Child Maltreatment (lecture 3)

Early Definitions of Physical Abuse

• Kempe et al.’s battered child syndrome — focuses almost entirely on the clear physical injuries (i.e. fractures and bruises)

• The medical model of child maltreatment positions physicians as key actors in detention, detection, reporting, research and early prevention

Why were early injury-only definitions of PA too narrow?

They failed to capture clearly abusive acts that did not result in visible harm, such as a parent shooting at a child but missing.

The US National Center of Child Abuse and Neglect

Shifted definitions of physical abuse to include not just harm, but also risk and endangerment standards.

Physical Abuse

Any act by a caregiver that results in, or could result in, a non-accidental physical injury or puts the child at risk of non-accidental physical injury.

The use of an implement, such as a belt or wooden spoon, in correcting a child's behaviour is also included

FNCIS-2019 (First Nations Canadian Incident Study)

• 14% of maltreatment cases involving First Nations children had physical abuse as the primary concern

• 57% were in the context of discipline/punishment

• 16% of investigations involving First Nations children involved children under the age of 4

OIS-2023 (Ontario Incident Study)

• An estimated 41,887 substantiated child maltreatment investigations

• Found that physical abuse was the primary type of abuse in 13% of substantiated maltreatment investigations, which is an incidence rate of 2 per 1000 children — half the rate of the prevalence (self-report)

SSPPS-2018 (Survey of Safety in Public and Private Spaces)

• 27% of Canadians over age 15 reported experiencing child maltreatment in childhood. Most commonly, physical abuse (24%) — 1 in 4 Canadians

• Men were slightly more likely to be physically abuse at 25%, Women: 22%

• 69% of Canadians who were physically abused reported that the most serious incident was perpetrated by a parent or step-parent

MHACS – 2022 (Mental Health Access to Care Study)

• 27.8% physical abuse in childhood (not much change) — a large portion of the population

• Males reported 32.7%; Females reported 23.1%

Corporal Punishment

Increases risk for more severe violence; most cases result from punishment. Parents do not necessarily intend to actually injure the child, but are angry and escalate in physical violence

• CIS found that inappropriate punishment (spanking, smacking) of children was a factor in 75% of proven physical abuse cases

Section 43

Section of the Canadian Criminal Code that provides a defence for parents or teachers using force for correction:

“Every schoolteacher, parent or person standing in the place of a parent is justified in using force by way of correction toward a pupil or child, as the case may be, who is under his care, if the force does not exceed what is reasonable under the circumstances.”

Some Guidelines of Section 43

1. Physical punishment, like slapping or spanking a child hard enough that it leaves a mark or bruise

2. Cannot be used on children younger than 2 years old or older than 12

3. Objects cannot be used on a child + not hitting them on the face/head

4. The physical punishment cannot be used on a child who is incapable of learning from the situation, because of disability or some other factor

5. The seriousness of the child’s behaviour is not relevant in deciding whether the force used was reasonable.

Demographics with Higher Rates of Abuse (self-report)

• Women overall report more overall abuse (not more physical abuse)

• Indigenous people

• Younger adults (18-34)

• People with disabilities

• Se*ual minorities

• Immigrants

• Lower income households

Some Possible Signs of Physical Abuse

• Injuries in suspicious locations. Definable bruise pattern (e.g., handprint, the shape of a serving spoon) and Bruising in non-mobile children

• Bald patches, matted hair. Child wears long sleeves/long pants even in warm weather. The child seems anxious when other children cry. Avoidance of physical contact with others

• Recurrent nightmares or disturbed sleep patterns, Delinquent behaviour, Abrupt decline in school performance, Mismatch between an injury and the explanation

Intergenerational Pattern of Abuse

It refers to a pattern where caregivers who were abused as children are more likely to abuse their own children. Can result in unmet emotional needs, low self-esteem, excessive dependency and difficulties tolerating stress that parenting demands

Unrealistic Expectations of Children

Not knowing the normative development of kids, and putting their own emotional adult needs on them. The child should do things beyond their developmental capacity and behave perfectly. When they fail to meet these expectations, then frustration and impulsive responses can escalate to violence

Other Caregiver Linked to Factors PA

• Harsh physical discipline, hostility, lack of empathy, and inconsistent or absent injury explanations — delay in seeking medical care to potentially avoid detection

• Social isolation, limited parenting support, intergenerational pattern of abuse, poverty, related stress, intimate partner violence, and limited/lacking coping resources

Physical Consequences of PA

• Bruises

• Fractures

• Head injuries/trauma

• Injuries from a fall

• Burns

• Abdominal trauma

Bruises

Most common physical injury resulting from PA. Accidents are rare in infants who aren’t mobile, risky under 6 months.

