Childhood Maltreatment E-Book

Christine Wekerle

• Herausgeber: Hogrefe Publishing
• Kategorie: Fachliteratur
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch
• Veröffentlichungsjahr: 2018

Seitenzahl: 242

Beschreibung

The new edition of this popular, evidence-based guide compiles and reviews all the latest knowledge on assessment, diagnosis, and treatment of Childhood Maltreatment – including neglect and physical, sexual, psychological, or emotional abuse. Readers are led through this complex problem with clear descriptions of legal requirements for recognizing, reporting, and disclosing maltreatment as well as the best assessment and treatment methods. The focus is on the current gold standard approach – trauma-focused CBT. An appendix provides a sample workflow of a child protection case and a list of extensive resources, including webinars. This book is thus invaluable for those training or working as expert witnesses in Childhood Maltreatment and is also essential reading for child psychologists, child psychiatrists, forensic psychologists, pediatricians, family practitioners, social workers, public health nurses, and students.

Leseprobe

Childhood Maltreatment

2nd edition

Christine Wekerle

McMaster University, Hamilton, ON, Canada

David A. Wolfe

Western University, London, ON, Canada

Judith A. Cohen

Drexel University College of Medicine, Pittsburgh, PA

Daniel S. Bromberg

Special Psychological Services, LLC, Bloomfield, NJ

Laura Murray

Johns Hopkins University, Baltimore, MD

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Saybrook University, Oakland, CA

Associate Editors

Larry Beutler, PhD, Professor, Palo Alto University / Pacific Graduate School of Psychology, Palo Alto, CA

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

David A. Wolfe, PhD, ABPP, Adjunct Professor, Faculty of Education, Western University, London, ON

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://us.hogrefe.com/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2018945003

Library and Archives Canada Cataloguing in Publication

Child maltreatment

Childhood maltreatment / Christine Wekerle, McMaster University, Hamilton, ON, Canada, David A. Wolfe, Western University, London, ON, Canada, Judith A. Cohen, Drexel University College of Medicine, Pittsburgh, PA, Daniel S. Bromberg, Special Psychological Services, LLC, Bloomfield, NJ, Laura Murray, Johns Hopkins University, Baltimore, MD. -- 2nd edition.

(Advances in psychotherapy--evidence-based practice ; v. 4)

Previously published under title: Child maltreatment.

Includes bibliographical references. Issued in print and electronic formats.

ISBN 978-0-88937-418-8 (softcover).--ISBN 978-1-61676-418-0 (PDF).--ISBN 978-1-61334-418-7 (EPUB)

1. Child abuse. 2. Abused children--Rehabilitation. 3. Abused children--Services for. I. Wekerle, Christine, 1962-, author II. Title. II. Series: Advances in psychotherapy--evidence-based practice ; v. 4

RC569.5.C55C47 2018

618.92’85822306

C2018-903377-0

C2018-903378-9

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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© 2019 by Hogrefe Publishing

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Format: EPUB

ISBN 978-0-88937-418-8 (print) • ISBN 978-1-61676-418-0 (PDF) • ISBN 978-1-61334-418-7 (EPUB)

http://doi.org/10.1027/00418-000

Citability: This EPUB includes page numbering between two vertical lines (Example: |1|) that corresponds to the page numbering of the print and PDF ebook versions of the title.

|v|Dedication

First and foremost, this book is dedicated to all victims who have lost their lives to causes related to child maltreatment – your imprints on this world are not lost. To all those who have survived abuse and neglect – your daily efforts to engineer your own resilience journey is acknowledged and admired. We appreciate the participation of all child maltreatment research participants in building the evidence base upon which this book is based. We recognize the tremendous efforts of trainees, research assistants, and other support persons who make the research enterprise happen on a daily basis. A special note of research thanks goes to Mr. Ronald Chung, who married his sweetheart Cindy during the creation of this book.

