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Course: Pediatric Nursing

Topic: Child Maltreatment Part-II

The Nurses International Community

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Module Goals

Learners will be able to:

Discuss the risk factors of maltreatment in children.
Discuss consequences of maltreatment in children.
Explain interventions/strategies for prevention of child maltreatment.
Delineate the steps in management of child maltreatment.
Discuss policies and regulations related to child maltreatment.
Discuss the role of the nurse in prevention and management of child maltreatment.

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Child Maltreatment: Risk Factors

Child

Under four years old or an adolescent.
Unwanted pregnancy, or failing to fulfil the expectations of parents.
Having special needs, crying persistently, or abnormal physical features.
Having an intellectual or physical disability or neurological disorder.
Lesbian, gay, bisexual or transgender.

WHO, 2020

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Child Maltreatment: Risk Factors (Continued)

Parent or Caregiver

Difficulty bonding with a newborn
Not nurturing the child
Maltreated themselves as a child
Lacking awareness, having unrealistic expectations
Misusing alcohol or drugs, including during pregnancy
Low self-esteem, poor impulse control
Having a mental or neurological disorder, financial difficulties
Being involved in criminal activity

WHO, 2020

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Child Maltreatment: Risk Factors (Continued)

Relationship within the family, partners, friends, peers.

Family breakdown or violence between other family members.
Being isolated in the community or lacking a support network.
A breakdown of support in child rearing from the extended family.

WHO, 2020

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Child Maltreatment: Risk Factors (Continued)

Community and Societal Factors

Gender and social inequality
Lack of adequate housing or services
High levels of unemployment or poverty
Easy access of alcohol and drugs
Inadequate policies and programmes
Social and cultural norms that promote or glorify violence
Poor social, economic, health and education policies

WHO, 2020

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Critical Thinking Question

A nurse reviews the health history of a young mother. She notes that the woman is unmarried and lives with her boyfriend who is recovering from substance abuse and is currently unemployed.

The couple live in a poor, rural area of town. The mother works as a checker in a local grocery store.

What concerns should the nurse have concerning the safety and welfare of the new baby? What are appropropriate interventions?

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Consequences of Child Abuse and Neglect

Attachment and Interpersonal Relationship Problems

Insecure and disorganized problems
Difficulty trusting others
Persistent anxiety and anger
Difficulty communicating and interacting
Difficulty forming healthy relationships throughout life
Difficulty in building romantic relationships

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

Contact info: info@nursesinternational.org

Attachment and interpersonal relationship problems

Babies and young infants exposed to abuse and neglect are more likely to experience insecure or disorganised attachment problems with their primary caregiver. Patterns of child-caregiver attachment are extremely important for a child's early emotional and social development. For children with an insecure attachment, the parent/caregiver, who should be the primary source of safety, protection and comfort, becomes a source of danger or harm. Without the security and support from a primary caregiver, babies and infants may find it difficult to trust others when in distress, which may lead to persistent experiences of anxiety or anger.

Insecure attachments alter the normal developmental process for children, which can severely affect a child's ability to communicate and interact with others and form healthy relationships throughout their life. Reviews of the literature have reported that child maltreatment is associated with problematic peer relationships in childhood and adolescence. Further to this, difficulties in peer relations may be a precursor to difficulties in romantic relations.

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Consequences of Child Abuse and Neglect (Continued)

Learning and Developmental Problems

Poor academic achievement
Delay in language development
May affect the problem solving skills and reading abilities

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

Contact info: info@nursesinternational.org

Learning and developmental problems

Strong associations have been made between child maltreatment and learning difficulties and/or poor academic achievement. Abuse and neglect in the early years of life can seriously affect the developmental capacities of infants, especially in the critical areas of speech and language.

Prospective research studies have consistently shown that maltreated children have lower educational achievement than other groups of children. In a meta-analysis by Veltman and Browne (2001), 31 of 34 studies (91%) indicated that abuse and neglect was related to poor school achievement and 36 of 42 (86%) indicated delays in language development. However, the authors acknowledged that studies associating child abuse and neglect with learning problems are problematic in that most studies do not know the intellectual status of children before maltreatment. A more recent longitudinal study of maltreated children in the United States found that chronicity of maltreatment affected maths scores negatively and type of maltreatment affected reading scores negatively but higher intelligence and daily living skills (e.g., ability to dress oneself, ability to perform household tasks) were protective factors against poor math and reading performance.

