Maltreatment

• Definition     • Recognition     • Reporting and Supporting

Definition

Child Maltreatment

• How are Neglect and Abuse Defined?     • Consequences of Child Maltreatment

Child maltreatment is a complex and pervasive issue which impacts children globally. The harmful effects of child maltreatment are evident through its various forms – child abuse and neglect, children witnessing violence or coercive treatment, and unintentional injuries related to child maltreatment (Schnitzer & Ewigman, 2008). The serious emotional, psychological, or physical harm that a child experiences as a result of child maltreatment can negatively impact a child’s future life trajectory. The scars of child maltreatment can last a lifetime.

Abuse occurs when an adult intentionally inflicts harm upon a child. Sadly, parents are responsible for more than 80% of all abusive acts, with relatives accounting for another 7% (Berk & Roberts, 2009). Although neglect is often included under the child abuse umbrella, it differs from other forms of abuse. Abuse includes the presence of harmful acts upon children (e.g., injury, rape), whereas neglect is the absence of an expected set of conditions in which children thrive (English et al., 2005).

Any cases of abuse are unacceptable. Many cases go unreported, indicating that the actual rates of child abuse are in fact much higher than estimated (Berk & Roberts, 2009; Lambie, 2005). It is estimated that 100 Canadian children die each year as a result of abuse (Berk & Roberts, 2009). In addition, most forms of abuse are interrelated, so children who experience one form of abuse will likely experience other types of abuse (Berk & Roberts, 2009). As a result, many of the same indicators of neglect and abuse in children are found across the four main categories of abuse. Rates of abuse by gender indicate that boys and girls suffer from similar amounts of physical abuse, while girls suffer sexual abuse four times more often than boys (Lambie, 2005). Considering that young children often have difficulty disclosing abuse (Brilleslijper-Kater et al., 2004), it is critical that professionals know the signs of child maltreatment and consult their local child protection agency, when abuse and/or neglect are suspected.

How are Neglect and Abuse Defined?

• Different types of abuse, including exposure to abuse in the home are described by Cunningham and Baker (2007). For this section the following indicators have been used to define neglect and abuse:

• Neglect is the most commonly reported form of abuse (Berk & Roberts, 2009), but has received the least amount of attention (English et al., 2005; Lewin & Herron, 2007). It is often grouped into subtypes:
• Failure to provide for a child’s basic needs (e.g., food, clothing, shelter, education, medical care, supervision/safety);
• Abandonment;
• Failure to provide for the child’s emotional well-being;
• Failure to seek treatment or follow a recommended intervention can also be a form of neglect.
• Emotional Abuse includes acts that could cause serious mental or behavioural disorders, including social isolation, repeated unreasonable demands, ridicule, humiliation, intimidation, or terrorizing. Exposure to domestic violence has sometimes been included as a separate category (Trocmé et al., 2003), although it is generally considered to be a form of emotional abuse.
• Physical Abuse is classified as assaults, such as kicking, biting, shaking, punching, beating, throwing, choking, burning or stabbing, that inflict physical injury.
• Sexual Abuse is classified as fondling, intercourse, digital or object penetration, sex talk, exhibitionism, commercial exploitation through prostitution or production of pornography, and other forms of sexual exploitation, and unnatural sexual practices.
  (Berk & Roberts, 2009; Department of Justice Canada, 2005; English et al., 2005; Lambie, 2005; Trocmé et al., 2005)

Consequences of Child Maltreatment

The short- and long-term consequences of child maltreatment vary considerably, with childhood death as the most serious outcome. Child maltreatment can also affect all areas of a child’s development. Although not exhaustive, the following list provides some of the outcomes of child maltreatment:

• Permanent disability
• Brain damage
• Delays in development
• Behavioural problems; aggression; psychiatric problems; post-traumatic stress symptoms; increased risk of suicide
• Poor academic achievement; learning disorders; attention problems
• Difficulties with social relationships
• Reproductive health problems; sexually transmitted diseases including HIV/AIDS
• Anxiety, depression; low self-esteem
• Anger, hostility, general mistrust of adults
• Failure to thrive
• Low birth weight
• Substance use
• Teen pregnancy
• Sexual revictimization
• Criminal behaviour including violent crime
• School truancy

