Child Maltreatment: A "What to Do" Guide for Professionals Who Work With Children

Table of Contents

List of Tables

  • Table 1 : Possible Signs and Symptoms of Child Maltreatment

Introduction

One of the most difficult challenges for professionals who work with children and parents is identifying child maltreatment and knowing when and how to report suspected cases. The purpose of this paper is to provide information about:

  1. how to identify and report suspected or observed child maltreatment;
  2. legal responsibilities; and
  3. approaches to prevention and treatment and the evidence about their effectiveness.

Information about the treatment of offenders is beyond the scope of this paper. Child welfare legislation is a provincial or territorial government responsibility. Individuals who require information on local resources should contact a local child protection agency. Contact information for local child welfare services can be found on the Centre of Excellence for Child Welfare's Web site (see Further Readings/Resources).

Diagnosing Maltreatment

Child maltreatment includes physical, sexual or emotional abuse, as well as neglect and exposure to family violence. Many signs and symptoms, both physical and behavioural, can be associated with child although a child who shows no maltreatment (Table 1), signs may also have been maltreated. However, it is important to note that the presence of one or more of these signs or symptoms does not confirm that child abuse or neglect has occurred. There is no single behavioural sign or symptom that warrants, on its own, a diagnosis of child maltreatment, as most of the behavioural signs are non-specific.

All signs should be considered in the context of the child's age and developmental stage and the explanations or history given by the child and caregiver.Footnote 1

Table 1: Possible Signs and Symptoms of Child MaltreatmentFootnote 1-6
Physical Signs Behavioural Signs
Physical abuse
  • Bruising of soft tissue (e.g., head, neck, trunk, arms)
  • Imprint of large, multiple, clustered bruises; bruises at different stages of healing
  • Burns (e.g., on hands, feet, genitalia)
  • Inadequately explained bone fractures
  • X-ray evidence of a history of multiple fractures
  • Head injuries, especially bleeding into the brain
  • Retinal bleeding

The behavioural signs listed below are not specific to any one type of child maltreatment. A child may show behavioural or emotional changes such as:

  • anxiety, depression, low self-esteem;
  • disruptive or aggressive behaviour;
  • hyperactivity;
  • sleep disorders or nightmares;
  • loss of skills (e.g., bedwetting);
  • unusual fear of physical contact with others;
  • lack of emotional expression when hurt;
  • unusual shyness, withdrawal, passivity;
  • suicidal ideation or behaviour;
  • sucking, rocking, biting;
  • poor social skills or interpersonal relationships; and
  • school absenteeism, running away, prostitution.

Children who have been neglected may beg for food or steal food. Children who have been sexually abused may show abnormal sexualized behaviour, but this can also occur as a result of other types of maltreatment, such as neglect.

Emotional abuse
  • Speech problems
  • Developmental delay
  • Unexplained physical symptoms
Neglect
  • Child found unsupervised, medical needs not met
  • Abandonment
  • Malnutrition, poor growth
  • Untidy appearance, poor hygiene
Sexual abuse
  • Trauma to genital or anal area
  • Unexplained sexually transmitted infection, vaginal/urethral infection or discharge
  • Pregnancy
Exposure to family violence
  • Increased risk of physical harm or injury due toproximity to an act of family violence

Reporting and Legal Implications

If I suspect that a child is being abused or neglected, should I report it?

To determine whether the situation should be officially reported, it is often possible to consult local child maltreatment experts or to make an anonymous call to the local child protection society (CPS) to discuss the situation and seek guidance.

When asking for advice, explain the concerns that led to your suspicion of child maltreatment. The professional consulted needs to outline the concerns in terms of risk factors, signs or behaviours, etc. (see Table 1) or to know the situation that led to the suspicion. Act quickly on your suspicion and, most importantly, keep the best interests of the child as your first priority.

