Chapter

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

J.14

CHILD PROTECTION AROUND THE
WORLD
Gordon Harper

Gordon Harper MD
Associate Professor of
Psychiatry, Harvard Medical
School, Boston MA 02115, USA
Conflict of interest: nonereported
Acknowledgements: Comments
and suggestions from Kim
Ferrecchia-Rivas MSW LCSW,
Wynne Morgan MD, andJohn Sargent MD are muchappreciatedGirl with Balloon. BanksyThis publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the editors or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the editors or IACAPAP endorse their content
or recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2020. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Harper G. Child Protection Around The World. In Rey JM, Martin A (eds), JM Rey’s IACAPAP e-Textbook ofChild and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions
2020.

Child Protection

J.14

1

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental HealthT

his chapter reviews child protection. Child neglect and abuse and theirsequelae are discussed in other chapters of the textbook (e.g., ChapterB.1). Although child protection is often thought to belong to social
work, with variable connections to mental health, the healthy development ofchildren and youth is so shaped by the ways that we protect them—a central
responsibility of every human society—that child protection belongs to child andadolescent mental health as well. This chapter reviews how that responsibility has
evolved and the forms it has taken around the world, specifically:• How responsibility for the child, once belonging solely to parents, hascome to be shared with the larger society• The forms that child protection takes around the world for prevention,
detection, and intervention• How public knowledge and political processes interact to determine
what society does to protect children, and• Current opportunities to enhance child protection, especially byaddressing the child’s context, not just the child.

“Please sir, may I havesome more?” Oliver Twist,
Dickens

CHILD PROTECTION – NOT LONG AGO,UNDISCUSSED
How children and their development are seen has changed through history(see Chapter J.9). The story of those changes has itself been changing. Ariès(1960) argued that child development was not written about, much less a field ofstudy, until the last century or so. More recent historians (Orme, 2001) have citedearlier writings on child development going back at least to medieval times.
As to responsibility for children, until modern times, parents, with support
from extended family, enjoyed unchallenged oversight of their children, who wereseen as property, an economic asset (if they could work or be sold) or a liability (ifill or developmentally delayed). Children gradually acquired the features of adults
and were respected to the degree that they became like an adult. Responsibility for“bringing up” the child rested squarely with the parent. Gradually, in the last two
centuries, with urbanization and other social changes, a different view of the childemerged. Disadvantaged children, especially orphans, began to be sympatheticallyportrayed, as in the work of Dickens.
In addition, increasingly objective descriptions of developing children (asby Binet, in describing cognition) launched child development as a field of study.
Newspaper reporting of abandoned or abused children aroused public concern.
In response, community responsibility for children grew, extending beyond whatparents alone could provide. Informal community support, especially fromreligious organizations, was supplemented in the US and elsewhere by the creationof agencies like the Society for the Prevention of Cruelty to Children (founded a
few years after the creation of the Society for the Prevention of Cruelty to Animals).
A culture’s understanding that a child has needs, thoughts, and feelings
and is not just a blank slate (either evil, according to the doctrine of original sin;or good, like Rousseau’s noble savage), resembles what, in individuals, is called
mentalization. That is, people gradually have come to see children as having theirown legitimate experience, which could be understood by others.
In the 20th century, this sympathetic view of the child has been extended,gradually and incompletely, to children from disempowered and stigmatizedChild Protection

J.14

New York Society for thePrevention of Cruelty toChildren (1875)

2

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Healthgroups, including racial and ethnic minorities, the economically disadvantaged, andthose with stigmatizing conditions, like developmental differences, homelessness,
criminal history, or substance use.
Institutions for orphans and abandoned children gradually replaced“indenture” programs—under which orphan children were hired out to intact
families—and “orphan trains”, that carried such children to be raised by and towork for pioneer families on the United States frontier. Orphanages, in turn,were replaced by individual placement in foster homes. Laws gradually madeneglect and abuse punishable offenses. Support for child welfare came about
despite opposition, often moralistic, blaming the “undeserving” poor for theirown poverty, or expressing a fear that public support would decrease parents’motivation to work. Advocates of children’s rights often had to contend withadvocates of parents’ rights who resented what they saw as state intrusion in theirlives (Bartholet, 2020). In effect, entire systems of child protection were established(see Gordon, 2011; Myers, 2008).

Advocating for children’s
rights, Bulgaria, 1924

In the 20th century, children’s rights were defined and codified in declarationsof the rights of the child, by the League of Nations in 1924 and by the United
Nations in 1959 (see Chapter J.7, The United Nations Convention on the Rightsof the Child and Implications for Clinical Practice, Policy, and Research).
The recognition of child abuse in the 19th century was not just theresult of increased public awareness of children’s lives. It was also a response toincreased child vulnerability, when isolated nuclear families could not provideon their own the support that traditionally came from extended families. The
modern assumption that biological parents will meet all a child’s needs misses
the traditional role of community, especially extended families, in supplementing
what parents provide. Some argue that modern societies overestimate the extent towhich biological parents by themselves can meet all of their children’s needs, andthat child protection systems are a necessary result.

