David M. Fergusson | Geraldine F H McLeod | L. John Horwood
Objectives: Childhood sexual abuse (CSA) has been associated with many adverse medical, psychological, behavioral and socioeconomic outcomes in adulthood. This study aims to examine the linkages between CSA and a wide range of developmental outcomes over a protracted time period to age 30. Methods: Data from over 900 members of the New Zealand birth cohort the Christchurch Health and Development Study were examined. CSA prior to age 16 was assessed at ages 18 and 21 years, in addition to: mental health, psychological wellbeing, sexual risk-taking behaviors, physical health and socioeconomic outcomes to age 30. Results: After statistical adjustment for confounding by 10 covariates spanning socio-demographic, family functioning and child factors, extent of exposure to CSA was associated with increased rates of (B, SE, p): major depression (0.426, 0.094, < .001); anxiety disorder (0.364, 0.089, < .001); suicidal ideation (0.395, 0.089, < .001); suicide attempt (1.863, 0.403, < .001); alcohol dependence (0.374, 0.118, < .002); and illicit drug dependence (0.425, 0.113, < .001). In addition, at age 30 CSA was associated with higher rates of PTSD symptoms (0.120, 0.051, .017); decreased self-esteem (-0.371, 0.181, .041); and decreased life satisfaction (-0.510, 0.189, .007). Childhood sexual abuse was also associated with decreased age of onset of sexual activity (-0.381, 0.091, < .001), increased number of sexual partners (0.175, 0.035, < .001); increased medical contacts for physical health problems (0.105, 0.023, < .001); and welfare dependence (0.310, 0.099, .002). Effect sizes (Cohen's d) for the significant outcomes from all domains ranged from .14 to .53, while the attributable risks for the mental health outcomes ranged from 5.7% to 16.6%. Conclusions: CSA is a traumatic childhood life event in which the negative consequences increase with increasing severity of abuse. CSA adversely influences a number of adult developmental outcomes that span: mental disorders, psychological wellbeing, sexual risk-taking, physical health and socioeconomic wellbeing. While the individual effect sizes for CSA typically range from small to moderate, it is clear that accumulative adverse effects on adult developmental outcomes are substantial. © 2013 Elsevier Ltd.
Lorraine Radford | Susana Corral | Christine Bradley | Helen L. Fisher
Objectives: To measure the prevalence of maltreatment and other types of victimization among children, young people, and young adults in the UK; to explore the risks of other types of victimization among maltreated children and young people at different ages; using standardized scores from self-report measures, to assess the emotional wellbeing of maltreated children, young people, and young adults taking into account other types of childhood victimization, different perpetrators, non-victimization adversities and variables known to influence mental health. Methods: A random UK representative sample of 2,160 parents and caregivers, 2,275 children and young people, and 1,761 young adults completed computer-assisted self-interviews. Interviews included assessment of a wide range of childhood victimization experiences and measures of impact on mental health. Results: 2.5% of children aged under 11 years and 6% of young people aged 11-17 years had 1 or more experiences of physical, sexual, or emotional abuse, or neglect by a parent or caregiver in the past year, and 8.9% of children under 11 years, 21.9% of young people aged 11-17 years, and 24.5% of young adults had experienced this at least once during childhood. High rates of sexual victimization were also found; 7.2% of females aged 11-17 and 18.6% of females aged 18-24 reported childhood experiences of sexual victimization by any adult or peer that involved physical contact (from sexual touching to rape). Victimization experiences accumulated with age and overlapped. Children who experienced maltreatment from a parent or caregiver were more likely than those not maltreated to be exposed to other forms of victimization, to experience non-victimization adversity, a high level of polyvictimization, and to have higher levels of trauma symptoms. Conclusions: The past year maltreatment rates for children under age 18 were 7-17 times greater than official rates of substantiated child maltreatment in the UK. Professionals working with children and young people in all settings should be alert to the overlapping and age-related differences in experiences of childhood victimization to better identify child maltreatment and prevent the accumulative impact of different victimizations upon children's mental health. © 2013 Elsevier Ltd.
Suzet Tanya Lereya | Muthanna Samara | Dieter Wolke
Objective: Being bullied has adverse effects on children's health. Children's family experiences and parenting behavior before entering school help shape their capacity to adapt and cope at school and have an impact on children's peer relationship, hence it is important to identify how parenting styles and parent-child relationship are related to victimization in order to develop intervention programs to prevent or mitigate victimization in childhood and adolescence. Methods: We conducted a systematic review of the published literature on parenting behavior and peer victimization using MEDLINE, PsychINFO, Eric and EMBASE from 1970 through the end of December 2012. We included prospective cohort studies and cross-sectional studies that investigated the association between parenting behavior and peer victimization. Results: Both victims and those who both bully and are victims (bully/victims) were more likely to be exposed to negative parenting behavior including abuse and neglect and maladaptive parenting. The effects were generally small to moderate for victims (Hedge's g range: 0.10-0.31) but moderate for bully/victims (0.13-0.68). Positive parenting behavior including good communication of parents with the child, warm and affectionate relationship, parental involvement and support, and parental supervision were protective against peer victimization. The protective effects were generally small to moderate for both victims (Hedge's g: range: -0.12 to -0.22) and bully/victims (-0.17 to -0.42). Conclusions: Negative parenting behavior is related to a moderate increase of risk for becoming a bully/victim and small to moderate effects on victim status at school. Intervention programs against bullying should extend their focus beyond schools to include families and start before children enter school. © 2013 Elsevier Ltd.
