Soaring rates of childhood poverty should wake up child protection policy makers

Reports out of the United States this week speak about soaring rates of children living in poverty, too often accompanied with homelessness. The National Centre on Family Homelessness states that there are 2.5 million children who were homeless for at least part of the year in 2013.

Neglect, one of the most common issues that child protection faces, is driven in very many respects, by poverty. The reasons are many, but include:

• inadequate shelter places children at risk of illness;
• many families are forced to find space in high crime, high risk areas;
• parents may be forced to leave children with inadequate caregivers while they try to hold on to marginal wage jobs;
• homelessness makes it hard to get kids to school;
• there is a lot of stress on parents trying to manage homelessness increasing risks of various forms of maltreatment;
• children may be recruited into petty crimes like shoplifting as a way to try to get food and other necessities;
• children lose connections to friends and community programs as families wander from place to place;
• parents find it hard to meet the emotional needs of their children.

It would not be hard to add to this list. When child protection becomes involved, parents are seen as neglecting children. However, this is not the kind of neglect that typically is related to a parent's lack of desire to do the right thing for their child. Rather, it is the reality of living without resources.

Taking children into foster care may be the limited solution available in many cases but it is a poor solution. It adds unnecessary pressure to the child protection system in the form of increased case loads and heavier demands on placements.

The National Centre on Family Homelessness points out that there are solutions. These can include increasing access to low cost housing; subsidized day care so parents can work; feeding programs; improving educational opportunities for parents. There can also be family oriented shelter programs (such as the Inn from the Cold program in Calgary, Alberta). 

The long terms costs of homelessness are seen in the children not being able to get an education and themselves entering the cycle of poverty. Homelessness adds to that cycle and the cost to society is long term. Chronic homelessness can be tackled. The City of Medicine Hat in souther Alberta has reported that they are on the brink of accomplishing this. But it took targeted efforts.

Hamzah Khan - a powerful child death that has so much to teach us

A Serious Case Review was published this past wee into the death in the UK of Hamzah Khan. She was profoundly neglect and when police entered the home, the partially rotted corpse was found. This is a disturbing case from several perspectives - a very unhealthy mother who was in no position to raise a child is a theme at the core of the this case.

The National Society for the Protection of Cruelty to Children (NSPCC) in the UK summarized the SCR stating that the issues include:

Maternal history of: alcohol dependency; depression; social isolation; domestic abuse; and reluctance to engage with services. Issues identified include: invisibility of children to education and health services; failure to take into account the impact of domestic abuse on children; absence of enquiry into the cultural and religious complexity of the family;  insufficient significance given to disclosure by adolescents; lack of professional curiosity; insufficient interagency cooperation. Themes for learning include: cognitive influence and human biases; viewing incidents in isolation and failing to identify patterns that represent harm to children; and tools for effective sharing and analysis of information.

These are powerful lessons indeed. The Daily Mirror noted that it was a neighbourhood police officer responding to a neighbour's complaint who ultimately led to the discovery. The police officer was persistent - a behaviour that should be considered essential for those working in the areas of child abuse and domestic violence.  The Daily Mirror also quotes the SCR author stating:

Very sadly, I cannot give assurances that a tragedy like this will never happen again in our country - as we can’t control or predict the behaviour of all parents, the vast majority of whom are doing their very best to care for their children.

The reality is just that. Even the best of child protection systems will not prevent all deaths for quite a variety of reasons. These include that we cannot see into every house. As well, there are clients who feign cooperation but do not actually follow through with interventions. Then there are the cases where the parent behaves unpredictably or the interventions simply don't work.

Another SCR was published this past week in the UK that reminds us that domestic violence is intricalty connected to child abuse. Perhaps more importantly, is the reminder that these issues are not unique to the more disadvantaged populations. Child protection and other professions can develop a bias when approaching a family that is more advantaged and can have the appearance of success. The facts of the case need to be considered. As the NSPCC noted:

the need to remember that child abuse crosses all class and gender boundaries and to consider the potential impact of bias on evaluations

These cases remind us that errors can repeat themselves. Followers of this blog will see some familiar themes. Thus, we must continue these conversations and do so widely creating a broad reminder of what good practice can look like. 

Mortgage default, foreclosure and Child Abuse

Many who have worked in the area of child abuse know that stress in family can be related to increased risk for abuse in a household. There has been recent suggestions that child abuse may be down in the economically struggling United States. A new article to be published in the journal Paediatrics puts a damper on such hope.

However, the article does show an important link between mortgage delinquency and foreclosure trends. Child abuse went up as these economic hardship factors also increased. The team looked at data from 38 hospitals meaning that the numbers are quite robust. The research concludes:

CONCLUSIONS: Multicenter hospital data show an increase in pediatric admissions for physical abuse and high-risk TBI during a time of declining all-cause injury rate. Abuse and high-risk TBI admission rates increased in relationship to local mortgage delinquency and foreclosure trends

The research also noted that unemployment did not show such a causation.

From a public policy perspective,  this really helps us to see that families facing the effect of losing housing are really under significant stress which affects the safety of children. This might well suggest that the appropriate intervention is to help find some form of place to live that offers dignity and safety for a family.