Second, this book is dedicated to professionals who, in their own ways, form a river of resilience to keep victims buoyant and moving forward. This book is dedicated to the memory of professionals who have shown a persistent devotion to violence prevention. We acknowledge the sizeable contributions of Dr. Mark Chaffin and Dr. Murray Strauss. We wish to remember further two individuals: Dr. Anne-Marie Wall, 1964–2005, an alcohol researcher who came to embrace work in the family violence field, coediting The Violence and Addiction Equation with Dr. Wekerle; and Dr. Angus MacMillan, 1930–2015, a pediatrician who advocated for the need to establish a children’s hospital, in part, to reflect the sensitivity in approach that children need in health care. His lifelong work in child health and violence prevention at McMaster University, inspired his daughter, Dr. Harriet MacMillan, a pediatrician and child psychiatrist, to initiate the Child Advocacy and Assessment Program (CAAP) at McMaster’s Children’s Hospital. She now leads the Violence, Evidence, Action Group (VEGA; http://projectvega.ca/).

|vi|Acknowledgments

This second edition represents an update covering the vast volume of new research in child maltreatment. We thank our publishers, acknowledging especially Robert Dimbleby and series editor Dr. Danny Wedding, and are grateful for their ongoing interest in child maltreatment knowledge exchange. The current authorship provides expertise in assessment and treatment issues, consistent with the current gold standard of trauma-focused cognitive behavior therapy with pediatric clients. Ongoing research that reflects the contributions of international teams and practitioners across diverse disciplines and systems, as well as those with lived experience, remains essential to upholding the foundational principles of doing no harm and acting in the best interests of the child. As professionals, we recognize the primacy of the child’s and adolescent’s right to safety and freedom from violence. Without physical and psychological safety, it is very challenging to optimize development and galvanize resilience. We are very pleased to join with you as part of the global collective to put children first, end violence, and to work toward peace and justice for all of the world’s children.