More injuries on central protected areas like the ears, trunks, genitals, back of hands, patterns of hands or objects, repeated and different stages of healing, are cause for concern, especially when the story behind it doesn’t make sense.

Human Bite Marks

An indicator of physical abuse. They are rarely accidental and have very distinctive patterns, indicating a potential assault.

Fractures

8-12% of all pediatric injuries, and abusive ones are 12-20%. Most common in infants, with over half occurring in children under 1.

The explanation doesn’t match the severity, red flag if there are multiple present without the history of a major trauma like a car accident/major fall. Long bones, ribs, and skulls are often abusive signs. Multiple ones at different ages also raise suspicion

Injuries from Falls

Serious injuries like fractures are rare, fatal injuries from short falls, like under 15 meters, are exceptionally uncommon (even greater height falls are often survivable).

Again, a disagreement with the parent’s story versus the injuries. If a caregiver reports a short fall as the cause of life-threatening injury, might consider and suspect whether it’s is inaccurate.

Burns

10-25% of pediatric cases may be the result of abuse. Many incidents can be accidental, but the severity, pattern and location matter.

Accidental ones have an irregular pattern, edges, and splash marks — If it was a forced emersion in boiling water, then it will look uniform and sharp. Ones that involve much of the torso, symmetrical shapes, with spared areas, the shape of household objects like heating grades, irons, curling irons, and heating utensils are suspicious

Head Injury

Common and dangerous form of abuse for younger children; most abused children hospitalized for this trauma are under 3.

Visible symptoms like depressed consciousness, seizures, respiratory distress, vomiting, and signs like retinal hemorrhage, bulging fontanelles, death or long-term disability. High-risk children who are suspected of being abused may be assessed for occult fractures and injuries

Shaken Baby Syndrome or “Abusive Head Trauma

Can be caused by the violent shaking of infants under 2, especially under 6 months.

Shaking causes the brain to move around the skull, leading to serious internal injuries like subdural hematomas, brain swelling, retinal hemorrhage (the soft spots on a baby's head), etc. The leading cause of child abuse mortality is concentrated in infants and very young children. Many surviors ecperience neurodevelopmental disability

Abdominal Trauma

Less common than head injuries, but the mortality and morbidity rates are substantial. The second leading cause of death after head trauma

They’re also difficult to assess, given bc sometimes there's little to no bruising, a delay in symptoms, and it depends on how deep the injury is to the abdominal cavity into the organs.

Non-Physical Consequences of PA

• Intellectual/academic problems

• Changes in cognitive processing

• Issues with interpersonal relationships

• Post Traumatic Stress Disorder

• Aggression

• Internalizing symptoms: Lower self-esteem, depression, suicidal ideation

• Substance abuse

Hostile Attribution

A psychological consequence of PA. It is a change in cognitive processing where the child tends to interpret others' ambiguous behaviors as having hostile intent.

Physical Abuse Increases the Risk for

Three types of adult behavior: Adult criminality, violent crime, and interpersonal violence.

Preventing Physical Abuse

• Strengthen the prenatal or post-natal period and the parent-child interactions during this time. Most effective when timed to key developmental stages

• Addressing harsh parenting beliefs, intimate partner violence, and aggressive behaviours towards children

Risk; injury

The CIS recognizes that maltreatment often involves chronic _____ rather than acute _____.

Occult Fracture

A fracture that is not detected at the time of injury and may only be found 3-4 weeks later on a CT scan or MRI.

Negative Child Outcomes with Spanking

Any two of: aggression, behavioural problems, slower cognitive development, or negative relationships with parents.