What to do if you suspect, or if a child discloses maltreatment

  1. Act on the suspicion quickly (i.e., do not wait for days or weeks).
  2. Keep the best interests of the child in mind, and protect the child from any further harm (i.e., keep the child from returning to the abusive or neglectful situation).
  3. Write down what you have been told and by whom, your observations and what you did.
  4. If the child has disclosed maltreatment, reassure him/her that it was right to do so, as he/she may have mixed feelings and/or feel loyalty to the perpetrator.
  5. Try to learn as much as you can about the situation and context, and find out if the child is currently at risk (e.g., is experiencing ongoing exposure to the perpetrator), but do not interview the child about details. That is the responsibility of the CPS.
  6. Contact the local CPS and report the situation. Provide identifying data and your contact information.
  7. In consultation with the CPS, consider immediate medical assessment/treatment of physical problems and referral to local emergency health services or sexual assault teams, etc.
  8. Consider referral to a mental health professional for assessment/treatment of any psychological or psychiatric problems.
  9. Short-term and long-term safety plans for the child should be prepared in collaboration with the CPS.

After an initial report to the CPS, what else should be done?

Reassure the child, both immediately and regularly thereafter, that it was right for him/her to disclose the situation. Allow the child to express his/her feelings and thoughts about the disclosure and subsequent events. The child should also have an assigned professional with whom he/she has an ongoing relationship (e.g., CPS personnel, family doctor), to permit monitoring and support.

Depending on the nature of your involvement with the child, his/her long-term physical and psychosocial health should be monitored. Given the variations in individual needs and available resources, it is not possible to make specific recommendations about the frequency and type of assessments that should take place and the professionals who should complete them. Such decisions are currently made on the basis of assessments of individual children and families. Children who have experienced maltreatment are more likely than non-maltreated children to experience future abuse or neglect.Footnote 7-11 Even in cases where abuse is suspected but not substantiated by the CPS, it appears that the risk of subsequent reports and substantiation is high.Footnote 12 Therefore, these children and their families may require close monitoring.

Legal Responsibilities Relative to Suspected Child Maltreatment

Child maltreatment reporting laws fall under the jurisdiction of provincial and territorial governments. Each province and territory has laws that mandate reporting by professionals of suspected child maltreatment.* Professionals must report cases in which there are "reasonable and probable grounds to believe" or "reasonable grounds to suspect that a child is or may be suffering or may have suffered abuse".Footnote 14

Abuse or neglect does not have to be proven for a report to be made. If the professional suspects that maltreatment has occurred, this is sufficient grounds to justify a report. The CPS is responsible for investigating reports and protecting the child.Footnote 14

Provided that a report is made in good faith, the person who submits it is protected from any legal proceedings. In most jurisdictions there are penalties for those who fail to make a report; usually, this applies to professionals who work with children, such as teachers, early childhood educators, police officers and health care providers. These professionals are expected to have the expertise needed to identify and to report suspected cases.Footnote 14 Members of the general public are not legally obligated to report fellow citizens or family membersFootnote 14 but are encouraged to do so when child maltreatment is suspected.

Where to Report Suspected Child Maltreatment

In most provinces and territories, suspected child maltreatment should be reported to the local CPS.Footnote 14 In Newfoundland, Saskatchewan, Prince Edward Island and the Northwest Territories, the laws allow reporting to the RCMP, which in turn is obligated to report suspected cases to the CPS.

In First Nations communities within every province – with a few exceptions in British Columbia (B.C.) and Ontario – child maltreatment has been delegated to First Nations Child and Family Service Agencies (FNCFSAs); reporting should therefore be to the appropriate FNCFSA.Footnote 15 In B.C. and Ontario, there are both fully and partially delegated FNCFSAs. The former have full authority to receive and respond to reports of child maltreatment. Partially delegated FNCFSAs do not have the authority to receive or assess reports of child maltreatment; consequently, in the communities where they function, reports must be made to the CPS. In the Northwest Territories and Prince Edward Island, there are no FNCFSAs; therefore, suspected maltreatment must be reported to the local CPS, even in First Nations communities. When in doubt, professionals can ask the local CPS office where to report suspected child maltreatment.

