IACAPAP Textbook of Child and Adolescent Mental Health

Section B
PERINATAL AND EARLY
CHILDHOOD RISK AND PROTECTIVE
FACTORS & DISORDERS

Associate Editors: Sarah Mares & Louise Newman

Photo: Peter Klashorst, Wikimedia Commons

IACAPAP Textbook of Child and Adolescent Mental Health

INFANT PSYCHIATRY

Chapter

B.1

EARLY MALTREATMENT AND
EXPOSURE TO VIOLENCE
Susan MK Tan, Norazlin Kamal Nor, Loh Sit Fong,
Suzaily Wahab, Sheila Marimuthu & Chan Lai Fong

Susan MK Tan MD (UKM),
DCH (London), MMed
Psych (UKM), Adv.M.Ch.
Ado.Psych (UKM), AM
Child & Adolescent Psychiatrist,
Department of Psychiatry,
Universiti Kebangsaan
Malaysia Medical Center, Kuala
Lumpur, Malaysia
Conflict of interest: none
declared

Norazlin Kamal Nor
MRCPCH(Lon), MBBS(Lon),
BSc(Lon)
Paediatrician, Departmentof Paediatrics, Universiti
Kebangsaan Malaysia Medical
Center, Kuala Lumpur,
Malaysia
Conflict of interest: none
declared

Loh Sit Fong B Eon(Kobe),
M Clin Psych (UKM)

ChildrenPlaying
LondonBridge,Psychologist , Departmentof Psychiatry, Universiti
Kebangsaan Malaysia Medical
Center, Kuala Lumpur, Malaysia

by William H.
JohnsonConflict of interest: none
declaredThis 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 Editor 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 Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2012. 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. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: Tan Susan MK, Kamal Nor N, Loh SF, Wahab S, Marimuthu S, Chan LF. Early maltreatment and exposure toviolence.. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Childand Adolescent Psychiatry and Allied Professions 2012.

Child maltreatment

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IACAPAP Textbook of Child and Adolescent Mental HealthChildren need a safe and secure environment that they can call home.
Besides providing shelter, home needs to be a place of both physical andemotional safety where children can find comfort, protection and security.
Thus, optimum development depends on the interaction of positive environmental
influences and inherent genetic disposition starting even prenatally (Shonkoff etal, 2000). Negative experiences at an early age have been shown to have long term
consequences for children, including changes in brain structure (National ScientificCouncil on the Developing Child, 2004). These stressors are not necessarily justphysical insults such as injury or infection; psychological or emotional ones areequally “toxic” for the process of growing up healthily, especially if there are no
supportive adult attachment figures to help the child buffer the stress. Whenthe immediate environment in which a child lives – his home – becomes a “warzone” with verbal and physical aggression, the suffering of the child is not only
limited to the point in time when it occurs but has repercussions for the rest of hislife. Research has shown that exposure to violence in the household has a lastingdevelopmental impact (US Department of Health and Human Services, 2003).
In this chapter the term “child” is used for human beings aged less than 18 years,“he” is used to describe both girls and boys and “parent” is used to describe parents,
carers, guardians and other individuals who have parental responsibilities.

HISTORICAL NOTEDr Henry Kempe created the terminology and concepts which are now
universally recognized. The “shaken baby syndrome” was identified in1972
by American pediatrician and radiologist John Caffey (American Academy of
Pediatrics, 2001). However, it was not until the 1970s that sexual abuse began tobe acknowledged and the 1980s and 1990s that emotional abuse was recognized.

CHILD MALTREATMENT
The definition (see Table B.1.1) of child maltreatment varies acrosscontinents and cultures but the focus is on similar salient points, which are:• Ill treatment (i.e., the opposite to nurturing)• The potential to cause harm to the child, including threats to harm as well
as neglect (failure to provide the basic necessities required for normal
development)• It usually involves parents or other people in the context of a relationshipof responsibility, trust or power (this includes teachers, religious leaders
etc.)•

Suzaily Wahab MD(UKM),
MMed Psych (UKM)
Psychiatrist, Departmentof Psychiatry, Universiti
Kebangsaan Malaysia Medical
Center, Kuala Lumpur, Malaysia
Conflict of interest: none
declared

Sheila Marimuthu
MBBS(Cal), MMed
Paeds(Malaya)
Paediatrician, Department ofPaediatrics, Hospital Kuala
Lumpur, Malaysia
Conflict of interest: none
declared

Chan Lai Fong MD(UKM),
MMed Psych (UKM)
Psychiatrist, Departmentof Psychiatry, Universiti
Kebangsaan Malaysia Medical
Center, Kuala Lumpur, Malaysia
Conflict of interest: none
declaredAcknowledgements: Our thanks
to Ms Madeleine Yong and Ms
Lois Engelbrech, Founding
Director s of Protect and Save
the Children (PS the Children)
Malaysia for their contribution.
Also to Dr Irene Cheah forreviewing the draft, Ms Siti
Haidah Mohd Ijam and Ms
Siti Suraya Mansor for theirsecretarial help

Exposure to (witnessing) violence, especially between parents.

In 1873 animals had rights but children did not
In 1873, a church worker, Mrs Etta Wheeler, who had been asked to visit the family, found a 9 year-old-girl, Mary-Ellen,
shackled to her bed, grossly malnourished, scarred and badly beaten. Mrs Wheeler was so appalled by what she saw that she
went to the authorities to report this horrifying child abuse.
The authorities turned her away. Mrs Wheeler refused to take no for an answer and petitioned the American Society for thePrevention of Cruelty to Animals (ASPCA). She was appalled that animals were protected but children were not. Mrs Wheeler
appealed to the ASPCA that children were members of the animal kingdom and must therefore be protected. It was on thesegrounds that the ASPCA did finally intervene. Mary-Ellen was removed from her abusive home and placed in foster care,
where she thrived. She went on to marry, have 2 daughters, and lived to the age of 92.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table B.1.1

The various types of child abuse*

Physical abuse

Physical harm or injury

Neglect/negligent treatment

Failure to provide for a child's basic needs anddevelopment in all spheres

Emotional abuse

Failure to provide a developmentally appropriate,
supportive emotional environment which results in
impairment of a child's emotional development or senseof self-worth

Sexual abuse

The involvement of a child in sexual activity that he (byvirtue of his age or stage of development):•
Does not fully comprehend•
Is unable to give informed consent to•
Is not developmentally prepared for.
Sexual abuse may be by adults or children who are in aposition of responsibility, have obtained children’s trust,or have power over the victim.