(Cicchetti & Toth, 2006; Shonk & Cicchetti, 2001, Wolfe et al., 2001 as cited in Berk & Roberts, 2009; Dubowitz et al., 2005; English et al., 2005; Fusco & Fantuzzo, 2009; McGowan et al., 2009; Prevent Child Abuse America, 2003; Sechrist, 2000 as cited in Lambie, 2005)

Recognition

• Risk Factors     • Neglect     • Emotional Abuse     • Physical Abuse     • Sexual Abuse

Maltreatment has not only far reaching and devastating effects, it also results in a generational cycle of abuse, violence and neglect. Preventing maltreatment is a critical intervention that can stop the cycle of abuse and hurt. Known risk factors, related to child maltreatment, need to be addressed in order to succeed in prevention efforts.

Risk Factors

The following table identifies the range of risk factors that can contribute to child maltreatment, including family, community, and cultural factors.

	Risk Factors Related to Child Maltreatment
Parents/caregivers	Psychological disturbance; cognitive impairment; physical or mental health issues; alcohol and drug use; history of maltreatment as a child; belief in harsh, physical discipline; desire to satisfy unmet emotional needs through the child; unreasonable expectations for child behaviour; young age (most under 30); low educational level
Child	Premature or very sick baby; difficult temperament; inattentiveness and overactivity; developmental problems
Family	Low income; poverty; homelessness; marital instability; social isolation/lack of social supports; domestic violence; frequent moves; large families with closely spaced children; overcrowded living conditions; disorganized household; lack of steady employment; other signs of high life stress; criminal activity
Community	High rates of violence and social isolation; few parks, child care centres, preschool programs, recreation centres, religious or cultural centres to serve as family supports
Culture	Approval of physical force and violence as ways to solve problems

(Lambie, 2005; Trocmé et al., 2005; Wekerle & Wolfe, 2003; Whipple, 2006, as cited in Berk & Roberts, 2009)

• Professionals have an important opportunity to intervene and stop the cycle of maltreatment. They can:

• Ensure children, adolescents and adults receive appropriate treatments for physical and mental illness
• Identify and address developmental concerns early
• Encourage individuals, families and communities to develop strong social support networks
• Ensure education re positive parenting and discipline is universally available
• Ensure literacy programs for adults are available
• Lobby for and support poverty reduction initiatives
• Promote treatment and cessation programs for substance use
• Promote and refer to culturally appropriate family support programs

Neglect

Possible Indicators of Neglect

PHYSICAL INDICATORS IN CHILDREN

Poor hygiene; unkempt; dirty or unbathed state; body odour; early childhood tooth decay; dirty clothes Unattended physical problems or medical needs; lack of routine medical and/or dental care Temporary abandonment by caregiver (e.g., alone in a car seat) Consistent lack of supervision Consistent hunger; distended stomach Inadequate clothing; inappropriate clothing for the weather Chronic diaper rash; infected sores or unattended skin disorders Infants or young children may display abnormal growth patterns; stunted growth; thin limbs or weight loss; sunken cheeks; dehydration; paleness; lethargy; poor appetite; unresponsiveness to stimulation Delays in development (e.g., motor, language, social skills); not meeting developmental milestones; failure to thrive; clumsiness

BEHAVIOURAL INDICATORS IN CHILDREN

Poor social skills and peer relations Falls asleep frequently outside of naptime; regularly appears fatigued Frequently absent from program(s) Begs or steals food; forages and hoards food; frequently "forgets" a lunch Self-destructive behaviour Delinquent behaviour Attention problems Negative view of self and others Little or indiscriminate crying Craves an enormous amount of attention or shows an inordinate amount of affection Anxiety, depression Listless Withdrawn; difficulty interpreting the emotions of others Lack of persistence, perseverance and enthusiasm Demonstrates lack of attachment to caregiver; may demonstrate indiscriminate attachment to other adults Little fear of strangers Independence and self-care beyond the norm; has a lot of responsibility at home; left to care for other children; assumes parental role Unimaginative play Discloses neglect