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Consequences of Child Abuse and Neglect (Continued)

Mental Health Problems

Post Traumatic Stress Disorder
Complex trauma
Attention Deficit Hyperactivity Disorder
Substance abuse
Psychotic and adjustment disorders
Depression and anxiety disorders
Eating disorders like anorexia and bulimia

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

Contact info: info@nursesinternational.org

Mental health problems

Extensive research has identified a strong relationship between child maltreatment and a range of mental health problems, with post-traumatic stress disorder (PTSD) often reported. Recent research suggests that diagnosing children with PTSD does not capture the full developmental effects of chronic child abuse and neglect and as noted previously, many researchers now prefer the term "complex trauma". Maltreated children experiencing PTSD symptoms are also often found to be experiencing other disorders such as attention deficit hyperactivity disorder, oppositional defiant and conduct disorders, substance abuse, and anxiety, mood, psychotic, and adjustment disorders.

Mental health problems, such as depression and anxiety disorders, have consistently been linked with child abuse and neglect, particularly for adolescents. In a review of seven large-scale studies, all studies showed a high association between child maltreatment and depression in adolescence. For example, the authors cited a longitudinal study by Brown and colleagues which found that children and adolescents who reported a history of abuse or neglect were three times more likely to exhibit a depressive disorder than non-maltreated children. Similarly, in a Victorian study of characteristics of children referred to a therapeutic health service for children who had been abused or neglected (the Take Two Program), 62% of children met the criteria for at least one mental health diagnosis.

Eating disorders, including anorexia and binge-purge behaviour (bulimia), may also be associated with child abuse and neglect. Sexual abuse has been widely linked to eating disorders in children and adolescents; however, experiencing other maltreatment types or multiple forms of abuse and neglect have also been shown to increase the risk of developing an eating disorder.

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Consequences of Child Abuse and Neglect (Continued)

Youth Suicide

Suicidal ideation
Suicidal attempts
Risks of repeated attempts are eight times greater for youths with a history of sexual abuse

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

Contact info: info@nursesinternational.org

Youth suicide

Research suggests that abuse and neglect significantly increases the risk of suicidal ideation and attempted suicide for young people. A systematic review by Evans and colleagues (2005) found a strong link between physical and sexual abuse and attempted suicide/suicidal thoughts occurring during adolescence. Similarly, in a systematic review of the literature, Miller and colleagues (2013) found that although all forms of maltreatment were associated with adolescent suicidal ideation and suicide attempts, child sexual abuse and emotional abuse might be more important than physical abuse or neglect. Supporting this, Brodksy and Stanley (2008) found that risks of repeated suicide attempts were eight times greater for youths with a sexual abuse history. The authors suggested that sexual abuse could be specifically related to suicidal behaviour because it is closely associated with feelings of shame and internal attributions of blame.

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Consequences of Child Abuse and Neglect (Continued)

Substance Abuse

Tobacco
Alcohol
Illicit drugs

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

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Consequences of Child Abuse and Neglect (Continued)

Behavioural Problems

Withdrawn
Sad
Isolated
Depressed
Aggressive
Hyperactive

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

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Consequences of Child Abuse and Neglect (Continued)

Physical Health Problems

Brain damage, Spinal cord injuries, hearing loss, Speech difficulties
Death- shaken baby syndrome
Diabetes
Lung diseases
Malnutrition
Heart attacks
Strokes
Bowel diseases
Chronic fatigue syndrome

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

Contact info: info@nursesinternational.org

Physical health problems

Research investigating the effect child abuse and neglect has on overall physical health has largely focused on outcomes in adulthood. However, data from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) in the United States has indicated strong associations between abuse/neglect and health problems in children/adolescents (Flaherty et al., 2006, 2009). Flaherty et al. (2006) found that exposure to one adverse experience doubled the odds of children having overall poor physical health at the age of 6 years, and tripled them if children had experienced four or more adverse experiences.