Exploitation

The use of the child in work or other activities for the
benefit of others, for financial gain, e.g., child labor.

*World Health Organization and International Society for Prevention of Child Abuse andNeglect (2006).

The “father” of childabuse
Serendipitously, the adventof radiology, took the
diagnosis of child abuse
to a new level. Dr Henry
Kempe, a US pediatrician,used X-rays to prove nonaccidental injuries in alarge number of children
admitted to his care. The
X-rays changes of old
fractures and abnormal
skeletal changes led to theidentification and official
recognition of physicalabuse and child neglect
by the medical community
through his seminal
work “The Battered Child
Syndrome” bringing theissue of child abuse to thefore of modern medicine in
the 1960s.

The diversity of legal definitions, practices and laws represents a wealth ofmodels to choose from to develop a suitable legal framework and practice in one’s
own country. One can thus model on what is deemed most appropriate for aparticular society. International organizations, which span countries and cultures,
usually adopt definitions and legal guidelines from the country most appropriate
for their practice. The World Health Organization (WHO) distinguishes several
types of child maltreatment: physical abuse; sexual abuse; neglect and negligent
treatment; emotional abuse; and exploitation.
Cultural values, standards of care in a community and poverty areimportant considerations in determining the presence of maltreatment and how
it is addressed. What are reasonable standards of discipline may change withtime as well as between societies. For example, physical punishment, which wasconsidered an aspect of appropriate parenting in days gone by – spare the rod,
spoil the child – is now widely seen as harsh or inappropriate (Creighton, 2004).
Although non-violent approaches to disciplining children are the most commonly
reported method (Runyan et al, 2010), violent disciplinary practices still occur
worldwide (UNICEF, 2010). A higher level of education in primary caregivers is
associated with lower levels of violent disciplining. Research in Sweden has shownthat legislation banning corporal punishment, if used in conjunction with public
promotion of alternative non-violent parenting methods, may reduce the use ofviolent disciplining (Ziegert, 1983).
So, how do we know if a child is being maltreated? If the universal principles
of children’s rights are violated or the child is at risk, at that time or at a later time,
to suffer negative consequences as a result of that action or lack of action, alarm
bells should ring. However, it was only with the Universal Declaration of Human
Rights (1948) and the Convention on the Rights of the Child (UNICEF, 1989)
that international legal instruments for the promotion and protection of children'sChild maltreatment

B.1

Children’s Rights (seealso Chapter J.7)
The Convention on the
Rights of the Child statesthat children everywhereare entitled to basic humanrights which include theright to:•Survival•
Develop to the fullest•
Protection fromharmful influences,abuse and exploitation•
Participate fully in thefamily, cultural andsocial life.

3IACAPAP Textbook of Child and Adolescent Mental Healthrights became available (see Chapter J.7). In 1873 animals had rights but children
did not. Mary-Ellen, the 9 year old child in the vignette, did not suffer in vain.
As the first recognized child abuse victim in North America, her case led to thefounding in 1874 of the Society for Prevention of Cruelty to Children (Finkelhor,
1984).

EPIDEMIOLOGY
Globally, there is a lack of reliable estimates of the prevalence of childmaltreatment, especially for low- and middle-income countries. Most prevalence
and incidence studies have been conducted in Western countries (Figure B.1.1).
Estimates vary widely depending on the country and the method used; hence,comparisons between countries should be interpreted with caution. Increasingawareness amongst professionals and the public has resulted in greater reportingof abuse.

In 1873 animals had rights
but children did not. In 1989,
children had rights too!
(CRC,1989)

Approximately 40 million children globally are estimated to suffer abuse eachyear (WHO, 2001). Between 25% and 50% of all children report having been
physically abused. Many are also victims of emotional abuse or neglect andwhat is reported may only be the tip of the iceberg. There is potentially a largepool of undetected maltreatment which may not have been recognized to be
due to abuse. For example, there are approximately 31,000 homicide deaths/
year of people younger than 15years. Many children who die are classified as“accidental deaths” – falls, burns, drownings – which may have been died due tomaltreatment. Further:• The International Labor Organization reports that there are 250 million
child laborers aged 5 to 14 years in developing countries. 15 million
Figure B.1.1

Rate* of child maltreatment in several countries according to type.

*Estimates vary widely depending on the country and the method used; comparisons between countries should be interpreted with caution.
Sources: Australian Institute of Health and Welfare (AIHW, 2004); Canada (Trocme & Wolfe, 2001) in Creighton, 2004; UK: Department of
Education and Skills (DES 2004); US: Department of Health and Human Services (US DHHS, 2003).

Child maltreatment

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4

IACAPAP Textbook of Child and Adolescent Mental Healthchildren in India are bonded laborers, working to pay off family debts(Human Rights Watch, 2001).
•

Approximately one million children are introduced to commercial
sexual exploitation worldwide (Casa Alianza, 2001)•

In armed conflict and refugee settings, girls are particularly vulnerable
to sexual violence, exploitation and abuse by combatants, security
forces, members of their communities, aid workers and others (WHO,2010)

Table B.1.2

Features of risk factors of abuse*

Child

Risk factors•

Younger age••

Constitutional vulnerabilities(e.g., cerebral palsy, mental
retardation, prematurity etc)
Difficult temperament
Chronic illness
Gender – for school aged
children, female gender higher
risk for sexual abuse while malegender higher risk for physical
abuse

•

•

•
•

Low socioeconomic status(poverty, unstable housing, low
education, unemployment, single
parenthood, young parental age)
Criminal history
Substance abuse
Chronic physical illness anddisabilities
Psychosocial factors (mental
health problems, poor coping
skills; lack of support fromspouse, family, community;
marital disharmony; domestic
violence)
Parents victims of abuse
Violence within the family