* The only province or territory where reporting of suspected child maltreatment is not mandatory is the Yukon, although other laws in that jurisdiction require most professionals and workers in education or childcare settings to report suspected child maltreatment. The Yukon is, however, in the process of changing the Children's Act, and mandatory reporting may come into effect in the near future.Footnote 13

If a Professional Does Not Report Suspected Child Maltreatment

Failure by a professional to report can result in prosecution by provincial or territorial authorities. He/she can be sued for civil liability and face disciplinary action from his/her professional licensing body.Footnote 14

Patient-Client Confidentiality

In the vast majority of cases, the duty to report child maltreatment overrides any privilege related to confidential information given to health care professionals, police and religious authorities. The only exception is if child maltreatment is suspected in the context of a solicitor-client (lawyer-client) relationship. This exception does not apply in Newfoundland and Labrador or the Yukon.Footnote 14

Updates to the Criminal Code Relative to Child Maltreatment

The Criminal Code has been recently updated to reflect current maltreatment issues. For example, it has been changed to designate female genital mutilation, child-sex tourism and sexual exploitation via the Internet as criminal acts. The Canada Evidence Act was also recently changed to allow children to be accompanied by support people when they provide testimony, to testify outside the courtroom and to not be cross-examined by the accused.Footnote 16

Prevention and Intervention

Preventing Physical Abuse by Parents

Programs that provide home visitation by nurses or paraprofessionals to help prevent child maltreatment have been widely implemented and evaluated across North America. Research has found that the Nurse Family Partnership (NFP),Footnote 17 a program of intensive home visitation by nurses to first-time socially disadvantaged mothers in the United States, is effective in preventing abuse and improving the outcomes of children. This program begins during pregnancy and continues until the child is two years old. Improvements have consistently been found with regard to the home environment, child behaviour problems and child injury rates.Footnote 17-25 Based on its successful outcomes and evaluation, the NFPFootnote 17 is recommended for first-time mothers with one or more of the following risk factors: poverty, single-parent status and young maternal age.Footnote 26 Further research is needed to determine whether the NFP findings can be extended to the Canadian context.

Effective Nurse Home Visitation

Provides education, training and support to families in the following areas:

  • prenatal, infant and child care, health and development
  • prevention of abuse and neglect
  • social interaction with infants and toddlers
  • family planning assistance
  • problem-solving and life skills
  • education and work opportunities and
  • community resource assistance.

What to Do if Physical Abuse Has Occurred

Little evidence is available on interventions that are effective once physical abuse has occurred. The only study that has carefully evaluated nurse home visitation in families where physical abuse or neglect had occurred found that visitation did not reduce the recurrence of either physical abuse or neglect.Footnote 7 Other high-quality studies evaluating parent-child interaction therapy, resilient peer-mediated treatment for withdrawn preschoolers, cognitive-behaviour therapy and family therapy have demonstrated promising results in terms of reducing abuse recurrence and/or improving child and parent outcomes.Footnote 8,Footnote 27,Footnote 28 These approaches warrant further study before being widely adopted.

Preventing Sexual Abuse

Of the different types of intervention aimed at reducing sexual abuse, education about sexual abuse provided in primary schools has been subject to the most study. Research shows that this education leads to improved knowledge about self-protection.Footnote 29 Whether this translates to a reduction in sexual abuse rates is not known.Footnote 26 Some studies suggest that it may increase rates of disclosure after abuse has occurred, but the results are not definitive.Footnote 30,Footnote 31

These programs can cause distress, but it does not seem to be severe or to interfere with the completion or success of the programs.Footnote 32 Although many such programs exist in Canada, it is important for families and professionals to be aware that it is unknown whether they actually prevent child sexual abuse, and to not rely on them as a form of prevention.Footnote 26,Footnote 33

Comprehensive Sexual Abuse Education

Teaches children self-protection skills and shows them how to identify potential abusive situations and how to tell a trusted adult if abuse occurs. It involves:

  • a broad, structured curriculum
  • group training
  • behavioural training
  • video training
  • parent involvement and
  • trained instructors.

