Murad Bakht-Lombock Lecture-Child Abuse PDF

DR.
MURAD BAKHT
MBBS(DAC), DTM&H(UK), DCH(IRL), Dip Ch Psych(C), FRCP(C)
ASSISTANT CLINICAL PROFESSOR
McMASTER UNIVERSITY, HAMILTON, ONTARIO, CANADA
CONSULTANT CHILD AND ADOLESCENT PSYCHIATRIST
BRAMPTON CIVIC HOSPITAL, BRAMPTON, ONTARIO, CANADA
VISITING SCHOLAR, UNIVERSITY OF GHANA, ACCRA MEDICAL SCHOOL,
GHANA
Wednesday, 4 June, 14
CHILD ABUSE
AND NEGLECT
INTRODUCTION
In Islam, we are taught to be gentle with our children.

Our beloved prophet Mohammed (peace be upon him) used to love
children. He would hold children in his arms and he would embrace
them.
There are many examples cited in this regards in the Hadith (AlBukhari and Muslim)
The children who are to be loved, cared for, protected and nurtured,
unfortunately are consistently subjected to maltreatment, abused,
neglected.
INTRODUCTION
Child abuse has become a major public health concern globally

associated with significant psychological morbidity in childhood,
adolescence, and expanding throughout the lifespan.
Various epidemiological studies support that child abuse and neglect
has increased dramatically across the world and is at an epidemic
proportion
Children in Muslim communities are no exception.
Developmental, psychiatric, and physical scarring are the result.
INTRODUCTION
At the conclusion of this lecture, the participant will be able to:
Define child maltreatment, abuse, and neglect

Learn the global epidemiology of child abuse
Understand a report of recent Canadian incident study of child
abuse and neglect
Identify indicators and risk factors for child abuse
Describe abuse circumstances, child and parental characteristics
Recognize sites of accidental and non-accidental injury
LEARNING OBJECTIVES
Learn impact of abuse in childhood and consequences in adults

Describe assessment of suspected abuse or neglect of a child
Explain intervention and management of child maltreatment, abuse,
and neglect
Discuss protective factors and prevention of child abuse
Statistics of muslim communities living in Canada and resources
available to them to seek support for prevention of child abuse and
neglect
DEFINITION OF CHILD MALTREATMENT
Physical abuse: infliction of non-accidental physical injury to a child ranging from minor bruises to death that is inflicted by a caregiver or other
individual who is responsible for the child
Sexual abuse: Any sexual act involving a child that is intended to provide
sexual gratification to the caregiver or another individual who has
responsibility for the child
Child neglect: failure to provide for a childs basic needs:

1) Physical neglect 2) Educational neglect 3) Emotional neglect and 4)
Medical neglect
Emotional abuse (psychological/verbal/mental abuse): Failure to act by

parents or other caregivers that have caused or could cause serious
behavioral, cognitive, emotional, or mental disorders
GLOBAL PREVALENCE OF CHILD MALTREATMENT AND ABUSE
In spite of recent national surveys in several low and middle income countries,
data from many countries are still lacking
In 1999 WHO estimated that 40 million children around the world aged 14
and under were suffering from abuse and neglect and required health and
social care services
International studies reveals that approximately 20% of women and 5-10% of

men were sexually abused as children, while 23% were physically abused as
children
Every year an estimated 34,000 homicides occur in children under 15
In armed conflict and refugee settings, girls are particularly vulnerable to sexual
assaults by combatants, security forces, aid workers and others
GLOBAL PREVALENCE OF CHILD MALTREATMENT AND ABUSE
In USA there was an estimated 900,000 reports of child maltreatment in

2002
Of those, 60% involved child neglect, 20% physical abuse,10% sexual abuse,and
7% emotional maltreatment. An estimated 1400 children died of maltreatment
in 2002
Girls are five times more likely to be the victim of sexual abuse. Infant boys
have the highest rate of fatalities
One well conducted large scale UK studies indicates 21% mild forms of
physical abuse, and 7% severe physical abuse. 6% admitted serious neglect.
Only1% reported sexual abuse by parents/caregiver
CANADIAN INCIDENCE REPORT OF CHILD ABUSE

Canadian incidence study of reported child abuse and neglect(CIS) collected
in 2008 indicates:
Rate of child maltreatment investigation was 39.2 per 1000 children
Among the substantiated cases, 4.9 per 1000 children (34% cases) were
exposure to intimate partner violence (IPV)
4.8 per 1000 children for neglect (34% cases)
36% of the total investigation were substantiated cases of child

maltreatment (14.2 per1000 children)
2.9 per 1000 children for physical abuse (20% cases)