Emily Putnam-Hornstein | Barbara Needell | Bryn King | Michelle Johnson-Motoyama
Objective: Data from the United States indicate pronounced and persistent racial/ethnic differences in the rates at which children are referred and substantiated as victims of child abuse and neglect. In this study, we examined the extent to which aggregate racial differences are attributable to variations in the distribution of individual and family-level risk factors. Methods: This study was based on the full population of children born in California in 2002. Birth records were linked to child protective service (CPS) records to identify all children referred for maltreatment by age 5. Generalized linear models were used to compute crude and adjusted racial/ethnic differences in children's risk of referral, substantiation, and entry to foster care. Results: As expected, stark differences between Black and White children emerged in the rates of contact with CPS. Black children were more than twice as likely as White children to be referred for maltreatment, substantiated as victims, and enter foster care before age 5. Yet, there were also significant differences across racial/ethnic groups in the distribution of socioeconomic and health factors strongly correlated with child maltreatment and CPS involvement. After adjusting for these differences, low socioeconomic Black children had a lower risk of referral, substantiation, and entry to foster care than their socioeconomically similar White counterparts. Among Latinos, before adjusting for other factors, children of U.S.-born mothers were significantly more likely than White children to experience system contact, while children of foreign-born mothers were less likely to be involved with CPS. After adjusting for socioeconomic and health indicators, the relative risk of referral, substantiation, and foster care entry was significantly lower for Latino children (regardless of maternal nativity) compared to White children. Conclusions: Race and ethnicity is a marker for a complex interaction of economic, social, political, and environmental factors that influence the health of individuals and communities. This analysis indicates that adjusting for child and family-level risk factors is necessary to distinguish race-specific effects (which may reflect system, worker, or resource biases) from socioeconomic and health indicators associated with maltreatment risk. Identifying the independent effects of these factors is critical to developing effective strategies for reducing racial disparities. © 2012 Elsevier Ltd.
J. P. Mersky | J. Topitzes | A. J. Reynolds
Research has shown that adverse childhood experiences (ACEs) increase the risk of poor health-related outcomes in later life. Less is known about the consequences of ACEs in early adulthood or among diverse samples. Therefore, we investigated the impacts of differential exposure to ACEs on an urban, minority sample of young adults. Health, mental health, and substance use outcomes were examined alone and in aggregate. Potential moderating effects of sex were also explored. Data were derived from the Chicago Longitudinal Study, a panel investigation of individuals who were born in 1979 or 1980. Main-effect analyses were conducted with multivariate logistic and OLS regression. Sex differences were explored with stratified analysis, followed by tests of interaction effects with the full sample. Results confirmed that there was a robust association between ACEs and poor outcomes in early adulthood. Greater levels of adversity were associated with poorer self-rated health and life satisfaction, as well as more frequent depressive symptoms, anxiety, tobacco use, alcohol use, and marijuana use. Cumulative adversity also was associated with cumulative effects across domains. For instance, compared to individuals without an ACE, individuals exposed to multiple ACEs were more likely to have three or more poor outcomes (OR range = 2.75-10.15) and four or more poor outcomes (OR range = 3.93-15.18). No significant differences between males and females were detected. Given that the consequences of ACEs in early adulthood may lead to later morbidity and mortality, increased investment in programs and policies that prevent ACEs and ameliorate their impacts is warranted. © 2013 Elsevier Ltd.
Debbie M. Sperry | Cathy Spatz Widom
To determine whether child abuse and neglect predicts low levels of social support in middle adulthood and understand whether social support acts to mediate or moderate the relationship between childhood abuse and neglect and subsequent outcomes (anxiety, depression, and illicit drug use). Method: Using data from a prospective cohort design study, children with documented histories of physical and sexual abuse and neglect (ages 0-11) during the years 1967 through 1971 and a matched control group were followed up and interviewed in adulthood. Social support was assessed at mean age 39.5, and anxiety, depression, and illicit drug use at mean age 41.2. Results: Adjusting for age, sex, and race, individuals with documented histories of child abuse and neglect reported significantly lower levels of social support in adulthood [total (p < . .001), appraisal (p < . .001), belonging (p < . .001), tangible (p < . .001), and self-esteem support (p < . .01)] than controls. Adjusting for age, sex, race, and prior psychiatric diagnosis, social support mediated the relationship between child abuse and neglect and anxiety and depression in adulthood. Four gender by social support interactions and one three-way [group (abuse/neglect versus control). ×. tangible social support. ×. gender] interaction moderated levels of anxiety and depression, particularly for males who were more strongly affected by high levels of social support. Conclusions: Social support plays a significant role in mediating and moderating some long term consequences of childhood maltreatment. Efforts to better understand the timing and mechanisms involved in these relationships are needed to guide preventive interventions and treatment. © 2013 Elsevier Ltd.