Childhood maltreatment has been linked to higher risk for a wide range of long-term and/or future health problems, including—but not limited to—the following: �

Diabetes �
Lung disease �
Malnutrition �
Vision problems �
Functional limitations (i.e., being limited in activities) �
Heart attack �
Arthritis �
Back problems �
High blood pressure �
Brain damage
Migraine headaches �
Chronic bronchitis/emphysema/chronic obstructive pulmonary disease �
Cancer �
Stroke �
Bowel disease �
Chronic fatigue syndrome

A common form of abuse affecting the health of babies is shaken baby syndrome. Health problems resulting from shaken baby syndrome may include brain damage, spinal cord injuries, hearing loss, speech difficulties and even death.

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Consequences of Child Abuse and Neglect (Continued)

Aggressiveness
Violence
Involved in criminal activities
Teenage pregnancy
Risk of sexually transmitted infections
Risk taking behaviour
Homelessness or housing instability
Unemployment
Homicide deaths

Australian Institute of Family Studies, 2014

Child Welfare Information Gateway, 2019

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Critical Thinking Question

The school nurse notices that a young child comes to school frequently without a coat during cold weather and wears ill fitting shoes.

What concerns should the nurse have?

How should the nurse address this situation?

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Prevention and Responding to Child Maltreatment (Continued)

Information and skills building sessions
Non-violent parenting education
Series of home visits in community settings
Awareness of maltreatment including its risk factors and consequences
Provide a line of support
Encourage and increase enrollment in quality education
Positive and violence free school environment

WHO, 2022

Contact info: info@nursesinternational.org

Requires a multisectoral approach.

Parent and caregiver support:

Information and skill-building sessions to support the development of nurturing, non-violent parenting delivered by nurses, social workers, or trained lay workers through a series of home visits or in a community setting.

Education and life skills approaches:

Increasing enrolment in quality education to allow children acquire knowledge, skills and experiences that build resilience and reduce risk factors for violence
Programmes to prevent sexual abuse that build awareness and teach skills to help children and adolescents understand consent, avoid and prevent sexual abuse and exploitation, and to seek help and support
Interventions to build a positive school climate and violence-free environment, and strengthening relationships between students, teachers, and administrators

Norms and values approaches:

Programmes to transform restrictive and harmful gender and social norms around child-rearing, child discipline and gender equality and promote the nurturing role of fathers

Implementation and enforcement of laws:

Laws to prohibit violent punishment and to protect children from sexual abuse and exploitation.

Response and support services:

Early case recognition coupled with ongoing care of child victims and families to help reduce recurrence of maltreatment and lessen its consequences.

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Prevention and Responding to Child Maltreatment (Continued)

Approach to strengthening good relationships between teachers and students
Legislation to prohibit maltreatment
Recognition, assessment and early intervention
Gender equality, promote father’s nurturing role

WHO, 2022

Contact info: info@nursesinternational.org

Requires a multisectoral approach.

Parent and caregiver support:

Information and skill-building sessions to support the development of nurturing, non-violent parenting delivered by nurses, social workers, or trained lay workers through a series of home visits or in a community setting.

Education and life skills approaches:

Increasing enrolment in quality education to allow children acquire knowledge, skills and experiences that build resilience and reduce risk factors for violence
Programmes to prevent sexual abuse that build awareness and teach skills to help children and adolescents understand consent, avoid and prevent sexual abuse and exploitation, and to seek help and support
Interventions to build a positive school climate and violence-free environment, and strengthening relationships between students, teachers, and administrators

Norms and values approaches:

Programmes to transform restrictive and harmful gender and social norms around child-rearing, child discipline and gender equality and promote the nurturing role of fathers

Implementation and enforcement of laws:

Laws to prohibit violent punishment and to protect children from sexual abuse and exploitation.

Response and support services:

Early case recognition coupled with ongoing care of child victims and families to help reduce recurrence of maltreatment and lessen its consequences.

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CDC

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Prevention and Responding to Child Maltreatment (Continued)

To maximize the effects of prevention and care, WHO recommends that interventions are delivered as part of a four-step public health approach:

Defining the problem
Identifying causes and risk factors;
Design interventions aimed at minimizing the risk factors
Disseminate information about the effectiveness of interventions and increase the scale of proven effective interventions

WHO, 2022

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Opportunities for Child Maltreatment Prevention

in Pediatric Primary Care (Nursing)

Screen for risk factors.

