Understanding Child Maltreatment

1. UNDERSTANDING CHILD MALTREATMENT
ANNE NIEC MD FRCPC
DIRECTOR, CHILD ADVOCACY AND ASSESSMENT PROGRAM
MCMASTER CHILDREN’S HOSPITAL, HAMILTON ONTARIO

2. CHILD ABUSE AND NEGLECT (CAN) DEFINITION
(1) Physical abuse (e.g., excessive
discipline)
(2) Sexual abuse (e.g., assault)
(3) Emotional abuse (e.g., verbal abuse;
confinement)
(4) Neglect (e.g., failures to supervise; to
provide life essentials)
Any act of omission or commission which results
in harm to a child’s emotional, physical or social
health or development

3. CHILD
WELFARE:
THE
CANADIAN
LANDSCAPE

4. CHARACTERISTICS OF SUBSTANTIATED
MALTREATMENT: CANADIAN DATA
Canadian Incidence Study (CIS) gathers data from child welfare
agencies across Canada every five years
Most recent report (2008) found:
• Approximately 85,000 substantiated child maltreatment
investigations in Canada that year
• Five major categories of maltreatment studied

5. PREVALENCE OF CHILD
TRAUMA IN CHILD WELFARE:
MALTREATMENT TYPES

7. MALTREATMENT AS
TRAUMA: STATISTICS
•In 2008, 18% of substantiated investigations involved multiple
categories of abuse (15,590 cases)
– 24% - Neglect and Exposure to Intimate Partner Violence
– 15% - Emotional Maltreatment and Exposure to Intimate
Partner Violence
– 15% - Neglect and Emotional Maltreatment
– 15% - Physical Abuse and Emotional Maltreatment
•Neglect is the primary substantiated concern in 68% of cases
with multiple concerns
•Data suggested that 42% of substantiated cases involved single
incidents; 58% involved multiple incidents (i.e., chronic trauma)
CIS, 2008

8. ETIOLOGY OF
MALTREATMENT
Multiply determined
More likely when stressors outweigh supports and risks are
greater than protective factors
Associated factors include
• lack of social support
• lack of parenting skills
• parental history of maltreatment
• single or young parenthood
• substance abuse
• parental psychopathology
• community tolerance of violence
8

10. IMPACT
Localized Effects
• specific to the trauma
Developmental Effects
• deeper and generalized impact which interferes with
developmental tasks or distorts the course of development

11. CHILD DEVELOPMENT
Basic developmental needs of all children
are
• physical
• cognitive
• emotional
• social

12. BASIC DEVELOPMENTAL
NEEDS
Physical
• nutrition
• safety
• adequate supervision
• health care
Cognitive
• stimulating environment
• opportunities for play and exploration
• language promotion

13. BASIC DEVELOPMENTAL
NEEDS
Social and Emotional
• development of reciprocal relationships with
parents, caregivers, peers
• trust
• social competence
• affect regulation

14. CHILD DEVELOPMENT
Key Tasks:
• attachment
• emotional and behavioural self-regulation
• development of self
• cognitive and academic functioning
• peer relationships

15. DEVELOPMENT
• each developmental stages has milestones
to achieve
• development is impacted by experiences
• positive experiences enhances
development
• negative experiences and adversity
interfere with achievement of milestones

16. DEVELOPMENT
early childhood is where cognitive and emotional
learning develops and when interfered with,
problems in thinking and reacting occur

17. WHAT HAPPENS IN
MALTREATMENT

18. BIOLOGY
The healthy brain physiologically
adapts to the abnormal world in
which the developing child finds
himself or herself
(Stirling et al 2008)

19. CORTISOL – THE STRESS HORMONE
released in response to stress
• helps generate new energy stores (blood
sugar) and diverts energy away from low-
priority activities in the body (ie. Immune
system)
forms a negative feedback loop to “turn
off” the HPA axis
receptors at key areas of the brain,
including hypothalamus, hippocampus
and the amygdala

20. BRAIN REGIONS
ASSOCIATED WITH STRESS
Hippocampus: learning
and memory.
Amygdala: emotional
processing & memory
for emotional events
Corpus Callosum:
communication
between left and right
hemisphere
Prefrontal Cortex
control of behaviour,
cognition, emotional
regulation
Corpus
Callosum

21. PHYSICAL IMPAIRMENT
• fine and gross motor delays
• failure to thrive
• increased health difficulties
(Kendall-Tackett, 2002)

22. PHYSICAL IMPAIRMENT
of all child maltreatment fatalities demonstrated,
1/3 resulted from neglect
• abandonment
• starvation
• inadequate supervision
• medical neglect
(Berkowitz, ‘01)

23. EMOTIONAL
IMPAIRMENT
affect regulation
poor attachment
• increased relationship difficulties and parenting
difficulties
development of the self-system
• more likely to view themselves and others negatively
more psychopathology