1.2 per 1000 children for emotional maltreatment (9% cases)
0.4 per 1000 children for sexual abuse (3% cases)
PHYSICAL ABUSE
Modes of physical abuse include:
Hitting/shaking/throwing
Poisoning
Burning/scalding
Suffocating
Drowning
SEXUAL ABUSE
Sexual abuse:
May involve forcing a child to take part in sexual

activity whether or not the child is aware of what is
happening
May involve physical contact, including penetrative or

non-penetrative acts
May involve non-contact activities e.g. encouraging a

child to behave in sexually inappropriate ways
INDICATOR FOR RISK OF SEXUAL ABUSE
Sexual knowledge and/behavior that seems inappropriate

to a childs age and maturity
Sexual play demonstrating sexual knowledge

Running away and fear of certain adults
Regressive behavior
Hostility/Aggression to others
Sleep and eating disturbances
Disclosures to adults, possibly a partial account
Promiscuity, pregnancy, sexually transmitted infections
EMOTIONAL ABUSE
Persistent emotional maltreatment causing severe and persistent

adverse effects on the childs emotional development
Some level of emotional abuse is involved in all type of

maltreatment
Conveying to a child that they are worthless/unloved/inadequate

Developmentally inappropriate expectations
Overprotection
Limiting a childs exploration and learning
Failure to provide adequate stimulations
Preventing the child from participating in normal social
interaction
EMOTIONAL ABUSE
Exposing the child to ill treatment
Victims are unlikely to complain
Causing the child to feel frequently frightened or in danger

Emotionally unavailable parenting
Using the child for fulfillment of parents psychological
needs is often unrecognized
Its presentation is non-specific

No specific findings on examination
MUNCHAUSENS SYNDROME BY PROXY

This rare condition occurs when false evidence of an illness is given by the
caregiver in order to mislead the medical profession. Its presentation pattern
includes:
Fabricating an illness
Doctor/hospital shopping
The young childs mother usually makes up the story. Sometimes
these mothers are in the health care profession
The warning signs are:
recurrent unexplained illness, inconsistent investigation results,

treatment ineffective or not tolerated, excessively attentive mother
refusing to leave the child, lack of concern on the mothers part even
though the sign and symptoms are serious
RISK FACTORS FOR CHILD MALTREATMENT
CHILD FACTORS:
Premature birth weight, birth anomalies

Difficult temperament
Physical/cognitive/emotional disability or chronic illness
ADHD, aggression, and behavior problems
Childhood trauma in a younger child

FAMILY FACTORS:
Domestic violence
Parental psychopathology, substance abuse, poor impulse

control
Inaccurate knowledge and expectations about childhood

development
Poor family communications and problem solving skills

Parents having been maltreated as a child
Highly stressed family: financial stress, single parent, lots of
children in the home, low employability, disability
SOCIAL AND ENVIRONMENTAL FACTORS:
Low socioeconomic status, homeless

Dangerous neighborhood
Social isolation and lack of support
Lack of access to health and child care
Poor schools
Exposure to environmental toxins
INDICATORS FOR RISK OF PHYSICAL ABUSE
Delay or failure to seek help

Vague/inconsistent accounts
Account not compatible to injury
Abnormal parental affect- lack of concern/hostility
Child looks sad, withdrawn, frightened
Child says something suggesting abuse
Bruises or fracture or fractures in a non-mobile child
PARENTAL CHARACTERISTICS FOR PHYSICAL ABUSE
Insensitive care of child
Domestic violence
Lack of awareness of
childs need
Learning disabilities
Past experiences
Abusive or neglectful
upbringing
Harsh punishments
Little encouragement
Poor supervision
Psychiatric problems
ABUSE - CIRCUMSTANCES
Poor social support

Social isolation
Displacement
Persecution
No respite for child
No helpful partner
No friends
Poor housing
ABUSE - CIRCUMSTANCES
Unemployment/Debt
Violent neighborhood
Personal values
Subculture of violence
Self before child
Tired and irritable
Recent arguments
Alcohol and drug abuse
COMMON SITES FOR ACCIDENTAL INJURY

Applies to only mobile child:
Forehead
Nose
Chin
Shoulders
Body spine
Elbows
Hand, Forearms
Knee, or Shins
SITES OF POSSIBLE NON-ACCIDENTAL INJURY
Head injuries, fractures

Black eyes
Ears bruises, tears
Chest, arms, shoulders and neck bruises
Abdomen
Thighs (bruises or scalds)
Cigarette burns
Twisting fractures
Buttock (bruises or scalds)
PSYCHOSOCIAL IMPACT IN ABUSED CHILDREN
Developmental delay
Cognitive/academic difficulties
School adaptation problems
Disturbed emotional development
Poor self-esteem
Maladaptive coping
Limited problem solving
Social communication skills
Poor relationship difficulties
INDICATOR OF NEGLECT
Dirty clothes/body smelly