CHILD WELL-BEING AND HEALTHY DEVELOPMENT
Since the mid-19th century, healthy development has been seen to depend
on:
•
•
•
•
•
•
•

Economic well-being
Physical health, including nutrition
Education
Safety from neglect and abuse
Positive parenting
Support for self-care and advocacy
Special support for those with developmental differences.

As the definition of child well-being has expanded, so has the list ofadversities that threaten the child, namely:••••

Abandonment and lesser forms of neglect
Poverty and malnutrition
Child labor
Exclusion from schoolChild Protection

J.14

3

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

•
•
•
•
•
•
•
•
•

Physical abuse
Corporal punishment
Emotional abuse, including neglect, exposure to violence, harassment
and bullying
Sexual abuse
Child marriage
Ritual mutilation, especially female genital mutilation
Factitious illness imposed on another, also known as Munchausen by
Proxy or medical child abuse
Online abuse – bullying, sexting
Discrimination against members of a disempowered or minority group.

Children working in factory.
United States, 1920s

Not everything listed here is universally acknowledged as a threat to thechild. Attitudes to some practices, like corporal punishment, differ over time andbetween countries. Other practices, like child marriage, are even more controversial
and seen differently by different groups within the same country. For instance,some groups hold that some rites of passage, like female genital mutilation, arepositive experiences, enhancing connection to the group and to culture-specifictraditions.
The resulting debate puts on one side some who see “children’s rights” as a
new form of Western colonialism (Shweder, 2000). Others, including advocatesfrom within the communities where such practices have been traditional, havestrongly condemned such practices. This debate resonates both with the worldwide debate about women’s rights and their right to control their bodies and withcritiques of societies’ supporting or eroding social connection in general.
Such views have influenced the establishment of child protection laws.
Other cultural differences such as, in the US, fear of government control, haveslowed the implementation of protective services. For instance, nearly universal
child care was established in the US during World War II to allow women tojoin the workforce, but with benefit for the children. Once the war was over, theprogram, seen as a government takeover of a family responsibility, was stopped,leaving stressed families without that support.
Important in countering such fear of social supports were studies showing
the effects, short- and long-term, of adverse childhood experiences, including
neglect and abuse. Research like the Adverse Child Experiences Studies from the
US Centers for Disease Control and Prevention have demonstrated that experiences
like neglect and abuse, over decades, impair health and shorten lifespan.
Positive childhood experiences also make a difference. Along with theAdverse Childhood Experiences, ACES, some have developed a metric to assessusing Resilience Childhood Experiences, RCEs. And recent work shows the longterm protective effects of positive childhood experiences (Bethell et al, 2019).
RCES and ACES together comprise ICEs, Influential Childhood Experiences.
There are networks now devoted to informing the public of such knowledge
and of using it to guide policy (for example, Harvard’s Center on the Developing
Child). Newer research links early abuse to details of later health, like the featuresof adults’ hallucinations (Rosen et al, 2020).

Child Protection

J.14

The advocate Bogaletch
Gebre, whose sisterdied after female genital
mutilation, was herself asurvivor of female genital
mutilation (NYTimes, 17
November 2019).

4

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

The role of the environment of child and family is even more importantin child protection than in other areas of child mental health. The importance lies
both in causation – the higher rates of abuse and neglect associated with socioeconomic status and with ethnicity, for example – and in mediating prevention
and recovery interventions (as discussed below). Higher rates of abuse and neglect
are not intrinsic features of the affected groups, but reflect adversities, historicaland current.

CHILD PROTECTION: PREVENTION, DETECTION,ASSESSMENT, PLANNING, RECOVERY
These terms echo those used in public health. Primary prevention refers
to measures directed at an entire population; secondary prevention to measuresdirected to a subpopulation deemed at risk; and tertiary prevention helps those
who already have a condition, to support recovery and adaptation.

“Baby Doe” on a milk carton,part of an effort to identify achild whose body was foundin Boston Harbor in 2015

Prevention
Child protection starts with promotion of healthy development. Promotive
measures may be universal—applied to all children in a population—like universal
education or healthcare, a kind of primary prevention. In this line, for example,
Sweden, like other Scandinavian countries, has a “family service” child welfare
approach, as opposed to a narrower “child protection” approach that is common
in English-speaking countries. These two approaches are contrasted in Table B.3.1.
In the US, the swings of the pendulum between these two poles have been
traced by the historian Lepore in response to the discovery of the body of an
abused child in Boston Harbor in 2015, known only as “Baby Doe” for weeks
before she was identified (Lepore, 2016).
For all children, measures used to promote healthy development include
income support, prenatal and postnatal care, parental leave, preschool education,and measures to prevent and respond to domestic violence.
Schoolteachers are often the first to recognize the signs of abuse or neglect
and to report them. Some systems have curricula devoted to child protection, toinform children about mental health, and the possibilities of neglect, abuse, ormolestation.

