child abuse or extreme neglect have occurred.

In particularly abusive or stressful environments, it's crucial to intervene quickly, as crucial, early developmental pathways that have repercussions long into life are being compromised continually if a secure, safe environment isn't achieved. The need for early, timely intervention, aimed at restoring a stable, nurturing environment especially in younger children (though equally as important for older ones too) is clear, and that is the goal of this model.  


Problems in this System And Solutions to them:

Low or Reluctant Reporting:

Though reports and awareness of child abuse has risen staggeringly in the past 50 years, due to increased awareness and societal change in the perception of the issue, many are still reluctant to report acts that may constitute child abuse. 

In the general community, reasons for this include confusion at the whole process, and how it works. Many feel that "because they don’t have proof and, if they’re wrong, they fear it will reflect badly" [55] and that the reporter or the person reported can have their reputations tarnished. This, however, is due to a lack of awareness about the protocols. Only suspicion is required to make a report, not proof and these reports can be done anonymously. As I said before it's safer to err on the side of caution, but this would be more easily achieved if there was more public awareness about the issue. A focus on fixing this issue is stressed in Australia's Council of Governors National Framework for Protecting Children [53], but the measures target only sexual abuse prevention, and it's listed as of last priority in New South Wales' child abuse prevention strategy [52] despite it being shown to work [54]. Societal confusion as to what entails child abuse is another factor which can again be increased by public awareness of reporting measures, but this isn't done enough and needs to be increased in priority (though it could be argued that funding here will reduce the money directed towards an already floundering front line). 
Another issue which can't really be dealt with is the lack of involvement, or of the reporter in the follow-up of child abuse reports. This is done for privacy and professional reasons, but if someone is suspicious enough to report it, they're most likely worried, and though sometimes information is give, if deemed safe, nothing is, or can really be done to ease that worry.

In terms of professionals working with kids, who are required in the US, Australia and Canada to report cases, there is also a reluctance to report. It's more concerning, as they're the ones most closely associated with kids, and in the case of healthcare workers, they're the most accurate, reliable notifiers and recognisers of child abuse. 
The reasons why include lack of awareness of the signs and symptoms of child abuse in particular, limited experience, poor documentation, low opinion of child protection services and lack of emotional support through the process [56]. In the case of doctors, 21% chose not to report cases of suspected child abuse [57] for similar reasons to above, with the added concern of legal repercussions and compromise of the relationship and treatment of the child/family concerned. In extreme cases, where stripping of parental rights is considered, there has to be a balance between the trauma and developmental issues caused by the losing a parental figure and the risk of further abuse incurred by staying with them. In the case of a mother needing a child to focus on however, the child's safety must come first. 

Fixing this involves further education (I'm doing my part here!) about the symptoms and signs of child abuse, its effects on the body and the workings of the child abuse system. Though there are guides for what should be learnt, there are no set requirements, and some universities do not offer much in the way of this during their courses.
But there are easy simple measures that can be taken to increase the rate of reporting too. As discussed above, there is an issue in documenting and hence following up on suspected child abuse reports. A study conducted in emergency departments found that a simple reminder-like note for follow up of children who presented with injuries resulted in a great increase of recording of the reason for injury (which is vital to determining if incidences were caused by child abuse), from 2% in the group without the note to 70% in the group with it, with further referral rates for issues also increasing [58].  


Lack of Resources to Deal With Child Abuse Notifications:

Including front line responses:

Many problems in funding and resource allocation exist within existing child protection services worldwide. Front line crisis intervention is almost always severely overburdened. Issues in this, are high rates of non professional reporting caused by mandatory reporting, lack of funding in some vital areas, bureaucratic issues when cases cross state lines (this occurs all over the world), and also the struggle in maintaining staff, and ensuring little burnout in such a harrowing, never ending, draining and often thankless job. 

Non professional reporting, reporting by those untrained in identifying child abuse, show lower rates of substantiation (14% in non professional reports versus 27% for professionals [60]) despite similar resources directed towards investigation and, though often in the right places, can lead to back-ups on an already overextended, waiting list heavy service (eventually leading to tragedies if cases are seen late). 

A balance must be struck between getting proper warning and overburdening an already stressed systems, and policies need to be well thought out, and centers well resourced to cope with the extra demand. Economic downturns and other issues can also increase the burden, and funding to these services must be preserved, even increased during these times. With a focus on early intervention, which is appropriate, many teenagers, especially older ones, are held in waiting lists for excessively long periods of time, leading to more tragedies, and more damage occurring. Remember, in the teen years, risk taking behaviors and patterns for life are established, so they are still of vital import.

The sharing of information between states, departments and NGOs should also become more fluid. This has less to do with privacy than it has negotiating bureaucratic lines, but is being dealt with in some countries, like Australia and Scotland with the breakdown of these lines, and the establishment of nationally consistent systems [53] [59].

In a field such as this, where horrific abuses are sighted all the time, burnout of workers is of concern as well. Caring for the carers is necessary in ensuring children are cared for but is hard to achieve in such an emotionally draining field. Cognitive therapy, and incorporating the issue of compassion fatigue in training does help in reducing this burden [61], but again, increasing the staff, to reduce the burden put on these workers in the first place is the best solution.