Julian D. Ford | Damion J. Grasso | Josephine Hawke | John F. Chapman
Objectives: This study replicates and extends the research literature on poly-victimization with a vulnerable and under-served population, juvenile justice-involved youths. Methods: N= 1959, 10-16 year old youths (76% male; 74% youth of color) consecutively newly admitted to juvenile detention facilities completed psychometric measures of trauma history, posttraumatic stress, affect regulation, alcohol/drug use, suicide risk, and somatic complaints. Results: Using latent class analysis derived from 19 types of adversity, three unique classes best fit the data. A poly-victim class (49% female, 51% youth of color) accounted for 5% of the sample and reported a mean of 11.4 (SD= 1.1) types. A relatively moderate adversity class (31% female, 70% youth of color) accounted for 36% of the sample and reported a mean of 8.9 (SD= 0.3) types of adversity and 2.65 (SD= 1.1) types of traumatic adversity. A low adversity class (59% of the sample; 17% female, 78% youth of color) reported a mean of 7.4 (SD= 0.4) adversity types but only 0.3 (SD= 0.45) types of traumatic adversity. The relatively moderate adversity class was comparable to poly-victims in endorsing extensive non-victimization traumatic adversity (e.g., accidental and loss trauma), but poly-victims were distinct from both moderate and low adversity class members in the likelihood of reporting all but one type of traumatic victimization, multiple types of traumatic victimization, and severe emotional and behavioral problems. Girls were at particularly high risk of poly-victimization, and African American and White youths also were at risk for poly-victimization. Conclusions: Although youth involved in the juvenile justice system typically have experienced substantial victimization, a poly-victimized sub-group, especially (but not exclusively) girls, warrants particular scientific, clinical, and rehabilitative attention in order to address the most severe behavioral and mental health problems and risks faced by this vulnerable population. © 2013 Elsevier Ltd.
Ryan Mills | James Scott | Rosa Alati | Michael O'Callaghan | Jake M. Najman | Lane Strathearn
Objective: To examine whether notified child maltreatment is associated with adverse psychological outcomes in adolescence, and whether differing patterns of psychological outcome are seen depending on the type of maltreatment. Methods: The participants were 7,223 mother and child pairs enrolled in a population-based birth cohort study in Brisbane, Australia. Exposure to suspected child maltreatment was measured by linkage with state child protection agency data. The primary outcomes were the internalizing and externalizing scales of the Youth Self Report (YSR) at approximately 14 years of age. Results: The YSR was completed by 5,172 subjects (71.6%), with increased attrition of cases of notified maltreatment. After adjustment for potential confounders, notified maltreatment was significantly associated with both internalizing behavior and externalizing behavior at 14. When evaluated as non-exclusive categories of maltreatment, physical abuse, neglect, and emotional abuse were each significantly associated with both internalizing and externalizing behavior after adjustment. When evaluated using an expanded hierarchical scheme that included combinations of multi-type maltreatment, the following groups had significantly higher internalizing behavior after adjustment: emotional abuse (with or without neglect), and multi-type maltreatment including physical (but not sexual) abuse with neglect and/or emotional abuse. The following groups were associated with externalizing behavior after adjustment: emotional abuse (with or without neglect), and multi-type maltreatment including physical abuse (with neglect and/or emotional abuse), or sexual abuse (with neglect and/or emotional abuse, and/or physical abuse). Conclusion: This study suggests that child neglect and emotional abuse have serious adverse effects on adolescent mental health and warrant the attention given to other forms of child maltreatment. Additionally, it confirms that young people who are notified for more than one type of maltreatment are at particular risk of adolescent mental health problems. © 2012 Elsevier Ltd.
Leroy H. Pelton
© 2014 Elsevier Ltd. This article constitutes a 20-year update to a previous publication (. Pelton, 1994), which showed that there is overwhelming evidence that poverty and low income are strongly related to child abuse and neglect. Subsequent evidence shows that the relationship continues to be strong. In addition, there is further evidence since the 1994 publication that this relation is not substantially due to class bias. Yet it is suggested that class bias does exist within the system. There is also further evidence that decreases in child maltreatment follow increases in material supports, and that job loss bears a complex relationship to child maltreatment. Findings pertaining to racial bias within the child welfare system continue to be mixed, but leave no doubt that racial disproportionalities within the system are overwhelmingly related to racial disproportionalities in the poverty population. There is continuing evidence that children placed in foster care are predominantly from impoverished families, and that changes in the level of material supports are related to risk of placement. It is suggested that the fact that there are nearly one million children in out-of-home placement (foster care and child-welfare involved adoption, combined) is indicative of the continuing dysfunction of the child welfare system, and that the differential response paradigm has not altered this dysfunction. A proposal for a fundamental restructuring of the child welfare system is recommended and restated here. Prospects for such change are briefly discussed. Also, to reduce poverty, a previously proposed universal social dividend and taxation system is briefly discussed and recommended.
