Mednotes

L24 Psychological Medicine Child Abuse

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tagspsychologicalmedicine, lecture
aliasesL24 Psychological Medicine Child Abuse

21 min read

Overview

This lecture aims to raise awareness of child abuse so that it is identified and acted on, including in both child and parent consultations. It covers the scale of the problem internationally and in New Zealand, the four types of abuse (neglect, emotional, physical, sexual), the verbal, physical and behavioural indicators that a child may be being abused or neglected, the important caveat that no indicator is specific to abuse, and what to do when abuse is suspected: who to notify, the legal framework, how to talk with and document the child, and what to avoid.

Scale of the problem

WHO estimates from prevalence studies (high income country data):

  • Approximately 25% of adults suffered physical abuse as a child
  • 36% experienced emotional abuse
  • 16% experienced neglect
  • 18% of girls and 8% of boys have experienced some form of sexual abuse

These figures come from the WHO publication Responding to child maltreatment: a clinical handbook for health professionals.

New Zealand, substantiated abuse and neglect findings (proportion of children with a substantiated finding, and count):

  • 2013: 1.80% (18,595)
  • 2014: 1.57% (16,289)
  • 2015: 1.33% (13,833)
  • 2016: 1.29% (13,598)
  • 2017: 1.14% (12,117)
  • 2018: 1.03% (11,662)
  • 2019: 1.14% (13,018)
  • 2020: 1.11% (12,861)

The overall trend is a decline in both proportion and count from 2013 to 2020, with a slight uptick in 2019.

Reports of concern to Oranga Tamariki across NZ: 2020, 58,588; 2021, 56,934; 2022, 49,349; 2023, 52,788. Reports fell from 2020 to 2022 then rose again in 2023.

Who notifies care and protection concerns (Child, Youth and Family data, reports of concern Jul-Dec 2014): Police other, that is reports not related to family violence, 11,468; Health 6,163; Other Government 5,127; Other notifiers 5,639; Education 4,794; Family 4,371; Police (family violence) 3,833; Non Government Organisations 1,433; Court 255. Total reports of concern requiring further action 43,083. Health is one of the largest single notifier groups.

The four types of child abuse

Neglect. Passive, unintentional ignoring of the child’s needs:

  • Physical needs, for example food, clothing and shelter
  • Safety needs for protection, for example supervision
  • Emotional, intellectual and developmental needs, for example not playing or interacting with them

Emotional abuse. A caregiver persistently or extremely thwarts a child’s basic emotional needs, intentionally carrying out acts such as:

  • Frequent criticism, ridicule, humiliation and threats
  • Frequent rejection, deprivation of affection, exclusion from family life
  • Frequent punishment for minor misdemeanours or for positive behaviours such as smiling or playing
  • Frequent blocking of peer relationships, isolation
  • Exposure to family violence, pet violence or criminality. In 2018, 79,200 children were recognised as having a family violence notification.

Physical abuse (PA). Deliberately inflicting injury on a child: hitting, kicking, throwing, biting, burning, scalding, strangulation or suffocation, stabbing, drowning or poisoning.

Sexual abuse (SA). The use of a child for sexual gratification, whether the child agrees or not. There must be a developmental age difference between the victim and perpetrator for it to be “sexual abuse”. Subtypes:

  • Non-contact sexual abuse, for example voyeurism, suggestive behaviour or talk, indecent exposure
  • Contact sexual abuse involving sexual intercourse or penetration
  • Non-contact sexual abuse excluding sexual intercourse but involving other acts of touching such as fondling, touching, kissing

Note the key distinction between the two abuse types by intent: neglect is passive and unintentional, whereas emotional and physical abuse are intentional or deliberate acts.

Childhood sexual abuse: victims and perpetrators

Worldwide estimates of childhood sexual abuse (CSA) (Stoltenborgh et al. 2011; Pereda et al. 2009b):

  • Girls, 18 to 20%
  • Boys, 8%
  • Girls have a 2 to 3 fold risk compared with boys

Perpetrators:

  • Adult males are the majority
  • Adolescent males, 25 to 42%
  • Females, 4 to 5%

New Zealand Police data on sexual assaults and related offences for 2018 (Patterson et al., 2023) by victim age group, as male/female/total: 0-4, 29/69/98; 5-9, 85/226/311; 10-14, 137/815/952; 15-19, 134/1,153/1,287; 20-24, 65/688/753; 25-29, 46/458/504; 30-34, 28/287/315; 35-39, 29/232/261; 40-44, 17/189/206; 45-49, 21/172/193; 50-54, 29/112/141; 55-59, 17/78/95; 60-64, 6/48/54; 65-69, 4/22/26; 70-74, 2/12/14; 75-79, 2/2/4; 80+, 2/13/15. Total 653 male, 4,576 female, 5,229 overall. Victimisation peaks in the 15-19 and 10-14 age bands and the large majority of victims are female.