Contents

Dedication

Acknowledgments

1 Description

1.1 Terminology

1.2 Definitions

1.2.1 Neglect

1.2.2 Physical Abuse

1.2.3 Sexual Abuse

1.2.4 Psychological or Emotional Abuse

1.2.5 Diagnostic Considerations

1.3 Epidemiology

1.4 Course, Prognosis, and Context

1.5 Recognizing, Reporting, and Disclosing Maltreatment

2 Theories and Models of Child Maltreatment

3 Diagnosis and Treatment Indications

3.1 Clinical Interview and Assessment

3.2 Forensic Mental Health Assessment

3.3 Specific Disorders Associated With Childhood Maltreatment

3.3.1 Mood Disorders, Self-Harm, and Suicidality

3.3.2 Anxiety Disorders

3.3.3 Posttraumatic Stress Disorder and Dissociation

3.3.4 Substance Use Disorders

3.3.5 Eating Disorders

3.3.6 Asymptomatic Victims

4 Treatment

4.1 Methods of Treatment

4.1.1 Stabilization and Skills Building

4.1.2 Trauma Narrative and Processing Phase

4.1.3 Integration and Consolidation Phase

4.1.4 Traumatic Grief Components (Optional)

4.1.5 TF-CBT Termination

4.2 TF-CBT Mechanisms of Action

4.3 Efficacy and Prognosis

4.4 Variations and Combinations of Methods

4.5 Challenges in Carrying Out the Treatments

4.6 Cross-Cultural Issues

5 Case Vignette

Overview

First Session

Second Session

Third Session

Fourth Session

Fifth to Ninth Sessions

Tenth and Eleventh Sessions

Twelfth to Fourteenth Sessions

6 Further Reading

7 References

8 Appendix: Tools and Resources

Child Welfare and Case Example of CPS Workflow

Work Flow for Child Abuse and Neglect Referrals

References

Resources for Clinicians Working With Childhood Maltreatment Cases

Assessment Measures

Guidelines for Identifying Childhood Maltreatment

Webinars

Resources for Particular Populations and Environments

Child Maltreatment Continued Education Modules

About the Authors

|1|1Description

My father began screaming.… It snowballed from there. I do remember his face being distorted by rage, barking at us like a drill sergeant. I remember veins bulging…. He hit my brother upside the face. I was next.… He knocked me down again, incensed, and then dragged me to the bed…. I thought I was going to die.… My dad and I bumbled our way through my youth…. I began to show troubling behavior. I began to steal … trying to fill something inside, trying to find power in my powerless life…. If I was so lovable, then why did those closest to me seem to see fit to treat me so badly?… I have so much compassion for my dad. He endured so much as a child, and then he was shipped off to war. He had suffered from PTSD.… While he and I did not speak for most of my early career, we have a healthy and loving relationship now. Through a combination of therapy and self-examination, he has fought hard for the happiness he has, and [now] … allows me to feel a lot of safety….

Jewel, American singer–songwriter–writer (Jewel, 2015)

1.1 Terminology

Worldwide, over 1 billion children were exposed to violence in 2014 (Hillis, Mercy, Amobi, & Kress, 2016). The Global Partnership to End Violence Against Children estimates that 120 million females and tens of millions of males are sexual abuse victims (UNICEF, 2014). Child maltreatment can be understood only by examining the nature of close relationships. Only through the context of relationships can such illogical, illegal, and illicit actions be repeated, over hours, over days, over years. “It is a private family matter” is a phrase that illustrates how child maltreatment was once treated; however, after decades of rigorous research and robust results, we are now realizing that child maltreatment is a serious public health issue with humanitarian and human rights import. As musician Jewel’s quote above reminds us, caregiver vulnerabilities deserve our compassion. Because of the drive to attachment, and later affiliation, children tilt toward tenderness. In a meta-analytic review of the adverse childhood events (ACEs) literature by Hughes and colleagues (2017), there was a strong urgency felt by all involved parties to prevent maltreatment, minimize its negative impact by targeting reoccurrence, and build resilience. With four or more ACEs, there was a 5–10 times increase in the likelihood of |2|problematic alcohol and drug use, 3–5 times increase in the likelihood of sexual health risk behaviors, and over 30 times increase in the likelihood of a suicide attempt. While cumulative stress in childhood is the key concern, five of the ACEs involve child maltreatment (physical, sexual, emotional abuse, neglect, exposure to intimate partner violence), while three are caregiver vulnerability factors (household substance abuse, mental health problems, criminality). The annual costs of maltreatment are estimated at between US $124 billion and US $585 billion in the US (Fang, Brown, Florence, & Mercy, 2012).

The adults’ issues do deserve therapeutic attention. Parental socioeconomic stress, personality vulnerabilities, addiction, partnership problems, social isolation, cognitive impairment, and psychopathology certainly impact parenting. The adults’ stress narrows their attentional capacities, leading to an overfocus on child problem behavior and an underattention to child discovery and positive behaviors. There is robust evidence for the harm of spanking and verbal abuse toward children, and yet, in developing countries in particular, most children experience adversive, coercive parenting. Overwhelmed adults also disengage from child care. However, the fact remains that adults take care of children; children do not parent and protect adults. The child’s stress systems are overwhelmed due to their dependent and in-development nature. Behaviorally, the child will freeze, faint, flee, or fight. Increasingly, youths are becoming more active, reporting their maltreatment directly to national and international child helplines (Bentley, O’Hagan, Raff, & Bhatti, 2016). Data from 2003–2013 from Child Helpline International – a global network of helplines – documents the fact that over 4 million children have reported violence, primarily at the ages of 10–18 years old; 60% of reportees were girls, and 58% of physical abuse perpetrators were family members (Child Helpline International, 2013). There is a changing landscape of dangers to youth: In 2015, the Internet Watch Foundation and partners removed over 68,000 URLs with child sexual abuse images worldwide (International Watch Foundation, 2016). The details alone should shock us into our advocacy roles as professionals: 3% of victims were assessed as 2 years old or under, with most victims assessed to be 10 years old and under; 85% of images were of girls, with 39% of images showing extreme violence. The drivers for this content are persons in developed nations: Most of these sites were hosted in North America and Europe.

