Preventing child maltreatment1 |

A public health approach to preventing child maltreatmentA public health approach to

preventing child maltreatment

Dr Dinesh Sethi

Violence and Injury Prevention

WHO European Centre for Environment and Health , Rome

Preventing child maltreatment2 |

Key facts and figures from the WHO European Region - 1

Key facts and figures from the WHO European Region - 1

• Almost 1,500 children aged 0-14 years died in the WHO European Region in 2002 as a result of homicide (*)

• The rates for children 0 – 4 years are double that for those aged 5 – 14 years.

• Occurrence of sexual abuse in childhood is as high as 20 % in women and 5 – 10 % in men (*)

• About 34 % of young people report being bullied at least once in the past 60 days (**)

• About 75,000 children are estimated to be involved in the sex trade in Eastern Europe (*)

• Available data suggest that severe physical punishment has an incidence of 5 – 8 % (*)

(*) Injuries and Violence in Europe, Why they matter and what can be done (2006) WHO Regional Office for Europe(**) Young people’s health in context - Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey (2004) WHO Regional Office for Europe

Preventing child maltreatment3 |

Standardized mortality rates for homicides in children aged 0 - 14 years for countries with more than 1 million inhabitants in the most recent year

(deaths/100,000 population)Source: WHO EURO Mortality Database June 2006

0 0.5 1 1.5 2

2004Russian Federation2004Ukraine2004Lithuania2005Estonia2004Kazakhstan2004Belarus2005Austria2004Latvia2002Slovakia1997Belgium2003Albania2003Israel2003Hungary2003Norway2004Republic of Moldova2004Romania2002Serbia and Montenegro2001Denmark2002Switzerland2003TFYR Macedonia2002France2003Armenia2003Portugal2004Finland2004Germany2002Sweden2004Netherlands2004Slovenia2004Czech Republic2004Kyrgyzstan2004Poland2004Uzbekistan2004Spain2004Bulgaria1998Turkmenistan2001Tajikistan2004Greece2004United Kingdom2002Azerbaijan2001Italy2001Georgia2002Ireland2004Croatia

SDR(0-14), Homicide and assault, per 100000, Last available

Preventing child maltreatment4 |

UN SG's Study onViolence Against Children

UN SG's Study onViolence Against Children

Gap between human rights commitment and investment in evidence-based prevention programmes and services

Preventing child maltreatment5 |

Objectives of the guideObjectives of the guide

Convey knowledge of what's needed to design and implement child maltreatment prevention programmes as outcome evaluation studies

Expand the evidence base to include more outcome evaluation studies from low- and middle-income countries

Help prioritize child maltreatment prevention in international and national health and development agendas

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Guide Content overviewGuide Content overview• Introduction

• Nature and consequences of child maltreatment

• Epidemiological and case-based information

• Prevention of child maltreatment

• Services for affected children and families

• Conclusions and recommendations

• Appendices

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IntroductionIntroduction

• Focus on child maltreatment in age 0-14 years• Perpetrators mostly parents and family members• Place of occurrence mostly private

• Professional audiences• Health• Social• Legal • Research

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Systematic, population-level approachSystematic, population-level approach

SurveillanceWhat is the Problem?

Identify risk and protective factors

What are the causes?

ImplementationScaling up effective

policy and programmes

Develop andevaluate

interventionsWhat works and for

whom?

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1. Nature and consequences: definition1. Nature and consequences: definition

Suicide self-abuse

Self-Inflicted

child partner elder

family/partner

acquaintance stranger

community

Interpersonal

social political economic

Collective

Violence

Nature of Violence:

Physical Sexual Psychological Deprivation

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IndividualRelationship/ Family

CommunitySociety

1. Nature and consequences: ecological model1. Nature and consequences: ecological model

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1. Nature and consequences: life course approach

1. Nature and consequences: life course approach

Adverse Childhood Experiences

Social, Emotional, & Cognitive Impairment

Adoption ofHealth-risk Behaviors

Disease, Disability

EarlyEarlyDeathDeath

Death

Birth

Death

Birth

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2. Epidemiological and case-based information2. Epidemiological and case-based information

• Population-based epidemiological surveys• Use of physical punishment• Exposure to child maltreatment• Current health risk behaviours• Current health status

• Facility-based case information• Non-fatal cases (known and suspected)• Fatalities (known and suspected)

• Using information for advocacy

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2. Population-based epidemiological surveys

2. Population-based epidemiological surveys

• Survey instruments• Parent-child Conflict Tactics Scale• Adverse Childhood Experiences Study questionnaires• Lifetime Victimization Survey Screening questionnaire• ISPCAN Child Abuse Screening Tools

• Adapting survey methods to local conditions

• Sampling strategies

• Ethical considerations

Preventing child maltreatment14 |

Categories and prevalence of Adverse Childhood Experiences

Prevalence (%)

Abuse, by Category Psychological (by parents) 11% Physical (by parents) 11% Sexual (anyone) 22%

Household Dysfunction, by Category Substance Abuse 26% Mental Illness 19% Mother Treated Violently 13% Imprisoned Household Member 3%

Category

Felitti et al, 1998

2. Epidemiological and case-based information2. Epidemiological and case-based information

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3. Prevention of child maltreatment3. Prevention of child maltreatment

PREVENTION IDENTIFICATIONREPORTINGREFERRAL

TREATMENT

INVESTIGATIONFOLLOW-UP

Address underlying causes and risk factors

Child maltreatment occurs

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3. Prevention of child maltreatment3. Prevention of child maltreatment• Societal and community

• Providing early childhood education and care• Reducing alcohol availability• Changing norms that support child maltreatment

• Relationship• Home visitation programmes• Training in parenting

• Individual• Reducing unintended pregnancies• Increasing access to pre- and post-natal services

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3. Prevention of child maltreatment3. Prevention of child maltreatment

Ecological level

Time from intervention to measurement

Infant/childParent/familyCommunity/ society

Infant developmentParental knowledge and expectations

Belief in acceptability of punishment

Educational achievement

Adult reporting health risk behaviours

Encounters with criminal justice system

Homicide rates in children 0-4 years old

Examples of outcome evaluation indicators

Short

Long

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4. Services for affected children and families4. Services for affected children and families

Child maltreatment occurs

PREVENTION IDENTIFICATIONREPORTINGREFERRAL

TREATMENT

INVESTIGATIONFOLLOW-UP

Preventing child maltreatment19 |

Integrated mental/physical health and forensic assessment– Consent

– History

– Top-to-toe physical exam, including genito-anal exam

– Documentation and treatment of injuries

– Mental health assessment

– Screening or treatment for STIs, HIV

– Prevention of pregnancy

– Forensic examination

Psychosocial support

Support services for families

4. Treatment and support4. Treatment and support

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Reporting laws: issues to consider

Integrated assessment of families at risk

Intervention for the best interest of the child

4. Protecting the child4. Protecting the child

Preventing child maltreatment21 |

Conclusions and recommendationsConclusions and recommendations

• Base policies, plans, programmes and services on scientific evidence

• Define child maltreatment cases and outcome indicators using international norms and behavioural definitions from well-tested instruments

• Design and implement prevention programmes and services as outcome evaluation studies

• Integrate wherever possible prevention and services into existing systems

Preventing child maltreatment22 |

Information on violence prevention in Europe

www.euro.who.int/violenceinjury

To obtain Preventing child maltreatment

Information on violence prevention in Europe

www.euro.who.int/violenceinjury

To obtain Preventing child maltreatment

Send an Email giving your name, organization, postal address and the number of copies required to:

violenceprevention@who.int

or download a PDF version from

http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf

Preventing child maltreatment23 |

Zurich project on the social development of

children

Zurich project on the social development of

children

Eisner, M. 2004. http://www.z-proso.unizh.ch/Dokumente/NEWSLETTER1en.pdf

Longitudinal study– 1000 children– 1000 parents

Prevention programme– Triple P– Paths

Randomized Control Trial