Chronic infestation (head lice)
Untreated medical condition
Lack of house rules and supervision
Increased rate of accidents
Wetting and soiling
INDICATOR OF NEGLECT
Failure to learn social rules

Attachment disorders, disorganized attachment
Indiscriminately friendly
Poor peer relationships
Low self-esteem
Developmental delays e.g. Language delay
PARENTAL CHARACTERISTICS FOR NEGLECT
Persistent failure to meet a childs basic physical, psychosocial need,

health or development
Maternal substance abuse during pregnancy

Failure to provide adequate food, clothing or shelter
Failure to protect a child from physical or emotional harm or danger
Failure to ensure access to appropriate medical care or treatment
Being unresponsive to a childs basic emotional needs
PARENTAL CIRCUMSTANCES OF CHRONIC NEGLECT

May occur across society. Increased risk if:
Low socioeconomic status

Poor social resources
Living in crime-ridden areas
History of intra-familial violence
Caregiver forensic history
Caregiver poor mental health
Depression
Alcohol/illicit substance dependence
CHILD CHARACTERISTICS FOR NEGLECT
Special need
Frequent or high pitch cry
Difficult temperament
Weak attachment to the child
Unwanted pregnancy
Premature birth
Early separation
Step-parent
EFFECT OF NEGLECT IN CHILDHOOD
Behavioral disorders e.g.; Conduct disorder

Externalizing-aggression, overactivity
Internalizing-anxiety, self harm, suicidal ideation
Increased risk of developing axis1diagnosis
Conduct disorder
Anxiety e.g.; PTSD
Depression
Eating disorders
Resilience
EXTREME EFFECT OF NEGLECT IN CHILDHOOD
Reduced brain size

Reduced brain activity
Reduced brain development
Deficit in processing facial emotion
Disinhibited attachment
Reduced emotional regulation
ADULT CONSEQUENCE OF CHILDHOOD NEGLECT
Drug dependence
Alcohol dependence
Anxiety
Depression
PTSD
Eating disorders
Obesity
Psychosis
DOMESTIC VIOLENCE
25% of all reported crime
Areas of high unemployment
90% of children are in the same or an adjacent

room where partner assault occurs at home
Economic deprivation
Personality disorder
Morbid jealousy
EFFECTS ON CHILD WITNESSES OF DOMESTIC VIOLENCE
Depends on developmental stage/gender/role

Disrupted sleep
Anxiety and other Emotional disorders
Psychosomatic disorders
Conduct disorders
Inappropriate adult roles
Reduced school attendance/performance
Inappropriate coping skills-especially aggression
ASSESSMENT OF SUSPECTED ABUSE OR NEGLECT
Physician should have a high index of suspicion for abuse when

evaluating an injured child; particularly delayed seeking of medical
care, inconsistent, and frequently changing stories
Obtain full history from multiple informants. Speak to them separately

regarding events.
Information from child, parent, siblings, babysitter, school, primary care

physician, and protective services may be indicated
Children may be reluctant to disclose abuse

Ask the child directly about means of discipline at home
Ask the child directly about having been touched in private places or
asked to do things to other peoples privates
ASSESSMENT OF SUSPECTED ABUSE OR NEGLECT
Assess for inconsistency of reports

Assessment of new onset of sleep disturbance, startled reaction, regression
Decline in academic and social functioning and regression
New psychiatric symptoms
Assessment of attachment issues, failure to thrive, PTSD
Behavioral difficulties
Sexual acting out or sexually provocative behaviors
PHYSICAL EXAMINATION OF SUSPECTED ABUSE OR NEGLECT
Multiple injuries at various stages of healing

History of failure to thrive
A history not consistent with the injury
Bruises in the pattern of a belt or fingers
Spiral fracture or rib fractures
Burn in a cigarette shape
Head and eye injuries, hemorrhages on fundoscopic examination
Unexplained serious abdominal injuries
Any injuries to genitals
MANAGEMENT OF CHILD ABUSE AND NEGLECT

The following assessment if child abuse/neglect identified;
The initial goal of treatment is to ensure that the child is safe and
to prevent further abuse
This is typically done with the protective service agencies
The abuser will require treatment, close monitoring and support if

the child is to remain in the home or return to the home
The child may be removed from home and placed in foster or a

group home or one of his/her relatives who can act as legal
guardian
MANAGEMENT OF CHILD ABUSE AND NEGLECT
Maintain child safety
Psychological intervention for child as indicated
Parent mental health treatment
Physical treatment for child if indicated