Harriet L. MacMillan | Masako Tanaka | Eric Duku | Tracy Vaillancourt | Michael H. Boyle
Objectives: Exposure to child maltreatment is associated with physical, emotional, and social impairment, yet in Canada there is a paucity of community-based information about the extent of this problem and its determinants. We examined the prevalence of child physical and sexual abuse and the associations of child abuse with early contextual, family, and individual factors using a community-based sample in Ontario. Methods: The Ontario Child Health Study is a province-wide health survey of children aged 4 through 16 years. Conducted in 1983, a second wave was undertaken in 1987 and a third in 2000-2001. The third wave (N=1,928) included questions about exposure to physical and sexual abuse in childhood. Results: Males reported significantly more child physical abuse (33.7%), but not severe physical abuse (21.5%), than females (28.2% and 18.3%, respectively). Females reported significantly more child sexual abuse (22.1%) than males (8.3%). Growing up in an urban area, young maternal age at the time of the first child's birth, and living in poverty, predicted child physical abuse (and the severe category), and sexual abuse. Childhood psychiatric disorder was associated with child physical abuse (and the severe category), while parental adversity was associated with child sexual abuse and severe physical abuse. Siblings of those who experienced either physical abuse or sexual abuse in childhood were at increased risk for the same abuse exposure; the risk was highest for physical abuse. Conclusions: These findings highlight important similarities and differences in risk factors for physical and sexual abuse in childhood. Such information is useful in considering approaches to prevention and early detection of child maltreatment. Clinicians who identify physical abuse or sexual abuse in children should be alert to the need to assess whether siblings have experienced similar exposures. This has important implications for assessment of other children in the home at the time of identification with the overall goal of reducing further occurrence of abuse. © 2012 Elsevier Ltd.
Michael Ungar | Linda Liebenberg | Peter Dudding | Mary Armstrong | Fons J.R. van de Vijver
Background: Very little research has examined the relationship between resilience, risk, and the service use patterns of adolescents with complex needs who use multiple formal and mandated services such as child welfare, mental health, juvenile justice, and special educational supports. This article reports on a study of 497 adolescents in Atlantic Canada who were known to have used at least 2 of these services in the last 6 months. It was hypothesized that greater service use and satisfaction with services would predict both resilience, and better functional outcomes such as prosocial behavior, school engagement and participation in community. Methods: Youth who were known to be multiple service users and who were between the ages of 13 and 21 participated in the study. Participants completed a self-report questionnaire administered individually. Path analysis was used to determine the relationship between risk, service use, resilience, and functional outcomes. MANOVA was then used to determine patterns of service use and service use satisfaction among participants. Results: Findings show that there was no significant relationship between service use history and resilience or any of the three functional outcomes. Service use satisfaction, a measure of an adolescent's perception of the quality of the services received, did however show a strong positive relationship with resilience. Resilience mediates the impact of risk factors on outcomes and is affected positively by the quality, but not the quantity, of the psychosocial services provided to adolescents with complex needs. Conclusions: Results show that resilience is related to service satisfaction but not the quantity of services used by youth. Coordinated services may not increase resilience or be more effective unless the quality of individual services is experienced by an adolescent receiving intervention as personally empowering and sensitive to his or her needs. © 2012 Elsevier Ltd.
Bryanna Hahn Fox | Nicholas Perez | Elizabeth Cass | Michael T. Baglivio | Nathan Epps
© 2015 Elsevier Ltd. Among juvenile offenders, those who commit the greatest number and the most violent offenses are referred to as serious, violent, and chronic (SVC) offenders. However, current practices typically identify SVC offenders only after they have committed their prolific and costly offenses. While several studies have examined risk factors of SVCs, no screening tool has been developed to identify children at risk of SVC offending. This study aims to examine how effective the adverse childhood experiences index, a childhood trauma-based screening tool developed in the medical field, is at identifying children at higher risk of SVC offending. Data on the history of childhood trauma, abuse, neglect, criminal behavior, and other criminological risk factors for offending among 22,575 delinquent youth referred to the Florida Department of Juvenile Justice are analyzed, with results suggesting that each additional adverse experience a child experiences increases the risk of becoming a serious, violent, and chronic juvenile offender by 35, when controlling for other risk factors for criminal behavior. These findings suggest that the ACE score could be used by practitioners as a first-line screening tool to identify children at risk of SVC offending before significant downstream wreckage occurs.