Lack of Focus on Prevention:

Touched on above, and occurring for various reasons including as the prioritisation of first line responses, preventing occurrences of child abuse is not focused on enough in policy. Prevention programs are classified into 3 classes, primary, those that target the wider public, secondary, those that target vulnerable populations or areas and tertiary, those designed to prevent further occurrences of abuse and neglect. 

It was found in 18 studies on preventative child abuse measures that primary and secondary interventions (those that occurred before abuse) reduced child maltreatment, improved parenting by the reduction of negative/unhelpful parenting, increased the use of positive and productive discipline strategies and achieved greater awareness of the importance of parenting. All showed lower rates of child abuse. [54]
But though these studies could find an association, poor outcome evaluation (in part due to the nature of the investigation, in part due to poor experimental design) of results meant that the effectiveness of these programs, on a cost-benefit anylsis basis, couldn't be ascertained, giving less incentive to implement such policies. However, intuition, as well as the results of these studies dictates that primary and secondary preventative measures to stop child abuse is a smart investment, as it not only reduces child abuse from occurring but also the burden of them being added to the already stressed waiting lists at child protection services. 

Examples of prevention programs. Specific examples include Nurturing Program USA, Signposts for Building Better Behavior, a research project in Australia, but these are a broad description of preventaitve measures.


Policy Improvements to Focus on Prevention:


There are many more preventative measures being taken now, but more needs to be done in this regard. The Australian government's Child Protection Legislation Amendment Bill of 2013, is committed to promoting good parenting through measures like the ones talked about above [62]. More targeted, secondary approaches to vulnerable areas and groups, such as Indigenous people or deprived schools, including the Home Advice Program and increases to the National Affordable Housing Agreement (to ensure safe environments are there for children) are detailed and planned for implementation in the Australian Council of Governors Report [53] too. Similar measures are also being pushed around the word. Rodney Hammond, director of the division of violence prevention and injury prevention and control, addressed the US congress and urged the increased use and advocacy of of parenting programs and in home visits to disadvantaged areas, upscaling of both preventative and intervention based approaches, and also asked for more data and evaluation of strategies being used [69]. The effects of his recommendations, and that of others in the field, were staggering, an example being the introduction of the "Tripple P", Positive Parenting Program in many states, and even Austraila. The European Economic and Social Committee is doing similar things, though mainly through non governmental organisations such as the European NGO alliance for Child Safety Online and the Missings Persons Intervention Manager [63]. The best thing about their policy is that it combines efforts and reduces bureaucratic barriers between nations as well. 
The increase in prevention of child abuse is assuring, but further investment on both prevention and dealing with front line issues of child abuse is still needed. 

401 kids foundation poster, an example of a primary prevention measure raising awareness of the issue.


Treating, Counselling and Managing Child Abuse Sufferers in Ideal Settings

Due to the vast variety of effects and varying impacts of child abuse, there are many, varied, "treatment" protocols to deal with the survivors of child abuse. The responses of the family and child to treatment are also varied, and complex issues arise from it. Responding to a crisis, and  the counselling after them (for both adults and kids) will be discussed. Remember - these are all in ideal, first world settings, and the goals change dramatically in third world settings where resources are limited. 

The Phases and Treatment of Crisis Situations
What happens after notifications

During stressful situations, there are 7 steps that can define the general response of children and the family during and after the actual precipitating event and the intervention that follows. [64] 
  1. Precipitating Event:  The unusual, unanticipated, of continual stress occurs and in this time, authorities are notified. If perpetrated by other outside the immediate family, a period of helplessness is incurred and confusion about the intervention itself may cause further damage to the child or family environment.
  2. Perception: The family and abused child may feel their relationship and family unit threatened by the investigation at this point. Or they may find it meaningful and reassuring, depending on the circumstances.
  3. Disorganised Reponse - Unfamiliar vulnerable feelings start to rise and escalate as behaviors and coping mechanisms used in the past to get past stresses fail in the light of further investigation or a traumatic event. Family and child's anxiety rises and stress builds up. If this phase is prolongued, the intvestigation/intervention may lead to further harm.
  4. Seeking New and Unusual Resources/Ties - Families and children turn to other people, be it neighbours, relatives or friends. Since different family members and the child have different perceptions, and they may seek validation for their own viewpoint, or may get advice from others such as "Be more submissive and your father/mother will calm down," "Leave the abuser" etc. 
  5. A Series of Chain of Events - Most crises, and the responses thus far set of further events which can cause further issues and further harm to the child. Personality/mood changes due to the investigation/interventions and conflicting feelings may lead to further violence, or the spending of rent/grocery money on drugs/alcohol to cope. Eviction of the child or parents may occur, setting off more crises.
  6. Previous Crises Become Linked to Current one: The events occurring may spur memories of past traumatic events or similar occurrences, and reliving experiences of previous traumas such as flashbacks may occur. 
  7. Mobilisation of New Resources after Intervention Works and Adaptation - A turning point occurs as tension and struggle evolve and healing can begin. The family member causing abuse may go to alcoholic anonymous meetings and start seeing effects of it, a job may occur or in the case of removal from the home, a child may settle into a new home. Issues occur beyond this time, so counselling and follow up is definitely needed. 

