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Child Maltreatment

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  Hi, my name is Jordan Greenbaum.I'm the medical director ofthe Stephanie Blank Center for Safe andHealthy Children atChildren's Healthcare of Atlanta.I specialize in child maltreatment,including abuse and neglect.Today we're going to talkabout child abuse and neglect.Let's start off with this, imagine this,your nine year old daughter comes to youand says, I've got something to tell you.She goes on to say that when she spent thenight with her best friend six months ago,she woke up to find the friend's fatherin her sleeping bag with his pants down.He was fondling her private parts andhe whispered to her not to say anything.He said this was their secret.If she told her friend,the friend would be very upset.Well, she tells you,this is a man, a big man.And she was afraid of him.So she didn't want to lose her friend,so she didn't say anything.Or imagine this.A friend of yours can, confides in youthat her daughter is living with a man whouses methamphetamine's.And she's worried that herdaughter is using drugs too.The daughter has a 4-month-old boy.The friend tells you that she's concerned,because whenever she goes and visits them.She has to pound on the doorto wakeup the parents.And when they finally come tothe door they seem very groggy.And often she, when she comes inshe finds the baby in a dark room,in a soaked diaper, crying and crying.Sometimes her daughter andboyfriend seem very agitated,she hears the boyfriend complainabout the babies crying, andtelling the mother that she's spoiling theinfant by lifting him up when he's crying.Last week when the friend went,she saw bruising on the baby's face,as if someone had grabbed the baby's face.But what are we seeing here?In the first case, we're seeinga victim of child sexual abuse.In the second, circumstances stronglysuggest possible, child neglect andphysical abuse.What is sexual abuse?Broadly defined,it's any sexual activity that's  perpetrated against a minor by threat,force, inti, intimidation or manipulation.This includes both contact andnon contact activities.So for example, vaginal intercourse orfondling, touching breasts over clothing.Or non contact activities like forcinga child to watch pornography orpose for pornography.It's a broad definition.What about physical abuse?Again, the definitions vary, but legaldefinitions are often quite vague such as,physical abuse involves any nonaccidental injury to a child.Physically abusive acts include a wholelot of things like kick, or burning, orchoking, or stomping on a child.In many states it includes acts orcircumstance that threaten the child withharm, or the subsidiant risk of harm.You don't necessarily have toshow that harm has occurred.Defining physical abusebecomes controversial.Because many states andcountries allow corporal punishment.And it's difficult to define the line thatseparates such punishment from abuse.And people really vary on that.Child neglect occurs whena child's basic needs are not met.The reasons they aren't metmay be multi-factorial, andinclude factors at individual level,such as the parental drug addictionthat we saw with our four month old.But they also include factors at thefamily, community, and societal levels.For example, few, few resources forparents in a community.Or societal ills such as poverty.There are different types of neglectincluding lack of appropriate supervision,emotional neglect.Physical, medical, andeducational neglect.And often there's more than one typeof neglect, neglect in a family.Finally emotional abuse, also referedto as psychological maltreatment.Involves a repeated pattern ofcaregiver behavior, or one or moreextreme incidents that convey to childrenthat they are worthless, flawed, unloved,unwanted, endangered or really only ofvalue in meeting someone elses needs.Emotional abuse is potentiallydevastating to children.And some people think that it is,.  Emotional abuse that causes the, longterm effects of child abuse and neglect.Physical wounds heal, broken bones heal,bruises heal, but the effects ofconstant belittling, terrorizing, orhumiliating a child thoseeffects are much harder to heal.Child abuse and neglect is extremelycommon in the United States,approximately 40% of American childrenhave been maltreated in some way.Different types of abuse range fromeighteen to 26% in prevalence.More than one in four females and one in20 males will experience sexual abuse.or sexual assault as a minor.Perpetrators of sexual abuse can beadults and are often a caregiver,such as the circumstances we typicallyassociate with sexual abuse.But they can also be peer perpetrators incircumstance we consider more typical ofsexual assault.And globally the situationis fairly similar.The World Health Organizationestimates that about 23%of the world's populationare victims of child physical abuse.In one multinational study,the prevalence of sexual abuse was 18% forgirls and nearly 8% for boys.With considerablevariation among countries.There are a lot of factors thatcan place children at risk forchild abuse and neglect.In our example, the four-month old infant,we saw caregiver drug addiction, andreally, unrealisticexpectations of the infant.Abuse is often intergenerational.So, an adult who has been abusedas a child is at increased risk ofhaving a child who themselves are abused.But it's important to rememberthat some abused kids have no riskfactors, none at all.Child maltreatment crosses allsocioeconomic, religious, national,racial and ethnic boundaries.There is no community, state orcountry that is immune fromchild abuse and neglect.So how do we recognize abuse?There's some situations that may raiseconcerns about possible physical abuse.For example,if you see a significant injury andthere's no history of any  trauma to explain it,or a history that doesn't make anysense to you, that might be a red flag.Typically, young infants who have not yetlearned to pull to stand andcruise, don't have any bruising.And when they do, it's typically a singleinjury with a very significant event,like a fall from an adult's arms.So any unexplained bruising ofa very young baby is of concern.How do we learn about sexual abuse?As in our example, the nine year old girl,a child's disclosure is the mostcommon way we learn about it.However, children may not immediatelytell an adult about the abuse anddelays in disclosing are very common.In our example,the child was afraid of the offender andthe possibility of losing her friend.So she didn't tell anyone,until after the friend andthe family moved away from town,and she felt safe.Many children never tell.Or, if they disclose,it's months, even years, later.Many parents come to our clinics withconcerns that their child has been abused,based on the child's behavior.And I think it's really important tostress that there is no single behavior.That definitively identifies a childas having been sexually abused.Some children have no behavior changes.Others have some behavior changes,but they're very nonspecific andmaybe related with any kind of stress,like loss of appetite or nightmares.Another thing to remember is thatwhile it's commonly assumed thata child victim of sexual abuse willhave physical changes to the genitalia.That identify a child as being abused.That is rarely the case.Not all forms of sexual abuse causeinjury, and when they do cause injurytypically the delay in disclosure meansthat those injuries have healed completelywithout any scarring, so by the time thechild is examined there is nothing to see.The exam is completely normal.So the majority of child victims thatwe see in our clinic do not havephysical findings th,that's diagnostic of prior trauma.Are there long term effectsof child abuse and neglect?Yes.
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