BEHAVIOURS OBSERVED IN AN ADULT WHO NEGLECT CHILDREN OR CONDITIONS IN THEIR HOMES

Fails to provide for the child's basic needs (e.g., food, shelter, education, clothing) Fails to ensure that the child receives medical treatment for illness or injury, or basic health care Excessive use of punishment May indicate that the child was the result of an unwanted pregnancy; may indicate that the child continues to be unwanted Frequent negativity about the child; highly critical May have unrealistic expectations of the child Caregiver puts own needs first Family history of neglect and poor parenting Overwhelmed with own personal problems and needs; may indicate that the child is hard to care for/hard to feed; describes the child as demanding Maintains a chaotic home life, with little evidence of regular routines (e.g., consistently brings the child to care very early, picks up the child very late) Has little involvement in the child's life: appears apathetic toward child's daily events; fails to keep appointments regarding the child; fails to use services offered; unresponsive when approached with concerns May show ignoring or rejecting behaviour towards the child Substance use while parenting; substance use during pregnancy May experience domestic violence May have acute mental health needs May lack support network Lack of provision for child's safety; unsafe environment; evidence of human or animal excrement; little food available Fails to provide adequate supervision: may be frequently unaware of, or has no concern for the child's whereabouts; leaves the child alone, unattended, in a dangerous place, or in the care of others who are unsuitable or who cannot look after the child safely

(Children's Aid Society of Ottawa, 2005; English et al., 2005; Grenier & Leduc, 2008; Lambie, 2005; Lewin & Herron, 2007; Powell, 2003; Rimer & Prager, 1998; Scannapieco & Connell-Carrick, 2005; Stocker & Dehner, 2001; Trocmé et al., 2005)

Emotional Abuse

Possible Indicators of Emotional Abuse

Although neither conclusive nor exhaustive, the presence of one or more of the following indicators should alert professionals to the possibility of emotional abuse. However, these indicators should not be taken out of context, nor used individually to make unfounded generalizations. Pay close attention to the duration, consistency, and pervasiveness of each indicator. If unsure about whether or not certain behaviours constitute emotional abuse, consult with child protection staff.

PHYSICAL INDICATORS IN CHILDREN

The child does not develop as expected; speech disorders; delays in physical or emotional development Frequent complaints of nausea, headaches, or stomach aches without any obvious reason Asthma, or severe allergies Child fails to thrive Wetting or soiling that is non-medical in origin Immature or overly mature behaviour May have "unusual" appearance (e.g., bizarre haircuts, dress, decorations) Dressed differently from other children in the family

BEHAVIOURAL INDICATORS IN CHILDREN

Extremely passive or undemanding; extreme withdrawal; anxiety; sadness; ADD/ADHD; stress Extreme attention-seeking behaviours; extremely demanding, aggressive, angry Low self-esteem; severe depression; self-destructive behaviours (e.g., suicide threats or attempts, substance abuse); antisocial or destructive behaviour Regressive behaviours and/or habit disorders (e.g., toileting problems, thumb-sucking, rocking, biting, head-banging) Sleep disturbances Overly compliant; too well mannered; too neat or clean Overly self-critical; high self-expectations that result in frustration and failure, or avoidance of activities for fear of failure Unrealistic goals to gain adult approval Fearful of returning home or being left alone Lack of self-confidence Poor academic performance Irregular attendance at school or program Displays extreme inhibition in play Runs away from home Has a lot of adult responsibility Poor peer relationships; lack of emotional connection with others Cruel to animals Discloses abuse