Impact of child abuse

Possible physical consequences:

  • Failure of growth
  • Developmental delays
  • Scarring, disfigurement, neurological damage, visual or auditory impairment
  • Death

Possible psychological consequences:

  • Low self-esteem, low self-efficacy
  • Relationship and sexual problems (attachment, trust)
  • Externalising behaviours and disorders: delinquency, aggression, violence, oppositional disorders
  • Internalising behaviours and disorders: suicide, anxiety, depression, self-harm
  • May affect cognitive development, with vocational problems
  • Post traumatic stress disorder

Identifying abuse: verbal indicators

Identification rests on three categories of indicator: verbal, physical and behavioural.

Verbal disclosure from the child may be direct, or tentative and incomplete. Verbal disclosure from an adult may be a direct report of what they have seen or heard, or a tentatively voiced concern about a situation. Indirect verbal evidence includes inconsistencies, discrepancies, a history that does not fit with the injury, and delayed treatment seeking.

Many children do not disclose abuse, because they:

  • Protect familiar perpetrators, especially family members
  • Yield to requests or threats about not telling
  • Feel ashamed, embarrassed, or to blame
  • Are avoidant
  • Fear threatened or imagined consequences and reprisals
  • May not understand they have been abused

Physical indicators

From the interagency guide Breaking the cycle: let’s stop child abuse together. The overarching caution is that all signs may be non-specific to abuse and may indicate conditions other than child abuse, so you are looking for a pattern of evidence rather than a single sign.

Bruises and welts. Suspicious features are multiple injuries, of differing ages and at differing sites.

  • Site: soft tissue areas, especially buttocks, genitals, upper thighs, back, cheek and neck, ear lobes and head. Bruising on the lower legs and arms is often the result of normal play.
  • Shape: the shape may reveal the cause, for example an oval with teeth marks, or finger tip bruising.

Cuts and abrasions. May be deliberate cuts. Cuts around the mouth of an infant may indicate force feeding. Hair pulling produces bald patches.

Scalds and burns. Many are accidental and tend to be superficial because the child pulls away. Abuse burns are often full thickness, from holding or sitting the child on a source of heat. Cigarette burns are circular and multiple. Deliberate scalds differ from accidental ones, for example a sock or glove pattern.

Fractures. Especially concerning in infants who are not mobile. Look for other signs, for example bruising, multiple fractures, or old fractures that were not treated.

Head injuries. Serious intracranial injury with multiple skull fractures requires major force.

Abdominal injuries.

Poisoning and apnoea attacks, especially if recurrent.

Genital injuries and other signs of sexual abuse.

  • If possible refer to MEDSAC (Medical Sexual Assault Clinicians), specialist doctors trained in forensic examination related to sexual abuse and assault.
  • Bruising or scratching of the inner thigh, grip marks, lacerations or bruising to the vulva or rectum.
  • Bleeding, pain, restricted movement.
  • Frequently there is no evidence or no conclusive evidence.
  • Sexually transmitted diseases: non-sexual transmission of STD is rare. Thrush is common and very rarely linked to sexual abuse.
  • Pregnancy.

Behavioural indicators

A New Zealand public awareness website lists signs that sexual abuse may be happening to a child, presented in the lecture with the caution flag:

  • a change in sleeping, eating, toileting or washing behaviour
  • becoming withdrawn
  • problems trusting others, avoiding certain people and places
  • acting younger than their age, becoming clingy and tearful
  • displaying sexualised behaviour or language which is age inappropriate
  • becoming angry, hostile, aggressive to others, or self-harming
  • learning or concentration difficulties
  • telling you about someone or something that worries them

Behaviours associated with CSA in the research literature: sexualised behaviour; internalising behaviours such as anxiety and depression; externalising behaviours such as aggression; somatic complaints such as sore stomach and headaches; regressive behaviours, meaning a return to a level of earlier maturity; fears; nightmares; toileting difficulties including enuresis (bedwetting at an age when bladder control should be established) and encopresis (faecal incontinence or soiling that is age inappropriate); behavioural problems; academic problems; tantrums; whining; and post-traumatic stress symptoms.