24. TRAUMA
the brain engages in a form of pattern recognition to cues
in the environment or in relationships which result in a
similar body response (hormonal, neuronal and then
behavioural) to the original trauma experiences
most vulnerable children (repeated or cumulative exposure to
adversity)
• show the largest negative reaction
• experience an exaggerated response to a stressor
• may be more vulnerable to negative inputs from the social world
• experience the worst of both worlds because their inherent risk
factors increase both the likelihood of poor health outcomes and
their susceptibility to the adverse effect of stressful experiences on
health
(Odger & Jaffee 2013)

25. DEVELOPMENTAL IMPACT
ASSOCIATED WITH COMPLEX
TRAUMA EXPOSURE
National Child Traumatic Stress Network (NCTSN) have put forth a
phenomenologically based framework to understand children’s
adaptation to complex trauma exposure and have identified 7 domains
of impairment
1. Attachment
2. Biology
3. Affect regulation
4. Dissociation
5. Behavioural control
6. Cognition
7. Self concept

26. COGNITION
abused and neglected children have reduced I.Q. and
lower academic achievement (Perez & Widom, 1994)
neglected children have worst delays in expressive
and receptive language compared to physically
abused and non-maltreated children (Gaudin in
Dubowitz, 1999)
neglected children have poorest school performance
(grades K – 12) of all maltreated children (Eckenrode
et al., 1993)

27. SOCIAL
• increased risk of aggression and violence in future
relationships
• higher rates of risky behaviour (violent criminal
behaviours, substance misuse/abuse)
• poor peer relationships
• poor intimate relationships

28. BEHAVIOUR
Behaviours
• can’t sit still
• not listening
• hurting others, hitting
• poor attention, lack of concentration
• poor social interactions, speech delays
Labels (Diagnosis): “ADD, ODD, CD, ASD”
*Pervasive Developmental Problems of Neglect

29. STRESS AND HPA FUNCTIONING
• HPA axis controls our
reaction to stress
• Stress/trauma experienced
in early years can lead to
ongoing dysregulation of
the HPA axis
• Predisposition to
psychiatric vulnerability
later in life.

30. Chronically elevated cortisol can have damaging effects on
physiological processes in the body and predispose to
psychiatric vulnerability
HEART DISEASE OSTEOPOROSIS OBESITY
DEPRESSION ANXIETY

31. IMPACT OF ADVERSITY
“Significant links in the literature that
growing up in a risky family with high
emotional reactivity, decreased social
competencies, deficits in emotional
understanding and the failure to develop
effective coping strategies within stressful
situations disrupts the processes that are
central to the maintenance of
health.”
(Odger & Jaffee, 2013)

32. ENVIRONMENT
Poverty remains one of the most
powerful determinants of whether and
how children experience adversity.
(Odgers & Jaffee, 2013)

33. ENVIRONMENT
POVERTY = community stress
high crime,
violence,
noise,
overcrowding,
poor schools
decreased local resources
(Cicchetti & Lynch 1993)

34. ENVIRONMENT
Chronic adversity ongoing stressors
• hostility
• lack of warmth among family members
• food insecurity
• financial insecurity
• under-resourced schools
• under-resourced neighbourhoods
(Odgers & Jaffee, 2013)

35. ACE STUDY
Relationship of childhood abuse and household dysfunction to many
of the leading causes of death in adults. The Adverse Childhood
Experiences (ACE) Study.
Authors:
Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, Marks.
Reference:
American Journal of Preventive Medicine 1998
May;14(4):245-58.

36. ABUSE NEGLECT HOUSEHOLD DYSFUNCTION
SOURCE: DISEASE CONTROL AND PREVENTION

37. BEHAVIOUR

38. ACE STUDY

39. ALLOSTATIC LOAD
the price the body pays
when confronted with repeated
major stressors
result of chronic exposure to high and sustained
neural and neuroendocrine responsiveness

40. PUBLIC HEALTH APPROACH
40
Surveillance
What’s the
problem?
Risk Factor
Identification
What’s the
cause?
Intervention
Evaluation
What works?
Implementation
How do you do
it?
Problem Response
(Potter et al., 1998)

41. INTERVENTION
POINTS
41
Long-term
outcomes
Prevention
before
occurrence
Prevention
of
recurrence
Prevention
of
impairment
Universal Targeted
Maltreatment

42. NURSE FAMILY PARTNERSHIP
PROGRAM
First-time disadvantaged mothers received home visits by
nurses
Began prenatally and extended until child’s 2nd birthday
(weekly and then tapered)
Nurses promoted 3 aspects of maternal functioning:
• health-related behaviors
• maternal life course development
• parental care of children
4
2

43. IMPLICATIONS FOR PREVENTION
OF PSYCHIATRIC DISORDER
Programs shown effective in preventing child
maltreatment may also prevent psychiatric disorder
Adolescents born to home-visited women reported:
• less running away
• fewer arrests and convictions
• fewer behavioral problems related to use of alcohol and
drugs
(Olds et al., 1998)
4
3

