1 abuse HK 2007

Child Abuse: 

Child Abuse Child Psychopathology and Clinical Assessment.

Child Abuse: 

Child Abuse Distresses Disturbs Confronts us all

Physical Abuse: 

Physical Abuse Any non accidental injury caused by the carer Beating, biting Strangulation Shaking…….

Emotional Abuse: 

Emotional Abuse This includes passive forms of abuse such as: Ignoring or rejecting the child Witholding affection or praise

Emotional Abuse: 

Emotional Abuse More active forms of emotional abuse include: Constant yelling Threatening Terrorising Belittling or verbally rejecting the child

Neglect: 

Neglect Failure to provide for the needs of: love and security opportunities for development new experiences praise & recognition food, housing, clothing,medical care & education

Non-organic Failure to Thrive: 

Non-organic Failure to Thrive Failure to meet the need for adequate nutrition and emotional stimulation decline from established pattern of growth weight below 3rd percentile psychomotor delays history suggestive of emotional/nutritional deprivation

Factitious Disorder (Munchausen) by Proxy: 

Factitious Disorder (Munchausen) by Proxy The deliberate feigning of physical or psychological signs or symptoms in another person under the person’s care. Victim typically the child, perpetrator typically the mother.

Factitious Disorder (Munchausen) by Proxy: 

Factitious Disorder (Munchausen) by Proxy Psychological need to assume the sick role by proxy No apparent external gains (eg. financial) No other mental disorder accounts for behaviour.

Sexual Abuse: 

Sexual Abuse The involvement of dependant, developmentally immature children and adolescents in sexual activities: that they do not fully comprehend to which they are incapable of giving consent or that violates boundary taboos

Sexual Abuse: 

Sexual Abuse Sexual abuse includes all forms of: Intercourse Masturbation Fondling Exhibitionism Exposure of a child to pornography

Secondary Abuse: 

Secondary Abuse This is the additional abuse by other people with whom the child comes into contact. Others’ reactions to the abuse The ignorance and confusion of professionals working with the child

Indicators: 

Indicators Physical Abuse - Child’s Behaviour states injury caused by someone is wary of physical contact seems frightened of parent/caregiver expresses little/no emotion when threatened or hurt offers unlikely explanation of injury

Indicators: 

Indicators Physical Abuse - Child’s Behaviour habitual absences from school cringes at sudden movements overly compliant, shy, withdrawn, passive uncommunicative nervous, hyperactive, aggressive, disruptive regressive behaviour

Indicators: 

Indicators Physical Abuse - Parents’ Behaviour offers illogical/no account of the injury appears unconcerned about child’s condition delays seeking medical attention attempts to conceal the injury takes child to several physicians/hospitals refuses to attend school/health centre appointments

Indicators: 

Indicators Sexual Abuse - Child’s Behaviour makes disclosure sexualized behaviour/inappropriate activity has detailed/sophisticated knowledge of sex excessively fearful when nappy changed or bathed fearful of a particular adult

Indicators: 

Indicators Sexual Abuse - Child’s Behaviour poor/deteriorating peer relationships first to arrive, last to leave at school reluctant to participate in physical activities regressive behaviour - eg bedwetting, speech loss overly protective of younger siblings

Indicators: 

Indicators Sexual Abuse - Child’s Behaviour loss of appetite sudden accumulation of gifts/money runs away delinquent/aggressive behaviour self injurious behaivour, eg. self harming, drug & alcohol abuse, prostitution, suicide attempts

Indicators: 

Indicators Emotional Abuse - Physical signs speech disorders delays in physical development failure to gain weight/height in infants small head circumference for age dry, sparse hair, bald patches severe nappy rash cold pink/purple hands &/or feet pot belly and loose stools

Indicators: 

Indicators Emotional Abuse - Child’s Behaviour overly compliant, passive and undemanding extremely demanding and aggressive anti-social, destructive behaviour low tolerance of frustration poor self-image unexplained mood swings