Detection
For children suspected or recognized to be at risk, detection may take theform of mandated reporting, one of the most widely enacted forms of protection.
Detecting and reporting child abuse became a responsibility of physicians (andother professionals) in the US in the 1960s. A pediatrician, Kempe, and colleagues(1962), drawing on clinical experience, including radiologists’ recognition thatchildren with repeated fractures might have inflicted injuries, reported theirfindings under the provocative title, “The Battered Child Syndrome.” Withina decade, nearly all US States enacted laws requiring professionals (medical andothers) to report to protective services any child whom they even suspected might
be at risk of abuse or neglect. While mandated reporting was accepted decades ago
in North America, it became a requirement of medical practice much later in othercountries, for example, in Germany.

Child Protection

J.14

To protect children withdifferences, a schoolbased program in the
US, “Understanding ourDifferences,” promotes
acceptance. Brian
Heffernan, a guest
speaker, reviews his schoolpresentation with his mother.
Boston Sunday Globe, 17
November 20195

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

Table B.3.1. Orientations to child protection*
Characteristic

Child protection

Family support

Goal

Protecting children from harm

Supporting families with social,economic and psychological difficulties

Entry to services

Single entry point; report or notificationby third party

Range of entry points and services

Basis of government
intervention andservices provided

Legalistic, investigatory, in order toformulate child safety plans

Supportive or therapeutic responses
to meeting the needs of children andfamilies or resolving problems

Place of services

Separated from family support services

Embedded within and normalised bybroad child welfare or public healthservices

Coverage

Concentrates on families at risk

Universal

Service approach

Standardised procedures; rigid
timelines

Flexible to meet clients’ needs

State-parent
relationshipOften adversarial

Partnership, relationship-based

Role of the legal
systemOften adversarial

Last resort; informal

Out-of-home care

Mainly involuntary

Mainly voluntary*Adapted from Price-Robertson et al (2014)

Assessment
Reporting is followed by investigative assessment, in which child protection
workers may have authority to access information, including health information,otherwise considered private. How such assessment is done varies greatly, ranging
from the use of standard clinical assessments borrowed from other clinical fields
to the use of formats specially designed for assessing risk. Investigation may
include review of police response to homes, contact with clinical providers,school personnel, extended family, and other state agencies. Systematic review
of assessment has shown predictable cognitive errors based on overly simple
assumptions, recognition of which can decrease these errors (Munro, 1999).
Assessment is challenging, starting with the child. Whatever the basis for a
protective report, the child may show (or feel, but not show) a variety of responses,
including confusion and emotional distress at intruders’ entry into family life, on
the one hand, and relief that a desperate situation has been recognized, on theother.

Child Protection

J.14

6

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

Regardless of how the child understands the situation, they may show
various symptoms, largely post-traumatic:
•
•
•
•
•
•
•

Emotional dyscontrol to the point of tantrums
Meanness to others
Failure to care for self or protect oneself
Self-injury or suicidal threats or behavior
School failure, with possible changes in language processing or learning
profileEmergent depression or other mood disorder
Emergent psychotic disorder

The assessment of the child considers several mental health possibilities:•••

A reaction to trauma and removal, needing understanding and support
from foster parents and protective workers, and likely to subside withtime
A similar reaction, but less likely to subside, needing mental healthsupportA major developmental or mental health condition, needing
consultation and referral.

This assessment is addressed in a Practice Parameter developed by theAmerican Academy of Child and Adolescent Psychiatry (Lee et al, 2015).
Hearing the child is an essential, but challenging, part of the assessment.
Without talking with the child, serious injuries or death can occur when theadult’s report is taken as the basis for dismissing a protective report (as shownin the documentary “The Trials of Gabriel Fernandez”). Abused children, like
adult victims of domestic violence (Snyder, 2019), may have difficulty finding
their voice, masked by:•••

Fear for their own safety, especially if they fear they will be identified as
the reporter or the one confirming the abuse
An ambivalent relationship with the perpetrator (for example, needing
as well as fearing); or
Feelings of guilt – blaming themselves for what has happened.

The effect of a clear statement of what has happened is powerful. Such astatement gives the child the sense of being heard and affirms that abuse is not thechild’s fault. As one youth posted in response to the video “ReMoved”, “It’s quiteamazing, because usually I feel like no one gets what happened.”
Hearing the child’s voice is facilitated, using developmentally appropriate
language, by:••••Interviewing the child in a safe place
Taking time
Acknowledging a problem (“We’re here because some things have notgone well…”)
Reinforcing the feeling of safety and value with statements like, “We’reinterested in hearing your experience, which sometimes is difficult,even scary. But our first goal is keeping you safe. You deserve that”

Child Protection

J.14

7

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

•

•

•

•

•

Considering the use, at least at the start, of impersonal language(“Often, people have trouble…” or, “Sometimes, children are confused
about…”), rather than personal language (“You…” or, “Your motheror father…”)
Acknowledging the possibility of guilt, and offering relief (“Whenthings go badly, children often blame themselves, feel that the trouble
is their fault. We don’t see it that way.”)
Acknowledging ambivalent relationships (“Parents sometimes care a lot
about their children, but things get in the way of taking good care…
We want to help kids stay in touch with parents, maybe even stay withthem, while we help with those problems.”)
Speaking respectfully but candidly about parents (“While a mother/father may care a lot about a child, sometimes they have troubles
with…”)
Acknowledging partnership in working toward a goal (“We want towork together with your mother/father to make things better. We’ll see
how that goes. Meanwhile , the plan for right now…”)

Assessing the parents and family is also challenging. Attitudes to parents
vary. At one time, parents were often seen as offenders, not as people needing
support (Bourne & Newberger, 1979). Today, most protective services aim toprovide a sympathetic and supportive relationship, in which shared planning forthe child can occur. Moving beyond the era when professionals spoke and families
listened, many now encourage the family to start the planning process by stating
their needs. Family-friendly language is used, as opposed to professional jargon.