Crisis management strategy: 

Due to factors like the sheer amount of families needing to be treated, and the effects that prolongued investigation and intervention can have in destabilising and environment, and hence causing more harm than good, intervention strategies usually are restricted to 4 - 12 weeks in duration. The main focus is to stop the current crisis from causing further harm, but past events and cycles are also a focus. 

The goals of crisis treatment always focus on managing the family environment, as it's vital to the child's development. The goals include relieving the acute symptoms of family stress, restoring the family and environment to pre-crisis functioning, identification of precipitating events and stressors, finding remediating measures or actions the family can take, making connections to past events (and making a plan to avoid the same pitfalls) and inciting a new way of thinking in the whole family [65]. 

The 9 step crisis management model:

In terms of counselling the family during the crisis, a 9 step model is adopted to reduce the harm to the child [66]. This model is generally used around the world, with slight variations and focuses from country to country, and remember, this has to occur within that 4 - 12 week timeframe. This whole process attempts to focus on the strengths, from the strong points in the child's esteem to the good bonds still present in families. 


  1. Rapidly Establish a Constructive Relationship - During this stage, the crisis worker must be sincere, respect everyone's feelings and be an active listener. A Rapport has to be developed with everyone invovled, and a good first session must be had to ensure that further consultations and attempts to help can still occur. 
  2. Elicit and Encourage Expression of Current Painful Feelings/Emotions - Anger, frustration and feelings relating to the current crisis are the focus at this stage, linkages to past events come second.
  3. Discussion of Precipitatng Event: Chain of events leading up to and after the crisis are discussed. How the family adapted to it should also be discussed in this stage.
  4. Assessing Strengths and Needs: Involved assessment of strength and needs begins immediately and continues through these steps. Children and adults strengths, and problem solving skills are tapped into to get them through this period.
  5. Forumulation of a dynamic plan: Focus shifts to why something happened. This is a crucial point of dealing with the current crisis, and the viewpoints of all parties are considered.
  6. Restore Cognitive Functioning: The crisis worker attempts to explore strategies the families are willing to adopt and motivated to work towards.
  7. Plan and Implement Treatment: A concrete plan of action is put forward. The plan needs to be simple and easy at first to ensure they follow up on it. The crisis worker continues to counsel the family, but most of the work is left as "homework" for the family to do. 
  8. Termination: Termination of support occurs when the family is back to functioning as before. The crisis worker continues to have meetings with the family, and any services that helped, such as access to counselors or family assistance packages are maintained if possible.
  9. Follow up: Meetings after the crisis is resolved are arranged. Putting a solid date on follow up meetings ensures that families keep working towards a goal.
Although this whole 9 step process centers around a crisis worker, a multidisciplinary team, of psychologists/counsellors, doctors, and friends and family ensures a good base of support that can lead to a more stable, nurturing household. As discussed above, these crisis workers are sent out on a "most needed" basis, with early intervention at younger ages, and closer to the point of crisis preferred. 

It is much preferred that children stay in the household, and maintaining a healthy home environment will be discussed in the therapy section, but in the event that repeated abuses or unceasing neglect is occurring, or when there is a good suspicion that it will continue, children are taken out of the home and put into foster care or related care, more caring, nurturing environments, or at the worst, (and it happens in 5% of cases in the first world[1]) into institutions like orphanages or aged care facilities. 
Some older children and teens in particular, end up not getting care, and actually become homeless. The rate of homelessness in teens is particularly worrying. 39% of the American homeless population are teenagers, 75% use drugs or alcohol to self medicate, and many of these left for abuse or neglect reasons (sexual abuse alone accounted for 17% of homeless teens) [67-68]

Improvements to the preventative measures, and improvements to the overall funding of crisis intervention will improve the outcomes of initial treatment strategies, as well as increased usage of multidisciplinary teams and continued involvement of the whole family in the measure. When crisis intervention occurs, change should be the eventual outcome, to prevent further occurrences from happening. 

Policies in Australia to improve this include the Child Protection Legislation Amendment Bill 2013 [63], which furthers funding into crisis management, and opens up more avenues of early removal of children, where necessary, such as making long term guardianship by relatives a shorter process and making open adoption an option, removing red tape and unnecessary administrative duties which increase harm to children who are left neglected in the meantime. 
The Governors Council Framework [53] is implementing policies to increase support programs to foster homes and relative uptakes, through continuing programs like South Australia's Time For Kids grandparent respite and Western Australia's Foster Care Partnership Policy and hopefully in the spreading of successful programs to other states. Improved support for young people leaving care, and a pledge to continually increase funding to child protection services is also promised.
In the US, policies are also adopted to improve the quality of foster care. The Success and Increasing Adoption Act 2008, for example, increased grants to foster carers for housing, medical and educational expenses, and also improves the ability of relatives to take step in and relieve the burden on foster carers while simultaneously providing more stringent checks to ensure they're taking good care of the children. But a focus on ensuring children leaving foster care are provided for is more prevalent, given the extremely high number of kids in foster care (800,000 in 2003) and the low rates of adoption of older kids in particular. The Foster Care Independence Act of 1999, as well as the Success and Increasing Adoption Act 2008, provides funding for life skill and transitional services for those leaving foster care by providing education and vocational training grants and basic lifestyle grants. 