Indicators: 

Indicators Emotional Abuse - Child’s Behaviour parentified behaviour inappropriately infantile depressed, suicidal behaviour neurotic traits, eg. phobias, compulsion

Indicators: 

Indicators Neglect - Child’s behaviour begging for/stealing food gorging food when available inability to eat when hungry withdrawn, pale, thin, isolated engages in delinquent acts little positive interaction with the caregiver

Indicators: 

Indicators Neglect - Child’s behaviour appears miserable, irritated poor social skills poor evidence of bonding little anxiety about strangers indiscriminate with affection poor/irregular school attendance

History Taking: 

History Taking Things to consider regarding parents intergenerational history of abuse poor self image poor impulse control/coping skills weak/non-existant boundaries external/chance events

History Taking: 

History Taking Things to consider regarding parents lack of understanding about children’s needs unrealistic expectations negative view of children firm beliefs in the value of punishment isolation/lack of supports

History Taking: 

History Taking Things to consider regarding children pre-natal history that impacts on attachment ante natal problems - sleeping, feeding, settling, etc. child never met parents’ expectations

History Taking: 

History Taking Things to consider regarding children difficulty with stages of development delays, temperament problems, etc. significant differences in child

Dynamics of Abuse: 

Dynamics of Abuse Emotional Impact Skewed sense of normality/world view Self-blame/guilt Little trust in self/own feelings/others Denial of emotions/feelings Secrecy Boundaries blurred/shattered

Dynamics of Abuse: 

Dynamics of Abuse Behavioural Impact Internalized behaviours low self esteem fears/anxiety/obsessiveness depression/withdrawal self abuse/mutilation suicidality

Dynamics of Abuse: 

Dynamics of Abuse Behavioural Impact Externalized behaviours promiscuity aggression, acting out/risk taking sexualized behaviour offending behaviour poor concentration

Dynamics of Abuse: 

Dynamics of Abuse Developmental Impact Attachment patterns/relationship templates Identity – sense of self, “differentness” Learning – opportunity & capacity to focus on learning Knowledge/experience of sexuality

Dynamics of Abuse: 

Dynamics of Abuse Impact on Family Functioning grief/shock/anger rejection/blame/disbelief overprotection confusion life consumed by the events/revenge questioning ability to parent

Dynamics of Abuse: 

Dynamics of Abuse Long Term Effects identity - living a life for others relationship difficulties repeated patterns mental health problems

Dynamics of Abuse: 

Dynamics of Abuse Factors that contribute to the impact: Developmental stage Chronicity Severity Level of threat/danger

Dynamics of Abuse: 

Dynamics of Abuse Factors that contribute to the impact: Specifics of the abuse Relationship to perpetrator Emotional health of the family Emotional health of the child

Dynamics of Abuse: 

Dynamics of Abuse Resilience the child’s personality the child’s ability and opportunity to access support

Traumagenic StatesFinklehor & Browne (1980), James (1989): 

Traumagenic States Finklehor & Browne (1980), James (1989) 4 states, expanded to 9 useful in treatment and planning Traumatic Sexualization Powerlessness Loss & Betrayal Stigmatization

Traumagenic States: 

Traumagenic States Fragmentation of Bodily Experience Eroticization Destructiveness Self Blames Dissociative Disorder Attachment Disorder

Reporting Child Abuse: 

Reporting Child Abuse Impediments to reporting Minimization Denial/resistance Inaction

Mandatory Reporting: 

Mandatory Reporting Professional Groups mandated to report include: Medical practitioners, nurses, police (since November, 1993) Teachers (since July 1994) The penalty for not reporting is a $1000 fine.