Regina Saile | Verena Ertl | Frank Neuner | Claudia Catani
After 20 years of civil war in Northern Uganda, the continuity of violence within the family constitutes a major challenge to children's healthy development in the post-conflict era. Previous exposure to trauma and ongoing psychopathology in guardians potentially contribute to parental perpetration against children and dysfunctional interactions in the child's family ecology that increase children's risk of maltreatment. In order to investigate distal and proximal risk factors of child victimization, we first aimed to identify factors leading to more self-reported perpetration in guardians. Second, we examined factors in the child's family environment that promote child-reported experiences of maltreatment. Using a two-generational design we interviewed 368 children, 365 female guardians, and 304 male guardians from seven war-affected rural communities in Northern Uganda on the basis of standardized questionnaires. We found that the strongest predictors of self-reported aggressive parenting behaviors toward the child were guardians' own experiences of childhood maltreatment, followed by female guardians' victimization experiences in their intimate relationship and male guardians' posttrautmatic stress disorder (PTSD) symptoms and alcohol-related problems. Regarding children's self-report of victimization in the family, proximal factors including violence between adults in the household and male guardians' PTSD symptom severity level predicted higher levels of maltreatment. Dist al variables such as female guardians' history of childhood victimization and female guardians' exposure to traumatic war events also increased children's report of maltreatment. The current findings suggest that in the context of organized violence, an intergenerational cycle of violence persists that is exacerbated by female guardians' re-victimization experiences and male guardians' psychopathological symptoms. © 2013 Elsevier Ltd.
Cathy Spatz Widom | Sally Czaja | Mary Ann Dutton
This paper describes the extent to which abused and neglected children report intimate partner violence (IPV) victimization and perpetration when followed up into middle adulthood. Using data from a prospective cohort design study, children (ages 0-11) with documented histories of physical and sexual abuse and/or neglect (n=497) were matched with children without such histories (n=395) and assessed in adulthood (M age =39.5). Prevalence, number, and variety of four types of IPV (psychological abuse, physical violence, sexual violence, and injury) were measured. Over 80% of both groups - childhood abuse and neglect (CAN) and controls - reported some form of IPV victimization during the past year (most commonly psychological abuse) and about 75% of both groups reported perpetration of IPV toward their partner. Controlling for age, sex, and race, overall CAN [adjusted odds ratio (AOR)=1.60, 95% CI [1.03, 2.49]], physical abuse (AOR=2.52, 95% CI [1.17, 5.40] ), and neglect (AOR=1.64, 95% CI [1.04, 2.59]) predicted increased risk for being victimized by a partner via physical injury. CAN and neglect also predicted being victimized by a greater number and variety of IPV acts. CAN and control groups did not differ in reports of perpetration of IPV, although neglect predicted greater likelihood of perpetrating physical injury to a partner, compared to controls. Abused/neglected females were more likely to report being injured by their partner, whereas maltreated males did not. This study found that child maltreatment increases risk for the most serious form of IPV involving physical injury. Increased attention should be paid to IPV (victimization and perpetration) in individuals with histories of neglect. © 2013 Elsevier Ltd.
Anne N. Banducci | Elana M. Hoffman | C. W. Lejuez | Karestan C. Koenen
© 2014 Elsevier Ltd. Adults with substance use disorders (SUDs) report a high prevalence of childhood abuse. Research in the general population suggests specific types of abuse lead to particular negative outcomes; it is not known whether this pattern holds for adults with SUDs. We hypothesized that specific types of abuse would be associated with particular behavioral and emotional outcomes among subst ance users. That is, childhood sexual abuse would be associated with risky sex behaviors, childhood physical abuse with aggression, and childhood emotional abuse with emotion dysregulation. 280 inpatients (. M age. =. 43.3; 69.7% male; 88.4% African American) in substance use treatment completed the Childhood Trauma Questionnaire (CTQ), HIV Risk-Taking Behavior Scale, Addiction Severity Index, Difficulties with Emotion Regulation Scale (DERS), Distress Tolerance Scale (DTS), and Affect Intensity and Dimensions of Affiliation Motivation (AIM). Consistent with our hypotheses, the CTQ sexual abuse subscale uniquely predicted exchanging sex for cocaine and heroin, number of arrests for prostitution, engaging in unprotected sex with a casual partner during the prior year, and experiencing low sexual arousal when sober. The physical abuse subscale uniquely predicted number of arrests for assault and weapons offenses. The emotional abuse subscale uniquely predicted the DERS total score, AIM score, and DTS score. Among substance users, different types of abuse are uniquely associated with specific negative effects. Assessment of specific abuse types among substance users may be informative in treatment planning and relapse prevention.