Therapy Beyond The Crisis Situation, For Children, Their Families and Adult Surivors:

The goals of counselling in children and adults differ, and aren't all unanimously agreed upon, and little in the ways of protocols are offered. There are general trends of therapies that seem to work however that I'll discuss now. 

Children and their Parents Undergoing Therapy:

The role of a therapist in helping a child is varied, depending on the circumstance, and these therapists can range from psychiatrists and psychologists to general practitioners and school counselors. I won't delve into detail in the actual psychotherapy used in children, as it's so diverse and varied, but their general role is to first establish a rapport with the child, build trust in them, encourage growth and development beyond the role of the victim, and to encourage the child to think for themselves. Talking about the abuses, looking at ways to minimise their impact and developing positive coping mechanisms are also of high priority. 

When counseling a child, it's very important to acknowledge their different responses, to remain clear and to engage with them as appropriate, considering their age and what they've been through.

One of the most important goals of therapy of the child is to put them into a positive, supporting environment, to allow proper growth patterns discussed in section 2 to occur. Getting kids to interact and deveop interpersonal skills is also an important goal. Therapy itself allows children a safe environment to interact with an adult, but group therapy is also encouraged, as it not only encourages social interaction, but gives them another positive, supportive environment to work through. 
Making the victims realise that they're not alone, which I touched on above, also helps the abused children and adult survivors of child abuse more open, and responsive to getting help. The stigmitisation of child abuse victims by society plays a huge role in the isolation that victims fear and should also be addressed. That stigma will continue however, until more general awareness of the harms and effects of child abuse and the long term impacts of it dries up. 

The therapist, as an adult, also often plays a nurturing role, something the child may not normally have, but must take care to not try and replace the parental figure and maintain boundaries. Attempting to mend the relationship of the child and parent (or adoptive parent or relative in the case of those taken away from their original parents) is also vital to this process. This can happen separately, but conjoint therapy, in a process parent child interaction therapy (PCIT), which teaches parents to encourage and nurture children, proper, non violent disciplinary methods, conducted regularly  is effective in restoring a healthy, stress free environment [70].

In the case of neglect, physical or sexual abuse (whether it be that directed towards the child or domestic violence) however, the major focus of therapy is on that of the abuser. Yes, children are taught coping mechanisms and encouraged to grow after abuse, but in abusive households, it's the abuser's, not the child's fault, that violence or abuse is occurring and they are the target of counseling and therapy. Who commits abuse? In terms of neglectful abuse, it is usually women who are the perpetrators, possibly because they're involved with children more, (this is where post partum depression, occurring in 5 - 25% of women plays a major role), accounting for 66% of neglect cases in the US [76]. However, physical and sexual abuse was mainly perpetrated by men, with 55.5% of physical abuse perpetrated by fathers/step fathers, 12% from unrelated men, and 90% of sexual abuse occurring by men [77]

Counseling the abusers is a highly specialised area of work and needs to be done with care. Counseling isn't directed towards anger, as many of these abusers control their anger well, can manipulate their thought processes and direct them towards children. Couple counselling alone isn't ideal either, as couples will likely break off into their own narratives and isolate eachother more or manipulate eachother in sessions (remember, many victims of abuse still love the perpetrators of the abuse, they're still family in a lot of cases) causing ineffective therapy. Good therapy of the abuser needs to show the abuser that they are the problem, gently, and though their issues, which may cause them to be abusive, do need to be dealt with through boosting their self esteem and cognitive therapeutic control techniques, it should be done in a context where they know they need to change their patterns of abuse. In the case of repeated abuse, or when crimes are committed however, crisis intervention needs to take place and children may need to be removed temporarily or permanently from the environment. Remember - the child should never be placed in harms way to protect the adults in therapy either.

For children put into foster care, counseling is aimed at both the carer and child and improving their relationship. Education of the needs of a child at certain ages, cultural and ethnic differences,  and teaching children to cope is taught directly to foster carers (because remember - foster care is designed to be temporary while adoption is permanent) is the aim of therapy here. For the child, the initial loss of family, the subsequent feeling of abandonment and the feeling of belonging to many families (a lot of whom they don't properly belong to) is hard to get over, and the establishment of healthy coping mechanisms and a supportive environment is necessary to ensure they turn out as functional as possible. 


Improving How We Look at Counseling: 
Fixing the problem before it becomes an issue

Most child abuse therapy is focused on fixing problems once they occur. However, little focus is given to dealing with the risk factors that make someone more likely to commit child abuse. Strong correlations can be drawn between child abuse, particularly in chronic neglect perpretators and those of lower socio economic status, with histories of drug and alcohol abuse, histories of domestic violence, mental health problems [72] as well as the psychopathology and impaired social interactions of the parents themselves [71]. For a long while, it was though that only the latter, something "wrong" or "screwed up" in the parent's psychology would lead to abuse, but the fact is that many more common issues such as those listed above, can also make someone more prone to perpetrating child abuse. The fact that child abuse becomes more common during recession is obvious in the significant rise of acute head traumas due to physical child abuse rising from 8.7 per 100,000 per year in 2004 to 14.7 per 100,000 a year in 2009,(a period of recession) in the US [75] and similar trends are seen over all types of child abuse around the world, showing clearly that stressful times, rather than psychological impairments cause child abuse.
Treating the stress of parents, and removing stresses from the overall environment will reduce incidence and prevalence of child abuse. But little focus is put on this. Granted, most of these issues are caused by hard to control factors, such as market forces, but counseling and therapy through simple things like public service announcements and the advocacy of parenting programs, discussed above, during hard times will reduce the occurrence and effects of child abuse. And improving access, and seeking out of counseling and therapy to parents going through hard times will reduce chances of child abuse occurring too. 