•
•
•
•
•

High local unemployment
Social isolation
Socio-cultural
Legal aspects
Disasters: natural or man-made

•

•
•
•

•

Family•••Society

Features of risk factors

•

•
•
•

•
•

Common presentations

Vulnerable & dependent
state
Attachment issues••

Lack of resources andeducation
Increased caregivers’
burdenLack of parental
supervision
Ineffective coping skills andparenting skills

•
•
•
•
•
•

Malnourishment
Inadequate health care
Emotional Abuse
Harsh physical punishment
Lack of supervision
Exposure to pornographic
materials

Cultural practices that
condone certain types of
abuse
Policies, or lack of, leading
to child exploitation
Lack of enforcement•

Sanctioned physical andsexual abuse (e.g., genital
mutilation)
Child soldiers
War rape
Prostitution

•
•
•
•

•
•
•

Fractures
Shaken baby syndrome(especially below 3 y/o)BruisesInternal bleeding
Choking
Smothering*Sources: Herrenkohl et al (2008); Mersky et al (2009); Stith et al (2009); Whitaker et al (2008).

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IACAPAP Textbook of Child and Adolescent Mental Health

RISK FACTORS
Table B.1.2 shows there are certain children, parent and family
characteristics that increase the likelihood of children being abused or neglected.
Early identification of such unmet needs with timely and sensitive intervention
to meet them could avoid the situation from becoming more serious and many
children being abused.

Parental factors
associated withchild abuse•••

Mother’s poor health or compromised nutritional status (for example teenage
mothers with an unwanted pregnancy living in poverty) may result in inadequate
nutrition and in preventable problems such as folic acid deficiency (increasing therisk of spina bifida), rubella, exposure to environmental toxic substances such as
mercury, lead and organophosphate insecticides, and both legal and illegal drugs.

•
•
•
•

CONSEQUENCES OF MALTREATMENT•

For child survivors of maltreatment the suffering happens not just at thatpoint in time; the deleterious impact, without adequate intervention, lingers on
decades later into adulthood. Mental health and physical health problems occur
during childhood as well as when they have grown up. Certain types of abuse may
cause long-term injuries, for example when the brain is directly damaged as in
the “Shaken baby syndrome”. Maltreated children with bone fractures may have ahigher risk of developing cancer (Fuller-Thompson et al, 2009).

Unemployment
Poverty
Family and maritalconflict
Domestic violence,
Drug or alcohol use,
Trouble with the law
Previous involvementwith child protection
services
Parental exposure
to physical abuse orfamily violence in theirchildhood.

Beside social problems, children who survive abuse or neglect are more
likely to have cognitive difficulties affecting learning, language development andacademic achievement. They are more likely to develop antisocial behavior withsubsequent delinquency, and teenage pregnancy (Johnson et al, 2006 ). They are
more likely to smoke cigarettes, use alcohol or illicit drugs (Dube et al, 2001); up
to two-thirds of people in drug treatment programs reported having been abused
as children (Swan, 1998).
Childhood maltreatment is strongly associated with poor physical andmental health outcomes in adulthood. As young adults, victims are at increased riskof depression, anxiety, eating disorders, obesity and attempted suicide (Silverman
et al, 1996), are more likely to have physical symptoms (both medically explained
and unexplained) and to engage in health-risk behaviours such as smoking, risky
sexual behaviors, alcohol and drug misuse. The greater the severity of maltreatment
the stronger is the association with poor outcomes in adulthood.
Science has refuted the belief that infants and young children are too young
to be affected by stressors. Exposure to stress during critical developmental periods
can have long term damaging effects to the developing brain resulting in structuralchanges (National Scientific Council on the Developing Child, 2010). Adverse
early infant experiences such as neglectful maternal care has been shown to have anegative impact on the developing brain. Drug and alcohol exposure in pregnancy
may also lead to neurobehavioral and neurohormonal changes in the offspringthat could have long-term adverse effects on memory, learning, and behavior (seeChapter G.1).
Mechanisms
Maltreatment causes stress. Stress responses include activation of hormonaland neurochemical systems, the sympathetic adrenomedullary system, producing

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IACAPAP Textbook of Child and Adolescent Mental Healthadrenaline, and the hypothalamo-pituitary-adrenocortical system, which produces
cortisol. Sustained or frequent activation of these hormonal systems can haveserious developmental consequences. For example, when children experience
severe or prolonged stress, their cortisol levels remain elevated for prolonged
periods. This toxic stress can turn specific genes “on” or “off” (Gunnar et al, 2006).
The relationship children have with their caregivers play a critical role in regulatingstress hormone responses. For example, children who have secure attachment
relationships have a more controlled stress hormone response when upset or
frightened; the contrary occurs in children whose attachment relationships are
insecure or disorganized (Loman et al, 2010).

Click on the picture to viewa video describing how
toxic stress derails healthy
development (1:52)

EVALUATION
Concluding that child maltreatment has taken place has important
implications for the child and the family (e.g., a child may be removed from afamily or a person may be imprisoned). While in some cases child abuse can beclearly seen to have occurred (e.g., if the child has evidence of physical injuries or ofbeing prostituted in the presence of witnesses), this is not clear cut in the majorityof cases, when ascertaining whether maltreatment has taken place is usuallydifficult. This is because, depending on their stage of cognitive development,children are often unable to remember events, are very suggestible and experience
conflicting emotions. For example, it has been shown that up to one-third of threeyear olds misidentify their own father in a photo-lineup – casting doubt on theirability to correctly identify a potential perpetrator (Lewis et al, 1995).
It needs to be distinguished between a mental health evaluation of children
in which maltreatment is suspected (e.g., in which a disclosure has been made or if
the clinician suspects that maltreatment has taken place) and the forensic interview– to elicit facts with a view to legal action. Optimally, once clinicians form theview that maltreatment has occurred, they should report it to the appropriate
authorities according to their local law; in these circumstances it is not the role ofclinicians to investigate whether maltreatment has actually occurred. Therapists
should never be the forensic examiner in those specific cases; not separating bothroles (investigation and treatment) will cause problems and hinder prosecutions
because therapists would not be objective and could be accused of contaminating
the child’s memories or planting new ones. The clinical – therapeutic – assessment
would not differ greatly from the clinical assessment of other children (see Chapter
A.5) and is not repeated here. This section focuses on the forensic evaluation(however, in societies where the luxury of adequate number of specialists is notavailable, forensic evaluation needs to be completed before intervention by thesame person for the reasons described above).
The age of the child and cognitive development needs to be kept in mind
and should influence the way in which the interview is conducted and the type of
information that can be obtained:••