Parental depression, substance abuse, intimate partner violence.

Identify family protective factors.

Social support, parenting competence.

Provide anticipatory guidance on challenging behaviors and developmental issues.

Infant crying, toilet training

Lane, 2014

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Opportunities for Child Maltreatment Prevention

in Pediatric Primary Care (Nursing)

Assess disciplinary actions

Help parents replace corporal punishment with more effective and less harmful strategies.

Discuss sexual development and behavior with parents.

Help parents and children become more skilled in communication about sexuality and sexual abuse.

Become knowledgeable about the availability and effectiveness of local community-based resources.

Lane, 2014

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Opportunities for Child Maltreatment Prevention

in Pediatric Primary Care (Nursing)

Help families to identify services that meet their needs.
Advocate for implementation and sustaining community-based services.
Advocate for implementation and sustaining federal, state, and local programs.

Lane, 2014

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Discussion Question

What actions can the nurse do to combat child maltreatment in the community?

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Nursing Management of an Abused Child

Show kindness and gentleness to the child and parents
Remain non-judgemental and non-threatening
Remain calm and non-aggressive toward the parents /child
Obtain history from the child and parents
Perform full and thorough examination
Document all the present and past injuries (fresh/healing wounds or scars)

Woods, 2019

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Abuse is best managed by a multi-disciplinary team who have experience with caring for abused children. Always be kind and gentle with the child, and handle the parents with support and understanding. Be non-judgmental and non-threatening as being accused of child abuse is always emotionally threatening. Stay calm and do not become aggressive with the parents. It is often very difficult to tell with certainty whether a child is or is not being abused.

A careful history from the child and family is important. Children rarely lie about abuse.
A full examination looking especially for unusual or unexplained injuries. The examination must not be traumatic for the child. Look for signs of malnutrition or neglect. Has the child been drinking alcohol?
All past and present injuries must be carefully documented. Make good notes as they may be used in court. Always date and sign the notes

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Nursing Management of an Abused Child (Continued)

Provide immediate physical and emotional treatment needed.
Consider the safety of child.
Remove child to safe place if needed.
Report the child and the case to the expert.
Report per policy: Notify the police, a social worker or child welfare officer immediately.

Woods, 2019

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Assessment of Child Who is Neglected

Listen and observe, provide comfort and understanding
Examine the child for abuse
Look for signs of sexual abuse (unnexplained/unusual injuries; fresh, healing wounds or scars)
Assess:

The signs of malnutrition or neglect
Behavior
Mood
Interaction between child and family
Other siblings for injuries

Document findings and interventions

Gonzalez et al., 2020

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Physical examination may not only demonstrate signs of physical abuse but may show signs of neglect.

Physical examination
Record signs like:

Poor oral hygiene with extensive dental caries
Malnutrition
Growth failure
Untreated diaper dermatitis
Untreated wounds

The general examination may show poor oral hygiene with extensive dental caries, malnutrition with significant growth failure, untreated diaper dermatitis, or untreated wounds.

All healthcare providers are mandated reporters, and, as such, they are required to make a report to child welfare when there is a reasonable suspicion of abuse or neglect.

One does not need to be certain, but one does need to have a reasonable suspicion of the abuse. This mandated report may be lifesaving for many children. An interdisciplinary approach with the inclusion of a child-abuse specialist is optimal.

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Assessment of a Sexually Abused Child

Perform anal and genital examination only once
Younger children: allow parent or caregiver to hold infant on their lap with their legs pulled up to expose the genitalia
Older child are best examined in the lateral position
This examination is usually not urgent
Note all signs of sexual interference
Perform vaginal examination if there is severe trauma
Describe the shape and appearance of the hymen
Swabs taken for culture
Findings must be carefully documented

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Parental Roles for Children and Youth

Who Have Experienced Abuse or Neglect

Model a positive outlook
Build confidence
Express support
Build connections and communication skills
Allow children to express their feelings
Be consistent and patient
Teach child or youth the importance of healthy behaviors
Address child’s physical safety
Validate, but do not dwell on the past
Develop positive and caring discipline techniques