Myths: 

Myths Children are too young to understand what has happened to them Children will forget, get over it quickly or just grow out of it. Therapy only makes them remember and upsets them. A lack of observable behavioural or psychosomatic responses means a child has not been upset by events

Facts: 

Facts Children are sensitive to and aware of changes in their world One does not have to understand an event to be effected by it – in fact confusion can make it worse Any major event, happy or sad, becomes a part of the child and his/her life and thus has an impact A child’s inner world may not be observable or recognized but still inhibit or constrain Children do not necessarily recover more quickly than adults (Gordon & Wraith, 1993)

Some Research: 

Some Research Goodman: child memory & suggestibility 4-5yr olds are no more suggestible than adults memories are inaccurate by omission rather than addition/exaggeration Myers-Williams: false memory 38% of adults taken to hospital as children for sexual abuse did not recall that abuse

Some Research: 

Some Research Sorenson & Snow: of 186 children with medical evidence of abuse, 80% initially denied the abuse Rosenbloom: 80% of children touched parents’ genitals – not an indicator of abuse ON ITS OWN Friedrich: Coercive, powerful, humiliating acts of sexualized behaviour by children are most concerning indicators of potential perpetrator behaviour

Assessment & Treatment: 

Assessment & Treatment Assessment Goals Gauge the impact of the experience Determine the child’s needs Plan treatment

Assessment: 

Assessment Goals Engage the child and family/carers How the child experiences/sees her world & herself How the child is coping with the memory of the abuse.

Assessment: 

Assessment Things to consider Developmental stage Attachments/way of relating Family context, responses, coping, supports Understanding of concepts: feelings, touch, good/bad Physical & mental state

Assessment: 

Assessment Things to consider Attention span/impulse control Coping skills Non-verbals Likes/dislikes, strengths/weaknesses

Assessment: 

Assessment Point of Time Prior to clear disclosure Immediately after disclosure Some time after the disclosure

Types of Disclosure: 

Types of Disclosure Accidental Observed by third party Suspicious physical injury Behavioural indicators Psychosomatic complaints

Types of Disclosure: 

Types of Disclosure Purposeful sharing a secret an attempt to get adults to stop the abuse fear of pregnancy

Disclosure: 

Disclosure Disclosure can occur over time Not often immediate Often fragmented The worst parts are often disclosed later

Disclosure: 

Disclosure Children test the water Your reaction Your persistence Can you be trusted?

Disclosure: 

Disclosure What to do? Listen and Validate Acknowledge that telling can be difficult. Express your belief in him/her and that you know that this happens to other children/young people too.

Disclosure: 

Disclosure What to do? Be clear/up front about what you can/must do next. Get support from/consult with colleagues, your supervisor, other professionals. Report the disclosure to the appropriate authority.

Assessment: 

Assessment Process cognitive vs emotional levels roles, rules, responsibilities, expectations play drawing projective and objective techniques telephones games, crafts

Assessment: 

Assessment Parental and Family Interviews Developmental history Disclosure/abuse history Family and marital history Relationships/boundaries/communication

Assessment: 

Assessment Parental and Family Interviews Problem solving/coping skills Symptoms/current concerns Discipline issues School issues

Assessment: 

Assessment Parental and Family Interviews Parental fears/expectations of therapy Resources/supports Shared and different perspectives

Assessment: 

Assessment Questionnaires, Self Reports, Cognitive Specific Abilities Tests, Projective Tests General behaviour check lists (eg. BASC) Parental Stress Inventory Trauma Symptom Checklist Other self reports (eg Beck Youth Scales, Self esteem inventories) Cognitive assessments CAT, TAT, Sentence Completion

Treatment: 

Treatment What’s needed? Individual, family, group therapy Therapy/support for parents Short term Long term

Treatment: 

Treatment Aims help the child make sense of her experience empower work on identity reconnect with the world develop adaptive coping skills

Vicarious Trauma: 

Vicarious Trauma What is it? An understandable response Not burnout Works on our vulnerabilities

Vicarious Trauma: 

Vicarious Trauma What can you do? Supervision Be aware of your vulnerabilities Therapy Cultivate other skills Have faith Have fun