Managing/Counseling Trauma Victims:

Trauma is a major side effect of many cases of child abuse, and occurs especially those who undergo severe physical and sexual abuses, though not restricted to them. Post traumatic stress disorder is common to those who suffered child abuse and maltreatment. Major symptoms or signs of PTSD are reliving the traumatic event/s with symptoms like palpitations, increased heart rate and even convulsions (I saw a vivid video in that lecture of a girl who'd suffered unspeakable traumas in Sudan almost seizing when reliving her past traumas), hyper-alert states, avoiding reminders of the event or objects, places or other stimuli that trigger reliving experiences and emotional numbness. 

A video explaining different reliving experiences of PTSD; nightmares and flashbacks. "A nightmare you can wake up from, and you realise isn't real."

Therapy for PTSD victims is diverse and varying, depending on what causes the abuse, their responses and coping mechanisms, can be required for children and adults and needs to be undertaken with even extreme care and sympathy. It can be delivered in group or individual settings, with the latter being important in ensuring they can function properly in society, and needs to be done once the child or adult is in a stable condition; that is, after drug, health, homelessness and suicidal ideation are dealt with. 

The general stages of PTSD therapy:

  1.  Achieving Patient Safety, Reducing Symptoms and Increasing Competencies - getting children and adults past their initial anxiety, or controlling symptoms, and importantly, removing triggers which can cause dangerous (to both the physical and mental health of the victim) reactions. Medications may be helpful in helping patients to sleep or reduce anxiety, other issues listed above need to be dealt with and ability to function basically needs to happen before therapy designed to reduce the impact of the traumatic events can begin. 
  2. Review and Appraise Trauma Memmories
    The success of this phase of treatment depends on the ability of the victim to relive the memories. In patients exposed to single traumas, as opposed to those who suffered multiple, complex trauma, this is usually achieved quicker. There are three major pathways in this stage.
     Exposure Therapy basically involves showing the victims signs or reminders of traumatic experiences over and over again until it stops having a response. In children in particular, evidence suggests this works best with combination with cognitive behavior therapy (in a process called Trauma-focused Cognitive Behavior Therapy [TF-CBT]), where the child is given physical or mental cues or actions to take when seeing that trauma to be able to tolerate it.
    Reprocessing therapy, where the therapist tries to reprocess the way the memory is activated to a less emotionally charged one (the explanation of how traumatic memories are processed is in section 2), is another way. Eye movement Desensitization and Reprocessing is an evidence based method of doing this. A positive memory or experience for the patient is found to control any flare ups first, then a patient is required to perform a simple motor task, often moving the eyes side to side (following the therapists finger) while reliving the traumatic memory, until it has little impact.

    Somatic Therapies are newer, and have less backing to them, but go through another process altogether, and don't involve reliving the experience at all. Basically, patients are taught to adapt and grow beyond the experience, often with focus on physical advancements, but basically the aim is to leave the past behind, minimise any impacts of trauma that do come up, and keep a focus on the future. I guess it's how I dealt with my cancer in that way (it's changed my ideology I guess - I always look at the big picture now).  
  3. Consolidating The Gains:
    Focus and improvements in social interactions is the final stage. 

Dealing With Adult Survivors of Child Abuse

Many adults today still bear scars of abuses from the past. It doesn't have to be physical or sexual abuse; again, neglect can be a big cause of it. There is a huge stigma and expectation about it; people expect victims to grow past it or "get over it" because they don't know, or can't appreciate the long lasting impacts it can have. The effects of this expectation are similar to that expectation that cancer survivors have to feel blessed and lucky that they survived cancer (something I talked about last post); people don't talk about it or seek help, or blame themselves for being "weak" and it needs to stop!  For the sake of cancer survivors and child abuse survivors alike. 
This leads to many people who were abused or neglected as children not talking about it,  and the fact that child abuse has long term, physically palpable effects means that many patients that you (if you're a healthcare worker) may be dealing with may have suffered some form of abuse in the past. 

The way child abuse victims dealt with their abuse in childhood, discussed in section 2, often persists into adulthood. Most children, especially those suffering complex, multiple, prolonged abuses develop avoidance, submissive, rather than approaching, aggressive, coping mechanisms. Many adults continue on forming maladaptive avoidance coping mechanisms that make dealing with trauma and becoming well adapted members of society afterwards [78].