Toddlers have difficulties identifying time and place and will probably
not be able to say how often something has happened, when it
happened, or even where it happened
Three to five year olds cannot think abstractly, may be easily distracted
during the interview or become restless. They may be able to datethings in relation to events such as before or after birthdays, bedtime,Child maltreatment

B.1

Behaviors that that
may indicate that achild may be abused
•

•

•

•

•

•

Unexplained delay inseeking medical help,
especially following afracture, serious burn/
scald
Explanation offeredby child or guardian is
not consistent with the
injuryDiscrepant
explanations given bymembers of the family
and other caregivers
History of ingestionof poison, alcoholor drugs, suicidal
attempts or running
away
Inappropriate responseof caretaker to child’s
injuries such as
denial that child is inpain, or minimizing ofsymptoms
Repeatedpresentations withinjuries, often todifferent doctors or
health care facilities.

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IACAPAP Textbook of Child and Adolescent Mental Health

•

•

•

etc. Asking them to draw or demonstrate what happened might beeasier for them than verbal communication
Six to nine year olds, although concrete thinkers, are increasingly capableof understanding concepts, able to orient themselves in time and spaceand draw simple floor plans. They can deceive more convincingly than
younger children and are more capable of keeping a secret. They usually
feel conflicted, confused, guilty and embarrassed, and may be afraid they
may be punished. They are reluctant and tentative in their disclosures
and withdraw if the interviewer is perceived as unsupportive. Role play,drawing and the use of dolls by trained personnel can be helpful
Preadolescents (aged 10-13) are typically more comfortable with aninterviewer of the same gender; feel awkward and self-conscious about
their bodies and about discussion of sexual issues. They normally
understand that what has happened to them is wrong but are likely
to feel responsible for the abuse; overwhelming guilt and shame often
leading to denial. They may respond better to brief, clinically oriented
questions and to a more formal approach to the interview. They needreassurance that they are not to blame for what has happened.
Teenagers are more likely to respond to an honest, open and direct
approach, showing respect for their concerns and support for theirneeds; avoiding coming across as critical or judgmental (Craig, 1998).

Click on the picture toview a slide show on childabuse (warning: extremelygraphic) (8:54)

Disclosure of abuse, particularly sexual abuse is gradual. Most children go
through stages, which include denial-disclosure-recantation-reaffirmation. Up to
70% of sexually abused children may initially deny the abuse. Younger children
are more likely to disclose the abuse accidentally through inappropriate statements
or actions such as sexualized play. Older children and teenagers are more likely todisclose the abuse purposefully because they are angry at the perpetrator or are
influenced by their peers.
The interview should be conducted by someone experienced in this area
in a child-friendly and non-threatening setting. The number of interviews should
be kept to a minimum by having as many of the multi-disciplinary professionals
involved as possible present. Ideally this should be done in a viewing room witha one way mirror or by videoing the interview, so as not to overwhelm the child.
The clinical history is most important and includes obtaining a history
from the child, in particular the social history, as well as corroborating evidence
from others. Family and social history are important to understand the family
background, living arrangements and support systems. As already highlighted,
certain risk factors are strongly associated with child abuse.
While the forensic interview aims to clarify who, what, where and when, thisdoes not mean that a good understanding of the child’s and family’s backgroundis not important. Questions should be open ended, backing off when sensing thechild is uncomfortable. Walking the child through familiar routines so the childcan describe them spontaneously is often helpful.

Shaken baby
syndrome: a ‘hidden’
abuseThis is a preventable causeof long-term neurologicaldamage and disability in apreviously healthy child. It
can be caused by vigorous
shaking of a baby (usually
younger than 2 years)
by the carer resulting in
rupture of intracranial bloodvessels when sheared
against the skull. It canpresent with:••According to Craig (1998), the basic format should include:••

A short rapport-building phase
An attempt to determine the child's developmental level,
communication skills, and knowledge of truth/lie, pretend/realChild maltreatment

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•
•

Drowsiness, lethargy
and fits
Subdural hemorrhage
or generalized
cerebral edema
Retinal hemorrhages
Fractures, for example
rib fractures.

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IACAPAP Textbook of Child and Adolescent Mental Health

•
•

•

•
•
•
•

The child's knowledge of body parts and ability to use words such as“on top of ”, “under”, “in front”, “behind” etc
Next, the main part of the interview (who, what, where and when) by
asking open ended questions like: "Do you know why you are here?""Your Mommy told me you've been having a problem with…”
Avoid teaching the child about sexual activity, correcting the child'sstatements, or giving judgments (e.g., the alleged perpetrator being abad person)
Don't use words the child does not understandDon't ask complicated or double-barreled questions
Avoid questions that can be answered with “yes” or “no”
Good ways to elicit information include questions such as: “Tell me
more”; “What makes you think so?” “Then what happened?” “Is there
anything else you want to tell me?”

Details that need elucidating include events that preceded the injury or
abuse, when and who first noticed the child was injured, how the child’s symptoms
developed and in what order. Certain circumstances are highly suspicious of abuse(refer to Box).
The physical examination
A thorough pediatric physical examination is imperative in all cases ofsuspected child abuse and many countries have their own guidelines setting out
how this is to be performed. The physical examination should be conducted in
a comfortable, child friendly environment, where the child can be put at ease.
If appropriate and available, the presence of a person known to the child may
help. The examination should be non-threatening, starting with the routine
measurements normally carried out on pediatric patients such as height, weightand head circumference. As the child is being examined for evidence of injury,
assessment of language and social skills can also be done as one interacts withthe child. Physical examination findings such as bruises, burns, abrasions or skinlesions should be documented accurately, including descriptions, measurements,
diagrams and photographs. Use simple diagrams to accurately draw and label
correctly the site of injury, left or right.