BEHAVIOURS OBSERVED IN ADULTS WHO ABUSE CHILDREN

Consistently degrades, criticizes, insults, ridicules, intimidates, humiliates or belittles the child, verbalizes negative feelings about the child to the child and others Compares the child to someone who is disliked or hated Terrorizes the child (e.g., threatens the child with physical harm or death, threatens someone or something the child loves; forces the child to watch physical harm being inflicted on a loved one) Isolates the child; does not allow the child to have contact with others, both inside and outside the family (e.g., locks the child in a closet or room) Consistently rejects or ignores the child; actively refuses to help the child or acknowledge the child's requests, needs or interests Blames the child for problems, difficulties, disappointments Displays violent behaviours; constant yelling; swearing May be inflexible and harsh; exhibits inconsistent behaviour Treats and/or describes the child as different from other children and siblings (e.g., does not provide food, clothing and care for child as well as for the other children in the family) Corrupts the child, teaches or reinforces criminal behaviour; provides antisocial role modeling; exploits the child for own gain Withholds physical and verbal affection from the child; withholds love, support, and guidance Makes excessive demands of the child; has unrealistic child expectations Exposes the child to sexualized/violent media (e.g., DVDs, TV) Communicates to the child that he is worthless, that his needs don't count, and that no one likes or loves him Substance use

(Case, 2007; Children's Aid Society of Ottawa, 2005; Christensen, 1999; Lambie, 2005; McKibbin & Walton, 2008; Muscari, 2004; Palmatier, 1997; Powell, 2003; Reardon & Noblet, 2008; Rimer & Prager, 1998; Trocmé et al., 2005)

Possible Exposure to Domestic Violence and Other Forms of Abuse

• In recent years, the number of cases of exposure to domestic violence has risen dramatically in Canada (Trocmé et al., 2005). Although domestic violence may result from angry and violent outbursts, ultimately, it is "about control, not anger" (Nies & McEwen, 2001, p. 604). When domestic violence occurs in the home, the well-being and development of children are often negatively impacted. Children who have been exposed to domestic violence suffer from significantly more social, emotional, and cognitive problems in comparison to their peers (Fusco & Fantuzzo, 2009). In some cases, studies have shown that "almost 75% of all children exposed to domestic violence were also involved in the violence" (Fusco & Fantuzzo, 2009, p. 254). As a result of exposure to domestic violence, boys who are exposed to abuse of their mothers are more likely to abuse their partner as adults, while girls who grow up in that type of environment are more likely to accept abusive relationships as adults (Grenier & Leduc, 2008).


• Children's exposure to abuse in the home should always be taken seriously. Children may be affected differently, but children who live with conflict and abuse are actively involved by assessing their own roles, worrying about consequences, engaging in problem-solving and attempting to protect themselves, siblings or the caregiver (Cunningham & Baker, 2007).


• Children who have witnessed abuse and coercive treatment in the home often display the same types of physical and behavioural indicators as children who are emotionally abused (see Possible Indicators of Emotional Abuse table). Furthermore, children can suffer from serious unintended injuries during violent episodes in the home, either in an effort to protect a family member or when objects have been thrown. Some children also experience post-traumatic stress symptoms as a result of witnessing family violence (Fusco & Fantuzzo, 2009).


• Adults who engage in domestic violence also share the same types of behaviours as adults who emotionally abuse children (see Possible Indicators of Emotional Abuse table). This may include: engagement in ridicule, intimidation, humiliation, degradation, insults, verbal criticism, blame; violent behaviours; threats; terrorization of family members; isolation of family members; jealousy and possessiveness (Jenkins & Davidson, 2001); control of partner's activities (Reyes, Rudman, & Hewitt, 2002), etc. In addition, risk factors that have been related to higher rates of domestic violence include poverty, substance use, and single female-headed households (Fusco & Fantuzzo, 2009).


• The victim of domestic violence is often the child's primary female caregiver, usually his mother. Victims often feel powerless to change their abuser's emotionally, physically, or financially controlling behaviours. Professionals can help victims, by recognizing the abuse, and offering an opportunity for disclosure and interventions. Professionals need to watch for a variety of behavioural indicators that victims may display. These may include:

• Injuries that do not appear accidental
• Explanations for injury that are vague or do not match the injury
• Embarrassment, shame, attempts to hide injuries
• Reserved, quiet, or frightened demeanor in abuser's presence
• Tense, jittery, no eye contact, defers to partner in answering questions
• Complaints of "bad nerves", sleep or appetite disturbances
• Mention of partner's temper; talks about avoiding troubles
• Misses appointments; does not follow up on medications or plans
• History of repeated injuries
• History of visits to emergency rooms, mental health clinics
• History of depression, anxiety, suicide attempts
• Multiple injuries in various stages of healing
• Apparent fearfulness, edginess, increased startle response
• Isolated with little access to money, resources, friends, family, job, transportation
• Alcohol or drug use
  (Jenkins & Davidson, 2001; Reyes, Rudman, & Hewitt, 2002)

Physical Abuse

• Shaken Baby Syndrome     • Indicators of Abusive Head Trauma (Shaken Baby Syndrome)

Possible Indicators of Physical Abuse

Although neither conclusive nor exhaustive, the presence of one or more of the following indicators should alert professionals to the possibility of physical abuse. However, these indicators should not be taken out of context nor used individually to make unfounded generalizations. Pay close attention to the duration, consistency, and pervasiveness of each indicator. If usure about whether or not certain behaviours constitute physical abuse, consult with child protection staff.

PHYSICAL INDICATORS IN CHILDREN

Presence of several, recurring injuries over time; unexplained injuries that are in various stages of healing Fractures, dislocations, multiple fractures all at once or over time; pain in the limbs, especially with movement; tenderness Distorted facial appearance with swelling, bleeding, bruising Limping or other abnormal use of limbs, without a reasonable explanation (e.g., lacks full range of movement in limb) Fractures of the ribs: painful breathing; difficulty raising arms Signs of possible head injuries (skull fractures included): swelling and pain; nausea or vomiting; patches of hair missing; irritability; lethargy; seizures; limpness; difficulty breathing; persistent crying; dizziness; unequal pupil size; bleeding from scalp wounds or nose Fractures in children younger than 12 months of age have been linked to abuse 40% - 56% of the time Facial injuries in infants and preschool children Cuts, scrapes, and welts inconsistent with normal play (e.g., bruises on cheeks; neck; back of arms and thighs); injuries inconsistent with the child's age and developmental phase Frequent hospital visits Unexplained injuries on questionable sites (e.g., on stomach, buttocks, ears, back of head, upper back, pubic area); bruises on children younger than 9 months of age are considered suspicious Bruising patterns, clustered bruising, or welts (e.g., from a wooden spoon, hand/finger print marks, belt) Burns from a cigarette; patterned burns (e.g., iron, electric burner); burns suggesting that something was used to restrain a child (e.g., rope burns on the wrists, ankles, neck); scalds Human bite marks Evidence of recent female genital mutilation (e.g., difficulty voiding, chronic infections, "waddling") Internal injuries Fractured or missing front teeth

BEHAVIOURAL INDICATORS IN CHILDREN

The story of what happened is inconsistent with the injury; refuses or is afraid to talk about injuries; denies injury; cannot recall or describe how injuries occurred Disruptive; destructive; nervous or hyperactive; violent towards others Exhibit depression or anxiety May show extremes in behaviour: extremely aggressive or passive, unhappy or withdrawn; extremely compliant/eager to please or extremely noncompliant Tries to hurt himself (e.g., self-mutilation) Expresses little or no emotion when hurt Wary or afraid of adults generally, or of a particular gender or individual Does not want to be touched; may cringe or flinch with physical contact May display over-vigilance, a frozen watchfulness, or vacant stare Academic or behavioural problems Afraid to go home; runs away from home Is frequently absent with no explanation, or shows signs of healing injury on return Tries to take care of the caregiver May be dressed inappropriately to cover injuries Poor peer relationships Evidence of developmental lags, especially in language and motor skills Discloses abuse

BEHAVIOURS OBSERVED IN ADULTS WHO ABUSE CHILDREN

May provide inconsistent explanations as to how the child was injured May delay seeking medical attention for injuries or illnesses Gives harsh, impulsive or unusual punishments Shows lack of self-control with low frustration tolerance; extreme anger; impatience Socially isolated; little support or parenting relief May have little knowledge of child development and/or have unrealistic expectations of the child May often express having difficulties coping with the child or makes disparaging remarks; describes child as different, bad, or the cause of own difficulties May demonstrate little or no genuine affection, physically or emotionally for the child May state that the child is accident-prone or clumsy May appear unconcerned, indifferent, or hostile to child and injury