Important

Behavioural indicators are non-specific. The same behaviours are common childhood presenting problems, and clinical populations, that is children being treated for psychological or behavioural problems, also show many of these symptoms. Children who have been sexually abused can be asymptomatic, with research estimates that 21 to 49% of children have no behavioural symptoms.

Conclusions from four decades of research:

  • There is no specific behavioural syndrome, pattern of symptoms or single symptom that identifies that a child has been sexually abused.
  • An absence of behavioural symptoms is not sufficient evidence to conclude that a child has not been abused.
  • The presence of inappropriate sexualised behaviour needs to be carefully considered in relation to why it is occurring, but is not a sufficient marker in and of itself to conclude that a child has been sexually abused.

Normal versus non age appropriate sexual behaviour

Normal sexual development behaviours:

  • 0-5 years: touch or rub their own genitals, show and look at private parts, childish sexual language such as “pee pee”, masturbation possible
  • 6-12 years: ask questions about menstruation, pregnancy and sexual behaviour, experiment with other children such as touching, kissing, showing, may masturbate in private
  • Adolescents: ask questions about sex and relationships, use sexual language and talk about sex acts to other teenagers, masturbate in private, experiment sexually with similar aged adolescents

Non age appropriate sexual behaviour is expressing sexual knowledge not usual for their age in language, behaviour or play, for example exhibiting adult like sexual behaviour, talk or play. Examples given: an 11 year old wanting to view an adult’s penis; a 4 year old demonstrating sexual intercourse with his teddy bears.

Problematic sexual behaviour (PSB) is child initiated behaviour involving sexual body parts that is either developmentally inappropriate or harmful to others, including sexual play that includes adult like acts of penetration, and excessive sexual behaviour.

This may not necessarily indicate sexual abuse. It also occurs in non-sexually abused children, and must be interpreted against environmental context, physical abuse, family dysfunction and behavioural difficulties.

What to do if you suspect abuse

The child’s safety and wellbeing is paramount. The first question is “is the child safe?”.

Who to notify:

  • Police, where there is imminent threat to the safety of the child, doctor or other person
  • A social worker at Oranga Tamariki, Ministry for Vulnerable Children

Oranga Tamariki is the NZ government agency responsible for child and protection concerns, previously Child Youth and Family (CYF). It has legal powers to intervene, works alongside Police, runs a 24 hour 7 day a week phone notification system, and is a useful source of information. Its guiding principles are that children’s needs are paramount and that the family aspect is important.

Your role:

  • Consider the possibility of abuse
  • Notice signs of abuse
  • Document all information
  • Assess and treat injuries
  • Notify and protect the child from further harm if deemed relevant

Te Whatu Ora child abuse policy and procedures outline who to notify, how to document, who to discuss the issue with, and self care.

Resources available online: Ministry for Vulnerable Children, Oranga Tamariki; the Ministry of Health family violence assessment and intervention guideline on child abuse and intimate partner violence; and the Recommended referral process for General Practitioners: Suspected child abuse and neglect, 2000.

The relevant statute is the Children, Young Persons, and Their Families Act 1989.

Paramountcy Principle, section 6: ”… [the] welfare and interests of the child or young person shall be the first and paramount consideration”.

Reporting, section 15: “Any person who believes that any child or young person has been, or is likely to be, harmed (whether physically, emotionally, or sexually) ill-treated, abused, neglected, or deprived may report the matter to a Social Worker or a member of the Police.”

Protection when disclosing, section 16: “No civil, criminal, or disciplinary proceedings shall lie against any person in respect of the disclosure … pursuant to section 15 … concerning a child or young person (whether or not that information also concerns any other person) unless the information was disclosed or supplied in bad faith”.

Talking with the child, and the child as a witness

Oranga Tamariki advice: “do not interview the child or young person about the disclosure or your concerns”. “Instead, listen carefully to what the child says, and later write this down, word for word if possible, noting the date and time you heard the child disclose”.