Key features in thephysical examinationof abused children
•
•
•
•
•

•

•

•

General demeanor
and appearance
Cleanliness, signs ofneglect, emotional
disturbance
Edema, bruises andredness of the scalp
Infant’s fontanelle forfullness
Fundoscopy findingsof retinal, preretinal or vitreous
hemorrhages
ENT: bleeding, tearsof the frenulum,
bruising or abrasion
inside the lips orpharynx
Rib tenderness,lung contusions;ruptured spleen or
viscous, duodenal
hematomas onchest and abdominal
examination
Bony or joint
tenderness or swelling

Suspect maltreatment if the answer is yes to any of the following questions(Mcdonald, 2007):
•
•
•
•
•
•
•

Is there an unusual distribution or location of lesions?
Is there a pattern of bruises or marks?
If there is a bite or handprint bruise, is it adult size?
If there is a burn, are the margins clearly demarcated with uniform
depth of burn?
If there is a burn, is there a stocking and glove distribution?
Are there lesions at various healing stages or ages?
Is the reported mechanism of injury inconsistent with the extent of
trauma?

Careful documentation is vital as doctors examining the child might beasked to testify in court regarding the evidence obtained and can refer to theirChild maltreatment

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Farah, a 15 year old girl, was brought to hospital by
police for attempting to jump off the 4th floor of a shopping
mall after her boyfriend broke off with her. She admitted
to feeling sad for a “long, long time” – since her parents
divorced when she was seven years old. Of all the four
siblings she missed her father the most as he used to spoil
her. After the divorce he remarried, had other children,
stopped visiting and ceased maintenance payments.
Farah’s grades deteriorated as she started to skipclasses going from an A-level student to the bottom of herclass. Her mother remarried a businessman three years
ago. He seemed to be the father figure and provider they all
longed for until his business failed and he turned to drugs.
He became increasingly violent towards her mother and all
the siblings and started raping Farah and her 10 year old
sister when their mother was working. He silenced them withthreats that he would kill their mother if they told anyone.
Farah tried to escape stepfather‘s abuse by staying awayfrom home at a shopping centre till late at night when her
mother came home. Farah began mixing with the boys in the
shopping complex and became a “girlfriend” to a “kind” 20year old convenience store worker because he listened toher problems. She started having intimate relations with thisboyfriend 10 months ago; she felt the need to please him to
keep his support.
She stopped having periods seven months ago andguessed she was pregnant because she “felt something
moving inside” although her periods had been irregular
for about a year. She told her boyfriend that she might bepregnant and he refused to have anything to do with her
anymore. She now wants to die or have an abortion.

own notes, which can be subpoenaed. All the information gathered should beclearly written up immediately to prevent errors and should be factual, concise
and accurate (in the child’s own words as far as possible), signed with the nameof the doctor, clearly written and dated (with an official stamp if required by local
procedures).
Investigations
A skeletal survey is recommended for children under the age of two years.
All children with head injuries should have X rays, CT or MRI scans, depending
on availability. Ultrasound examinations can detect excessive free fluid andhematomas to help diagnose intra-abdominal injuries. Blood tests needed include
a full blood count and coagulation tests to diagnose bleeding disorders in patients
who present with bruising; drug screens are useful if poisoning, accidental orotherwise, is suspected.

SEXUAL ABUSE
There is no universal definition of child sexual abuse. The WHO defines
it as the involvement of children in sexual activity (a) that they do not fullycomprehend, (b) to which they are unable to give informed consent or for whichchildren are not developmentally prepared and cannot give consent, or (c) that
violate the laws or social taboos of society. Other definitions include the use of achild for sexual gratification by an adult or significantly older person (Tomison,
1995 p2). In practice, identifying child sexual abuse is complex and what is
considered sexual abuse may vary depending on local customs (e.g., female genital
mutilation), legislation (criminal or child protection laws), and the relationshipbetween the child and the perpetrator. While some behaviors would be consideredsexually abusive by almost everyone (e.g., the rape of a 10-year-old child by aparent), others are more ambiguous (e.g., consensual sex between a 19-year-old
and a 15-year-old). Legal age of consent also varies between countries. Unlike
in other types of maltreatment, whether sexual abuse has occurred or not varies
depending on the relationship between victim and perpetrator:•

Adults with no familial relationship to the child. Any sexual behavior
between a child under the age of consent and an adult is abusive

Child maltreatment

B.1

Physical indicatorsof child sexual abuse(not necessarily
present):
•
•

•
•

•

Bleeding from thevagina, external
genitalia or anus
Injuries such as tears
or bruising to thegenitalia, anus orperineal region
Sexually transmitted
diseases (STD),
vaginal discharge
Trauma to thebreast, buttocks,
lower abdomen or
thighsAdolescent pregnancy

10IACAPAP Textbook of Child and Adolescent Mental Health

•

•

•

Family members of the child. Any sexual behavior between a child andan adult family member is still abusive (consent, equality and coercion
concepts are usually inapplicable in instances of intra-familial abuse)
Adults in a position of power or authority over the child (e.g., teachers,
health professionals). Age of consent laws are usually not applicabledue to the imbalance of power that exists and the breach of personal
and public trust when professional boundaries are violated
Adolescent or child perpetrators. Existence of abuse would depend onwhether the activity is consensual, the age differential and whether there
is an imbalance of power (e.g., sexual activity between two 15-year-olds
where one suffers from an intellectual disability). Sexual exploration
between consenting adolescents at a similar developmental level is notconsidered abuse.