IICAPS illustrates
that family-driven carecan give voice to families
as well as professionals.
As professionals listen
to the family’s needs
and plans, they havein mind a model of how
problems are transmitted
across generations,a model in which
attunement, attachment,
and mentalization playa part. Thinking thisway, they both support
the family and have a
way of understanding
mechanisms that
contribute to problems
and that, mobilized
appropriately, canpromote recovery.

This approach is used by in-home therapy services in the US like Intensive
In-Home Child & Psychiatric Service (IICAPS) in Connecticut (Woolston et al,2007). This approach is also described in Allen (2018). The team, as it develops
a plan for each family, can also gather data showing how differences in attachment
and mentalizing mediate the transmission of trauma across generations (Stob et
al, 2019).

Planning
Assessment leads to a decision: either to rule out that abuse or serious
risk of abuse is occurring or to substantiate (support) the report. If the report
is supported, the next decision is whether the child can remain with parent(s) orneeds to be relocated to a safe setting.
Here the protective pendulum has swung widely. It was once assumed thatthe abused or neglected child needed, first of all, to be separated from the family.
More recently, the negative consequences of such automatic relocation have beenrecognized. These include loss of connection with birth relatives, relationships thatfor many protected children remain important, and repeated broken attachments
sustained when living in a series of foster or group homes. In addition, evidence
for lasting benefit from treatment away from parents has been weak (Lewis et al,1980). A contemporary approach is reflected in the document Foster Care – a Path
to Re-unification, from the US Children’s Bureau (2019).
Recognizing the child’s need to sustain a relationship with the biologicalparents has led others to develop ways to find previously unrecognized familyChild Protection

J.14

8

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Healthresources in order to support children’s ties to the family and keep them out of
substitute—and often, temporary—care with strangers. Such efforts include the“Family Finding and Permanency” work started by Kevin Campbell in Australia(see box) and, in the US, “the Urgency of Permanency” started at the Walker
Program in Massachusetts.
The variety of forms that protection can take is summarized in Table B.3.2.
Striking the balance between these two goals – effective protection and supporting
and using ties with primary family – remains a challenge for child protection.
When risk to the child is acute and severe, protective services may seek custody.
Protective custody may be obtained immediately but will usually entail court
proceedings at some stage.
When data are ambiguous, neither confirming risk nor allowing dismissalof protective concerns, the ambiguity may be managed by developing a provisionalplan, starting with acknowledgement of uncertainty and stipulating criteria
to be used, after a period of observation, to further define or rule out the needfor intervention (Harper, 2016a). Although support may start with change ofparenting or of residence, it often includes mental health treatment and special
education services as well.
“In-home support” takes many forms:
•
•
•
•
•

Economic support
EducationPeer support
Treatment
Jointly developed “safety plan”

Family Finding
and Permanency:
Current Projects
The Path Out ofFoster Care Crisis
Runs ThroughFamilyBy Kevin Campbell andJill Borgeson.
An article on thelanguage of family
finding evolving in
response to years oflearning from practiceand research.
Family Finders
Helping Vulnerable
WA Kids
By Kate Campbell.
An article on Kevin’s
work in Western
Australia.
Good Business, Real
Results: Time for
Radical Change inChild Protection
By Kevin Campbell.

Providers – biological kin or foster parents – must demonstrate:•••

Trauma awareness
Mature impulse control and
The ability both to understand the child’s experience and to help thechild understand what has happened, including the effects of relocation.

All of these should provide safety and nurturance for the child recoveringfrom abuse or neglect. They should also provide what children need for long-term
recovery and growth. For the child removed from the family home, out-of-homecare may take the form of:•••“Kinship care”, foster care, residential care (see Table B.3.2)
Relationship support—with the family of origin, with relatives, withpeers, with co-survivors in recovery
Mental health care, which may include psychotherapy and psychoactive
medication—psychoactive medications are more often prescribedfor children in protective custody than for their peers (see below;
overprescribing is also addressed in a guideline from the American
Academy of Child & Adolescent Psychiatry).

A substitute caregiver must be screened for criminal or legal history and riskof domestic violence, physical or emotional. Kinship care has the advantage offamily connection, but must provide safety not available with the child’s original
family. Prospective foster parents (possibly a person known to the child but notChild Protection

J.14

9

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

Table B.3.2. Recovering from Abuse or Neglect
WHERE IS THE
CHILD?