Child as a witness, strengths:

  • Even very young children can report their experiences
  • If asked open-ended questions they do so accurately, for example “tell me what happened”, “tell me more about that”, “what happened next”

Child as a witness, weaknesses:

  • Limited memory retrieval and verbal skills, so it is hard to get full information
  • Suggestive and coercive questioning can lead to inaccuracies, for example “isn’t it true that your brother touched your fanny”, “so your mum gave you that bruise didn’t she”, “if you tell me we can put him in jail and keep other children safe”

Forensic or evidential interviewing is a distinct, highly skilled activity: developmentally appropriate, research based about the best ways to interview, using free recall or open-ended questions, avoiding leading, suggestive and coercive practices, developing rapport and a child friendly environment, and obtaining evidence.

Assessing risk when talking with the child:

  • Talk in a developmentally appropriate way
  • Ask open-ended questions, for example “how did your arm get hurt?”
  • Recognise that the child may feel ashamed, responsible or scared
  • Be supportive of the child
  • Monitor your own response: remain calm, do not react strongly to what the child has said, listen, do not avoid
  • As appropriate, reassure the child that what happened to them was not okay, that you believe them, and that they are not in trouble and you will help them

Things to avoid:

  • Jumping to conclusions on the basis of not much or contradictory evidence
  • Questioning or talking to the child in a suggestive manner, for example “who did this to you?” when the child has said they fell off a swing
  • Introducing content the child has not said, for example “so were you in the bedroom when he showed you his diddle?”
  • Pressuring the child into telling what happened

Documentation

Suspected abuse requires careful documentation:

  • Detailing on body charts. The lecture shows a blank body-map proforma with front and back outlines of a child’s body, including the genital area, plus separate outlines of hands and feet, and a data table for name, NHI, date of birth and address.
  • Writing the child’s disclosure verbatim
  • Recording accurately the details of current and historical injuries
  • Documenting what was said and by whom, the date and time, any discrepancies, and any failure to seek medical help

Professional issues and self care

Consider your own response to these situations and how to deal with it. You may initially panic or feel stressed. Seek input from colleagues and professional services, and talk. Named supports include Student Health and EAP (Employee Assistance Programmes), and self care.

If the lecture raises issues for you: Student Health Services, free phone 0800 479 821 (including cellphones) or 03 479 8212; your General Practitioner; the Associate Deans of Student Affairs.

Self-test

  1. List the four types of child abuse and give the defining feature of each.
  2. Distinguish neglect from emotional abuse in terms of intent, and give two examples of each.
  3. State the WHO prevalence estimates for physical abuse, emotional abuse, neglect and sexual abuse.
  4. What additional criterion, beyond sexual use of a child, must be met for an act to count as “sexual abuse”?
  5. Distinguish the three subtypes of sexual abuse.
  6. Describe the worldwide prevalence of childhood sexual abuse by sex, and the distribution of perpetrators.
  7. List four reasons why a child may not disclose abuse.
  8. Explain what “indirect verbal evidence” of abuse means and give two examples.
  9. Describe the features of bruising that raise concern for physical abuse, and the sites where bruising is more likely to be innocent.
  10. Distinguish accidental from inflicted burns and scalds.
  11. Why is a fracture in an infant particularly concerning, and what else should you look for?
  12. What is MEDSAC and when should you refer to it?
  13. Explain why the presence of sexualised behaviour is not sufficient to conclude a child has been sexually abused, and why its absence is not sufficient to conclude they have not.
  14. What proportion of sexually abused children are estimated to have no behavioural symptoms?
  15. Distinguish normal sexual development behaviour in a 6-12 year old from problematic sexual behaviour.
  16. State the Paramountcy Principle and the section of the Act it comes from.
  17. Under section 15, who may report and on what threshold of belief?
  18. What legal protection does section 16 give to a person who discloses, and what is the one exception?
  19. What is Oranga Tamariki’s advice about interviewing a child who has disclosed, and what should you do instead?
  20. List the strengths and weaknesses of a child as a witness.
  21. Give three questioning practices to avoid when a child may have been abused, with an example of each.
  22. List the elements of careful documentation in suspected child abuse.
  23. A 3 year old is brought to you with an oval bruise with teeth marks on the buttock, a healing full-thickness circular burn on the forearm, and a parental history of falling off a swing given two days after the injury. Explain which features raise concern and what you would do.
  24. Integrative: a colleague says a child cannot have been abused because they are behaving normally and denied anything when asked “did your dad hurt you?”. Using the evidence on behavioural indicators and on children as witnesses, explain what is wrong with both parts of that reasoning.

Answers

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