Saskia Euser | Lenneke R.A. Alink | Fieke Pannebakker | Ton Vogels | Marian J. Bakermans-Kranenburg | Marinus H. Van IJzendoorn
The prevalence of child maltreatment in the Netherlands was in 2005 first systematically examined in the Netherlands' Prevalence study on Maltreatment of children and youth (NPM-2005), using sentinel reports and substantiated CPS cases, and in the Pupils on Abuse study (PoA-2005), using high school students' self-report. In this second National Prevalence study on Maltreatment (NPM-2010), we used the same three methods to examine the prevalence of child maltreatment in 2010, enabling a cross-time comparison of the prevalence of child maltreatment in the Netherlands. First, 1,127 professionals from various occupational branches (sentinels) reported each child for whom they suspected child maltreatment during a period of three months. Second, we included 22,661 substantiated cases reported in 2010 to the Dutch Child Protective Services. Third, 1,920 high school students aged 12-17 years filled out a questionnaire on their experiences of maltreatment in 2010. The overall prevalence of child maltreatment in the Netherlands in 2010 was 33.8 per 1,000 children based on the combined sentinel and CPS reports and 99.4 per 1,000 adolescents based on self-report. Major risk factors for child maltreatment were parental low education, immigrant status, unemployment, and single parenthood. We found a large increase in CPS-reports, whereas prevalence rates based on sentinel and self-report did not change between 2005 and 2010. Based on these findings a likely conclusion is that the actual number of maltreated children has not increased from 2005 to 2010, but that professionals have become more aware of child maltreatment, and more likely to report cases to CPS. © 2013 Elsevier Ltd.
Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. In the present case report, a 12-year-old orphaned boy was physically abused by a close relative who caused actual bodily and emotional trauma to the boy. After satisfactorily managing the trauma and emotional effects to the patient, in addition to the counseling services provided to the caregiver, the patient made a steady recovery. He was also referred to a child support group for social support, and prepare him together with his siblings for placement in a children's home in view of the hostile environment in which they were living.
Keywords: Etiology, child abuse, child neglect, management
For a long time, child protection in general has been perceived as a matter for the professionals specializing in social service, health, mental health, and justice systems. However, this problem remains a duty to all, and more so a concern for other social scientists such as anthropologists, economists, historians, planners, political scientists, sociologists, and humanists (e.g., ethicists, legal scholars, political theorists, and theologians) who contribute to the understanding of the concepts of and strategies in child protection and the responsibility for adults and institutions with roles in ensuring the safety and the humane care of children under their care. Child abuse, therefore, is when harm or threat of harm is made to a child by someone acting in the role of caretaker.[1,2] It is a worldwide problem with no social, ethnic, and racial bounds. Child abuse can be in the form of physical abuse, when the child suffers bodily harm as a result of a deliberate attempt to hurt the child, or severe discipline or physical punishment inappropriate to the child's age. It can be sexual abuse arising from subjecting the child to inappropriate exposure to sexual acts or materials or passive use of the child as sexual stimuli and/or actual sexual contacts. Child abuse can also be in the form of emotional abuse involving coercive, constant belittling, shaming, humiliating a child, making negative comparisons to others, frequent yelling, threatening, or bullying of the child, rejecting and ignoring the child as punishment, having limited physical contact with the child (e.g., no hugs, kisses, or other signs of affection), exposing the child to violence or abuse of others or any other demeaning acts. All these factors can lead to interference with the child's normal social or psychological development leaving the child with lifelong psychological scars. Lastly, child abuse can be in the form of child neglect, when an able caregiver fails to provide basic needs, adequate food, clothing, hygiene, supervision shelter, supervision, medical care, or support to the child.
It is usually difficult to detect child abuse, unless one creates an atmosphere that would encourage disclosure by the child being abused. Nonetheless, a good medical and social history may help to unravel the problem. Signs and symptoms of child abuse commonly include subnormal growth of the child, unexplained head and dental injuries, soft-tissue injuries like bruises and bite marks, burns and bony injuries like broken ribs, in the absence of a history pointing to the cause or causes of the trauma. The present case report describes a child who was abuse by a very close relative, and who caused physical and psychological trauma to the young lad.
Peter, a 12-year-old boy, accompanied by his maternal aunt, presented at the local university Dental Hospital (Pediatric Dental Clinic) in Kenya in October 2012, with a complaint of a large, painful left facial swelling related to the left upper incisors. He had been referred from a local rural hospital where he had been taken by the same aunt, for treatment of the swelling. The swelling had occurred only 2 days prior to visiting the local hospital, and 4 days before presenting himself at the University Dental Hospital. Enquiry about the causes of the swelling provided unclear answers. Family history indicated that the young boy was a first-born among three siblings (9-year-old girl, 5-year-old boy), and that their single parent (mother) had been deceased for 6 years due to HIV-related complications. The three children had moved to live with their maternal grandparents and their seven sons. The patient had no adverse past medical history and had never consulted a dentist previous to the present problem. The boy was in grade seven in a local primary school and had the aspiration of becoming a medical doctor in future. It was not possible to establish from the aunt or the boy the situation of the patient's other siblings.