These statistics highlight the need to support two of the UN’s Sustainable Development Goals (SDGs): SDG 5.2, to “eliminate all forms of violence against all women and girls in public and private spheres” (United Nations, 2017); and SDG 16.2, to “end abuse, exploitation, trafficking, and all forms of violence and torture against children” (United Nations, 2017). For clinicians engaged in cases of family violence, it is important to be aware of the full range of violence and risks, as well as the resilience resources. We need to be prepared to consider cross-cutting issues, such as the environment and poverty, alongside human rights and public health initiatives in violence prevention, as expressed in the principles underlying the SDGs.

While we may think of child maltreatment as relevant to a child or family, its ripples extend much further. Violence is a social determinant of health, and there are disparities in the ways in which violence affects relationships, parenting, and communities. In a 27-year birth population cohort, economic and social instability were found to be predictors of child maltreatment (|3|Doidge, Higgins, Delfabbro, & Segal, 2017). Higher rates of maltreatment are linked to economic and financial crises in countries, as well as poor adult financial health in terms of employment and property ownership (Currie & Widom, 2010). The implications of poverty include spill-over effects that further impact physical health.

An ongoing concern is the disproportionate numbers of socioeconomically disadvantaged children in out-of-home care. For example, according to Statistics Canada, in 2011 (Turner, 2016), Aboriginal children aged 14 and under accounted for 7% of Canadian children but 48% of foster care children (Aboriginal is the term used in the study for this report and reflects predominantly First Nations children, but also Métis and Inuit children. For the report on the 2011 National Household Survey data [Turner, 2016]). Of these, 44% lived with at least one Aboriginal parent. Indigenous cultural practices promote well-being, as they target a balance in mental, physical, emotional, and spiritual well-being, as well as the maintaining of a tangible connection to community resources. Children and youths living in indigenous communities are also exposed to land-based trauma, where the ongoing requirement to defend and protect land and water resources is heightened with environmental concerns over corporate and government challenges to treaty rights. Recently, a connection was made between government and public health concerns such as clean water, degradation of land, and available green space, on the one hand, and location and (re)location of children and families on the other. In the United Nations Declaration on the Rights of Indigenous Peoples (United Nations General Assembly, 2007);, rights to intellectual property, traditional knowledge, language, and ancestral domains, as well as treaty and land rights, are detailed. Article 22 specifically addresses children, stating that they have a right to “full protection and guarantees against all forms of violence and discrimination” (p. 9). People in governmental positions and professionals in care and contact positions are duty bearers, upholding our duty to support well-being and to address violence. As such, we have a responsibility to respect, promote, and realize human rights, and to abstain from human rights violations.

The portrait painted herein of child maltreatment is one of adult disadvantage and poor decision making, often in the context of historical and current violence and deprivation. The body of research is clear that maltreatment is an environmental and relationship toxin, a modifiable health risk factor, and a driver of health care costs. Yet, in day-to-day experience, violence is one adult’s choice among a myriad of other options for that one child. A parent’s capacity to buffer a child from the parent’s own stress, as well as to scaffold a child’s response, is critical to developing the adaptive serve-and-return mutual attention interactions, which include the capacity for interactive repairs – the how to of reconciling conflictual interactions. A serve-and-return interaction occurs when a child is given feedback on their actions or verbalizations from the parent, thereby engaging the child in a reciprocal manner. Interactive repairs involve exchange between the parent and child working together to remedy conflict, allowing for the parent to take responsibility for correcting a potentially harmful interaction. An example of this would be the parent explaining the use of punishment that is reasonable or apologizing for a harsh discipline approach, letting the child know what they should expect in the |4|future, as an alternative to the particular parenting choice. Too often, a child or youth will take on a narrative of blame, with the burden of shame, guilt, and secretiveness tipping the scales toward self-harm rather than self-care.