IN-HOMESUPPORTKINSHIP CARE

FOSTER CARE

LOCATION

In familiar home,with parents

In home withrelatives

In a new home, withnew (foster) parents

ALONG WITH

Often, usual family
members

Relatives, family
members, maybe
siblings

RELATIONSHIP
WITH PARENTS

Continues, but
hopefully withchangeUsually kept up by
visitsMay or may notcontinue

May or may notcontinue

RELATIONSHIP
WITH SIBLINGS

Continues

Usually kept up, byvisits if not living
together

May or may notcontinue

May or may notcontinue

THE CHILD IS
PROTECTED
THROUGH

Intensive in-homesupports: parent
aides, behavioral
coaching, indicatedmedical care

Change ofcaretakers

ADVANTAGESOF THIS MODE
OF CARE

Maintains key
attachment
relationships

Maintains family
relationships, even
if not living withparents

Fresh start with new
family, relationships

Sometimes, only careavailable

No guarantee ofchangeRisk of frequent
Not always available
changes; loss of new
or acceptableattachments“Institutional” care; noclose relationships
replacing parents;
weak evidence of
lasting effectivenessDRAWBACKS OF
THIS MODE OF
CARERESIDENTIAL
CARE
In a group setting,designed both tohouse and to heal

Foster parents andProfessional staff andtheir children, maybe
other children
other foster children

Change of caretakers Change of caretakers

related, like a teacher, friend of the family, child’s friend’s family, boy or girl scout
leader etc.) must be screened as well. As stated above, re-unification with the familyof origin may or may not be a goal – the challenge is to balance the contrasting
goals of “rescue through separation” and of “supporting connections”.
Talking Recovery
Wherever the child lives, various kinds of support aid recovery. Support
starts by informing the child of what is happening, a difficult but importantconversation. In a developmentally appropriate way, one aims to:•••

Respect the child’s view of their needs (which may or may not include
recognizing that they need protection)
Let the child know that they are not to blame for what has happened,
andGive concrete information about the next steps.

One must affirm the child’s need for protection – that the current parent(biological or not), despite strengths and some degree of devotion to the child, has
not been meeting the child’s needs – and outline what will happen.

Child Protection

J.14

Immediate protection
The need for immediate
protection arises, forexample, when a mothertwo weeks post-partum
has a depression withcommand hallucinations tokill the baby. The protective
team, with mental healthconsultation, makes an
emergency assessment (thechild is at acute, immediaterisk) and plan to ensure thechild’s safety.

10

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental HealthGirls Educational &Mentoring. GEMS’ unique
Victim, Survivor, Leader ™
program model is the gold
standard for organizations
serving trafficking victims
and survivors across thecountry and GEMS trains
thousands of professionals
every year on its bestpractices.

Recovery must also take a longer view of outcomes. A short term view
focused on “stabilization” or absence of repeat injuries in the short term is notenough. For example, serial foster placements, as noted above, fail to provide
the child with lasting connections. In this way, outcomes in child protection,
as in other areas of child mental health, go beyond the framework called the“Triple Aim” (patient experience, population health, per capita cost), thatis widely used in evaluating health care. In child mental health, the goals arebroader: health (physical, developmental, relationship) over the longer term of thechild’s development; patient experience that includes both child and parent; andcosts beyond healthcare to include costs in mental health, education and special
education, juvenile justice, and social services.

Recovery communities
For all children, but especially for those recovering from conditions thathave included social isolation and shame, finding and growing with a recovery
community is a key part of recovery. These recovery communities may be generic(youth associations) or specifically aimed at recovering groups. Two examples oforganizations that support recovery in adolescent girls and young women who
have suffered commercial sexual exploitation are “My Life, My Choice” and “Girls
Educational & Mentoring Services” (GEMS).
In many countries, child protection is made more difficult by the existenceof “silos”: locating protection services in parallel agencies not responsible to eachother and sometimes not even communicating. For instance, in most States in
the US, children’s services are divided between education, health, mental health,social service, and juvenile justice. Isolation from other agencies may be moreprevalent in child protection services than in other public services. Such isolation
was one of the system failures identified in the documentary “The Trials of Gabriel
Fernandez,” about the death of a child in Los Angeles who had been reported
as needing protective supervision. For families who already have to deal withfragmented lives, separation of services in this way makes recovery more difficult.

IMPLEMENTING SERVICES: KNOWLEDGE TO
PRACTICEAs discussed in the child and adolescent mental health policy chapter ofthis Textbook (J.6), public programs result from the interaction of knowledge
base, political will, and political strategy. In healthcare, the term “implementation

Child Protection

J.14

11

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Healthscience” is now used for translating knowledge of what can be done into widespreadpractice (Bauer et al, 2015). Child protection—at the intersection of media
reporting (sometimes inflammatory), public opinion (sometimes sympathetic andsometimes stigmatizing), and the political process—illustrates this interaction.
In the US, for example, increasing publicity about abandoned and abusedchildren, coinciding with a political administration determined to act on longrecognized social problems, led in the first decade of the 20th century to thefounding of the Federal Children’s Bureau, the passage of the “first State laws” toprevent abuse and neglect, and the convening of the first national conference on
the needs of children. But a generation elapsed before federal support to the States’
children’s services included money, in response to economic depression and an
administration committed to social support. This support became known as “Aidto Families with Dependent Children” (Murray & Gesiriech).
The vulnerability of those services to public opinion and political pressure
was shown again in the 1990s in the US, when an administration largely seen
as progressive, responding to negative characterization of welfare payments
as encouraging dependency, terminated the “Aid to Families with DependentChildren Program”, replacing it with “Temporary Assistance to Needy Families,”
which included work requirements for mothers. Consequences of this more
restrictive support program were often negative.