Mandatory Reporting Laws

There is often debate about whether mandatory reporting laws should exist. Should mental health, medical, education and other professionals be required to report cases where they suspect that child abuse is occurring? There have been many examples in the media where mandatory reporters have over reacted to information. In Canada, there is the recent case in Ontario where a child drew a picture of what was thought to be her father holding a gun. This resulted in an over reaction even to the point of the father being arrested.

What does a professional do when an older teenager discloses abuse in a session and then insists that the case not be reported? The child makes a cogent case that reporting will make things worse - what then? These are difficult ethical dilemmas for many professionals.

A court in the United States has shown the damage that can be done when a report is not made. While the case from Oklahoma shows that there were many errors including purposeful deceit, it does make the point that it is up to the child protection authorities to decide on a case, not the mandatory reporter.

In Florida, partially in response to the high profile Sandusky case one suspects, the legislature has now made it possible to levy serious fines on universities for failure to report. The Florida bill goes further according to Tampa Bay Online :

Additionally, the bill makes it mandatory for everyone to report suspected child abuse or neglect, even if the alleged perpetrator is not the child's caregiver. Previously, the public only was required by law to call in a report if a caregiver was responsible. 

 Opponents of mandatory reporting laws feel that they lead to an over reporting of cases and that pressure to err on the side of protecting the agency leads to unnecessary and intrusive actions by child protection authorities. They feel that it results in children coming into care who do not need to be there and thus, destroying families as well as dispersing resources that can be better spent on families that really are abusing their children.

This of course begs the question - if nobody is required to report, then how will cases get known to child welfare? Where is the balance?

Psychosomatic problems in abused children

In a Swedish study on the connection between somatic issues with children, there was a clear link between these and children who were physically abused. It was more evident when they also witnessed inter personal violence (IPV) on top of the physical abuse. It is of some interest that the issues did not seem to arise from IPV witnessing on its own. The studies results of looking at over 2500 students aged 10, 12 and 15 in 44 different schools showed:

• One in six of the children (16%) had suffered physical abuse or witnessed IPV in the home -- 9% reported just physical abuse, 4% reported IPV alone and 3% reported both.
• Two-thirds of the children (66%) reported at least one psychosomatic symptom and just over a third of these children (35%) reported three symptoms or more.
• The most common symptoms were headache (38%), sleeplessness (36%) and stomach ache (31%).
• 86% of the children who reported that they were physically abused and had witnessed IPV at home reported at least one psychosomatic symptom, with 41% reporting three or more, compared with 17% of the non-abused children.
• 82% of the children who reported physical abuse only reported at least one symptom, with 35% reporting three or more symptoms compared with 17% of the non-abused children.
• There was no significant difference in the symptoms reported by children who did or did not report just IPV.
• When confounding factors, such as chronic conditions, bullying and school performance were taken into account, the odds of a child suffering physical abuse, with or without IPV, was 112% higher (OR 2.12) than a child who was not being abused. When IPV was added into the equation, this rose to 171% higher (OR 2.71)
• The odds for a child suffering physical abuse only was 72% higher (OR 1.72) and the odds for IPV only was 9% higher (OR 1.09).
• Abused children with chronic conditions reported significantly more psychosomatic symptoms than abused children without chronic conditions.

This study echoes previous research that has seen a link between abuse and physical symptom presentation. A Toronto study published in 2011 found a link between child abuse and peptic ulcers in adulthood.

In 2010, researchers in the United States concluded:

Children who have been abused psychologically, physically or sexually are more likely to suffer unexplained abdominal pain and nausea or vomiting than children who have not been abused, a study led by University of North Carolina at Chapel Hill researchers concludes.

All of this suggests, of course, that when we see children or adults who present with physical symptoms that may be more somatic in their origins, we should be asking about abuse experiences.

 
References:

Carolina Jernbro, Birgitta Svensson, Ylva Tindberg, Staffan Janson. Multiple psychosomatic symptoms can indicate child physical abuse - results from a study of Swedish schoolchildren. Acta Paediatrica, 2012; 101 (3): 324 DOI:10.1111/j.1651-2227.2011.02518.x

E. Fuller-Thomson, J. Bottoms, S. Brennenstuhl, M. Hurd.Is Childhood Physical Abuse Associated With Peptic Ulcer Disease? Findings From a Population-Based Study. Journal of Interpersonal Violence, 2011; DOI:10.1177/0886260510393007

University of North Carolina School of Medicine (2010, March 8). Abused children more likely to suffer unexplained abdominal pain, nausea or vomiting. ScienceDaily. Retrieved February 11, 2012, from http://www.sciencedaily.com­/releases/2010/03/100308170957.htm

Child Abuse Hospitalizations

A study published this week in the American journal Paediatrics has a look at the issue of children who are abused and end up in hospital. This might be seen as a the more probably serious end of the abuse spectrum, although as a a clinician I do see families where they have abused children and avoided getting the child treated. The study did not look at children with suspicious injuries, only those who were coded as abused.

