Child clinical intervention: models and approaches

Child Clinical Intervention

Part I Child Abuse

Physical abuse of children occurs throughout every social strata, although there may be an increased incidence among those living in poverty. Abuse often occurs at moments of great stress, and the perpetrator strikes out in anger at the child. The perpetrator may also have been abused as a child and may have poor impulse control. Because of the relative size and strength difference between adults and children, the abused child can be severely injured or killed. Abuse frequently occurs from shaking an infant, which causes bleeding over the brain (subdural hematoma) and is often referred to as 'shaken baby syndrome'. The incidence of child abuse is remarkably high and fairly accurately reported. The total abuse rate is 25.2 per 1000 children with physical abuse counting for 5.7 per 1000, sexual abuse 2.5 per 1000, emotional abuse 3.4 per 1000 and neglect accounting for the vast majority 15.9 per 1000 children. Risk factors include poverty, lack of education, single parenthood, alcohol or drug abuse and a host of other factors. However, child abuse occurs in all strata of society."

As is abundantly clear, from the above quote issued by the National Institute of Health child abuse is serious business. Children are one of the most vulnerable members of society. In addition, given their general impressionable nature, the abused can eventually become the abuser. This source of this vicious circle has to be controlled and eliminated.

Part I of this paper will deal with the three most common kinds of child abuse - physical, sexual and emotional. I will list out clinical issues, behavioral issues, symptoms, signs and tests for these specific kinds of child abuse.

Perpetrators:

More than 80% of victims (84%) were abused by a parent or parents. Mothers acting alone were responsible for 47% of neglect victims and 32% of physical abuse victims. Non-relatives, fathers acting alone, and other relatives were responsible for 29%, 22% and 19%, respectively, of sexual abuse victims."

This is one of the most worrying aspects of child abuse. If child abuse were primarily committed by unknown third parties, we could have taken extreme measures to supervise children. However, since parents and relatives constitute the largest percentage of abusers, we get into a 'who will guard the guardians.' Parents are naturally assumed to be the ones most interested in the welfare of their children. When they abuse their own children, the problem can be quite tough to deal with.

And before, we begin looking at the individual kinds of child abuse, here is a sobering thought:

Child fatalities are the most tragic consequence of maltreatment. Approximately 1,200 children died of abuse or neglect in the year 2000-a rate of 1.71 children per 100,000 children in the population. The increase in the rate of fatalities compared to earlier years is hypothesized to be largely attributable to improved reporting.

Youngest children were the most vulnerable. Children younger than one-year-old accounted for 44% of child fatalities and 85% of child fatalities were younger than 6 years of age."

When so many children out there are abused to a point that they die, we have to sit up and pay attention. Child abuse is not just another social problem. It is an issue that attacks the core of decency and social behavior. And given it feeds on itself to an extent makes it all the more dangerous. This part of the paper will attempt to inform the reader of the some of the major issues related with child abuse. After all, awareness is the first step for improving a bad situation.

Child Physical Abuse

Physical abuse, which is 19% of all substantiated cases of child abuse, is the most visible form of abuse and may be defined as any act which results in a non-accidental trauma or physical injury. Inflicted physical injury most often represents unreasonable, severe corporal punishment or unjustifiable punishment. This usually happens when a frustrated or angry parent strikes, shakes or throws a child. Physical abuse injuries result from punching, beating, kicking, biting, burning or otherwise harming a child. While any of these injuries can occur accidentally when a child is at play, physical abuse should be suspected if the explanations do not fit the injury or if a pattern of frequency is apparent. The longer the abuse continues, the more serious the injuries to the child and the more difficult it is to eliminate the abusive behavior."

It is easy for mass media to paint a picture of a physical child abuser as a 'monster', but that does not seem to be helping. Given the size and strength differential between the abuser and the child, some serious damage can be caused. What complicates this situation is that children are naturally prone to injuries and often do not raise suspicion when injured. Additionally, the child may not know that he/she is being abused and hence may choose to not talk about it. What is worse that in many cases, the child may be led to believe that this physical abuse is the child's fault. This leads to physical abuse, compounded by emotional abuse.

Indicators: There are several physical indicators of physical child abuse. None of these is deterministic. Depending on the explanation and frequency of occurrence, these could indicate abuse.

Physical Indicators of Physical Child Abuse:

bite marks unusual bruises lacerations burns high incidence of accidents or frequent injuries fractures in unusual places injuries, swellings to face and extremities discoloration of skin"

Damage done by physical child abuse does not stop at physical indicators. Given the mental make up of children, physical abuse can change the way they think and approach life. This could lead to altered behavior. Hence, in addition to physical indicators, one has to carefully watch out for behavior indicators of physical child abuse.

Behavioral Indicators in Child avoids physical contact with others apprehensive when other children cry wears clothing to purposely conceal injury, i.e. long sleeves refuses to undress for gym or for required physical exams at school gives inconsistent versions about occurrence of injuries, burns, etc.

A seems frightened by parents often late or absent from school comes early to school, seems reluctant to go home afterwards has difficulty getting along with others, little respect for others overly compliant, withdrawn, gives in readily and allows others to do for him/her without protest plays aggressively, often hurting peers complains of pain upon movement or contact has a history of running away from home reports abuse by parents"

As any parent would report, a lot of behavioral characteristics mentioned above exist in their children to varying degrees. These might be natural and often not a cause of worry. And this is exactly the reason detecting physical child abuse is not easy.

Clinical Issues: At a clinic, several symptoms can indicate physical child abuse. Some of these would require a doctor or a qualified practitioner to make a finding. Here is a list

Symptoms appearance at an emergency room with an injured child and an improbable explanation delayed appearance at an emergency room with an injured child bruise marks shaped like hands, fingers, or objects (belt) specific patterns of scalding seen when a conscious child is immersed in hot water burns from an electric stove, radiator, heater or other hot objects on the child's hands or buttocks cigarette burns on exposed areas or the genitals black eyes in an infant human bite marks lash marks choke marks around neck circular marks around wrists or ankles (twisting) sutures - separated bulging soft spot (fontanel) on the infants head unexplained unconsciousness in infant"

Additionally, there are tests that can be run to understand the nature and extent of the physical damage. These tests will not indicate whether abuse or accident has occurred, but they can provide clues and also be used to decide on a line of treatment and therapy.

Physical examination may show other injuries, such as:

multiple retinal hemorrhages (bleeding in the back of the eye) internal damage such as bleeding or rupture of an organ from blunt trauma any fracture in an infant that is too young to walk or crawl evidence of epiphyseal fractures (often multiple) of long bones or spiral type fractures that result from twisting fractured ribs evidence of skull fracture(s) (occasionally multiple fractures of different ages may be present) subdural hematoma (collection of blood in the brain) without plausible explanation"

Child Sexual Abuse: Abusive nature does not occur in isolation. Often a sexual abuser could also be a physical abuser. But specifically in the case of sexual child abuse, there are two important things to keep in mind:

1) Even a grown up might see some behavior of the offender, mere as 'affectionate'.

2) Sexual child abuse is far more prevalent in the case of the female child.

The sexual development and perspective of a child is very much underdeveloped compared to that of an adult. As a result, the child may not know how to deal with sexual abuse. This makes it tougher for the grown up to detect sexual child abuse cases. Nonetheless, the behavioral changes of sexually abused children might provide an indicator.

Behavioral Warning Signs A Child May Have Been Abused

Any one sign doesn't mean the child was abused, but several of them mean that you should begin asking questions

Nightmares, trouble sleeping, fear of the dark, or other sleeping problems.

Extreme fear of 'monsters'.

Spacing out at odd times.

Loss of appetite, or trouble eating or swallowing.

Sudden mood swings: rage, fear, anger, or withdrawal.

Fear of certain people or places (e.g., a child may not want to be left alone with a baby-sitter, a friend, a relative, or some other child or adult; or a child who is usually talkative and cheery may become quiet and distant when around a certain person).

Stomach illness all of the time with no identifiable reason.

An older child behaving like a younger child, such as bed-wetting or thumb sucking.

Sexual activities with toys or other children, such as simulating sex with dolls or asking other children/siblings to behave sexually.

New words for private body parts.

Refusing to talk about a 'secret' he/she has with an adult or older child.

Talking about a new older friend.

Suddenly having money.

Cutting or burning herself or himself as an adolescent."

Child Emotional Abuse

Emotional abuse, which is 8% of all substantiated cases of child abuse, is commonly defined as the systematic tearing down of another human being

Emotional abuse is probably the least understood of all child abuse, yet it is the most prevalent, and can be the cruelest and most destructive of all types of abuse

An infant who is being severely deprived of basic emotional nurturing, even though physically well cared for, can fail to thrive and can eventually die." child is a bundle of joy for many. But a child is not a toy to be played and used at will. One has to appreciate that the child is a small human being. And like all human beings, the child has emotional needs. The emotional makeup of a child might not have developed enough to withstand harsh treatment. Harshness or callousness when dealing with a child can cause scars for life.

Emotional abuse is a pattern of behavior that attacks a child's emotional development and sense of self-worth. Emotional abuse includes excessive, aggressive or unreasonable demands that place expectations on a child beyond his or her capacity. Constant criticizing, belittling, insulting, rejecting and teasing are some of the forms these verbal attacks can take. Emotional abuse also includes failure to provide the psychological nurturing necessary for a child's psychological growth and development -- providing no love, support or guidance."

The problem in identifying and dealing with emotional abuse is that at lower levels of intensity, the occurrence of abuse is debatable. For instance mild levels of belittling could be seen as 'kidding'. Another example could be that of criticizing and insulting. Depending on the issue that leads to such abuse, the grown up could actually be convinced that they are doing this to the child for 'his own good'. These mild forms of abusive behavior could actually be seen as 'nurturing'.

Where does nurturing stop and abusing begin is sometimes a grey area. Also, if victims are repeatedly made to believe that this emotional abuse is for their own good, they might actually buy into that logic. This would cause them to inflict similar abuse when they get the chance.

All this is not to say that emotional abuse is always a result of good intentions. There is definitely opportunity for malicious emotional child abuse too. There are several observable and behavioral indicators that a child has been subjected to emotional abuse.

Observable Indicators child rocks, sucks, bites self inappropriately aggressive, destructive to others suffers from sleep, speech disorders restricts play activities or experiences demonstrates compulsions, obsessions, phobias, hysterical outbursts

Behavioral Indicators negative statements about self shy, passive, compliant lags in physical, mental and emotional development self-destructive behavior highly aggressive cruel to others overly demanding"

Common kinds of emotional abuse are:

1) Rebuffing: Making a child feel worthless, blaming him when he/she is not at fault, being incommunicado with the child.

2) Ignoring: Not bonding with the child, rejecting or overlooking affectionate advances of the child, being away from the child for prolonged periods.

3) Scaring: Threatening a child with physical pain, death or desertion, exposing the child to a high degree of fear related to the supernatural.

4) Isolation: Locking up a child, keeping away from other children, disallowing participative activities.

5) Debasing: Exposing a child to pornography, alcohol, and drugs, encouraging criminal or cruel behavior.

Mandated Child Abuse Reporting Laws

The Child Abuse and Neglect Prevention and Treatment Act, as amended, requires States to make provision for the reporting of known or suspected instances of child abuse and neglect (42 U.S.C. 5106a).

Think about it. If a child has the flu, it is naturally understood that parents and family would take the initiative in doing something about it. But when parents and family are the largest category of offenders in cases of abuse, we clearly need to have other eyes and ears to detect abuse. As a result, the law makes it mandatory to report abuse in many cases.

Every State and the District of Columbia have statutes identifying mandatory reporters of child maltreatment, and under what circumstances they are to report. A mandatory reporter is a person who is required by law to make a report. Any person, however, may report incidents of abuse or neglect. Today, reporting laws embrace all professionals working with children. Individuals typically designated as mandatory reporters include:

Physicians, nurses, hospital personnel, dentists;

Medical examiners;

Coroners;

Mental health professionals and social workers;

School personnel;

Law enforcement officials; and Child care providers.

In approximately 18 States, any person who suspects child abuse or neglect is required to report."

Every state has its own statute regarding mandatory child abuse. Here is one from Florida:

Fla.Stat.Ann. 39.201(1) (West, WESTLAW through End of 2001 1st Reg.Sess.)

WHO MUST REPORT

Any person;

Physicians, osteopathic physicians, medical examiners, chiropractic physicians, nurses, or hospital personnel engaged in the admission, examination, care, or treatment of persons;

Other health or mental health professionals;

Practitioners who rely solely on spiritual means for healing;

School teachers or other school officials or personnel;

Social workers; day care center workers; or other professional child care, foster care, residential, or institutional workers;

Law enforcement officers; or judges.

CIRCUMSTANCES

When they know, or have reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child's welfare.

PRIVILEGED COMMUNICATION

Fla.Stat.Ann. 39.204 (West, WESTLAW through End of 2001 1st Reg.Sess.)

The privileged quality of communications between husband and wife and between any professional person and his or her patient or client, or any other privileged communications except that between attorney and client or the privilege provided by 90.505 [providing for the confidentiality of communications made to a clergy member for the purpose of spiritual counsel], as such communication relates both to the competency of the witness and to the exclusion of confidential communications, shall not apply to any communication involving the perpetrator or alleged perpetrator in any situation involving known or suspected child abuse, abandonment or neglect, and shall not constitute grounds for failure to report as required by the reporting laws regardless of the source of information requiring the report, failure to cooperate with the Department, or failure to give evidence in any judicial proceeding relating to child abuse, abandonment, or neglect."

Part II Child Disorders

Introduction: There are several disorders in children that are not easy to detect and cure. In addition many of them do not really have any known causes. In this part of the paper, we will look at three such disorders:

1) Autism

2) Attention Deficit Disorder / Attention Deficit and Hyperactivity Disorder

3) Down Syndrome

Autism

Autism was much misunderstood until recently. Originally, people regarded an autistic child as a 'crazy' child, or less frivolously a 'mentally retarded' child. Even with the recognition of autism treatment and cure were elusive. But, we have progressed considerably since then. Today treatment and therapy has considerably improved the lot of the autistic. There are now special schools that are equipped to take care of and nurture autistic children. Here is how a U.S. government site, the Autism Information Center, describes Autism.

Autism spectrum disorders (ASDs) are a group of developmental disabilities that are caused by an abnormality in the brain. People with ASDs tend to have problems with social and communication skills. They also are likely to repeat certain behaviors and to not want change in their daily activities. Many people with ASDs also have unusual ways of learning, paying attention, or reacting to different sensations. ASDs begin during childhood and last throughout a person's life."

One of the important characteristics of Autism is that it is very rare. Further, children begin with a low level of speech, motor and emotional development. Hence, parents do not necessarily have a good benchmark of what to expect. Infant autism might hence go totally undetected.

Autism is found in every country and region of the world, and in families of all racial, ethnic, religious, and economic backgrounds. Emerging in childhood, it affects about 1 or 2 people in every thousand and is three to four times more common in boys than girls."

Diagnosis:

To date, there are no medical tests like x-rays or blood tests that detect autism. And no two children with the disorder behave the same way. In addition, several conditions can cause symptoms that resemble those of autism. So parents and the child's pediatrician need to rule out other disorders, including hearing loss, speech problems, mental retardation, and neurological problems

Autism specialists use a variety of methods to identify the disorder. Using a standardized rating scale, the specialist closely observes and evaluates the child's language and social behavior. A structured interview is also used to elicit information from parents about the child's behavior and early development. Reviewing family videotapes, photos, and baby albums may help parents recall when each behavior first occurred and when the child reached certain developmental milestones. The specialists may also test for certain genetic and neurological problems."

As the above clearly shows, diagnosis is tough even for autism specialists. These specialists used statistical measures of expected development in a child to figure out autism. However, no such data is intuitively available to the parent. A paranoid parent may worry about autism at every minor deviation from the 'normal'. While another parents might continue to overlook symptoms of autism, because 'all children are different'.

Treatment / Cure: To begin with, it is important to be patient and understanding with an autistic child. The world of an autistic child is somewhat different from your world. Attention, focus, concentration, pain, survival instincts are just some of the things that are different for the autistic child. In addition to being an understanding adult, today there are a lot of things that can actually be done. Gone are the days when an autistic child had to be institutionalized. Today they can lead much more normal lives.

Methods are available to help improve their social, language, and academic skills. Even though more than 60% of adults with autism continue to need care throughout their lives, some programs are beginning to demonstrate that with appropriate support, many people with autism can be trained to do meaningful work and participate in the life of the community."

Attention Deficit Disorder / Attention Deficit Hyperactivity Disorder

First, let us resolve a minor issue of nomenclature: What is the difference between Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD)?

The difference is mainly one of terminology, which can be confusing at times. The 'official' clinical diagnosis is Attention Deficit Hyperactivity Disorder, or ADHD. In turn, ADHD is broken down into three different subtypes: Combined Type, Predominantly Inattentive Type, and Predominantly Hyperactive-Impulsive Type.

Many people use the term ADD as a generic term for all types of ADHD. The term ADD has gained popularity among the general public, in the media, and is even commonly used among professionals. Whether we call it ADD or ADHD, however, we are all basically referring to the same thing."

For someone with ADD, the world seems to be in fast forward play. Sounds and images are continuously changing. An unaffected person gets programmed to tune out some sounds and distractions. Some with ADD keeps noticing all of these and cannot concentrate. Because of the distracted, they very often miss noticing important sounds or images. For instance, they may not notice that you just spoke to them, or they might miss an object which is headed in their direction.

A rigorous review of scholarly journal articles on ADD yields the following collation of important statistics:

ADHD affects an estimated 4.1% of youths ages 9 to 17 in a 6-month period."

About 2 to 3 times more boys than girls have ADHD."

Children with untreated ADHD have higher than normal rates of injury."

ADHD often co-occurs with other problems, such as depressive and anxiety disorders, conduct disorder, drug abuse, or antisocial behavior."

Symptoms of ADHD usually become evident in preschool or early elementary years. The disorder frequently persists into adolescence and occasionally into adulthood."

Treatment

Medically treating ADD has produced some results:

Three medications in the class of drugs known as stimulants seem to be the most effective in both children and adults. These are methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). For many people, these medicines dramatically reduce their hyperactivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as handwriting and ability in sports. Recent research by NIMH suggests that these medicines may also help children with an accompanying conduct disorder to control their impulsive, destructive behaviors."

Down Syndrome

Down Syndrome is caused due to the presence on extra chromosome 21. People who have Down syndrome have some physical and intellectual variations from the general populace.

The estimated incidence of Down syndrome is between 1 in 1,000 to 1 in 1,100 live births. Each year approximately 3,000 to 5,000 children are born with this chromosome disorder. It is believed there are about 250,000 families in the United States who are affected by Down syndrome."

Children with Down syndrome have certain identifying features:

1) Their physical development is retarded.

2) Their mental development is usually retarded (but this can vary considerably).

3) They possess less developed motor skills.

4) They learn to walk and talk later than other children.

Causes of Down Syndrome

Although many theories have been developed, it is not known what actually causes Down syndrome. Some professionals believe that hormonal abnormalities, X-rays, viral infections, immunologic problems, or genetic predisposition may be the cause of the improper cell division resulting in Down syndrome. It has been known for some time that the risk of having a child with Down syndrome increases with advancing age of the mother; i.e., the older the mother, the greater the possibility that she may have a child with Down syndrome."