Forms of child sexual abuse include physical contact (such as touching,fondling or any form of contact with breasts or genitalia, including using objects,
vaginal intercourse, and sodomy) and nonphysical abuse (such as exposing children
to pornography, erotic talk, and exhibitionism); this may occur in dyads, groups,
sex rings, as sexual exploitation, and as ritual abuse.
Child sexual abuse may be uncovered in various ways. A child may disclose
the sexual acts directly or indirectly with age inappropriate behavior, particularly
overtly sexualized behavior. Older children may present with self-destructive
behaviors, drug use, suicide attempts, self-mutilation or running away from home.
These children may also have an unexplained accumulation of money and gifts.
There are indicators peculiar to child sexual abuse listed in the Box.

The role of thephysicianThe role of the physician(as separate from thetherapist) in child sexual
abuse cases
•

•

•
•

•

Examining victims of child sexual abuseOnce sexual abuse has been uncovered, there is a need to protect the childfrom further harm and help in treatment and rehabilitation. It is important toemphasize again that the therapist should not be the forensic examiner unless there
is no one else available, in which case the forensic examination and legal proceduresshould precede the therapy.
Physical examination is no different from that of maltreated children,
as described above, although the emphasis would be on those aspects and areas
relevant to sexual abuse. The absence of abnormal physical findings does not
exclude the possibility of abuse – less than 10% of substantiated child sexual abusecases have physical findings on examination. This may be due to, among otherreasons, the type of abuse (e.g., nonphysical) or the timing of the examination in
relation to the abuse. In the physical examination of females one should keep inmind the possibility of normal and abnormal variants of external genitalia (e.g.,
hymeneal cleft) and non-specific findings including erythema, labial adhesions(normally found in 17%-39% of prepubertal girls), vaginal discharge, condyloma
acuminatum or anal fissures in a young child.
For the proper procurement of medico legal evidence, timely and accurate
collection of samples is needed. Forensic issues to be mindful of include notallowing the child to bath or clean up, although the child may feel disgusted anddirty, until the physical examination is completed and samples taken. To reduce
distress, perform the physical examination as soon as possible after the incident(also seminal DNA degenerates after 72 hours). Label correctly each item ofChild maltreatment

B.1

•
•

To identify any injury(including ano-genital,
extra-genital trauma,
other physical signs ofabuse or neglect)
To detect thepresence of STD,
pregnancy (pregnancy
prevention may be
indicated in somecountries)
To consider postexposure prophylaxis
for HIV.
To identify any otherforensic evidence that
may corroborate theexistence of abuse(e.g., body fluids)
To accurately record
any physical findings
and the result ofinvestigations (e.g.,through photographs)
To explain andinitiate any necessary
treatment
To rule out psychiatricemergencies (e.g.,suicidality).

Examination insexual abuse cases
Never use any type of force
or coercion to performthe medical examination,
which may re-traumatize
the child. Sedation (with theappropriate consent) may
be necessary to facilitate
proper examination as wellas to procure medico legal
evidence.

11

IACAPAP Textbook of Child and Adolescent Mental Healthclothing packed in bags provided with the child’s name in the presence of police
and utilize a “rape kit” to obtain samples (individual countries may have different
kits, like they have different guidelines as to how the forensic examination should
be conducted).

LEGAL ISSUES
Each country has its own legislation about child protection. Many countries
have legislated mandatory reporting to child protection bodies; a police report may
also be required. For example, in Malaysia (Child Act 2001), Child Protectors(social welfare officers) are authorized to conduct home visits and place victims
in a safe environment and it is mandatory for all doctors to report to the Child
Protectors once child abuse is uncovered.

MANAGEMENT
Regrettably, even in high income countries such as the US, a very large
proportion of the victims of maltreatment do not receive any treatment or services– apart from investigation. Thus, given the frequency of this problem, the unmet
need is enormous; welfare services dealing with maltreatment are stretched if not
overwhelmed everywhere in the world.
Treatment will require different targets depending on the type of abuse (e.g.,physical, sexual, neglect), the symptoms and their severity, whether the child has
been removed from the family (e.g., it is in foster care or in an institution) and what
treatment seeks to achieve (e.g., family preservation or reunification). There is very
limited evidence about what treatments are effective (Wathen & MacMillan, 2005).
In practice, the parents and not the child are often the main focus of intervention.
In these cases, the stronger effects are achieved by targeting parents and the parentchild interaction context in home-based settings during early childhood, designing
multicomponent interventions delivered by professionals for teaching parenting
competency skills, and targeting families of higher risk children (Thomlison, 2003).
For example, a controlled trial in the US involving 192 parents in child welfare –with an average of six prior referrals and most with all of their children removed –in which parents attended a program of “parent-child interaction therapy” found asignificant reduction in future child welfare reports (Chaffin et al, 2011). Traumafocused cognitive behavior therapies and parent-child interaction therapy appear
to be superior to general psychotherapeutic treatments.
The first step is to ensure that the effects of maltreatment are not worsenedby the subsequent management delay as the child’s development marches on,which regrettably often happens due to poor coordination of services and careplanning (system abuse). While the focus should be on the welfare of the child, thetraditional practice of managing child maltreatment by physically removing thechild to a place of safety focuses primarily on the physical well-being of the childalone. This protects the child from further harm from the same perpetrator but
might not address his emotional and psychological needs vital for healing.
In general, psychiatric management can be divided into acute and longterm. During the initial presentation, a full assessment of the victim’s conditionis needed. In severe cases, inpatient admission might be considered, for example,
in cases of severe depression, high suicide risk or acute psychosis. Admission may

Child maltreatment

B.1

Issues to keep inmind following
sexual abuse inadolescents
•

•

•
•
•
•
•

Teenage pregnancy,
parenthood andabortion (illegal insome countries),
abandoned babies
Culturally
unacceptable sexual
practices (e.g.,homosexual practices)
Impact of sexual
abuse and exploitation
Implications of chronic
illness (e.g., pelvic
inflammatory disease)
Chronic psychologicaland emotional
complications
StigmaImpact on academic
and occupational
functioning andopportunities.

Click on the picture toaccess the Malaysian
Guidelines for HospitalManagement of Child
Abuse and Neglect (2009).
Most countries have theirown guidelines.