(Children's Aid Society of Ottawa, 2005; Grenier & Leduc, 2008; Lambie, 2005; Powell, 2003; Rimer & Prager, 1998; Trocmé et al., 2005; Ziegler, Sammut, & Piper, 2005)

Shaken Baby Syndrome

• Another form of abuse that is caused by physical trauma to a child is shaken baby syndrome (SBS), now also called Abusive Head Trauma (AHT). This terminology includes a broader rage of injuries such as:

• Shaking
• Blunt impact
• A combination of blunt impact and shaking
  (Christian & Block, 2009)

• Shaken baby syndrome is the result of violent shaking of an infant or small child (Reynolds, 2008), while AHT includes shaking and injuries caused by hitting the child hard or with an instrument, or causing him to hit his head. Continuous infant crying is often the trigger for the shaking. With an infant's larger head and weaker neck muscles, even five seconds of vigorous shaking can cause injury. However, due to the lack of external signs of injury (Mraz, 2009), abusive head trauma is often difficult to diagnose. AHT occurs most frequently in infants younger than six months of age, although it has been recorded in children up to five years of age (Reynolds, 2008; Smith, 2003). Sadly, approximately one-third of children who are victims of AHT will die (WHO, 2002), and less than a third of infants who survive will develop normally (Reynolds, 2008). Other outcomes of AHT can include:

• Permanent visual impairment
• Seizures
• Permanent brain damage
• Developmental delays
• Learning disabilities
• Severe motor dysfunction
• Paralysis
• Epilepsy

Men carry out this type of abuse twice as often as women (Reynolds, 2008). As in any form of suspected child abuse, further investigation and consultation with child protection agencies may be necessary.

In the following table, a list of indicators of AHT is provided. If several of these indicators are noted, immediate attention by a primary health care provider or emergency doctor is required.

Indicators of Abusive Head Trauma (Shaken Baby Syndrome)
History of poor feeding Vomiting Lethargy or irritability Hypothermia Failure to thrive Increased sleeping and difficulty arousing Inability to lift head Inability to suck, swallow, smile or vocalize Seizures Difficulty breathing Retinal bleeding – occurs in 50 – 100% of cases Bulging eyes Blue skin Mild anemia	Inability of eyes to focus or to track objects Skeletal injury – old and new fractures are often found Massive intracranial bleeding – most common cause of death in shaken infants Bulging fontanelle (soft spot) Coma Bradycardia (slow heart rate) Complete cardiovascular collapse Sometimes bruising in shape of hand imprints on infant's trunk or extremities

(Reynolds, 2008; Smith, 2003)

Sexual Abuse

• Possible Indicators of Sexual Abuse

Children's Sexual Behaviour in Context

To accurately identify childhood sexual abuse, it is helpful to first understand developmentally appropriate sexual behaviours in young children. Surprisingly, there is little research that has been conducted on children's normal sexual development and experience (Schoentjes, Deboutte, & Friedrich, 1999). Furthermore, what little research is available, is also dated (Volbert, 2001). It is challenging to pinpoint normal sexual development, considering that a number of factors can influence a child's sexual behaviour. These include:

• Age of child
• Maternal level of education
• Family nudity
• Family attitudes toward sexuality (Schoentjes, Deboutte, & Friedrich, 1999)
• Culture (Volbert, 2001).

In the following table, developmentally appropriate sexual behaviours that have been documented in young children are outlined.