The fact that many adult patients, and drug and alcohol users are disproportionately affected by child abuse in hospital admissions, cases and deaths[79] [30], shows that it should be something that's screened for more on consultations with doctors. Simply asking the question "Were you treated okay" or "were you abused s a child?", as a physician, trained professional or even friend of someone who's suffering has been shown to increase disclosure rates, and thereby, the ability to get help dramatically [80]. It's not really a question you'd ask straight away on a first consultation, sure, but if signs of a maladapted person, such as a "needy", "suppressed", "substance-abusing" patient who often has difficulties adjusting to society, show through, and a good rapport or relationship between the two of you is established, that question can be all they need to give them not only access to help, but validation that they have suffered, which can mean the world to them. Of course, screening for abuse victims is hampered by the patient's own coping mechanisms and attributes, as they often deny or minimilize the impacts of what they've been through, but still, asking can't hurt. 

Therapy for PTSD I've discussed just above, but therapy overall needs to be conducted by people who are trained in it. It involves first of all disclosing that there may be emotions and memories brought up that may be haunting, it needs to occur in a safe environment, with mental health staff on the ready, and a good bond needs to be developed between the counselor and the victim. They are encouraged to develop more positive coping mechanisms, emotional support, and again, group therapy does help in achieving this; not only to let them know they're not alone but to give them an extended supportive environment to develop good habits from.

If you're interested, or an abuse victim yourself, the Adults Surviving Child Abuse Childhood website is a great resource for more information.

What About Dealing With Child Abuse in the Third World?

So far, we've talked about how we deal with child abuse, and how to improve how we deal with them, in ideal, developed world settings. But in the third world, where our definitions of child abuse and neglect is rampant and often just a consequence of poverty, war or other issues, dealing with the issue is more complex. Improving how we deal with these issues is a much harder prospect than it is in our countries, and the systemic changes required to deal with poverty, inequality and war on a large scale I won't talk about too much (often, it just can't be done); how we deal with the direct impacts of child abuse, and what YOU can do to make a change though, I will.   

How we deal with Child Abuse in Wartorn/Disaster Regions Teaches Us How To Restore Communities and Economic Activity
Which Reduces Incidences of Child Abuse 

War and disaster zones are more common in the third world, and have many issues, which I discussed briefly in section 1, related to them. The cases and methods of improving communities overall that I make though can be applied to places not suffering war as well.
In the case of children who have experienced war, it's obvious how much stress they may be feeling from their environment, leading to developmental issues in the future, but often, the stress the parents are dealing with, or the complete absence of parents in the cases of many orphans, are very high and occur around in whole communities. 

When dealing with communities that have been destroyed by war, there are many disruptions to the culture and society as a whole which, when repaired, will lead to the reduction of child abuse, neglect and other atrocities that come with it. How do we repair those in areas still suffering?  

Dr Dawson is a trauma specialist who works with children in both Australia and wartorn African and Middle Eastern nations. Her efforts and experience in improving communities struck by war, by integrating herself and training key members to deal with trauma, is leading to research and examples which can be replicated around the world to help reduce the impacts of trauma and especially child abuse due to war. Her observations are not just 

In war torn communities, culture and way of life is absorbed. The role NGOs and charity plays in restoring some semblance of order is huge, and often targeted toward children, and it is good. However, follow up, or work in restoring a community, and the environment and family structure around the child, which is just as crucial to their development and chances of being abused, is often not. 

High rates of alcoholism, substance abuse stemming from the lack of employment or ability to provide for the kids, often leads fathers and men to perpetrating rape and violence regularly, and often this is directed to their own children, or that of others. NGO handouts to children can shift the balance of a family, and when children become the providers, that can change the whole dynamic of a family. This issue becomes more prevalent when war has lasted generations, as it has in areas like Sudan and Somalia, and leads to a vicious cycle of a society that doesn't know how to farm, hunt, build and provide, leading to abused children who often also become abusing parents. Therefore, restoring the order and balance can make a huge impact on the community as a whole. 

Restoring The Economy:

As I mentioned above, a lack of knowledge of how to farm, build and provide is often just as important an issue as the lack of resources to provide them. 
The International Crops Research Institute (ICRISAT), provide training and advice on producing quality seeds to new sustainence farmers that has resulted in methods that have restored the agricultural community in countries like Tanzania and Zimbabwe [81]. The Gates Foundation, which has committed 2billion dollars so far towards the improvement of agriculture also focuses on the education of new farmers, alongside the increased participation of women in the field (which increases the labour force and hence productivity), and makes good measures to track the progress of these, allowing for further development to occur in this field [82]. The gates foundation also sponsors research into genetically modified maize, in particular, which allows farming to occur in drought ridden areas, areas with poor soil and, due to the quick growth of maize, allows it to happen in disaster areas too [82], and the role of genetically modified, superior seed in alleiviating not only the burden of poverty in the nation, but also the redevelopments of communities, which lead to better outcomes in child abuse, is huge.

An interesting, low cost way of informing farmers of new methods of farming that are not only more efficient, and produce more crop per hectare but better for the environment too. More info:
Why and how we see being green not only good for the environment, but profitable too. 


The education of farming is one example, there are many industries which are being enhanced to regrow communities and restore order to them. Improving the overall economic activity in many fields and sectors in the third world is a great way to cause change and an easy way for you to get involved is below.