In 1960, an incident
illustrated the relationshipbetween publicity andpolicy change. A State in
the US terminated welfare
payments to families whena child was born out of
wedlock, breaking a State
rule. Resulting publicity
and public outrage led to an
administrative decision, later
supported by legislation andthe courts, that the States
could not simply ceaseservices for needy families
for breaking such a rule –the State had to develop
other services.

The effect of political change has also been evident in support of research on
child abuse and neglect by the US National Academy of Sciences. After a report in1993 called for new research, a follow up report two decades later reviewed the costsof child abuse and neglect and made ambitious recommendations regarding the
research base (“New Directions in Child Abuse and Neglect Research”). But witha change in administration two years later, not only have those recommendations
faded from view, but research on child abuse and neglect no longer appears on theagenda of the National Academy of Sciences.
Public knowledge about child protection is also informed by investigative
journalism. Exposés appear both in print and screen media. For instance, in theUS, an investigative report in a newspaper documented the story of a child whosustained many changes in foster and pre-adoptive placements, as reunification
with biological parent was endorsed and then discarded as a goal (Lazar, 2019b).
A television documentary, “The Trials of Gabriel Fernandez,” mentioned above,
recounted not only the torture and abuse that led to the death of an 8-year-old,but the failed processes in the protective system. These resulted in indictments ofsocial workers as well as of the child’s mother and her partner.
Shortcomings identified in such investigative reporting illustrate the paththat leads from knowledge of abuse and neglect, through detection and reporting,to protective intervention. Obstacles on this path include:

Problems in program design:••

Failures in striking a balance in mission between protection throughseparation and family reunification
Conflicts of interest, for instance when providers contracted to provide
services are incentivized not to take protective actions that will increase

Child Protection

J.14

12

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health•••expenses and would “fail the mission”—i.e., decrease the rate of family
re-unification, if that is the (cost-saving) goal
Other conflicts of interest, for instance between contractors andgovernment officials responsible for contracting
Administrative pressures to meet quantitative goals, like the use of
expensive out-of-home placements, resulting in failure to provide
protection
Failure to acknowledge and counteract social, economic, and ethnic
disparities.

Problems in implementing programs:
•

•
•

•

Inadequate human resources, such as understaffing (in the US, agencies
have been sued for having caseloads greater than 30 cases per worker),and the assigning of less trained workers to challenging positions
without adequate support (as in “The Trials of Gabriel Fernandez”)
Failure to follow established policies, like documenting sites of repeatedinjuries, or monitoring the activities of frontline staff
Failure to monitor policy consequences, for instance, when family
reunification is promoted for clinical and budgetary reasons but without
tracking the outcomes needed to assess the effects of such policy
Failure to help child-serving agencies work together by countering thefrequent isolation of those involved in child protection.

A challenge needing emphasis in protective services is stress on workers,
which needs acknowledgement and special support. Workers in other fields areoften protected from physical hazards, like exposure to harmful chemicals. Among
healthcare workers, the psychological burden of stress and unreasonable work
schedules are recognized. But for workers in protective services, acknowledgementof the stresses they routinely encounter, starting with secondary trauma, is muchless common. This challenge, identified historically (Copans et al, 1979) andrecently (Rakoczy, 2009; Child Welfare Information Gateway), is still missing
effective, systems-wide response.
For this and other challenges, one solution offered is to establish an
independent oversight body (Lazar, 2019a). In Los Angeles, after the tragedy
reported in “The Trials of Gabriel Fernandez” documentary, an independent Child
Protection Board was established, but without the recommended authority or
funds.
Another remedy would be to create in child protection the culture that hascontributed to quality and safety in healthcare and in other industries. For instance,in the US, while the Federal government supports children’s services in dozens ofStates, outcomes are examined and analyzed in only a handful. Evaluations tracknumbers participating and access to services, but give less attention to functional
outcomes, let alone what can be learned from such reviews. This difference seems
to arise from the isolation of child protection from other areas of healthcare, fromunderfunding of services for people from ethnic minorities and backgrounds ofpoverty, and especially for evaluation of such services, and from political reluctance
to examine too closely a politically sensitive area of practice (Harper, 2018).
Implementation of a culture of quality improvement in child protection
entails:
Child Protection

J.14

13

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health•••

A commitment to review adverse events from a systems point of view,not a personalized approach that strives to find a person to blame
After adverse events, regular review conferences for teaching andlearning, protected—like medical reviews—from “discovery” andSupport structures for vulnerable front-line workers.