Developmentally Appropriate Sexual Behaviours in Children Younger Than 6 Years of Age

Asks questions about sexuality Plays doctor games Touches mother's breast Likes to be nude Likes to walk in underclothes Has erections Touches own genitals; masturbates Is aware of genital differences between sexes able to label genitalia; often uses nontechnical terms to describe Scratches anal and/or crotch area Looks at people when they are nude Cuddles

Children aged 2 – 7 years typically do not associate genitalia with any sexual function – only with pregnancy/birth Curious about how babies are born Sits with crotch or underwear exposed May undress in public Kisses adults not in the family Kisses other children not in the family Purposely displays genitals to peers (typically up to age 4) Fascinated by excretion; curiosity about bathroom behaviours By age 4, shows an increased need for privacy, especially in the bathroom

(Brilleslijper-Keter, Friedrich, & Corwin, 2004; Brittain, 2005; Schoentjes, Deboutte, & Friedrich, 1999; Stoudemire, 1998; Volbert, 2001)

Possible Indicators of Sexual Abuse

Although neither conclusive nor exhaustive, the presence of one or more of the following indicators should alert professionals to the possibility of sexual abuse. However, these indicators should not be taken out of context nor used individually to make unfounded generalizations. Pay close attention to the duration, consistency, and pervasiveness of each indicator. If unsure about whether or not certain behaviours constitute sexual abuse, consult with child protection staff. 

(Berk & Roberts, 2009; Brilleslijper-Kater et al., 2004; Brittain, 2005; Brown, Brack, & Mullis, 2008; Children's Aid Society of Ottawa, 2005; Department of Justice Canada, 2005; Felman & Nikitas, 1995; Glicken, 2006)

PHYSICAL INDICATORS IN CHILDREN

Unusual or excessive itching or pain in the throat, genital, or anal area Vaginal discharge; genital odour Torn, bloody, or stained (e.g., signs of semen) underclothing Pain on urination, elimination, sitting down, walking or swallowing Blood in urine or stool Injury to the breasts, genital or anal areas: redness; bruising; lacerations; tears; swelling; bleeding; infection Poor personal hygiene or excessive bathing Abdominal pain Constipation Sexually transmitted disease Frequent urinary tract or yeast infections Foreign objects in vagina or rectum

BEHAVIOURAL INDICATORS IN CHILDREN

Displays sexual behaviour and knowledge that is beyond the child's age and stage of development Detailed and sophisticated understanding of sexual behaviour; age-inappropriate explicit drawings, descriptions Age-inappropriate sexual behaviour with dolls, toys, self, pets or others; provocative behaviour with adults; intrusive sexual behaviour with same-age children; expresses sexual aggression towards younger children; compulsive sexualized talk; excessive masturbation Atypical play behaviours (e.g., repeated reenactments of the trauma, aggressive play, sexualized play) Frequently asks to go to the bathroom; recurring physical complaints with no physical basis Nightmares, night terrors, and sleep disturbances Loss of appetite; sudden change in weight (either gain or loss) Clinging or very demanding of affection or attention; fear of abandonment if caregiver leaves momentarily Reluctance, fear or refusal to go to a parent, relative, friend for no apparent reason; mistrust of others; fearfulness Hyperactive or anxious; preoccupied; excessive worry about siblings; excessive crying Low self-esteem; depression; withdrawal; strong feelings of shame or guilt Sudden change in behaviour (e.g., outgoing child becomes withdrawn) or progress Regressive behaviour (e.g., bed-wetting, thumb-sucking, speech loss) Resists being undressed, or when undressing, shows apprehension or fear Afraid to go home; runs away Poor relationships with peers; social isolation Aggressive behaviour; self-injurious behaviours Lags in development Puts mouth on other child/adult sex parts; puts tongue in mouth when kissing Puts objects in vagina or rectum Repeatedly plays with or smears feces; purposely urinates in inappropriate places (e.g., on furniture) Touches animal sex parts Discloses sexual abuse

BEHAVIOURS OR CONDITIONS OBSERVED IN ADULTS WHO ABUSE CHILDREN

Relationship with the child may be inappropriate, sexualized or spousal in nature States that the child is sexual or provocative Shows physical contact or affection for the child that appears sexual in nature Permits or encourages the child to engage in sexual behaviour Is frequently alone with the child and is socially isolated May be jealous of the child's relationships with peers or adults Discourages or disallows child to have unsupervised contact with peers May use substances to lower inhibitions against sexually abusive behaviour May have an addiction to drugs, alcohol, or other substances Treats one child significantly differently to other children in the family May be unusually overprotective, over-invested in the child (e.g., clings to the child for comfort) Abuser is usually a male who is familiar to the child (e.g., father, step-father, boyfriend) May use internet or mobile phones to expose children to pornography