It is time for individual and collective professional action to reflect a culture of respect for child and adolescent rights and the safeguarding of their dignity and integrity. This includes all disciplines and needs to extend to the impact for physical health. Child maltreatment, in combination with other ACEs, is linked to elevated risks for physical inactivity, overweight or obesity, diabetes, cardiovascular disease, cancer, liver and/or digestive diseases, respiratory disease, and poor self-rated health (Hughes et al., 2017).

In this work, we focus on child maltreatment and related impairment to mental health, with a trauma-informed approach to assessment and treatment. This book seeks to provide practical information on the scope and nature of the problem of child maltreatment, with relevant statistics and research to put into action. We will expand our discussion of the trauma-informed intervention, the current gold standard of trauma-focused cognitive behavior therapy (TF-CBT), which has been applied widely and across diverse settings. Intervention that seeks to improve adolescents’ capacities in mentalizing (thinking about thinking) has also shown promise in randomized trials with adolescents. Such reflective practice may serve to enhance a sense of agency and control where there is emotional dysregulation, and may be valuable especially to youths who have experienced child sexual abuse (CSA) specifically. Future work – especially within the ACE framework; with child protective service (CPS) samples; and including indigenous youths and lesbian, gay, bisexual, transgender, questioning, and other (LGBTQ+) youths – will be interesting to consider, as this research base evolves. Brief case scenarios and case examples collated from accumulated clinical practice experiences appear throughout this book, and are intended to convey the phenomenology of, and approach to, child maltreatment. In Appendix 1 and Appendix 2, we provide additional resources and a case example of one child welfare process.

1.2 Definitions

Legal definitions of childhood mistreatment in most countries consider children to be in need of protection if their life, health, or safety may be endangered by the conduct of their caregiver:

Child maltreatment, sometimes referred to as child abuse and neglect, includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity. (WHO; http://www.who.int/en/news-room/fact-sheets/detail/child-maltreatment)

Internationally, many countries have taken up the precepts of the United Nations Convention on the Rights of the Child (CRC; United Nations General Assembly, 1989). The CRC tasks signatory countries with being solutions |5|focused, via all means appropriate, be they legislation, education, or social welfare and prevention initiatives, to ensure that the child’s and adolescent’s right to nonviolence is protected. The use of the term violence is intended to include neglect, which may be functionally related to the toxic stressors of violence, and may, as a phenomenon, be an active or more passive assault on the child.

The Global Partnership to End Violence Against Children (http://www.end-violence.org/) signifies the urgency and agency for capacity building, as globally, research highlights the risk of the spread of child maltreatment across borders. Some legal definitions include being at-risk for child abuse and neglect as the starting point for action, so as not to wait for an explicit event to be captured by a professional, witness, or concerned citizen. While some jurisdictions have a voluntary involvement option to engage with CPS for services, parents are typically not the reporters of their own abuse and/or neglect. Legal definitions emphasize parental deviance and wrongdoing, and may focus on the implicit intent to harm, or the parent’s inability to protect the child from harm.

Definitions have evolved to allow greater recognition of the individual, family, and social context of maltreatment, because most reports of child maltreatment involve non-life-threatening injuries, with the key exception being infants exposed to nonaccidental head trauma. Most physical abuse involves bruising, swelling, and redness, rather than broken bones or severe injuries, although not all CPS cases for investigation would receive medical screening for old injuries. Some jurisdictions require a pediatrician’s diagnosis of child abuse and neglect.

A social science perspective places primary importance on the relational context, where there is the greatest psychological impact, as studies in recent years have documented the unique, robust impact of emotional maltreatment. This perspective builds on legal definitions by including the antecedents and consequences of maltreatment within its developmental and ecological context, as well as making comparisons with expected, “normal” developmental patterns. All forms of child maltreatment can be isolated incidents or episodes, although it more often reflects a chronic pattern of dysfunctional relating. The World Health Organization (WHO) defines four main categories of maltreatment: (1) neglect, (2) physical abuse, (3) sexual abuse, and (4) psychological or emotional abuse (WHO, 2016). The American Psychological Association guidelines for psychological evaluations of child maltreatment can be found at on the Web (http://www.apa.org/practice/guidelines/child-protection.aspx).