What to Do if Sexual Abuse Has Occurred

Several randomized controlled trials indicate that trauma-focused cognitive-behaviour therapy (CBT-TF) is an effective treatment for children who have symp-toms of post-traumatic stress disorder (PTSD), depression and/or anxiety related to sexual abuse.Footnote 34-39 CBT-TF has been evaluated for a number of age groups such as preschoolers, school age children and adolescents.

Trauma-Focused Cognitive-Behavioural Therapy (CBT-TF)

Key components of CBT-TF include:

  • a supportive therapeutic relationship
  • psychoeducation
  • stress management training
  • gradual exposure (i.e., developing the child's trauma narrative)
  • recognition and management of abuse reminders
  • cognitive processing and
  • cognitive coping skills.

Studies indicate that the participation of a non-offending parent or caregiver improves the therapy outcome for the child.Footnote 34,Footnote 35 The parent component of the therapy parallels the child component and addresses child management skills. CBT-TF is a promising intervention, and studies are underway to assess its effectiveness in community settings. The research evidence on other promising treatments for abuse-related PTSD is not as strong or as clear as it is on CBT-TF.Footnote 40

Promising Treatments for Sexual Abuse-Related PTSD:

  • Individual abuse-focused psychodynamic therapy and
  • Medication (i.e., selective serotonin reuptake inhibitors [SSRI])

Preventing Neglect

The Nurse Family Partnership (NFP) described on page 5 has also been shown to be effective in preventing neglect. Nevertheless, these positive findings are specific to the NFP and may not be applicable to similar programs.

What to Do if Neglect Has Occurred

No interventions studied to date can be recommended to treat the effects of neglect. However, a number of interventions appear to hold promise for neglected children and their families. Group play training and resilient peer-mediated treatment for withdrawn preschoolers may improve social behaviour; therapeutic day treatment may improve self-esteem;Footnote 28,Footnote 41-43 multisystemic therapy and parent training may improve parent-child relations, reduce parenting problems and decrease family social problems.Footnote 44

Interventions for Emotional Abuse

Very little research on emotional abuse prevention or treatment has been conducted; there is still debate about how to define emotional abuse.Footnote 45 Given the lack of research on this issue, there are no interventions that can be recommended. Clearly, this is an area that requires more study.

Helping Children Who Have Been Exposed to Family Violence

Most of the research on interventions to deal with family violence has focused on programs to prevent recurrence (including treatment programs for batterers), which have had mixed results and cannot be widely recommended.Footnote 46 Programs designed to help children who have been exposed to family violence have not been the focus of sufficient research. Therefore, no specific type of intervention can be recommended at this time; this is another area that warrants investigation.

When Maltreatment Has Occurred But a Child Has No Signs or Symptoms

It is not clear whether treatment should be provided to children who have been subjected to maltreatment but show no associated signs or symptoms. Some experts suggest that such children should be assessed for risk factors that increase their likelihood of having psychosocial symptoms, and should receive education to identify and to normalize their feelings and to prevent further victimization. Parents should also receive appropriate education on child maltreatment.Footnote 40 Other experts advocate waiting while closely watching for behavioural changes.Footnote 26 The experts agree that when concerns arise, prompt assessment, intervention and/or referral are indicated. Specific, effective treatments for many psychosocial problems, such as depression, that may occur in maltreated children have been identified.Footnote 47-50

Removing a Child From the Parents'/ Caregivers' Home

Decisions about removing a child from the parents' or caregivers' home temporarily or permanently can be complex and difficult. Research findings are unclear as to the circumstances in which a child should be removed from the home and the specific timing of such a removal. These decisions are typically based on negotiations among families, health professionals, child welfare professionals and, at times, the courts. The importance of "permanency planning," that is, maxi-mizing stability in the living situation of children under the care of child protective agencies, has been emphasized.Footnote 51

Implications for Practitioners

Dealing with child maltreatment can be very stressful. Practitioners may need personal support and/or professional help when managing maltreatment cases.