Ensure involvement of social services, school and wider
network
Parent-child interaction therapy

Parenting programs that improve sensitivity of care and
support parent
PROTECTIVE FACTORS TO PREVENT CHILD MALTREATMENT

CHILD FACTORS;
Ability to recognize danger and adapt
Good health
Ability to distance oneself from intense feelings

Ability to imagine oneself at a time and place in the
future in which the perpetrator is no longer present
Good school
Adults outside the family who serve as positive role
models/mentors

CHILD FACTORS
Average or or above intelligence
Easy temperament
Hobbies or interest
Good peer relationships and social
skills
Positive self-esteem
Internal locus of control

FAMILY FACTORS;
Secure attachment
Supportive family environment
Parental working through of their own abuse

history
Household rules and supervision

Extended family support

FAMILY FACTORS
Family expectation of prosocial

behavior
Middle to high socioeconomic status

Access to health and child care
Sufficient housing
Steady parental employment
Religious affiliation
MUSLIM COMMUNITIES IN CANADA
In 2013 Canadas population was estimated 35,158,300
Muslims in Canada originate from more then 85 nations and comprise

dozens of ethno-racial and linguistic groups
They mostly live in urban centres e.g Toronto, Montreal,Vancouver etc
Islam is the 2nd largest religion after Christianity and the fastest growing
religion in Canada
Canadian Muslims, both male and female, are more likely then overall
population to have completed one or more university degrees
According to Canadas 2011 national household survey 1,053,945 Muslims

lives in Canada, about 3.2% of the total population
7.7% of the population of Toronto is Muslim making Toronto the highest

concentration of Muslims of any city in North America
VIOLENCE IN THE LIVES OF MUSLIM GIRLS AND WOMEN IN

CANADA
The kind of violence that Muslim girls and women may face in Canada or
elsewhere- are often portrayed in western media with images of honour
killings, forced veiling, and other forms of violence committed by their male
family and community members
Muslim girls and women in Canada may face violence based on racism,
Islamophobia, poverty, and other factors
Experience in social exclusion can be a major part of school experience for

many newcomer Muslim youth
Newcomer Muslim girls experiencing domestic violence may find language

barriers prevent them from properly communicating their situation to seek
help
NEWCOMER GIRLS IN CANADA PROVIDE A LIST OF STRATEGIES

THAT THEY HAVE IDENTIFIED AS MOST HELPFUL TO THEM
Developing strategies to confront systemic racism and sexism

Developing anti-racist curricula relevant to girls and young women
Creating meaningful cultural programs
Creating safe spaces for girls to talk about racism and violence
Encouraging strategies of resistance
Encouraging others to see equality as a societal necessity
Muslim girls need to be acknowledged not only as victims of violence,
but also as a vital part of the solution to these problems
TORONTO CHILDREN AID SOCIETY

CHILD PROTECTION AGENCY
Protection services; Children Aid Society (CAS) mandated from the

provincial government to intervene in any situation where a child under 16
years of age has been or is threatened with physical, emotional, or sexual
abuse or neglect
All professionals including teachers and health care workers are obliged by
law to report their suspicions of child abuse or neglect to the local CAS
Also, every member of the public has a duty to report suspected child abuse
PROGRAM AND SERVICES PROVIDED BY TORONTO CHILDREN

AID SOCIETY
There are over 800 staff and 600 volunteers in Toronto Children Aid Societies
working in many different program areas. Some of these services includes:
Kinship; kinship care is the full time nurturing and protection of children
Adoption; when a child cannot grow up with their biological family,

adoption becomes an option often facilitated by CAS
Community development and prevention; prevention is the key. The best

way to deal with child abuse and neglect is to prevent it
Family support services
Foster care; temporary placement of a child in care in an approved CAS

foster home
Volunteer services
Anti-oppression, anti-racism
RESOURCES FOR MUSLIM COMMUNITY IN CANADA
A training manual for service providers serving Muslim communities,

Addressing domestic violence in Canadian Muslim communities is available
through the Muslim Resource Centre for Social Support and Integration
Many Muslim-run or Muslim-friendly organizations across Canada provide

assistance to Muslim communities
These include the Islamic Social Services Association in Winnipeg, the