Child Welfare Information Gateway, 2018

Contact info: info@nursesinternational.org

Model a positive outlook: When faced with a problem, show the child or youth that the problem is only for a short time and that things will get better: Children and youth learn from the ability to bounce back from and work through tough situations.
Build confidence: Let the child or youth know when he or she does something well, such as demonstrating kindness or honesty.
Express support: Express love, empathy, and support verbally and physically. Express love through words, notes, and hugs.
Build connections: Create bonds with friends and family that can support the child or youth during challenges and teach him or her to consider other people’s feelings.
Allow children to express their feelings. Teach them how to identify and describe their feelings and commend them for expressing feelings of hurt or sadness without acting out.
Be consistent: If said will be there, be there. If said will listen to concerns, listen. This will help teach the child or youth that people can be trusted.
Be patient. Children’s reactions to trauma vary as widely as the types of trauma one can experience. There isn’t a one-size-fits-all solution.
Teach the child or youth the importance of healthy behaviors. Have open and honest talks about the dangers of drugs and alcohol, smoking, and sexually inappropriate behavior. Teach the child the importance of eating properly and exercising.
Address the child’s physical safety first by assuring him or her that no one will physically touch or harm them. This will help the child or youth develop feelings of trust and openness to psychological and emotional healing. �
Address the past as the past. Help the child or youth identify elements of his or her current life that are different from the past. Use this as a chance to discuss expectations and personal boundaries—limits set in relationships that protect our sense of self. To encourage feelings of belonging and attachment, provide regular routines around mealtime, naps, and bedtime; talk with the child or youth about the importance of feelings; and teach him or her to solve problems in age-appropriate ways.
Be available.
Provide consistent support to build feelings of trust and safety. �
Be supportive and empathic. Comfort the child or youth when he or she is upset, modeling appropriate displays of affection and building self-esteem. �
Be encouraging. Listen and be involved and interested in the child’s activities. Stay aware of his or her interests and friends and stay actively supportive.F

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Developing Caring Discipline Techniques

Child Welfare Information Gateway, 2018

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Critical Thinking Question

A nurse is developing a class for new teenage parents.

What information should be included to prevent child maltreatment?

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Red Flags

The Child:

Has sudden change of behavior
Appears fearful of parent or guardian
Displays inappropriate sexual behaviors toward other children
Has foul smelling odor
Is missing school frequently without medical note
Has Sudden change in quality of school work
Appears sad or depressed

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

In country like Nepal, a significant number of toddlers, more than half, aged between one and two or more, are disciplined with the use of physical force.

Unicef, 2018

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References:

Andrews, M.M., Boyle, J.S. & Collings, J. W. (2020). Transcultural Concepts in Nursing Care (8th Ed.). Wolters Kluwer, Philadelphia, PA.

Australian Institute of Family Studies (2014, January). Effects of child abuse and neglect for children and adolescents. https://aifs.gov.au/cfca/publications/effects-child-abuse-and-neglect-children-and-adolescents

Child Welfare Information Gateway. (2019). Long-term consequences of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/

Contact info: info@nursesinternational.org

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References:

Child Welfare Information Gateway. (2018). Parenting a child who has experienced abuse or neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. https://www.childwelfare.gov/pubs/parenting-CAN/

Gonzalez, D., Bethencourt, M. A., McCall, J. D, et al (2021, Jul 10). Child Abuse and Neglect (Nursing) StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568689/

Lane W. G. (2014). Prevention of child maltreatment. Pediatric clinics of North America, 61(5), 873–888. https://doi.org/10.1016/j.pcl.2014.06.002

Contact info: info@nursesinternational.org

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References:

Unicef. (2018, September o6). Press Release: Eight Out Of 10 Children In Nepal Experience Violent Discipline – UNICEF. https://www.unicef.org/nepal/press-releases/eight-out-10-children-nepal-experience-violent-discipline-unicef

WHO. (2020, June 8). Child maltreatment. https://www.who.int/news-room/fact-sheets/detail/child-maltreatment

Woods, D. (2019). Child Healthcare: Home and Society (CH. 14). Better Care. h ttps://bettercare.co.za/learn/child-healthcare/text/0-3-contents.html

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