Identification and Reporting

Whenever a practitioner is carrying out a medical, psychiatric or other assessment of a child, it is important to be alert for any reports, signs or symptoms that suggest maltreatment may occur or has occurred. If there are concerns, further evaluation is warranted. Should the clinician suspect that child maltreatment has occurred, he/she is legally obliged to report this.

Prevention and Intervention

Practitioners will be called to advocate for children and their families, and to make recommendations on prevention, management and treatment. It is important to keep informed about evidence-based approaches to intervention, as this field is evolving. The child's safety is the main priority, and appropriate options should be considered in cooperation with CPS and, if necessary, the police. The child's immediate safety must be ensured and urgent health concerns addressed. Next, the child's physical and psychosocial health and development should be assessed in detail. If signs, symptoms or disorders related to maltreatment are detected, plans should be made for management and treatment and/or the child should be referred to appropriate services. If the appropriate specific interventions outlined above are available, the child should receive them. If they are not available, or if the child or family do not respond to an intervention, further treatment should be sought.

Evidence-based treatments for many childhood disorders (e.g., depression) are available to varying degrees; where they are not available, practitioners should seek the best available treatment and advocate for more training and services. If a child does not have signs or symptoms of maltreatment, regular assessments of health and development should be completed and the child's safety should be monitored on a regular basis.

Communication and Documentation

Given the number of professionals who may be involved with a child who has been maltreated, it is essential that their roles and responsibilities be defined and that the lines of communication be as clear and direct as possible. Any maltreatment-related documentation must be clear, comprehensive and promptly completed.

Further Readings/ Resources

Centre of Excellence for Child Welfare

www.cecw-cepb.ca

Faculty of Social Work
University of Toronto
246 Bloor Street W.
Toronto, ON M5S 1A1
Fax: (416) 946-8846

The Centre of Excellence for Child Welfare (CECW) fosters research and disseminates knowledge about the prevention and treatment of child abuse and neglect. This includes reports on current statistics on child welfare in Canada. Through the Centre's Web site, an extensive list of resources and publications can be accessed, databases of published and in-progress child welfare research can be searched, and a network of Canadian child welfare researchers is available. The Web site also contains a policy section that includes specific child welfare legislation for each province and territory. Information on how to report suspected cases of child maltreatment and on how to contact provincial/territorial ministries responsible for children's services, and local resources for children and parents, can also be accessed www.cecw-cepb.ca/Other/ProvAssistance.shtml .

Centre of Excellence for Early Childhood Development

www.excellence-earlychildhood.ca

3050, boulevard Édouard-Montpetit
Bureau A-205
Montréal (Québec) H3T 1J7
Tel.: (514) 343-6111, ext. 2541
Fax: (514) 343-6962

This Centre of Excellence provides information on research in the field of early childhood development. Its Web site also contains an encyclopedia on early childhood development that provides evidence-based information on a wide variety of topics of concern to parents and researchers, educators and service providers working with young children and their families.

Child Welfare League of Canada

www.cwlc.ca

75 Albert Street, Suite 1001
Ottawa, ON K1P 5E7
Tel.: (613) 235-4412
Fax: (613) 235-7616

The Child Welfare League of Canada houses the Canadian Resource Centre on Children and Youth. In this resource centre, publications on a wide variety of issues related to children and youth are available, including the brochures Discipline Without Hurting and Parenting in Canada.