Some of these activities are carried out by organizations like “Zero Abuse
Project”, which, through consultation and training to child-serving agencies, aim toenhance protection by engaging people and resources through a trauma-informed
approach of education, research, advocacy, and technologies that strengthen
investigations, expose abusers, and provide survivors with pathways to recovery.

MOVING AHEAD: CHILD PROTECTION MEANSLOOKING AT THE CONTEXT, NOT JUST THE CHILD
AND PARENTS
Easily overlooked when the child has acute needs, the child’s context(beyond the family) must be addressed to decrease risk, both to the index childand to children in general. Some aspects of context bear on the situation of thechild and family:•••

Socio-economic status, especially poverty, powerfully influences childoutcome. Although higher rates of abuse and neglect are well known
to be associated with poverty, income disparities and the legacy of racialand ethnic discrimination are often omitted from discussions of childprotection. An exception is The Harlem Children’s Zone, a project thatprovides economic, nutritional, and educational support to an at-risk
population of children, starting in early childhood. While reducing
educational disadvantage, not abuse or neglect, is the primary goal,child safety is enhanced as well
Historical and current discrimination, especially against ethnic andsexual minorities, enhances risk. Dedicated advocacy groups, likethose found at www.twloha.com‎, www.strongfamilyalliance.org, andwww.ncai.org, provide support for such youth
Generational context.
As mentioned above, transgenerationaltransmission of trauma is addressed by programs like IICAPS.

Aspects of Context that Bear on the Ways We Provide
Services
How are our services organized?

•

The isolation of many child protection services from other child-serving
agencies has been mentioned above. Long-term child well-being, as well as morale
among child protection workers and cost efficiency, argues for bringing these
services together. Some States have reorganized child-serving agencies into a single
agency to promote that goal.

•

Medication – can we prescribe in context?
In the US, prescription to children in public custody of more psychoactive
medications and in higher doses than those prescribed to their peers has promptedChild Protection

J.14

Do you havequestions?
Comments?

Click here to go to the
Textbook’s Facebook
page to read texbook
news, share your views
about the chapter withother readers, question
the authors or editor
and make comments.

14

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental HealthFederal oversight, in particular a requirementthat States implement oversight and management
programs for such practice. This is a striking
example of context: it is not a feature of the children
themselves, but of the lack of coordination of
medication prescription with other aspects of child
service and the lack of State oversight of prescribingthat result in such high levels of prescription.
In a simplified model, central nervous
dysfunction produces symptoms that lead (usually)a medical practitioner to make categorical diagnoses
and then to prescribe agents aimed at the central
nervous system. A comprehensive model would
include more of the context. For instance, in thechild:• The developmental stage• Intrapsychic factors• The child’s self-understanding• Understanding of their symptoms andalliance with treatment.
In the doctor, factors are relevant like:
•
•
•
•
•
•

Experience level
Role in the treatment system
Relationships and coordination withother therapists
Scope of “evidence” to be considered
Relationship with the child andRelationship with parent/guardian.

Such a larger, contextual view is advocated in the Recommendations fromthe American Academy of Child and Adolescent Psychiatry (2015); see also Harper(2016b).

Beyond Talk – How Can We Use Non-Verbal Media?
In child mental health, it is always worth looking for opportunities touse play, music, theater, and social connections. But this is especially true when
dealing with a population for whom language may not be a strength, like children
recovering from abuse and neglect. That difference may be constitutional or an
acquired liability – related to the abuse and neglect and to trauma, or interrupted
connection with those with whom children first use language.

A creative use of recovery
narratives presented apopular movie, “Antwone
Fisher,” about a soldier,survivor of early abuse andneglect, getting help fora breakdown while in theservice. He later meets
his long-lost mother, still
struggling with addiction.
The movie was shown in a
fancy theatre to an audienceof children in public custody,
most of whom had neverseen adverse experiences
like theirs told as a recovery
story and presented in sucha celebrated setting.

Relevant here are domains not often considered, like art, play, and the
media. A silent and guarded child may come alive when a silent and guarded childhears a song or a story, or watches a movie that make a connection where words did
not suffice. A striking example was the use of a popular movie—”Antwone Fisher,”featuring a famous African-American actor, about a soldier with a traumaticbackground—shown in a fancy downtown theater full of children in State custody.
Such an event, in a high-prestige setting, sharing openly a narrative otherwise
hidden by shame, uses play and story-telling to open up the path to recovery.
Child Protection

J.14

15

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
Allen JG (2018). Mentalizing in the Development and Treatment
of Attachment Trauma. New York: Routledge.

Harper G (2018). Toward evaluation in human services: Getting
past the barriers. Psychiatric Services 69:228-230.

American Academy of Child and Adolescent Psychiatry (2015).
Recommendations about the Use of Psychotropic
Medications for Children and Adolescents Involved inChild-Serving Agencies.

Jones CM, Merrick MT, and Houry DE. “Identifying
and preventing Adverse Childhood Experiences:
Implications for Clinical Practice.” JAMA 2020;
323:25-26.

Adverse Childhood Experiences (ACES). Centers for Disease
Control and Prevention

Kempe CH, Silverman FN, Steele BF et al (1962). The batteredchild syndrome. JAMA 181:17-24.