Urbanisation is occurring at rapid rates, as people exit rural communities as there are simply not enough jobs there to provide. The improvement of rural communities and improving resources and businesses, the major being agriculture there is one way to go about change, but rapid urbanisation has led to the growth of megacities, which are not only areas of mass squalor and poverty, but also hubs of child abuse, slavery and labour too. The lack of employment there similarly leads to issues for children, but there is plenty of labour in the informal sector there, and the providence of education on building, plumbing/dealing with sanitation and other sectors not only improves the conditions of slums in the area, but also their economic activity leading to a productive economy, higher ability to attain education and eventually, less instances of child abuse.
Cites Alliance is an organisation which focuses on slum upgrading, and provides the materials, and utilises the labour and the community inside the slum to cause change, and this is an excellent article showing how they've caused huge changes in the slums of Agra.  
  
In terms of the resources required, many charity organisations and NGOs do make a big difference in providing materials for farmers, builders and education to boost economic activity, reduce poverty and thus reduce the incidence of child abuse in third world countries.

Microloans, and microcredit are a way to increase economic activity dramatically. Basically, they work by giving small scale loans, starting from $25 and going up, without the need for collateral or a source of income that's already there which stops many in the third world from getting a loan to beat their poverty. Through these loan, people can purchase products, materials or get education to help them out in their daily lives, and gain an ability to earn an income. Most loans given out are given to entrapeneurs, and even though there's no collateral, the repayment rates are over 99%, due to a huge sense of gratitude and cultural significance placed on helping them out in their time of need. The best thing about these foundations is that they often create businesses and give people a way to get employment; which stimulates economic activity not only for the person who's gotten the loan, but also their community around them. And they often go towards women too, which doubles the workforce. Organisations like Kiva.org, and the Grameen Foundation, are there, and you can get involved too!

On Kiva.org, you can pick and choose who you want to make a loan to, and can sort out sectors you're interested in and make a change that way, and most importantly, you get the money paid back to you to donate again or withdraw if you need to. It's actually a great way to save money - it makes sure I don't waste it that's for sure - and you change lives in the process! I give a $25 loan a week to add to my balance and am continually getting paid back and redonating the money, and you should get on it too!


Restoring Culture:

Just as important as revitalising an economy is the restoration of a community's culture. This can be through the reintroduction of dances, sport and traditional cooking which Dr Dawson explained led to a man she was working with literally crying as he ate his own nation's dish for the first time in Congo (often humanitarian aid comes in the form of rice, bread, things we like to eat, and not what locals consume, and people in disaster areas and war zones and refugee camps in particular, though anyone who gets humanitarian aid is likely to develop this, simply forget how to cook foods). This restoration of culture empowers adults, leading to less child abuse, and also gives children and teenagers a sense of identity, and the simple ability to play once again, something that many in poverty are just not able to do.

The power of restoring sporting activities is just as huge in that respect. It allows play and competitiveness to occur without violence, and gives parents and children alike a respite from their struggles. How you can help on this front is easy - if you have sporting equipment that you no longer fit you, as I know I do in my garage, donate them to charities that donate them, either to your local communities or to Africa, as the BootsForAll Foundation in Australia does.

An example of the work Dr Jennifer Dawson does is below.


 Dealing With Trauma in the Third World 

Individual counseling is a luxury that many can't afford or get access to in the third world. And abuse after trauma is something that is rampant, and has huge effects on children long into their life as I discussed in section 1 and 2. 

The lack of a proper, functional community and environment with normal paradigms and roles is a major factor in this and restoring that order is of vital import, as I discussed above, but in terms of dealing with trauma, there are a few successful community level interventions that do help. 

The counseling of individual children on a one to one basis isn't feasible over a large population, especially in war, disaster zones and refugee camps, where many children are abused, but the training of adult figures on how to deal with these issues, and to parent on the other hand, is.

Dr Dawson enters communities and provides basic training on the recognition of trauma, how to control the symptoms and basic counseling as well to adults, such as school teachers, policemen and military, wanting to help. The role of these adults, and what they can do is amazing. In communities where many children are orphans, and many have seen their parents killed, were made to go through the trauma of killing or raping their own parents themselves, these teachers, farmers, and soldiers become mothers and fathers to the children, and allow them some semblance of normal development from youth (which is vitally dependent on an adult figure, not only in the first 3 years of life, but particularly from the ages of 6 - 12 where they develop moral characteristics and need an adult role model in life).

In terms of the trauma, she integrates herself with the community, teaches teachers to do the work she does and basically attempts to control trauma symptoms and reduce the amount of triggers out there. One example she gave, was the littering of skulls and bones and human carcasses, done purposefully to scare children in a school yard where she was doing her work. The presense of these bones and pieces of flesh were causing episodes of violence and biting among many children, as they relived some of their previous traumas. When these reminders, or triggers were cleared, the volence in the school stopped. It's not ideal, but it allows children to grow without that burden on their shoulders.

The fact that so many children in those areas have gone through trauma made group therapy and support more readily accessible. One thing she remarked on that struck me was that levels of trauma in Australia and the African nations she worked in were similar, despite the hugely different stressors that caused them, because in Africa there were so many others who'd been thruogh the same thing while in Australia, there was a sense of isolation. Not only in the survivors themselves, but in the community. We go months, sometimes years, sometimes our whole existence in our homes without speaking to our neighbours, while over there, that doesn't occur. She'd lectured 50 to 100 child and teenaged women at a time on how to cope with their sexual abuse, and in her last trip down there, did so to a class of young men too; a first. That openness and ability to cope is an advantage to achieving therapy.