1.2.1 Neglect

Neglect covers a wide range of failure-to-care events, in those situations in which the parent is in the position to provide care. It is common in CPS referrals, and may be most notable during early child development. Neglect occurs when a child’s parents or other caregivers are not providing the requisites for a child’s emotional, psychological, and physical development, and may occur for a wide range of reasons (e.g., infants failing to thrive based on lack of appropriate nutrition due to limited understanding of basic needs). |6|Physical neglect occurs when a child’s needs for food, clothing, shelter, cleanliness, medical care, safe living conditions, and protection from harm are not adequately met. Emotional neglect occurs when a child’s need to feel loved, wanted, safe, and worthy is not met. Emotional neglect can range from being unavailable to active rejection.

There remains still a “neglect of neglect” in the empirical literature, and clinically, when evaluating abuse, it may be helpful to reflect on whether anything was missed that would suggest neglect. Neglect types include supervisory neglect, refusal or delay in providing health or mental health care, custody refusal or related neglect, abandonment or desertion, failure to provide a home, failure to look after personal hygiene, housing hazards or poor sanitation, nutritional neglect, and educational neglect. Some definitions of neglect also include emotional neglect (a marked indifference to a child’s need for affection, attention, and emotional support).

Supervisory neglect is one of the most common forms of neglect – leaving the child unattended, in the care of other children, with dangerous persons, or in dangerous places – overlapping with accidental injuries, sexual abuse risk, and death (e.g., drowning). Failure-to-thrive is defined in terms of multiple measures of physical growth faltering due to malnutrition (e.g., weight-for-height, body mass index, growth change from stable to unstable patterns, head circumference). Postpartum maternal depression may be a co-occurring concern with any form of neglect.

1.2.2 Physical Abuse

Physical abuse is the deliberate application of force to any part of a child’s body, which results or may result in a nonaccidental injury. Physical abuse includes behavior such as shaking, choking, biting, kicking, burning, or poisoning a child; holding a child under water, or any other harmful or dangerous use of force or restraint (e.g., locking a child in a closet or tying them to a chair); or striking with hard objects (e.g., wooden spoon, belt, etc.). Some injury features increase suspicion, such as multiple fractures in a child or fractures in babies who are not yet crawling or walking and have no known medical conditions (“not cruising, no bruising”).

Children will generally bruise accidentally on their boney areas – such as knees, shins, and ankles – and not on soft tissue areas such as the stomach, chest, back, neck, and ears. Injuries to soft tissue areas, as well as any multiple bruises, increase concern. Shaking is a serious behavior that should always be avoided, as it may cause injury to the infant from the pressure of the adult’s hands on the rib cage, the child’s chin impacting their chest, or violent action causing internal decapitation. Shaking is thought to be the cause of unexplained infant mortality and cognitive damage. The leading causes of child abuse death are abusive head trauma, blunt abdominal trauma, and suffocation, with greatest vulnerability in the first 2 years of life.

Child physical abuse is often connected to physical punishment or is confused with child discipline, with excessive force applied. Parents who have inappropriate developmental knowledge and expectations of their children, those who may have an intellectual disability limiting their understanding of |7|child behavior, those with harsh or inconsistent parenting practices or who lack knowledge and compassion for the child’s developing status, and those who parentify children as caretakers of siblings, parents, or the household are at risk for abusing their children. Such parents need to be taught a child-centered, developmentally appropriate, nonviolent disciplinary approach, as well as to increase positive joint attention and shared positive affect to enhance both feelings of parental satisfaction and parenting competency. All professionals need to be familiar with both the physical and psychological manifestations of child abuse injury.

1.2.3 Sexual Abuse