An extra-oral examination showed a young boy with a normal gait, sickly, unkempt, rather withdrawn, and small for his age. He had asymmetrical face due to the swelling involving his left submandibular region and spreading upwards to the inferior orbital margin, febrile (39.1°C), a marked submandibular lymphadenopathy on the left side, the skin overlying the swelling was warm, shiny and fluctuant, and the lips were dry and incompetent (2 cm) and as shown in [Figures 1a–c]. However, the temporomandibular joint movements were normal. The patient was also found to have a big, healing scar on the dorsal surface of the left foot, the cause of which was also unclear [Figure 1].
(a) Frontal and (b) lateral (c) profiles of the patient showing the facial asymmetry with the left submandibular to infra-orbital and the healing scar on the foot
Intra-oral examination revealed a young boy in the permanent dentition with un-erupted third permanent molars, poor oral hygiene with heavy plaque deposits on the tongue and a generalized but moderate inflammation of the gingiva. There was a grade three mobility in relation to 11, 12, 21, 22 and a grade two mobility in relation to 23, 24, 25 (Miller mobility index). There was intramucosal swelling in relation to 21-24 extending labially/buccally (measuring 4 cm × 3 cm) and palatally (measuring 3 cm × 2 cm). On elevation of the upper lip, active discharge of pus mixed with blood and some black granules could be seen emanating from the abscess. There were no alveolar/bone fractures elicited, but carious lesions were present on 46 (occlusal), 47 and 37 (buccal). Orthodontic evaluation showed Angles class I molar relation on the left and edge to edge tending to class II on the right side. The canines were in class I relationship bilaterally. There was an anterior over-jet of 3 mm (11/21), an overbite of 20%, coincidental dental/facial midline and crowding on the upper right arch with 15 palatally displaced as can be seen in Figure 2a–c.
(a) Intra-oral photographs of the patient showing the labial and (b) palatial swelling in relation to displaced 21 and 22 (c), generalized marginal gingival inflammation, palatally displaced 15, moderate dental plaque deposits and a moderate anterior...
For investigations, orthopantogram, intra-oral periapical 11, 12, upper and lower standard occlusal and bite wing radiographs were taken and examined. In addition, clinical photographs, study models, and vitality tests for the traumatized teeth were undertaken. A diet and nutrition assessment, full blood count, stool microscopic analysis for ova and cyst and bacterial culture and sensitivity were also undertaken.
The results of the radiographs showed un-erupted with potential impaction of 48 and 38, an upper midline radioluscence, widened periodontal space in relation to 11, 21 (with a mesial tilt), 22, occlusal caries on 46 and buccal caries on 47 and 37. There was the presence of root fractures involving the apical one-third of 21, 22. Vitality tests conducted on the traumatized incisors showed false positive (may be due to the presence of infection). The blood analysis showed the presence of neutrophilia (suggestive of bacterial infection), mild iron deficiency, but he was sero-negative. From the diet chart, the boy was generally on a noncariogenic diet that lacked the intake of fruits and animal proteins. Nutritional assessment revealed a boy with a height of 144 cm, a weight of 28 kg, and a body mass index (BMI) of 13.5 Kg/m2 (below 5th percentile (given the ideal BMI should be 17.8 Kg/m2 in the 50th percentile).
From the history adduced and the results of the investigations, a diagnosis of child abuse and neglect was reached, with the boy having suffered traumatic injuries resulting in facial cellulitis, Ellis class VI fracture involving 21, 22 associated dentoalveolar abscess and subluxation of 11, 12. In addition, there were dental carious lesions on 46 (occlusally), 47 and 37 (buccally) and a relatively severe malnutrition. The patient had also moderate plaque induced gingivitis, mild anemia (microcytic and iron deficiency), mild dental fluorosis, potentially impacted 48 and 38 and crowding in the upper right and lower anterior arches.
The objective of treating the boy was to eliminate the pain, infection, improve the general and oral health, restore carious teeth, improve esthetic and report the child abuse and neglect to the relevant authorities. In the initial phase of treatment, the patient was admitted for 4 days and placed on dexamethasone 8 mg stat, cefuroxime 750 mg 3 times a day, metronidazole 500 mg 3 times a day, diclofenac 50 mg tablets alternating 4 hourly with oral paracetamol 1000 mg 3 times a day, to run for 5 days. Patient was also placed on chlorhexidine mouthwash 10 ml twice daily for 7 days and ranferon (hematinics) 10 ml to be used twice a day for 1 month. The second phase of treatment included incision and drainage of the abscess, followed by the splinting of the mobile teeth in the upper dental arch using semi-rigid splint of 0.6 mm stainless steel round wire for 4 weeks while. Root canal treatment of 11, 21, 12, and 22 followed thereafter. A referral of the patient was made the child support center in the main referral hospital, plus the patient was placed on future recalls to determine whether the patient would have overcome the problem and the oral health was maintained in good condition.