Lambie, 2005; Paradise, 2002; Powell, 2003; Reece, 2000; Rimer & Prager, 1998; Scannapieco & Connell-Carrick, 2005; Schoentjes, Deboutte, & Friedrich, 1999; Trocmé et al., 2005; WHO, 2002)

Reporting and Supporting

• Reporting Malltreatment     • Supporting Children Who Have Been or May Be Maltreated • Supporting Adults Who Have or May Maltreat Children

Reporting Maltreatment

As professionals working directly with young children and families, situations may arise in which child abuse and/or neglect are suspected. According to the Child and Family Services Act (1990), any professional who works with children and who has reasonable grounds to suspect that a child has suffered harm or is at risk of harm, must report their suspicions immediately to a child protection agency. According to the UN Convention on the Rights of the Child (1989), a child is defined as any human being under the age of 18 years.

To support children's well-being, professionals have a legal and ethical obligation to consult with or report any suspicions of maltreatment to a Children's Aid Society. This includes indicators of neglect, sexual abuse, physical abuse, and emotional abuse, including a child's exposure to domestic violence (MCYS, 2005). In situations where the signs of abuse may not be straightforward, or where certain cultural practices conflict with Canadian law (e.g., female genital mutilation), consultation with a local child protection agency is recommended. Emergency services are available 24 hours/day, seven days a week at all child protection organizations.

The ongoing duty to report is also an important consideration for professionals. Even if a report has already been made to a child protection agency regarding a particular child, another report must be filed if additional reasonable grounds for concern arise.

Reporting Child Abuse and Neglect: It's Your Duty

Supporting Children Who Have Been or May be Maltreated

Professionals can support maltreated children in a number of ways. By closely monitoring a child's ongoing progress, and overall health and well-being, professionals can often detect any unusual changes in the child's behaviour or development. A home visiting program such as Healthy Babies Healthy Children can provide this ongoing monitoring and may be available for at risk families with children up to the age of six years. When serious concerns arise, professionals can help with referrals to the appropriate services or supports.

For children who have already suffered the damaging effects of maltreatment, professional therapy such as play therapy or therapeutic day care may be required (WHO, 2002). Rimer and Prager (1998) note that maltreated children benefit from stable, supportive, and nurturing environments with predictable adults. In order to support the healing process, they also suggest that a maltreated child may need help to develop:

• Positive self-image and self-esteem
• Trust
• Ability to identify and express emotions
• Communication skills
• Skills to identifying and solve problem situations
• Conflict resolution skills
• Overcoming developmental lags

Supporting Adults Who Maltreat or Who Are at Risk of Maltreating Children


It is important for all professionals who work with children and families to have some form of training to help them identify the signs of abuse in children and families. This training can also provide them with the tools to effectively teach about the prevention of maltreatment (Brown, Brack, & Mullis 2008). There are a number of support programs and services available to caregivers or other adults who maltreat or who may be at risk of maltreating children. Some of these options may include:

• Long-term therapy
• Parent support groups or networks (e.g., Parents Anonymous)
• Parent education programs – often provided in centres; can enhance caregivers' parenting skills, understanding of child development, and positive discipline strategies
• New parent support programs (includes information about prenatal care, effective discipline strategies, addressing children's developmental needs, stress management techniques)
• Home visitation programs – caregivers are visited in their homes, and support, information and appropriate community referrals are provided to prevent child maltreatment
• Therapeutic day programs for adults abused as children
• Abuse prevention training programs (e.g., sexual abuse prevention programs)
• Social programs to support families
• Financial planning and occupational skills training
• Media campaigns to raise awareness of caregivers
• Interventions with multiple components (e.g., child care, parenting skills training, family support)
  (Berk & Roberts, 2009; Lambie, 2005; Mikton & Butchart, 2009; WHO, 2002)