Summary

Child abuse and neglect is far more prevalent and encompassing than institutional abuses by priests, the army and select actors that you hear about on the news. It's not something that happened that people should "just get over". It's not being dealt with well in the developed world and it's MUCH worse elsewhere.

But there ARE things we can do about it. If you're a medical student, a doctor, a nurse, a teacher; if you're worried about someone or if you want to make a difference - recognise the signs of it, just under here, and ask that question if you're concerned.

If you've read this far, you probably are. 

You can raise awareness about the issue, you can help out victims yourself, you can help dispell that myths behind child abuse or you can save money and make a difference at the same time by helping out organisations like Kiva and Cities Aliance and make a difference in places which aren't as lucky as us. 

But the best thing you can do is BE AWARE of the issue. And I hope I've helped you do that. 





Physical Sign
When to Report or Suspect Abuse or Neglect
Bruising
Bruising in shape of hand, teeth, stick etc.

Includes petechiae (red or purple spots)

If not caused by medical condition

Explanation is suspicious. Examples include:

               - bruising of child not mobile

               - multiple bruises in clusters

               - bruises of similar size or shape around body

               - bruising on non body parts of body, eg buttocks or face or eyes

               - bruising is suggestive of strangling/constriction
Bites
               - May be caused by animals or siblings

               - Presense of bites on carer may suggest response by child (remember, most  instances of child abuse are perpetrated by family members)
Lacerations  (cuts)/ Scars
Again if explanation is suspicious and no medical condition established. Not necessarily perpetrated by adults, can be self harm, but that may indicate other abuse
What to look out for, scars/cuts that are:
                - multiple
                - Symetrical in distribution
                - On areas usually protected by clothing
                - On ears or face
                - On neck/ankles/wrists
                - Children that are immobile
Burns/Thermal Injuries
Burns that are suspect of abuse include those with improper explanations again, but also suspect abuse/neglect:
                - If child is not independently immobile.
                - If burns are on hands, soles of feet, buttocks etc.
                - In the shape of an instrument, eg, cigarette
                - Indicate forced immersion into hot water, eg. scalds to buttocks, limbs, symetrical in distribution or with sharply delineated borders
Cold Injury
Cold injuries, including hypothermia are suspect of neglect or physical harm.
Fractures
If explanation isn't suitable and evidence is clear of physical abuse. More obvious.
Head/Brain Injury
In absense of major confirmed accidental trauma or medical cause, suspect abuse if:
                - Explanation is absent or unsuitable
                - Child is under 3 years of age
                - There are also retinal haemorrhages (bleeding), rib or long bone fractures or other associated injuries.
                - Multiple subdural (below outer surface of brain) haemorrhages with or without subarachnoid haemorrhage or ischamic damage
           
Spinal Injury
 Suspect abuse/neglect when no obvious accidental trauma confirmed. Signs of abuse include:
               - Findings on skeletal imaging.
                - Neck injury associated with inflicted head injury
                - Unexplained kyphosis (curvature or deformity of spine)
                - Back injury with focal neurological symptoms too
Eye trauma, General Injury, Oral Injury and Organ damage
Suspect if explanation unsuitable and congenital abnormalities/other defects ruled out.

Signs of Sexual Abuse:


Physical Sign
When to Report or Suspect Abuse/Neglect
Ano-genital Signs and Symptoms
Suspect if child has symtpoms or signs like:
                - Genetial/Perianal injury (bruising, laceration, swelling or abrasion) and explanation isn't present or suitable
                - Persistent or recurring genital/anal symptom (bleeding/discharge) that has no medical explanation
                - Has anal fissure, constipation and Crohn's disease and passing hard stools has been excluded as cause
                - Gaping anus is examined and no medical explanation available
                - Dysuria that is persistent and recurrent with no medical explanation like worms, poor hygiene, allergies or kidney issues/infections
                - If foreign bodies are present in vagina or anal cavity
Sexually Transmitted Infections
 Consider sexual abuse if child has:
               - Hepatitis B without non sexual medical explanation  (mother to son transmission, or other non sexual transmission like blood contamination)
                - Anogential warts without other explanation
                - Gonorrhoea, chlamydia, syphilis, genetal herpes, Hep C, HIV, trichomonas or other STI infection without other explanation

For those above age of consent, but with other issues such as a clear difference in mental capability, incestuous relationship or relationship with figure of trust such as a coach, teacher, minister of religion also apply
 
For all of the above - differing age of consent laws for differing countries also play a factor and should be considered appropriate to your setting.              
Pregnancy
Similar to above, consider sexual abuse, appropriate to your local laws, if someone presents pregnant and is under the age of consent or has "other issues" described above.


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[55] Long R, "Confusion and Fear Contribute to Lack of Sexual Abuse Reports" Bang or Daily News, 17/8/2012
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[57] Sege R, "To Report or Not to Report: Examination of the Initial Primary Care Management of Suspicious Childhood Injuries,"Academic Pediatrics Volume 11, Issue 6, Pages 460–466, November–December, 2011
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