12IACAPAP Textbook of Child and Adolescent Mental Healthalso be required for treatment of physical injuries or for the protection of thechild. Acute and short term problems often observed include: fear and anxiety,sleep problems and nightmares, somatic problems, anger/acting out, lowered selfesteem, social withdrawal or isolation, school difficulties, feelings of powerlessness,stigmatization, and symptoms associated with trauma. Ongoing problems such as
depression, post-traumatic stress disorder, relationship issues, juvenile delinquency
and substance abuse have to be anticipated. Factors affecting the consequences ofchild abuse and neglect include the:••••Child's age and developmental stage at the time of abuse
Type of abuse (physical abuse, neglect, sexual etc.)
Frequency, duration, and severity of abuse
Relationship between the victim and abuser (English et al, 2005).

In the long term, there is a considerable body of evidence showing thatmaltreatment during childhood is a factor that increases the risk for almost all
psychiatric conditions, and these should be appropriately managed as described inother chapters of the book. Another important aspect of management is to support
the child with the help of an attachment figure, e.g., helping the child deal with
non-supportive family members and cope with court proceedings (Center on theDeveloping Child, 2007).

“It is easier to build strong
children than to repair brokenmen.”
Frederick Douglass (1817–
1895)

Effective
interventions forchildren and families
at risk of pooroutcomes•

PREVENTION
Preventing child maltreatment before it occurs is as important as treatment(Finkelhor, 2009). Reducing child abuse is possible but requires a coordinatedmulti-sectorial approach. Effective prevention programs support parents and teachpositive parenting skills. Ongoing care of children and families can reduce the riskof maltreatment reoccurring and can minimize its consequences. Longitudinal datafrom the Perry Preschool Project research shows that successful intervention resultsin decreased expenditure in the juvenile and criminal justice systems, decreased
special education costs, increased tax revenue from higher incomes, and decreased
reliance on government assistance. Cost-savings from reductions in crime were theprimary saving mechanisms observed (Rolnick & Grunewald, 2003).
While some prevention programs are universal (e.g., education aboutparenting through advertisements or media programs, creating awareness of the evilof family violence, universal home visitation for new mothers), most are targeted
to families with the risk factors highlighted. These would include more intensive
home visitation, screening, detection and treatment of maternal depression, andparenting programs. The last, based on the principles of social learning theory,
deliver lower intensity modalities of parent management training programs such as“Triple P” (Positive Parenting Program) (Graaf, 1998) (see Chapters A.9 and D.2).
Both home visitation and parent training programs have been shown to be effective
but much more work and resources are required in this area. Policymakers, NGOs
and important community figures (e.g., religious, academic) have role to play inthis endeavor.
Policymakers
Using the information gathered over decades of research, it is imperativethat policy makers be convinced of the importance of implementing policies toChild maltreatment

B.1

•

•

•

•

Early and intensive
support by skilled
home visitors forvulnerable families
who are expecting afirst child
High-quality, centerbased, early education
programs for young
children from lowincome families
Two-generation
programs thatsimultaneously provide
direct support forparents and highquality, center-basedcare and education foryoung children fromfamilies experiencing
significant adversity
Interventions thatprovide specialized
services matched tothe problems they
are asked to addressfor young children
experiencing toxic
stress from abuseor neglect, severematernal depression,
parental substanceabuse, or family
violence
Parent management
training programs.

13

IACAPAP Textbook of Child and Adolescent Mental HealthPrevention strategies from an NGO’s perspective
P.S. The Children, a non-profit organization in Malaysia built its framework on
research from the US, UK and Australia and adapted it to the Malaysian context.
Research indicates that far more children are abused than actually reported. Thus,
preventing sexual abuse is paramount and it seeks to:•••
Educate adults to better protect children•
Galvanize communities to develop support systems for children•
Teach all children appropriate protective behaviors•
Teach high risk children how to use support systems
Teach abused children who are too afraid to tell that what abuse was not their fault and help with otheremotional health issues to minimize long-term negative effects of the abuse
Prevent child abuse victims of today from becoming offenders of tomorrow.

meet the needs of vulnerable children. They need to be aware that:
•

•

•

•

No single program, approach or mode of service delivery has beenshown to be a “magic bullet”. There are ways to promote the healthy
development of young children. The key is to select strategies thathave documented effectiveness, assure they are implemented well,and recognize the critical importance of a strong commitment tocontinuous program improvement
Successful large-scale programs require rigorous assessment and periodic
monitoring of the quality at individual implementation sites, as well as
training and technical assistance for continuous quality improvement
Return on investment is more important than up-front costs. Longterm societal benefits are of greater importance than short-term costs.
Four key challenges of note are:
1. Matching support and services to the needs and strengths ofthe children and families to be served
2. Paying careful attention to the quality of implementation
when effective model programs are taken to scale
3. Developing new intervention strategies for children andfamilies for whom conventional approaches appear to haveminimal impact
4. Providing an environment that supports ongoing,
constructive evaluation and continuous program
improvement“Contexts” for policy consideration include:
1. The nuclear family
2. Out-of-home settings
3. Multi-generational programs
4. Family economics and maternal employment
5. Environmental contamination.