The third phase of treatment involved interceptive orthodontics with the extraction of 15 to relieve the crowding in the area. Oral hygiene instructions were availed to the patient and the guardian, placement of fissure sealants was done for the premolars and molars to help reduce plaque retention on these teeth, preventive resin restorations were placed on 37, 46, and 47. The root fractures involving the apical one-third of 21 and 22 meant that the two teeth were to be initially dressed using non setting calcium hydroxide, and after healing, root canals are filled in the usual manner [Figure 3].
Postobturation intraoral periapial radiograph showing the restoration on 12, 11, 21, and 22
Nutrition evaluation had initially been done and when the patient was re-evaluated after 1 month, he had gained bodyweight up to 1 kg. The child support center continued to carry out psychotherapy, and during one of the sessions, the patient confessed to having undergone physical abuse and threatened not to divulge any information by one of the uncles. The center considered placing the boy into a children's home, probably together with his siblings. Radiographic examinations evaluation after 3 months indicated some external apical root resorption taking place on 21 and 22. Further follows-ups were to continue. After 10 months, the oral health and general heath of the patient had remarkably improved as shown in Figure 4.
Posttreatment photographs taken after 10 months showing improved oral health of the patient and the glimmer of confidence in the patient as shown in a-d respectively
All types of child abuse and neglect leave the affected child with long-lasting scars that may be physical or psychological, but they are the emotional scars that leave the child with life-long effects, damage to the child's sense of self, the ability to build healthy relationships and function at home, work or school. This situation can in turn result in the child turning to alcohol or drugs to numb the painful feelings. On the other hand, the exposure by the child to violence during childhood can increase vulnerability of that child to mental and physical health problems like anxiety disorder, depression, etc.,[8,9] and make victims more likely to become perpetrators of violence later in life. The oral cavity can be a central focus for physical abuse due to its significance in communication and nutrition.[3,11]
A neglected and abused child like the one described here, can become helpless and passive, displaying less affect to anything whether positive or negative in his or her encounters. The patient described was vulnerable to abuse as he already lacked the parental protection in his early life, and was living in a poor, but large family where competition for available resources must have been stiff. The abuser, therefore, his own uncle, probably did not like their presence gave him the assumption that the children would grow up to take away what he probably thought would be his dues from the family.
In Kenya and even in many other countries, data on the prevalence of child abuse is still scarce. A Kenyan study undertaken in 2013 showed that violence against children was very high, with 31.9% and 17.5% female and male, respectively reporting having been exposed to sexual violence, 65.8% and 72.9% female and male respectively to physical violence. In the same study, 18.2% and 24.5% female and male, respectively had been abused prior to attaining 18 years of age, and only 23.8% female and 20.6% male reported not having experienced any form of violence during childhood. Child abuse in Kenya, therefore, appears to be a rampant problem within the society. In all cases of abuse reported in the literature, the perpetrators were most often well-known to the children. The motive of child abuse has not always clear, just as it was the case with the patient described here. The patient under study here hailed from a family with low socio-economic background where providing for extra needs in the family could have been a problem. Even during treatment of the patient the family found the cost of treatment to be very high and unaffordable to them, and a waiver of the cost had to be sought and obtained from the University Dental Hospital. Further, the child having been orphaned with the death of their single parent (mother) left these children unprotected and vulnerable to such abuse from uncles who may have been competing for same needs in an already crowded family. It is possible that factors as poverty, social isolation, and familial disruption could have contributed to the abuse meted by this boy. The fact that the problem was established at this stage, it probably provided the patient and his siblings with the opportunity to get early support and avert serious health problems for them. The referral to the local child protection authority was done to attain this goal and also to have the children monitored consistently for their safety from further child abuse. The child protection agency was indeed considering placing them in the custody of a children's home, though sadly, according to a report by the Kenyan Government, the utilization of these support services had not been very high, for reasons unknown.
The treatment of the patient was carried out in a humane manner, and assistance provided whenever possible to have the full treatment completed. The problem of nutrition was still a difficult one for this large family with a poor background. Nonetheless, the guardian was still briefed on the issue, and informed about the importance of a balanced diet for optimal growth and immunity boosting for such young child, and suggestions for alternative cost-effective foods for the child. It was hoped that the support services of giving the patient and probably his siblings a new home would help the young child to grow and develop normally without fear of abuse.
The management of child abuse can be complicated, and often require a multidisciplinary approach, encompass professionals who will identifying the cause of the abuse or neglect, treatment of the immediate problems and referral of the child to the relevant child protection authority for action. Counseling services for the child and the caregivers should form part of the management regime. In the present case, the objectives were met and the patient got full benefits of this approach.
Source of Support: Nil
Conflict of Interest: None declared.
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