44. 44
www.fhs.mcmaster.ca/net

45. IMPAIRMENT
1. Attachment: problems with relationship boundaries, lack of
trust, social isolation, difficulty perceiving and respond to
other’s emotional states and lack of empathy
2. Biology: sensory-motor developmental dysfunction,
sensory-integration difficulties, somatization, and increased
medical problems
3. Affect regulation: poor affect regulation, difficulty
identifying and expressing emotions and internal states.
Difficulties communicating needs, wants and wishes

46. IMPAIRMENT
4. Dissociation: amnesia, depersonalization, discrete states
of consciousness with discrete memories, affect, and
functioning, and impaired memory for state-based events
5. Behavioural control: problems with impulse control,
aggression, pathological self-soothing, and sleep problems

47. IMPAIRMENT
6. Cognition: difficulty regulating attention, problems with a
variety of executive functions, planning, judgment, initiative,
processing new information, focusing, task completion,
cause and effect, speech delay
7. Self-concept: Fragmented and disconnected
autobiographical narrative, disturbed body image, low self-
esteem, excessive shame, and negative internal working
models of self

48. PROTECTIVE
FACTORS
Responsive care giver who believes and can validate the child and their
feelings and experiences
Tolerate and manage the associated affect
Manage their own affective responses
Child with easy temperament
External attribution for blame
Effective coping
Talents, skill and spirituality
Positive beliefs about ones self

49. RISK FACTORS
Care giver has own history of childhood complex trauma
Caregivers with impaired attachment relationships
Child can trigger the parents own maladaptive coping

50. NCTSN PROPOSED
TREATMENT MODEL
Safety:
Self-regulation:
Self-reflective information processing:
Traumatic experiences integration:
Relational engagement:
Positive affect enhancement:

51. WELL-BEING IS WELL-DOING
HEALTH AND SOCIAL SERVICES

52. A PROMISE AND PREMISE OF
INNOVATION
…a dysfunctional policy environment
has marginalized prevention to the
detriment of health outcomes. … To
deal with this change, we need new
modes of distributed healthcare
delivery, a health economy based on
prevention, and new technological
literacies. (Ranck, 2012, p.8).
There is a need to apply this to CAN prevention
as a key driver of human development, health,
and resilience.

53. Vulnerability Resilience
Sensitivity Re-setting
Response
Hazard / Loss Resources / Potential
Child Abuse and Neglect as Toxic Stress

54. UN CONVENTION ON THE RIGHTS OF THE CHILD AND
CHILD ABUSE AND NEGLECT (CAN)
Globally adopted, legally binding, action-oriented
(1) The right to survival  CAN is deadly
(2) The right to protection from harmful influences, abuse and
exploitation CAN is common
(3) The right to develop to the fullest CAN increases odds of
physical, mental, and financial poor health
(4) The right to participate fully in family, cultural and social life
Need to focus on resilience within CAN populations

56. RESILIENCE
• Competence in the face of adversity
(Garmezy 1984)
• Socially supportive relationships promote
resilience
• Children’s ability to maintain and recover from
significant adversity depends on the overall
balance of risk and protective factors in the
children’s environment (Ciccheti 2006)

57. INTERVENTIONS
Physical safety
Psychological safety
“One of the most important factors influencing children’s
psychological adjustment is the degree of support they receive from
their parents and other caregivers.”
(Stirling et al 2008)

58. INTERVENTION - PRINCIPLES
1. Reshape the child’s perceptions and emotional
responses
2. Help caregivers address their own behaviours
3. Inform and educate caregivers about the effects of
adversity and reasons for behaviours in the child
4. Guide caregivers to less reactive and more positive
parenting strategies (discourage aggressive
responses, promotion of calm, consistent and
predictable environments)

59. INTERVENTION
Informed by a formulation and
understanding of the child and his/her
needs
vs.
Removal of risk factors, provide safety
and treat behaviours alone

60. INTERVENTIONS
Range of options:
comprehensive evaluation – developmental, neuropsychological, cognitive,
medical
academic supports
education about child abuse and reactions of children
teaching safety skills
stress management, emotional regulation skills
trauma therapy, trauma narrative, TF-CBT
assisting emotional and cognitive processing (correcting untrue or distorted
ideas about how and why the trauma occurred)
home visitation (Nurse-Family Partnership)
art therapy
medications
respite
out of home placement

61. TAKE HOME MESSAGES
• Neglect has some of the worst outcomes for
children
• Child abuse that occurs in the context of family
relationships results in complex trauma
• Children who have a history of maltreatment
must be understood in a developmental
perspective
• It is important to formulate an understanding
with the lens of adversity and trauma

62. CONCLUSION
“The most beautiful people I've known are
those who have known trials, have known
struggles, have known loss, and have found
their way out of the depths.”
― Elisabeth Kübler-Ross

63. THIS WORK IS IN PART DUE TO
SUPPORT FROM A CIHR TEAM GRANT
"UNDERSTANDING HEALTH RISKS AND
PROMOTING RESILIENCE IN MALE
YOUTH WITH SEXUAL VIOLENCE
EXPERIENCE”
(PI: C. WEKERLE, GRANT # TE3-138302)
ACKNOWLEDGEMENTS: