Introduction

• In recent years, increasing attention has been given to the issue of child abuse and neglect.

Studies indicate that every day a significant number of children are exposed to serious maltreatment and neglect leading to physical and psychological injury and serious long-term consequences. Researchers are continuously examining the wide range of potential consequences of child abuse and neglect. Mounting evidence suggests that, in addition to the immediate negative effects on children, maltreatment is associated with a host of problems manifested in adolescence and adulthood.

• The role of the health practitioner in the protection of children is critical.

In their capacity as “front-line workers”, health practitioners often come into contact with children and families experiencing violence. Often, the only known signs of abuse and neglect are detectable by health practitioners. Fortunately, they can intervene effectively to diminish many of the potential adverse consequences of child maltreatment. By reporting substantiated, alleged, and even suspected cases of child maltreatment to child welfare authorities, health practitioners offer abused children the chance to live violence-free and to address their victimization. Tremendous progress has been made by the health community to advance the welfare of children, and there is still more work to be done.

• This booklet is designed to offer health practitioners essential and up-to-date information on child maltreatment.

The first section of this booklet provides a general overview of child maltreatment. Definitions, the extent of the problem and factors influencing maltreatment are all examined. The second section outlines the possible consequences of child maltreatment. Information is drawn from research into both short- and long-term consequences. The third section discusses the issue of reporting child maltreatment for health practitioners. Some commonly asked questions are answered, reporting tendencies and biases are addressed, and some common signs of maltreatment are highlighted.

An Overview of Child Maltreatment

• In British Columbia, five-year-old Matthew John Vaudreuil was found dead with 11 fractured ribs, a fractured arm and bruises all over his body. He was tortured and deprived of food before he was murdered by his mother. Prior to his death, 24 different physicians attended to Matthew on 75 separate occasions – often for serious physical injuries.

• In Ontario, Sara Podniewicz, an infant of six  months, was beaten to death by her mother and father. Three weeks earlier, she had received medical care for an arm broken under suspicious circumstances.

• In New Brunswick, three-year-old John Ryan Turner died, a victim of severe parental emotional abuse, physical abuse and neglect after being seen by numerous professionals.

Yes, these cases do represent the extreme end of the child abuse spectrum. They are nonetheless very real. They illustrate the pain and suffering of real Canadian children. In 1996 alone there were 47 children murdered by their parents in Canada; 34 (72%) of these victims were under the age of six.1

While most child abuse victims are not murdered, they do live with ongoing violence, indifference and a lack of attention to their basic needs. In 1996, there were approximately six million children under the age of 15 in Canada.2 If only 5% of these children were abused or neglected (a very modest estimate), there would have been 300,000 victims of child maltreatment that year alone – all under the age of 15.

Defining Maltreatment*

It is difficult to develop a universal definition of child abuse and neglect. What some people view as abusive, others see as normal and acceptable parenting. Most professionals in child protection, however, do share a common understanding of what constitutes child abuse. It is the mistreatment of a child or a disregard for the developmental needs of a child by a parent, guardian or caregiver resulting in injury, emotional/psychological harm or the potential for such harm. For simplicity, the term child maltreatment will be used throughout this booklet to represent all forms of child abuse and neglect.

• Physical abuse refers to the beating or battering of a child and includes poisoning, burning, hitting, kicking, biting, shaking, throwing, choking or any other harmful force or restraint. Physically abusive behaviour is often justified in the name of discipline. Research suggests, however, that physical discipline is not an effective method of positively influencing children’s behaviour.3 Furthermore, the use of physical force as a means of discipline has the potential to escalate into much more violent beatings.4

• Sexual abuse refers to the use of a child for the sexual gratification of an older adolescent or adult and involves the exposure of a child to sexual contact, activity or behaviour. It may also include invitation to sexual touching, intercourse or other forms of exploitation such as pornography or child prostitution. Note that sexual abuse can occur between children. The key to defining an act as abusive is the difference in age and power between the  victim and the offender.

• Neglect can be described as a failure to provide the physical and/or psychological necessities of life to a child. It is often difficult to define and detect. Examples of neglect include not providing appropriate food, clothing and/or shelter for a child, consistently ignoring his or her concerns and needs, or not providing developmentally appropriate levels of supervision. Neglect may have more devastating effects on children than other forms of maltreatment because it often remains undetected and is an ongoing pattern of parenting.5

• Emotional abuse is commonly defined as acts of commission and omission which are judged on a basis of community standards and professional expertise to be potentially damaging psychologically. Similar to neglect, emotional abuse is also difficult to define and detect. Emotional abuse does not occur in a single episode but rather is a form of repeated and sustained “mental violence”. Such behaviours as rejecting, degrading, terrorizing, isolating, corrupting/exploiting and withholding positive emotional responses are considered forms of emotional abuse.

• Witnessing family violence involves exposing children directly or indirectly to violence within their family. Children may be physically present and observe the violence or they may be in another room and able to hear the violence. Children may not see or hear anything but notice the aftermath, such as smashed furniture or bruises on the victim. The majority of children who witness family violence view the assault of one of their parents, most often their mother. Children might also witness assaults of a sibling or another family member.

The Extent of the Problem

It is difficult to know how widespread child maltreatment is in Canada. Many professionals agree that child maltreatment is vastly under-reported.6 To demonstrate, the Iceberg Model (Figure 1) illustrates the five possible levels of child maltreatment identification.

Figure 1.    Iceberg Model: Child Maltreatment Identification

Source: Trocmé, McPhee, Tam & Hay, 1994.

The Iceberg Model is useful in understanding the difficulties in obtaining accurate child maltreatment incidence rates – a large proportion of cases remains either unreported or unknown to child welfare authorities. Even if we were to examine only substantiated cases within Level 1, accurate national data are still unreliable. Definitions of maltreatment, the age of the clientele, and the method of data collection and reporting vary among provincial and territorial child welfare authorities in  Canada.

However, as a first step, Health Canada is supporting a national incidence study of child maltreatment. The study, entitled the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), will contribute to a better understanding of the extent and dynamics of child maltreatment. Operational definitions and data collection methods will be standardized in cooperation with provincial and territorial authorities. The study will generate information and knowledge to assist those who provide services to children and youth at risk of maltreatment. Researchers and practitioners have previously attempted to determine prevalence and incidence rates of child maltreatment.

Major Canadian Findings on the Extent of Child Maltreatment

• Child maltreatment or other symptoms of serious family problems affect an estimated 20% to 40% of all Canadian families.7

• On any given day, there are 45,000 to 60,000 young people in the care of child welfare authorities in Canada.8

• Recent studies predict that 1,200 new cases of physical abuse per one million population will arise each year.9

• The fatality rate from physical abuse is estimated to be between 4% and 6% and as high as 10% if an injured child is placed back in the family home a second time.10

• Data in 1991 from a sample of 16 police forces across Canada revealed 1,154 cases of child sexual abuse involving single victims and single abusers.11

• One in two females and one in three males in Canada have been victims of unwanted sexual acts, including being subjected to sexual exposure, being sexually threatened, being sexually touched, or being the victim of an attempted or completed sexual assault; 80% of these incidents occurred when the person was under 18.12

• Despite parents’ intent to shield children, nearly all incidents of family violence are seen or heard by children; approximately 70% of children also try to intervene in the violence.13

• A survey of Canadian street youth found that 43% had been physically abused and 21% had been sexually abused.14

• A study of teenage runaways found that 75% of females and 38% of males reported that they were victims of child maltreatment.15

• In 1993, an Ontario study found there were an estimated 46,683 child maltreatment investigations undertaken. Of this total, 41% were alleged to have involved physical abuse; 25% sexual abuse; 30% neglect; 10% emotional abuse and 2% other.* Following these investigations 27% were substantiated, 30% remained suspected and 42% were  unfounded.16

*Total is more than 100% because of an overlap among multiple forms of maltreatment.

Factors Influencing Maltreatment

Child maltreatment is an extremely complex social problem. Many theories have proposed explanations for its occurrence. A simplified model is depicted in Figure 2. Maltreatment can be reduced to the interaction among four broad factors: the parent or caregiver, the child, the situation and the level of support. Each factor can serve to increase or decrease the likelihood that abuse will occur.

Figure 2.    Child Maltreatment Equation

Maltreatment occurs within all family types and all segments of the population regardless of differences in religion, ethnicity, race, class or gender. However, children living in economic disadvantage are at a much higher risk for maltreatment than more privileged children.17 Poverty and unemployment, it appears, can create excessive stress on families and a climate for abuse and neglect. Impoverished families are less able to access support services during times of need. As well, families living in poverty often become involved with social service agencies for financial support and are therefore more likely to be reported to child welfare authorities. Moreover, some research indicates that potential reporters, such as hospital staff, display bias in their reporting behaviour and are more likely to report cases of suspected maltreatment in families of other racial groups or low income.18

It is generally agreed that the major factors which increase the probability of maltreatment occurring in a child’s life are the following19:

Parent/Caregiver

• history of childhood maltreatment
• alcohol and/or drug addiction
• mental illness
• limited education/parenting skills

Child

• living with a disability
• serious behavioural problems

Situation

• low socioeconomic status
• unemployment
• high-risk communities
• single-parent family

Level of Support

• lack of community support
• social isolation

* Please note that the legal definition of child maltreatment varies among Canadian jurisdictions. It is imperative that you refer to the applicable legislation in your own province or territory. [RETURN]

Consequences of Child Maltreatment*

There is a tendency for people to view the effects of maltreatment as less serious if the impact appears to be temporary and disappears in the course of a child’s development. But Browne and Finklehor (1986) make a strong argument against this perception of maltreatment.

Adult traumas such as rape are not assessed ultimately in terms of whether or not they will have an impact on old age. They are acknowledged to be painful and alarming events whether their impact lasts for one year or ten. Similarly, childhood trauma should not be dismissed because no long-term effects can be demonstrated... abuse needs to be recognized as a serious problem of childhood if only for the immediate pain, confusion and upset that can ensue (emphasis added; p. 22).

Child maltreatment is not, however, a short-term crisis in a child’s life. Although children are removed from violent homes or leave home to live on their own, the effects of experiencing abuse in their childhood follow them through life. Child maltreatment can affect all aspects of a child’s life, including the following:

• Psychological
• Physical
• Behavioural
• Academic
• Sexual
• Interpersonal
• Self-perceptual
• Spiritual
• Subsequent Violence

*For simplicity, the consequences of physical, sexual and emotional abuse, neglect and witnessing family violence will be presented together as one category.

Psychological Consequences

Child maltreatment may permanently alter the psychological well-being of a child. Following maltreatment, children are known to display the following problems:

• extreme and repetitive nightmares20

• anxiety21

• unusually high levels of anger and aggression22

• feelings of guilt and shame – for sexually abused victims this can be quite severe, especially if the victim experienced some degree of pleasure during part of the abuse23

• sudden phobias, such as a fear of darkness or  water24

• psychosomatic complaints, including stomach aches, headaches, hypochondriasis, faecal soiling, bed wetting and excessive blinking25

• general fearfulness and a specific fear of others of the same gender as the abuser26

• depressive symptoms, long bouts of sadness, social withdrawal27

• self-reported social isolation and feelings of stigmatization.28

After continued exposure to maltreatment, children may develop further psychological complications:

• significant increase in rates of psychiatric disorders29

• dissociation, intrusive thoughts, suicidal ideation and more acute phobias30

• more serious levels of anxiety, fear, depression, loneliness, anger, hostility and guilt31

• distorted cognition, such as chronic perceptions of danger and confusion, illogical thinking, inaccurate images of the world, shattered assumptions about the world and difficulty determining what is real32

• decreased effectiveness in comprehending complex roles33

• difficulty in thinking through or resolving social problems.34

Despite the growing interest in the effects of child maltreatment, few studies have examined the long-term psychological consequences in the general population. However, it is known that adolescents and adults with a history of maltreatment are over-represented in the prison population and that they tend to display more psychiatric problems in adulthood, such as Post Traumatic Stress Disorder and Major Depression.35 Additionally, such specific psychiatric disorders as Multiple Personality Disorder and Borderline Personality Disorder have been linked to child maltreatment.36

Physical Consequences

In addition to the obvious physical injuries, such as broken bones, bruises and scarring, maltreatment is also related to several additional physical complications for children, including the following:

• children who have suffered serious and chronic neglect are more likely to be smaller and lighter than non-maltreated children, which has been shown to affect long-term health37

• children who are physically abused (or shaken in the case of very young children) may suffer permanent neurological damage, dramatically affecting their future development38

• weight problems – often emerging as eating disorders39

• serious sleep disturbances and bouts of dizziness when awake40

• other stress-related symptoms, such as gastrointestinal problems, migraine headaches, difficulty breathing, hypertension, aches, pains and rashes which defy diagnosis and/or treatment41

• poor overall health.42

Behavioural Consequences

Maltreated children are known to display the following behavioural problems:

• developmental delays43

• clinging behaviour, extreme shyness and fear of strangers44

• troubled socialization with peers – constant fighting or socially undesirable behaviours, such as bullying, teasing or not sharing45

• poor school adjustment and disruptive classroom behaviour.46

There is a growing understanding among researchers that child maltreatment is associated with a host of behavioural problems that manifest themselves in adolescence:

• school-age pregnancy47

• self-destructive behaviours such as self-mutilation or burning48

• truancy and running away behaviour49

• delinquency and prostitution50

• early use of drugs/alcohol and substance abuse/dependence51

• eating disorders, such as anorexia, bulimia or obesity – primarily among female victims52

• suicide and suicide attempts.53

Evidence suggests that many of these problems continue into adulthood and become ingrained patterns of behaviour. It is believed that in order to deal with the trauma of being abused and neglected, children and youth develop such behaviours as coping strategies. And although these behaviours eventually become self-destructive, they are often extremely difficult to abandon. Additional behavioural difficulties may continue into adulthood:

• increased aggression and violence54

• homelessness55

• criminal offending – crimes which are sexual in nature are often associated with sexual abuse while violent crimes are more often linked to physical abuse56

• chronic substance abuse/dependence.57

Academic Consequences

One of the most destructive consequences of child maltreatment may be the detrimental effect on a child’s  school performance. Over and over again, research indicates that maltreated children demonstrate reduced intellectual functioning and perform very poorly in school. And poor school performance can have serious long-term consequences. Academic failure has been associated with antisocial behaviour and quitting school. These behaviours in turn increase the risk of long-term decreased productivity, long-term economic dependence and generally lower levels of satisfaction with life as adults.58 Maltreated children may display the following:

• lower overall school performance test scores and lower language, reading and math scores59

• grade repetitions, disciplinary referrals and a high number of suspensions60

• working and learning at below average levels (as reported by teachers)61

• weaker orientation to future vocational and educational goals compared to non-maltreated children.62

It is understandable that maltreated children will perform poorly in school. Not only do they face the obvious complications associated with a violent home life, but neglectful and abusive parents are less likely to provide an intellectually stimulating environment for the child, read to the child, supervise homework and generally become involved in their child’s academic life.

Sexual Consequences

In general, maltreatment adversely affects a child’s concept of sexuality, reduces his or her ability to set appropriate boundaries and often instills a fear or negative perception of sex. While the majority of sexual consequences are the result of sexual abuse, other forms of maltreatment can also be sexually destructive. For example, a neglected child may seek sexual intimacy very early in life in order to fulfil an unmet need for parental intimacy. This creates a risk for teenage pregnancy or sexually transmitted diseases. The following are the major sexual consequences of maltreatment reported in the literature:

• engaging in open or excessive masturbation, excessive sexual curiosity and frequent exposure of the genitals63

• simulated sexual acts with siblings and friends, inappropriate sexual behaviour such as breast or genital grabbing64

• premature sexual knowledge, sexualized kissing in friendships and with parents.65

In adolescence and adulthood, maltreated children continue to display sexually maladaptive behaviour:

• orgasmic disorders and painful intercourse66

• promiscuity67

• dissatisfaction with sex and negative attitudes about sex.68

These problems are often the result of introducing a sexual component into a parent-child relationship which affected the child’s sense of sexuality and intimacy. In essence, a child who has suffered sexual abuse can, as a result, have difficulty distinguishing between a sexual and a non-sexual relationship and therefore introduce a sexual element into all relationships.

Interpersonal Consequences

Child maltreatment can interfere with a person’s ability to develop meaningful and appropriate relationships from childhood through to adulthood. Abused and neglected children are consistently rated by their peers as demonstrating socially undesirable behaviour.69 Children displaying multiple psychological and behavioural problems often have a difficult time both developing and maintaining healthy relationships. Victimization reduces social competence and limits empathic ability, both of which are necessary to establish satisfying relationships with others. Maltreated children have been known to display the following interpersonal problems:

• insecure attachments to parents and caregivers70

• a loss of close friends71

• difficulty in trusting others72

• relationship problems, such as overly sexualized or overly conflicted relationships73

• chronic dissatisfaction with adult relationships and fear of intimacy.74

Self-perceptual Consequences

Parental abuse undoubtedly affects the self-esteem of a child. A lack of interest in a child or a violent attack on a child, for example, will likely lead the child to develop a sense of unworthiness. Maltreatment has been associated with distorted or extremely negative self-images starting in childhood and continuing throughout one’s life. Maltreated children typically view themselves as bad, worthless or unlovable and may develop the following problems:

• extremely low levels of self-esteem75

• feelings of being “out of control”76

• inaccurate body images which often lead to eating disorders77

• overwhelming sense of guilt or self-blame for the abuse78

• impairment of a cohesive sense of identity79

• self-disgust, self-denigration, self-hatred.80

Spiritual Consequences

Often, children who have been abused and neglected report having lost their sense of faith, not just a religious belief in a divine being, but also their faith in  themselves, other people and the world around them. It is common for maltreated children to display what some authors have called a shattered soul or soul pain.81 Moreover, adults who have experienced maltreatment display less interest and participation in organized religion. Systematic battering, sexual abuse, emotional attacks or the long-term neglect of a child is likely to destroy his or her spirit or enthusiasm for life. While often overlooked in the literature, the shattered soul may prove to be an extremely significant long-term consequence of child maltreatment.

Subsequent Violence

Victims of child maltreatment often become further victimized as adolescents and adults and/or become violent themselves toward their own children and in intimate relationships. According to studies on the intergenerational transmission of child maltreatment, one third of all victims grow up to continue a pattern of seriously inept, neglectful or abusive child rearing as parents; one third do not; and one-third remain vulnerable to the effects of child maltreatment depending upon social stressors in their life.82 Adults and adolescents who report a history of child maltreatment may demonstrate the following:

• maltreatment of their own children83

• a history of being a victim of a violent assault by a non-family member during adolescence84

• perpetrating dating violence in adolescence and/or spousal violence in adulthood85

• becoming a victim of an assaultive partner (most often a male abuser) and/or the victim of additional sexual assaults.86

Generalized Consequences

While the consequences of maltreatment were discussed collectively, one can generalize a link between certain consequences and specific forms of maltreatment (Figure 3). It can also be generalized that females tend to display more inward consequences, such as suicidal ideation, eating disorders, low self-esteem and psychological disorders, while males tend to display more outward consequences, such as increased aggression, delinquency and spousal abuse.

Figure 3.    Generalized Consequences and Forms of Maltreatment

Factors Influencing the Consequences of Maltreatment

It has been suggested that the severity of the consequences a child experiences as a result of maltreatment are related, in part, to the following factors:

• the length of the abuse
• the severity of the abuse
• the relationship of the abuser to the victim.

Therefore, long-term severe abuse perpetrated by a parent tends to produce more detrimental effects than shorter-term, less severe abuse by a stranger. But, this is not always the case. Studies have found high rates of emotional and behavioural problems in abused children when the abuse was characterized as “not serious enough” to warrant intervention by child welfare authorities.87 While maltreatment may be less severe, it is often endured over a long period of time. The chronic and pervasive nature of this form of abuse may impact a child’s development far more than the immediate visible harm. This would suggest that families experiencing less severe maltreatment still require intervention.

Family and Social Context

It is also often argued that the consequences of maltreatment are related more to the family and social context in which a child grows up than to the abuse itself. For example, research shows that a large proportion of maltreated children live in families experiencing poverty. It is thought that the poverty, rather than the maltreatment, is more of a factor in the development of an abused child’s problems. However, when controlling for such variables as maternal age, socioeconomic status and family type, a significant relationship still exists between maltreatment and serious consequences, such as aggression, school maladjustment, attempted suicide, substance abuse and delinquency.88

Resiliency

The potential consequences of child maltreatment are often overwhelming. It is remarkable that so many children are able to “recover” from chronic child abuse and neglect and maintain functional lives. This notion of child resiliency, whereby children from disturbed or violent homes sometimes rise above adversity and develop effective coping skills and strategies, is often considered in the literature.89 Introducing the term “resiliency” is not intended to minimize the suffering of children, nor justify criticism of those who are not as resilient. However, the concept can have those unfortunate effects. Furthermore, as Browne and Finklehor (1986) argue, viewing the abuse of a child in terms of future consequences can lead us to ignore the immediate pain and trauma a child experiences during the abuse. And while children may appear to be resilient, it is impossible to know the full potential of a child. Their lives may appear to be functional, but we do not see what has been lost to the abuse. We often miss the hidden effects – the silent emotional pain, the terror-filled nightmares or the sudden overwhelming fear of darkness.

Reporting Issues for Health Practitioners

While the issue of reporting is addressed in this booklet, it is also important to consult the applicable child welfare legislation within your province or territory.

The Reporting Process

To report child maltreatment in Canada, one does not need to be able to substantiate that abuse has occurred. A professional needs only to suspect maltreatment; it is the role of the child welfare authority to investigate and substantiate all reports. The process of reporting maltreatment (Figure 4) is the same within all jurisdictions in Canada.

Figure 4.    Multi-Step Process of Identification and Reporting of Child Maltreatment

In Stage 1, the health practitioner must assess and evaluate the injury, which does not need to be physical in nature; it may be psychological or emotional. The practitioner is required in Stage 2 to identify or diagnose whether maltreatment may have occurred. If maltreatment definitely did not occur, then the practitioner does not inform the child welfare authorities, but if there remains any doubt, Stage 3 requires that a child welfare authority be contacted. In Stage 4, the appropriate authority will investigate and determine if maltreatment has occurred.

Common Questions about Reporting

• If I report, am I violating the ethics of confidentiality?

Reporting child abuse almost always requires breaking confidentiality. However, the duty to report takes precedence over the duty to maintain confidentiality. Remember, it is a criminal offence not to report (except in Yukon).

• As a health practitioner, can I make an anonymous report of child maltreatment?

Yes, you can make an anonymous report of child maltreatment to the child welfare authority in your province or territory. However, the preferred mode of proceeding for most organizations and practitioners is to inform clients, before reporting, that a report will be made and then divulge your identity to the child welfare authorities. It is, however, your choice.

• Will the family be told who reported the maltreatment?

No. If you make a report and you decide to include your name and position, you can request that the information  remain strictly confidential and never be released to the family. But again, many practitioners and organizations believe in being honest and upfront with their clients.

• Will I have to go to court once I make a report?

Although you may have offered your identity during a report of maltreatment, it is extremely unlikely that you would be called in to court. Doctors and other health practitioners have given testimony in court about the nature and extent of child maltreatment injuries. But usually they have agreed to testify as a medical expert and not as the individual who has made the report.

Why Practitioners Sometimes Do Not Report

In a survey of general physicians across Canada, 90% of the respondents considered their role to be essential or important in the protection of children – yet only half of these physicians had any training regarding the complexities of child maltreatment.90 Despite mandatory reporting laws and the importance of early identification in initiating treatment, investigations of reporting behaviour reveal that a large proportion of child maltreatment cases remain unreported.91

The following are some of the major reasons professionals cite to explain their lack of reporting and responses to these concerns:

• Lack of sufficient evidence – It is not required that the health practitioner be certain that a child is the victim of maltreatment; one needs only to suspect maltreatment. To delay reporting may put a child (and other children) at further risk. It also places the professional at risk of sanctions. There is no liability for making a report as long as it is not made maliciously.

• Belief that the child or family will be harmed more than helped – While not reporting may sometimes appear to be in the best interests of a child, it is not. Yes, it does disrupt the family and it may often be rather difficult for a child to deal with such disruptions, but early detection and intervention may prove to dramatically reduce a child’s risk of severely negative long-term consequences.

• Belief that reporting constitutes an intrusion into the private family domain – For years this argument was also used to justify the lack of intervention in spousal assault. While it is true that the primary responsibility for childrearing is and will remain that of the family, parents often need support from the community. The raising of competent and healthy children is a collective responsibility. The state needs to intervene on behalf of children in order to offer support to parents and, in some cases, remove children from their homes temporarily or, in the most serious cases, permanently.

• Perception of reporting as limiting the degree to which a practitioner can exercise professional judgement when facing suspected maltreatment – This is true; mandatory reporting laws do limit professional discretion. Nonetheless, most health professionals are not as well trained in maltreatment issues as are child welfare workers. In keeping with the best interests of the child, practitioners should work in cooperation with those specifically trained in such issues to facilitate appropriate investigations and interventions.

• Belief that reporting will negatively affect the therapeutic relationship between a practitioner and his or her patient – Notwithstanding the legal and moral issues of failing to report maltreatment, research has shown that this is not the case. The establishment of a strong therapeutic alliance prior to making a report appears to be predictive of a better post-report outcome.92 Therefore, a previously strong connection between a practitioner and a patient will frequently remain intact regardless of whether a report of maltreatment is made.

Reporting suspected or confirmed cases of child maltreatment is not a decision to be taken lightly. Serious changes to the family and to the life of the maltreated child quite often occur. However, it has been demonstrated that maltreated children who have identified their abuse tend to adjust and become more functional than maltreated children who have not identified their abuse. In a study of adults, three subject groups were chosen:

Group A were maltreated as children and had identified their abuse.

Group B did not experience maltreatment as children.

Group C were maltreated as children but had not identified their abuse.

When the three groups were compared, it was found that Group B (non-abused) were the highest functioning, followed by Group A (abused and identified), while Group C (abused and not identified) demonstrated the lowest level of functioning. It appears that those who deny or minimize their abuse as a coping mechanism may experience even more detrimental personal and social adjustment problems.93

Reporting Tendencies and Biases

Research has been conducted into some of the variables that affect a person’s decision to report child maltreatment to the authorities.

• People are less likely to report maltreatment if the abuse is seen as partially caused by a child’s misbehaviour.94 Subjects in one study were given two sets of vignettes and asked to rate the seriousness of each incident. In the first vignette, a young boy was beaten  because he left his bike in the driveway. The parent drove over the bike and then hit the child in the face, knocking him down and splitting his lip. In the second vignette, a trash can was left in the driveway by an unknown individual and the parent responded in the same way. Consistently, the second vignette was rated as much more abusive and serious than the first. However, regardless of the rationalization for physical abuse, it is never warranted. This bias should not influence a practitioner’s decision to report a case of maltreatment.

• Reporting behaviour is related to the age and gender of both the abuser and the victim. One research study found that cases of physical abuse and neglect involving younger children and younger parents were more likely to be reported by hospitals than cases involving older children.95 In another series of vignettes, subjects rated the abuse of a boy as more severe than identical vignettes involving a girl.96 In the same study, vignettes involving physical abuse by fathers were rated as significantly more abusive than those involving abuse by mothers.

• Ethnicity and socioeconomic status have been found to affect reporting behaviour. Examinations of hospital reporting indicate that families of other racial origin and lower income families have a higher probability of being reported for abuse than Canadian-born families and families with incomes over $25,000.97

In addition, specific characteristics of a practitioner can affect reporting behaviour, such as the following:

• gender
• views on child discipline
• parental status
• personal history of maltreatment
• place of employment.98

To counter these prejudices, health practitioners must attempt to identify their own personal biases. As well, imagining a difference in the presenting situation, such as changing the age, gender or socioeconomic background of the victim, in order to re-examine the case, may prove helpful.

Some Common Signs of Maltreatment

Common signs that may help health practitioners detect that an incident of child maltreatment has occurred have been identified:

• a parent or caregiver attributing an injury or accident to a child’s sibling

• a delay in bringing a child in for medical attention

• explanations for injuries that do not match the  developmental capabilities of the child

• injuries that are clearly older than claimed

• lack of explanation for an injury

• inconsistency between the severity of the injury and the explanation offered

• injuries in uncommon areas of the body for children

• extreme diaper rash and/or scars from old sores

• bald spot on the back of an infant’s head.

Conclusion

While research does link maltreatment with a myriad of detrimental outcomes for children, longitudinal research is still needed to truly improve our understanding. There is a clear absence of data that outlines development from infancy to adulthood in maltreated children. While maltreatment needs to be understood as an extremely serious social problem simply for the immediate impact it has on children, findings of longitudinal research will be important in improving the identification and treatment of maltreatment victims.

Children who have been maltreated tend to fare much worse in life than those who have not. It is that simple. Exposing a child to maltreatment will greatly reduce his or her chances of becoming a healthy, competent and happy individual. In order for children to achieve developmental milestones, they need to develop countless skills and aptitudes, such as the following:

• the capacity for trust and empathy with others

• the capacity for impulse control

• the ability to focus attention

• an internalized sense of values

• the ability to control aggression

• the ability to accept reasonable adult authority

• a sense of membership in society and an identification with its value system

• a sense of hope and confidence about the future.99

Child maltreatment makes the attainment of these attributes extremely difficult, if not impossible. Early identification and reporting of cases of maltreatment will offer an abused or neglected child the chance to overcome many of the otherwise likely consequences of maltreatment. This will take a community effort and an ongoing commitment by health practitioners to help strengthen Canadian families and foster children’s optimal development.

Notes

1.    Fedoroycz (1997).

2.    Statistics Canada, CANSIM, Matrix 6367.

3.    Newson & Newson (1990); Straus (1991);  Simons, Johnson & Conger (1995).

4.    Durrant & Rose-Krasnor (1995).

5.    Gauthier, Stollak, Messé & Aronoff (1996).

6.    Trocmé, McPhee, Tamm & Hay (1994);  Warner & Hansen (1994); Gracia (1995); Begin (1996).

7.    Webber (1993).

8.    National Crime Prevention Council (1997).

9.    Manitoba Family Services (1993).

10.    Manitoba Family Services (1993).

11.    Biesenthal & Clement (1992).

12.    Badgley (1984).

13.    Yawney (1996).

14.    National Crime Prevention Council (1997).

15.    Janus, McCormack, Wolbert Burgess & Hartman (1987).

16.    Trocmé, McPhee, Tamm & Hay (1994).

17.    Armitage (1993); Pelton (1994); Fergusson & Lynskey (1997).

18.    Hampton & Newberger (1985).

19.    Howing, Wodarski, Kurtz & Gaudin (1993); Meston (1993); Standing Committee on Social Development (1994); Manion & Wilson (1995); Fergusson & Lynskey (1997).

20.    Oates (1996).

21.    Oates (1996).

22.    Loos & Alexander (1997).

23.    Oates (1996).

24.    Gilmartin (1994).

25.    Oates (1996).

26.    Gilmartin (1994).

27.    Mian, Marton & LeBaron (1996).

28.    Varia, Abidin & Dass (1996).

29.    Fergusson & Lynskey (1997).

30.    Gilmartin (1994).

31.    Oates (1996).

32.    Gilmartin (1994).

33.    Varia, Abidin & Dass (1996).

34.    Yawney (1996).

35.    Dutton & Hart (1992); Silverman, Reinherz & Giaconia (1996).

36.    Briere (1989); Stone (1990); Rivera (1991).

37.    Yawney (1996).

38.    Meston (1993).

39.    Gilmartin (1994).

40.    Gilmartin (1994).

41.    Gilmartin (1994).

42.    Yawney (1996).

43.    Yawney (1996).

44.    Oates (1996).

45.    Feldman, Salzinger, Rosario, Alvarado, Caraballo & Hammer (1995).

46.    de Paúl & Arruabarrena (1995).

47.    Smith (1996).

48.    Oates (1996).

49.    Kurtz, Gaudin, Wodarski & Howing (1993);  Manion & Wilson (1995).

50.    Manion & Wilson (1995).

51.    Malinosky-Rummell & Hansen (1993); Chandy, Blum & Resnick (1996).

52.    Chandy, Blum & Resnick (1996).

53.    Fergusson & Lynskey (1997).

54.    Loos & Alexander (1997).

55.    Gilmartin (1994).

56.    Oates (1996); Fergusson & Lynskey (1997).

57.    Downs, Smyth & Miller (1996).

58.    Steinhauer (1996).

59.    Kurtz, Gaudin, Wodarski & Howing (1993); Oates (1996).

60.    Kendall-Tacket & Eckenrode (1996).

61.    Kurtz, Gaudin, Wodarski & Howing (1993).

62.    Malinosky-Rummell & Hansen (1993).

63.    Friedrich & Luecke (1988).

64.    Mian, Marton & LeBaron (1996).

65.    Oates (1996).

66.    Gilmartin (1993).

67.    Gilmartin (1993).

68.    Gilmartin (1993).

69.    Feldman, Salinger, Rosario, Alvarado, Caraballo & Hammer (1995).

70.    Cicchetti & Toth (1995).

71.    Oates (1996).

72.    Varia, Abidin & Dass (1996).

73.    Gilmartin (1993); Varia, Abidin & Dass (1996); Loos & Alexander (1997).

74.    Gilmartin (1993); Singer (1989).

75.    Varia, Abidin & Dass (1996); Loos & Alexander (1997).

76.    Gilmartin (1993).

77.    Gilmartin (1993).

78.    Oates (1996).

79.    Varia, Abidin & Dass (1996).

80.    Gilmartin (1993).

81.    Miller (1984); Steele (1987); Shengold (1989).

82.    Oliver (1993).

83.    Oliver (1993).

84.    Fergusson & Lynskey (1997).

85.    Malinosky-Rummell & Hansen (1993); Downs, Smyth & Miller (1996).

86.    Gilmartin (1993).

87.    Gracia (1995).

88.    Howing, Wodarski, Kurtz & Gaudin (1993); Fergusson & Lynskey (1997).

89.    Middleton-Moz (1992); Wolin & Wolin (1993); Sundelin Wahlsten (1994).

90.    Hendry (1997).

91.    Warner & Hansen (1994); Beck & Olgoff (1995); Kennel & Agresti (1995).

92.    Steinberg, Levine & Doueck (1997).

93.    Varia, Abidin & Dass (1996).

94.    Dukes & Kean (1989).

95.    Hampton & Newberger (1985).

96.    Howe, Herzberger & Tennen (1988).

97.    Hampton & Newberger (1985).

98.    Warner & Hansen (1994).

99.    Steinhauer (1996).

Bibliography

American Psychological Association. (1995). Twenty-four questions (and answers) about professional practice in the area of child abuse. Professional Psychology: Research and Practice, 26, 377-385.

Armitage, A. (1993). The policy and legislative context. In Wharf, B. (Ed.), Rethinking Child Welfare. Toronto: McClelland and Stewart, Inc.

Badgley, R. (1984). Sexual offenses against children and youth. Ottawa: Supply and Services Canada.

Bass, E., & Davis, L. (1988). The courage to heal: A guide for women survivors of child sexual abuse. New York: Harper.

Beck, K. A., & Olgoff, J. R. P. (1995). Child abuse reporting in British Columbia: Psychologists’ knowledge of and compliance with the reporting law. Professional Psychology: Research and Practice, 26, 245-251.

Begin, P. (1996). Child Abuse. Ottawa: Political and Social Affairs Division, Research Branch, Library of Parliament.

Biesenthal, L., & Clement, J. (1992). Canadian statistics on child sexual abuse. Ottawa: Research and Statistics Directorate, Corporate Management, Policy and Programs Sector, Department of Justice.

Briere, J. (1989) Therapy for adults molested as children: Beyond survival. New York: Springer.

Brodeur, A. E., & Monteleone, J. A. (1994). Child maltreatment: A clinical guide and reference. St. Louis: GW Medical Publishing Inc.

Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Ottawa: Minister of Supply and Services. (Reprinted from Psychological Bulletin, 99, 66-77).

Cicchetti, D., & Toth, S. L. (1995). A developmental psychopathology perspective on child abuse and neglect. Journal of American Academy of Child and Adolescent  Psychiatry, 34, 541-565.

Chandy, J. M., Blum, R. Wm., & Resnick, M. D. (1996). Gender-specific out- comes for sexually abused adolescents. Child Abuse & Neglect, 20, 1219-1231.

Crittenden, P. (1988). Family and dyadic patterns of functioning in maltreating families. In Browne, K., Davis, C., & Stratton, P. (Eds.), Early prediction and prevention of child abuse. New York: John Wiley and Sons.

Department of Multiculturalism and Citizenship, Human Rights Directorate. (1991). Convention on the Rights of the Child. Ottawa: Supply and Services Canada.

de Paúl, J., & Arruabarrena, M. I. (1995). Behaviour problems in school-aged physically abused and neglected children in Spain. Child Abuse & Neglect, 19, 409-418.

Dinsmore, C. (1991). From surviving to thriving: Incest, feminism, and recovery. New York: State University of New York.

Downs, W. R., Smyth, N. J., & Miller, B. A. (1996). The relationship between childhood violence and alcohol problems among men who batter: An empirical review and synthesis. Aggression and Violent Behaviour, 1, 327-344.

Dukes, R. L., & Kean, R. B. (1989). An experimental study of gender and situation in the perception and reporting of child abuse. Child Abuse & Neglect, 13, 351-360.

Durrant, J. E., & Rose-Krasnor, L. (1995). Spanking: Should I or Shouldn’t I. Winnipeg: Department of Family Studies, University of Manitoba.

Dutton, D. G., & Hart, S. D. (1992). Evidence of long-term, specific effects of childhood abuse on criminal behaviour in men. International Journal of Offender Therapy and Comparative Criminology, 36, 129-137.

Federal Provincial Working Group on Child and Family Services Information. (1994). Child Welfare in Canada: The Role of Provincial and Territorial Authorities in Cases of Child Abuse. Ottawa: Supply and Services Canada.

Fedorowycz, O. (1997). Homicide in Canada – 1996. Juristat, 17. Canadian Centre for Justice Statistics, Statistics Canada.

Feldman, R. S., Salzinger, S., Rosario, M., Alvarado, L., Caraballo L., & Hammer, M. (1995). Parent, teacher, and peer ratings of physically abused and nonmaltreated children’s behaviour. Journal of Abnormal Psychology, 23, 317-334.

Fergusson, D. M., & Lynskey, M. T. (1997). Physical  punishment/maltreatment during childhood and adjustment in young adulthood.  Child Abuse & Neglect, 21, 617-630.

Friedrich, W. N., & Luecke, W. J. (1988). Young school-age sexually aggressive children. Professional Psychology: Research and Practice, 19, 155-164.

Garbino, J., Guttman, E., & Seeley, J. W. (1986). The psychologically battered child. California: Jossey-Bass.

Gauthier, L., Stollak, G., Messé, L., & Aronoff, J. (1996). Recall of childhood neglect and physical abuse as differential predictors of current psychological functioning. Child Abuse & Neglect, 20, 549-559.

Gilmartin, P. (1994). Rape, incest, and child sexual abuse: Consequences and recovery. New York: Garland Publishing Inc.

Gove, T. J. (1995). Report of the Gove Inquiry into child protection in British Columbia. British Columbia: Gove Inquiry into Child Protection.

Gracia, E. (1995). Visible but unreported: A case for the “not serious enough” cases of child maltreatment. Child Abuse & Neglect, 19, 1083-1093.

Hampton, R. L., & Newberger, E. (1985). Child abuse incidence and reporting by hospitals: Significance of severity, class and race. American Journal of Public Health, 75, 56-68.

Hendry, E. (1997). Engaging general practitioners in child protection training. Child Abuse Review, 6, 60-64.

Howe, A. C., Herzberger, S., & Tennen, H. (1988). The influence of personal history of abuse and gender on clinician’s judgements of child abuse. Journal of Family Violence, 3, 105-119.

Howing, P. T., Wodarski, J. S., Kurtz, P. D., & Gaudin, Jr., J. M. (1993). Maltreatment and the school-aged child: Developmental outcomes and system issues. New York: The Haworth Press.

Janus, M. D., McCormack, A., Wolbert Burgess, A., & Hartman, C. (1987). Adolescent runaways: Causes and consequences. Toronto: D.C. Heath and Co.

Kendall-Tacket, K. A., & Eckenrode, J. (1996). The effects of neglect on academic achievement and disciplinary problems: A developmental perspective. Child Abuse & Neglect, 20, 161-169.

Kennel, R. G., & Agresti, A. A. (1995). Effects of gender  and age on psychologists’ reporting of child sexual abuse. Professional Psychology: Research and Practice, 26, 612-615.

Kurtz, P. D., Gaudin, Jr., J. M., Wodarski, J. S., & Howing, P. T. (1993). Maltreatment and the school-aged child: School performance consequences. Child Abuse & Neglect, 17, 581-589.

Loos, M. E., & Alexander, P. C. (1997). Differential effects associated with self-reported histories of abuse and neglect in a college sample. Journal of Interpersonal Violence, 12, 340-360.

Ludwig, S., & Kornberg, A. E. (1992). Child abuse: A medical reference. New York: Churchill Livingstone.

Malinosky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114, 68-79.

Manion, I. G., & Wilson, S. K. (1995). An Examination of the Association Between Histories of Maltreatment and Adolescent Risk Behaviours. Ottawa: Supply and Services Canada.

Manitoba Family Services. (1993). Child protection and child abuse: A handbook for nurses. Winnipeg: Author.

Mathews, F. (1996). The Invisible Boy: Revisioning the Victimization of Male Children and Teens. Ottawa: National Clearinghouse on Family Violence, Health Canada.

Meston, J. (1993). Child abuse prevention programs. Ottawa: Vanier Institute of the Family.

Mian, M., Marton, P., & LeBaron, D. (1996). The effects of sexual abuse on 3- to 5-year-old girls. Child Abuse & Neglect, 20, 731-745.

Middleton-Moz, J. (1992). Will to survive: Affirming the positive power of the human spirit. Florida: Health Communications, Inc.

Miller, A. (1984). Thou shall not be aware: Society’s betrayal of the child. New York: Meridian.

National Crime Prevention Council. (1997). Young people say: Report from the Youth Consultation Initiative. Ottawa: Author.

Newson, J., & Newson, E. (1990). The extent of physical punishment in the U.K. London: Approach.

Oates, R. K. (1996). The spectrum of child abuse: Assessment, treatment, and prevention. New York:  Brunner/Mazel, Inc.

Oliver, J. E. (1993). Intergenerational transmission of child abuse: Rates, research, and clinical implications. American Journal of Psychiatry, 150, 1315-1325.

Pelton, L. H. (1994). Is poverty a key contributor to child maltreatment: Yes. In Gambril, E., & Stein, E. (Eds.), Controversial Issues in Child Welfare. Massachusetts: Allyn & Bacon.

Reese, R. M. (1994). Child abuse: Medical diagnosis and management. Pennsylvania: Lea & Febiger.

Rivera, M. (1991). Multiple Personality: An outcome of child abuse. Toronto: Education/Dissociation.

Shengold, L. (1989). Soul murder: The effects of childhood abuse and deprivation. New Haven: Yale University.

Silverman, A. B., Reinherz, H. Z., & Giaconia, R. M. (1996). The long-term sequelae of child and adolescent abuse: A longitudinal community study. Child Abuse & Neglect, 20, 709-723.

Simons, R. L., Johnson, C., & Conger, R. D. (1995). Harsh corporal punishment versus quality of parental involvement as an explanation of adolescent maladjustment. Journal of Marriage and the Family, 56, 591-607.

Singer, K. I. (1989). Group work with men who experienced incest in childhood. American Journal of Orthopsychiatry, 59, 468-472.

Smith, C. (1996). The link between childhood maltreatment and teenage pregnancy. Social Work Research, 20, 131-141.

Standing Committee on Social Development. (1994). Children at risk. Toronto: Ontario Legislative Assembly.

Steele, K. (1987). Sitting with shattered soul. Pilgrimage: Journal of Exploration & Psychotherapy, 15, 19-25.

Steinberg, K. L., Levine, M., & Doueck, H. J. (1997). Effects of legally mandated child-abuse reports on the therapeutic relationship: A survey of psychotherapists. American Journal of Orthopsychiatry, 67, 112-122.

Steinhauer, P. D. (1996). The primary needs of children: A blueprint for effective health promotion at the community level. Ottawa: Caledon Institute of Social Policy.

Stone, M. H. (1990). Incest in the borderline patient. In Kluft, R. P. (Ed.), Incest-related syndrome in adult psychopathology. Washington, DC: American Psychiatric  Association.

Strauss, M. A. (1991). Discipline and deviance: Physical punishment of children and violence and other crime in adulthood. Social Problems, 38, 133-154.

Sundelin Wahlsten, V. (1994). Development and survival: A study of children at risk living in adverse psychological milieu. Child Abuse & Neglect, 18, 715-723.

Trocmé, N., McPhee, D., Tam, K. K., & Hay, T. (1994). Ontario incidence study of reported child abuse & neglect. Toronto: The Institute for the Prevention of Child Abuse.

Varia, R., Abidin, R. R., & Dass, P. (1996). Perceptions of abuse: Effects on adult psychological and social adjustment. Child Abuse & Neglect, 20, 511-526.

Warner, J. E., & Hansen, D. J. (1994). The identification and reporting of physical abuse by physicians: A review and implications for research. Child Abuse & Neglect, 18, 11-25.

Webber, M. (1991). Street kids: The tragedy of Canada’s runaways. Toronto: University of Toronto Press.

Wolin, S., & Wolin, S. (1993). The resilient self: How survivors of troubled families rise above adversity. New York: Villiard Books (Random House).

Yawney, D. (1996). Resiliency: A strategy for survival of childhood trauma. In Russell, M., Hightower, J., Gutman, G. (Eds.), Stopping the violence: Changing families, changing futures. Canada: Benwell Atkins Limited.

Appendix A: Additional Resources

Organizations

	Canadian Foster Family Association
	Canadian Institute of Child Health
	Child Welfare League of Canada
	Institute for the Prevention of Child Abuse
	Vanier Institute of the Family

Child Welfare Contacts

	Newfoundland Department of Social Services		Manitoba Department of Family Services
	Prince Edward Island Department of Health and Social Services		Saskatchewan Department of Social Services
	Nova Scotia Department of Community Services		Alberta Department of Family and Social Services
	New Brunswick Department of Health and Community Services		British Columbia Ministry of Social Services
	Quebec Ministère de la Santé et des Services sociaux		Yukon Department of Health and Social Services
	Ontario Ministry of Community and Social Services		Northwest Territories Department of Social Services

Medical Reference Books

	Child maltreatment: A clinical guide and reference. Brodeur & Monteleone. (1994)
	Child abuse: A medical reference. Ludwig & Kornberg. (1992)
	Child abuse: Medical diagnosis and management. R.M. Reese. (1994)

Other Booklets Available from the National Clearinghouse on Family Violence

	Family Violence: Clinical Guidelines for Nurses, Canadian Nurses Association. (1992)
	Child Abuse: Awareness Information for People in the Workplace. F. MacLeod. (1995)
	Violence Issues: An Interdisciplinary Curriculum Guide for Health Professionals, L.A. Hoff. (1994)
	Family Violence Handbook for the Dental Community, Denham  & Gillepsie. (1994)