First Nations Child & Family Caring Society of Canada (FNCFCS)

www.fncfcs.com

1001–75 Albert Street
Ottawa, ON K1P 5E7
Tel.: (613) 230-5885
Fax: (613) 230-3080

The purpose of the Caring Society is to promote the well-being of all First Nations children, youth, families and communities, with a particular focus on the prevention of, and response to, child maltreatment. The Society's Web site provides an inventory of First Nations research and many downloadable documents about aspects of First Nations and Aboriginal child welfare in Canada, as well as access to the on-line journal First Peoples Child & Family Review. The site also provides contact information for all First Nations and Aboriginal child and family service agencies in Canada.

Health Surveillance and Epidemiology Division, Public Health Agency of Canada

www.phac-aspc.gc.ca/cm-vee

Injury and Child Maltreatment Section
Public Health Agency of Canada
200 Eglantine Driveway
Jeanne Mance Building, AL: 1910C
Tunney's Pasture
Ottawa, ON K1A 0K9

The Health Surveillance and Epidemiology Division works to strengthen surveillance and research on the national and international level in the areas of injury and maltreatment. One of the Injury and Child Maltreatment Section's main activities is to direct the Canadian Incidence Study of Reported Child Abuse and Neglect. A full report of the Canadian Incidence Study of Reported Child Abuse and Neglect - 2003 is available on its Web site.

Stop Family Violence

www.phac-aspc.gc.ca/nc-cn

Family Violence Prevention Unit
Public Health Agency of Canada
200 Eglantine Driveway
Jeanne Mance Building, AL: 1909D1
Tunney's Pasture
Ottawa, ON K1A 0K9
Tel.: 1-800-267-1291 or
(613) 957-2938
TTY: 1-800-561-5643 or
(613) 952-6396
Fax: (613) 941-8930

The National Clearinghouse on Family Violence (NCFV) is Canada's national resource centre for information about violence and other forms of abuse in relationships of kinship, intimacy, dependency or trust. The NCFV provides a variety of information resources on child maltreatment. For more information, please contact the NCFV toll-free at 1-800-267-1291 or visit the NCFV Web site at www.phac-aspc.gc.ca/nc-cn

Suggested Readings 1214-1222.

Bilukha, O., et al. "The effectiveness of early childhood home visitation in preventing violence: A systematic review," American Journal of Preventive Medicine 28, 2, Supp. 1 (2005): 11-39.

Canada. Dept. of Justice Canada. Child Abuse: A Fact Sheet. [Online]. Ottawa: The Dept., 2003. Available: www.justice.gc.ca/en/ps/fm/childafs.html

Canada. National Clearinghouse on Family Violence. Child abuse: Reporting and classification in health care settings, prepared by S. K. Loo et al. Ottawa: Health Canada, 1996.

Canada. National Clearinghouse on Family Violence. The consequences of child maltreatment: A reference guide for health practitioners, prepared by J. Latimer. Ottawa: Health Canada, 1998.

Daro, D. A. "Prevention of child sexual abuse," Future of Children 4, 2 (1994): 198-223.

Kaplan, S. J., D. Pelcovitz, and V. Labruna. "Child and adolescent abuse and neglect research: A review of the past 10 years. Part I: Physical and emotional abuse and neglect," American Academy of Child and Adolescent Psychiatry 38, 10 (1999):

MacMillan, H. L. "Child maltreatment: What we know in the year 2000," Canadian Journal of Psychiatry 45, 8 (2000): 702-709.

Olds, D. L., et al. "Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial," JAMA 278, 8 (1997): 637-643.

Olds, D. L., et al. "Prenatal and infancy home visitation by nurses: Recent findings," Future of Children, 9, 1 (1999): 44-65.

Putnam, F. W. "Ten-year research update review: Child sexual abuse," Journal of the American Academy of Child & Adolescent Psychiatry 42, 3 (2003): 269-278.

References

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