Child maltreatment

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IACAPAP Textbook of Child and Adolescent Mental Health

REFERENCES
American Academy of Pediatrics: Committee on Child Abuse
and Neglect. (2001). Shaken baby syndrome:rotational cranial injuries-technical report. Pediatrics,
108:206-210.
Casa Alianza (2001). Report on Trafficking of Children in Central
America and Mexico.
Center on the Developing Child (2007). A Science-Based
Framework for Early Childhood Policy: Using Evidence
to Improve Outcomes in Learning, Behavior, and Healthfor Vulnerable Children. Harvard University.
Chaffin M, Funderburk B, Bard D et al (2011). A combined
motivation and parent-child interaction therapy
package reduces child welfare recidivism in arandomized dismantling field trial. Journal ofConsulting & Clinical Psychology, 79:84-95.
Creighton SJ (2004). Prevalence and Incidence of Child Abuse:
International Comparisons.
Craig B (1998). The Art of the Interview in Child Abuse Cases.
Dube SR, Anda RF, Felitti VJ et al (2001). Childhood abuse,household dysfunction and the risk of attemptedsuicide throughout the life span: Findings from theAdverse Childhood Experiences Study. Journal of theAmerican Medical Association, 286:3089-3096.
English DJ, Upadhyaya MP, Litrownik AJ et al (2005).
Maltreatment's wake: The relationship ofmaltreatment dimensions to child outcomes. Child
Abuse and Neglect, 29:597-619.
Finkelhor D (1984). Child Sexual Abuse: New Theory andResearch. New York: Free Press.
Finkelhor D (2009). The prevention of childhood sexual abuse.
The Future of Children, 19:169-194.
Fuller-Thomson E, Brennenstuhl S. (2009). Making a link
between childhood physical abuse and cancer:
results from a regional representative survey. Cancer,
115:3341–3350.
Graaf ID, Speetjens P, Smit F et al (1998). Effectiveness of the
Triple P Positive Parenting Program on behavioral
problems in children: a meta-analysis. Behaviour
Modification, 32:714-735.
Gunnar M, Vazquez D M (2006). Stress neurobiol­ogy anddevelopmental psychopathology. In D Cicchetti, D
Cohen (eds), Developmental Psychopathology, Vol 2:
Developmental Neuroscience, 2nd ed. New York: Wiley.
Herrenkohl T, Sousa C, Tajima E et al (2008). Intersectionof child abuse and children’s exposure to domestic
violence. Trauma ,Violence &Abuse, 9:84-99.
Human Rights Watch. 2001. Easy Targets: Violence Against
Children Worldwide. Human Right Watch, New York.
Johnson R, Rew L, Sternglanz RW (2006). The relationshipbetween childhood sexual abuse and sexual healthpractices of homeless adolescents. Adolescence, 41:221234.
Lewis C, Wilkins R, Baker L et al (1995). “Is this man yourdaddy?” Suggestibility in children’s eyewitness
identification of a family member. Child Abuse &Neglect, 19:739-744.

Child maltreatment

B.1

Loman M, Gunnar MR and the Early Experience, Stressand Neurodevelopment Center Team (2010).
Early experience and the development of stress
reactivity and regulation in children. Neuroscience &Biobehavioral Reviews, 34:867-876.
Mcdonald KC (2007). Child abuse: approach and management.
American Family Physician, 15:221-228.
Mersky JP, Berger LM, Reynolds AJ et al (2009). Risk factors
for child and adolescent maltreatment: a longitudinal
investigation of a cohort of inner-city youth. Child
Maltreatment, 14:73–88.
Ministry of Health Malaysia (2009). Guidelines for the HospitalManagement of Child Abuse and Neglect. Medical
Development Division, Ministry of Health Malaysia,
pp77-78.
National Scientific Council on the Developing Child (2004).
Young Children Develop in an Environment ofRelationships. Working Paper No1.
National Scientific Council on the Developing Child. (2010).
Early Experiences Can Alter Gene Expression and AffectLong-Term Development. Working paper No 10.
Rolnick A, Grunewald R. (2003). Early childhood development:
Economic development with a high public return. The
Region, 17:6-12.
Runyan DK, Shankar V, Hassan F et al (2010). Internationalvariations in harsh child discipline. Pediatrics,
126:701-711.
Shonkoff JP (2012). Technical report: the lifelong effects ofearly childhood adversity and toxic stress. Pediatrics,
129:232-246.
Shonkoff JP, Phillips DA (eds) (2000). From Neurons to
Neighborhoods: The Science of Early Childhood
Development. Washington, DC: National Academy
Press.
Silverman AB, Reinherz HZ, Giaconia RM (1996). The
long-term sequelae of child and adolescent abuse:a longitudinal community study. Child Abuse andNeglect, 20:709-723.
Stith SM, Liu T, Davies LC et al (2009). Risk factors in childmaltreatment: A meta-analytic review of the literature.
Aggression and Violent Behavior, 14:13–29
Swan N (1998). Exploring the Role of Child Abuse on Later
Drug Abuse: Researchers Face Broad Gaps inInformation. NIDA Notes, 13(2).
Tomison AM (1995). Update on Child Sexual Abuse (Issues
Paper No. 5). Melbourne: National Child Protection
Clearinghouse.
Thomlison B (2003). Characteristics of evidence-based childmaltreatment interventions. Child Welfare, 82:541569.
UNICEF (2010). Child Disciplinary Practices at Home Evidence
from a Range of Low- and Middle-Income Countries.
New York, NY: UNICEF.
UNICEF (1989). Convention on the Rights of the Child.

15

IACAPAP Textbook of Child and Adolescent Mental Health

US Department of Health and Human Services (2003). The
Child Abuse Prevention and Treatment Act: Including
Adoption Opportunities & the Abandoned Infant
Assistance Act as Amended by the Keeping Children andFamilies Safe Act of 2003.
US Department of Health and Human Services (2003). Child
Maltreatment. Washington, DC: Administration on
Children, Youth and Families.
Wathen AH, MacMillan H (2005). Treatment of child neglect:a systematic review. Canadian Journal of Psychiatry,
50:497-504.
Whitaker DJ, Le B, Hanson RK et al (2008). Risk factors for theperpetration of child sexual abuse: A review and metaanalysis. Child Abuse & Neglect, 32:529–548.

World Health Organization (2001). Prevention of Child Abuse
and Neglect: Making the Links between Human Rights
and Public Health. Geneva: WHO.
WHO and International Society for Prevention of Child Abuse
and Neglect (2006). Preventing Child Maltreatment:a Guide to Taking Action and Generating Evidence.
Geneva:WHO.
WHO (2010). Factsheet on Child Maltreatment.
Ziegert KA (1983). The Swedish Prohibition of corporalpunishment: A preliminary report. Journal of Marriage
and Family, 45:917-927.

Children celebrating eid Mubarak in Malaysian traditional costumes.

Child maltreatment

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