Ariès P (1960). L’Enfant et la vie familiale sous l’Ancien regime.
Paris, Plon (translated as Centuries of Childhood: A
Social History of Family Life. Centuries of Childhood.
London: 1962)

Lazar K (2019a). Overhaul foster care reviews, say advocates.
Assert independent agency could boost accountability.
Boston Globe, 23 April.

Bartholet E (2020). Contested child protection policies, inDwyer J G ed, The Oxford Handbook of Children andthe Law. Oxford University Press, New York.
Bauer MS, Damschroder L, Hagedorn H et al (2015). An
introduction to implementation science for the nonspecialist. BMC Psychology 3:32. https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC4573926/
Bethell C, Jones J, Gombojav N et al (2019). Positive
childhood experiences and adult and relationshiphealth in a statewide sample: Associations acrossadverse childhood experiences. JAMA Pediatrics.
DOI:10.1001/jamapediatrics.2019.3007.
Bourne R, Newberger EH (1979). Critical Perspectives on Child
Abuse. Lexington MA: D C Heath
Center for the Developing Child, Harvard University. Applying
the science of child development in child welfare
systems. https://developingchild.harvard.edu/
resources/inbrief-the-science-of-neglect-video/Child Welfare Information Gateway. Burnout, Compassion
Fatigue, and Secondary Traumatic Stress. https://www.
childwelfare.gov/aboutus/Children’s Bureau (2019) Report on Foster Care – a Path toReunification.
Copans S, Krell H, Gundy JH et al (1979). The stresses oftreating child abuse. Child Today 8:22.
Declarations of Children’s Rights: at http://www.un-documents.
net/gdrc1924.htm and athttps://web.archive.org/web/20130926070812/http://www.
un.org/cyberschoolbus/humanrights/resources/child.
asp
Gordon L (2011). Child welfare: A brief history. Social Welfare
History Project.
Harper G (2016a) Decreasing ambiguity in child protection.
Journal of American Academy of Child & Adolescent
Psychiatry 55:349-350.
Harper G (2016b). The Prescriber in Context: developmental
and institutional context. Presented at Annual
Meeting of American Academy of Child andAdolescent Psychiatry. Available on request.

Child Protection

J.14

Lazar K (2019b). She’s been bounced through more than adozen foster homes. And she’s just 6. Boston Globe.
24 August.
Lee T, Fouras G, Brown R et al (2015). Practice parameter forthe assessment and management of youth involved
with the child welfare system. Journal of the American
Academy of Child & Adolescent Psychiatry 54:502-517.
Lepore J. Baby Doe. The New Yorker, 1 February 2016.
Lewis M, Lewis DO, Shanok SS et al (1980) The undoingof residential treatment: A follow-up study of 51
adolescents. Journal of the American Academy of Child
Psychiatry 19:160-171.
Murray KO, Gesiriech S (not dated). A Brief Legislative
History of the Child Welfare System. https://www.
masslegalservices.org/system/files/library/Brief%20
Legislative%20History%20of%20Child%20
Welfare%20System.pdf
Munro E (1999). Common errors of reasoning in childprotection work. Child Abuse & Neglect 23:745-758.
Myers JEB (2008). A short history of child protection in
America. Family Law Quarterly 42:449-463
New Directions in Child Abuse and Neglect Research. National
Research Council 2014. Washington, DC: The
National Academies Press.
Orme N (2001). Medieval Children. New Haven: Yale
University Press.
Price-Robertson R, Bromfield L, Lamont A. International
Approaches to Child Protection. What can Australia
learn? CFCA Paper No. 23 — July 2014
Rakoczy S (2009). Compassion Fatigue in Child Welfare. The
New Social Worker.
https://www.socialworker.com/feature-articles/practice/
Compassion_Fatigue_in_Child_Welfare/“Removed” video available at https://www.youtube.com/
watch?v=lOeQUwdAjE0
Rosen C, McCarthy-Jones S, Chase KA et al (2020). The roleof inner speech on the association between childhood
adversity and ‘hearing voices’. Psychiatry Research 286.
doi.org/10.1016/j.psychres.2020.112866
Shweder R (2000). What about “female genital mutilation”?
And why understanding culture matters in the firstplace. Daedalus 129:209-232.

16

J M Rey’s IACAPAP Textbook of Child and Adolescent Mental Health

Snyder RL (2019. No Visible Bruises: What We Don’t Know
about Domestic Violence Can Kill Us. New York:
Bloomsbury.

Woolston JL, Adnopoz, JA, Berkowitz SJ (2007) IICAPS: A
Home-Based Psychiatric Treatment for Children andAdolescents. New Haven: Yale University Press.

Stob V, Slade A, Brotnow L et al (2019). The family cycle: An
activity to enhance parents’ mentalization in children’s
mental health treatment. Journal of Infant, Child &Adolescent Psychotherapy 18:2 DOI:10.1080/15289168.2019.1591887.

Zero Abuse Project: Fighting Child Sex Abuse. Available at www.
zeroabuseproject.org“The Trials of Gabriel Fernandez” available at https://www.
netflix.com/title/80220207

Child Protection

J.14

17