Muslim Resources Centre for Social Support and Integration in London,
Ontario, and Amal Women Centre in Montreal
Many Toronto-based Islamic organizations and agencies serve Muslim

communities in greater Toronto
CONCLUSION
Child maltreatment defined as physical and emotional

mistreatment, sexual abuse, neglect, child exploitation, and
exposure to intimate partner violence.
Child abuse has increased dramatically globally. It is likely due

to an increase awareness and reporting.
Maltreatment is associated with significant developmental,

psychological and physical impairment in childhood,
adolescence and extending across the life span.
CONCLUSION
All clinicians who come in contact with children should have

a high index of suspicion for abuse potential when
evaluating particularly non-accidentally injured children.
Exploring risk factors and abuse circumstance could lead to
early identification of maltreated and abused child.
Ensuring child safety must be the initial goal. Further

management should be aimed at the child and care giver;
the assistance and support they need including appropriate
intervention for prevention and rehabilitation
REFERENCES
Addo.A.S.(2013) Consultant child and adolescent psychiatry Glasgow,U.K: Maltreatment; ASA UGMS
Children Aid society of Toronto;Vision and Mission.Information Booklet
Riley K.M((2011): Violence in the lives of Muslim girls and women in Canada CIHR IRSC,
Symposium,Sept 22-24,2011 London ONT,
Stubbe.D (2007) Child and Adolescent psychiatry,Lippincott Williams &Wilkins
Afifi.T.O (2011); Child maltreatment in Canada: An understudied public health problem.Canadian

journal of public health Nov/Dec 2011
David Coghill et al (2009). Child and Adolescent psychiatryOxford university press

Public health agency of Canada(2008)Canadian incidence study of reported child abuse and neglect,
Executive summary
Wikipedia.org ; Demographics of Canada

World health organization (2014);Health topics; Child Maltreatment

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DR.

In Islam, we are taught to be gentle with our children.

Child abuse has become a major public health concern globally

Define child maltreatment, abuse, and neglect

Learn impact of abuse in childhood and consequences in adults

DEFINITION OF CHILD MALTREATMENT

Child neglect: failure to provide for a childs basic needs:

Emotional abuse (psychological/verbal/mental abuse): Failure to act by

GLOBAL PREVALENCE OF CHILD MALTREATMENT AND ABUSE

International studies reveals that approximately 20% of women and 5-10% of

Every year an estimated 34,000 homicides occur in children under 15

GLOBAL PREVALENCE OF CHILD MALTREATMENT AND ABUSE

In USA there was an estimated 900,000 reports of child maltreatment in

CANADIAN INCIDENCE REPORT OF CHILD ABUSE

Rate of child maltreatment investigation was 39.2 per 1000 children

4.8 per 1000 children for neglect (34% cases)

36% of the total investigation were substantiated cases of child

2.9 per 1000 children for physical abuse (20% cases)

Modes of physical abuse include:

May involve forcing a child to take part in sexual

May involve physical contact, including penetrative or

May involve non-contact activities e.g. encouraging a

INDICATOR FOR RISK OF SEXUAL ABUSE

Sexual knowledge and/behavior that seems inappropriate

Sexual play demonstrating sexual knowledge

Persistent emotional maltreatment causing severe and persistent

Some level of emotional abuse is involved in all type of

Conveying to a child that they are worthless/unloved/inadequate

Exposing the child to ill treatment

Victims are unlikely to complain

Causing the child to feel frequently frightened or in danger

Its presentation is non-specific

MUNCHAUSENS SYNDROME BY PROXY

The warning signs are:

recurrent unexplained illness, inconsistent investigation results,

RISK FACTORS FOR CHILD MALTREATMENT

Premature birth weight, birth anomalies

RISK FACTORS FOR CHILD MALTREATMENT

Parental psychopathology, substance abuse, poor impulse

Inaccurate knowledge and expectations about childhood

Poor family communications and problem solving skills

RISK FACTORS FOR CHILD MALTREATMENT

SOCIAL AND ENVIRONMENTAL FACTORS:

Low socioeconomic status, homeless

INDICATORS FOR RISK OF PHYSICAL ABUSE

Delay or failure to seek help

PARENTAL CHARACTERISTICS FOR PHYSICAL ABUSE

Insensitive care of child

Poor social support

COMMON SITES FOR ACCIDENTAL INJURY

SITES OF POSSIBLE NON-ACCIDENTAL INJURY

Head injuries, fractures

PSYCHOSOCIAL IMPACT IN ABUSED CHILDREN

Dirty clothes/body smelly

Failure to learn social rules

PARENTAL CHARACTERISTICS FOR NEGLECT

Persistent failure to meet a childs basic physical, psychosocial need,

Maternal substance abuse during pregnancy

PARENTAL CIRCUMSTANCES OF CHRONIC NEGLECT

Low socioeconomic status

CHILD CHARACTERISTICS FOR NEGLECT

EFFECT OF NEGLECT IN CHILDHOOD