As in most studies of child abuse, it is the youngest children at highest risk. In this case, children under a year were seen as most vulnerable.  Science Daily notes that the study concluded:

They found 4,569 children were hospitalized in the U.S. in 2006 due to serious abuse; 300 of these children died. Children in their first year of life were at highest risk, of being hospitalized, making up 58.2 per 100,000 children in this age group.

The study found the incidence rate to be higher than Sudden Infant Death Syndrome. They also found that there was a correlation between this physical abuse and poverty, although one must bear in mind that the poor have fewer options when it comes to accessing medical services. Thus, that may have brought them more to light.

This study is valuable in that it helps us to see the incidence rate but also a way to think about the rate in comparison to other serious disorders that affect children.

The study will be published in the March 2012 issue of Paediatrics.

What does violence cost us?

In a most fascinating group of studies, the National Academies Press has published Social and Economic Costs of Violence: Workshop Summary. Of particular interest is a series of papers that consider the direct and indirect costs of violence. Clearly, as a society, we are putting out very significant amounts of money as a result of violence. In the first of these papers, Waters et al., identify that in the USA, the cost of interpersonal violence equals about 3.3% of that country's GDP. The majority of costs are born by publicly funded services. Consider the GDP figures (US Dollars):

Canada - 1.57 trillion - 2010

Australia - 954 billion - 2009

Germany - 3.3 trillion - 2010

South Africa - 363 billion - 2010

Switzerland - 523 billion - 2010

UK - 2.246 trillion - 2010

USA - 14.5 trillion - 2010

One immediately gets the sense that, even with variations in rates of inter personal violence (IPV), the costs are extraordinary. The study considered various forms of IPV including child abuse and neglect, violence in intimate relationships, elder abuse, sexual violence, violence in the workplace and youth violence. The study authors are from John Hopkins University, the World Bank and the World Heath Organization.

A second study by Dong looking at elder abuse raises the challenge that many forms of abuse are likely underreported. Perhaps only 1:14 cases come to the attention of authorities suggesting that some costs are being borne by society without society knowing that is what is being paid for. It also suggests that the victims are not being identified. As Deng notes, "Elder abuse includes physical abuse, sexual abuse, emotional abuse, neglect (both caregiver and self-neglect), and financial abuse. Available prevalence data suggest that at least 10 percent (or 5 million) of the U.S. elderly persons experience abuse each year, and many of them experience it in multiple forms " (p.6-16). The implications for morbidity and mortality are significant.

As Hemenway notes in his brief paper, the costs can be difficult to fully quantify because the nature of many costs can be intangible. Take the costs related to street violence. He states:

"There are also large psychological costs caused by street violence. Exposure to violence (e.g., witnessing violence) increases the risk for psychiatric, emotional, behavioral, and health problems. Psychiatric problems include posttraumatic stress disorder (PTSD), depression, anxiety, intrusive thoughts, sleep problems, and personality change. Emotional problems include anger, nervousness, withdrawal, loneliness, and despair. Behavioral problems include low academic performance, risky sexual behavior, substance abuse, delinquency, and violence. Finally, exposure to violence has been linked to such health problems as asthma, heart disease, and low birth weight babies.

There are also high community costs of street crime that accrue when people and institutions try to avoid the shootings and protect themselves. Commercial and residential locations can be affected. Businesses do not want to locate in areas of high crime, tourists do not want to go there, and people do not want to live there. This leads to fewer jobs and to flight from the neighborhood of higher-income people who can afford to leave (e.g., “white flight”). The loss of jobs, good stores, community social capital, and positive role models leads to neighborhood deterioration.

To avoid being shot, residents also change their behavior concerning recreation, shopping, leisure, and other activities. Children are not allowed to play outside, residents are less likely to go out at night, and they are less likely to accept evening work. People live behind locked doors. Having fewer people on the street further reduces the safety of being on the street". (p.6-24).

Another paper by Huesmann from the University of Michigan, reports that violence is highly contagious. He states:

"One of best-established findings in the psychological literature on aggressive and violent behavior is that violence begets violence. This contagion of violence appears to be a universal phenomenon. The contagion of violence occurs within families. Violence between partners increases the risk of violence directed at children and increases the risk of the children behaving violently themselves. Having one violent individual in a family makes it more likely there will be others. It is true within peer groups. Violence by some peers increases the risk of violence by others. Violence by peers directed outward not only stimulates violence by others that is directed outward, but stimulates violence between peers within the group. This is true in neighborhoods and communities. Violent communities and neighborhoods breed violence in those who join the community or neighborhood. Introducing violence into a community increases the risk of greater violence throughout the community. It even appears to be true within nations and cultures, and it is true across generations. Children “catch” it from their parents, and parents can catch it from their children.

Violence is highly contagious. Not only is it spread from the perpetrators of violence to the victims, but it is spread to onlookers and observers. It is not surprising that violent victimization leads to violent retaliation within and between families, peer groups, schools, communities, ethnic groups, cultures, and countries. What may be more surprising to some is that simply the observation of violence also leads to increased violence within and between all of these groups". (p. 6-25).

A final paper in this section looks at the implications of fear on children and their development. There are long term implications for the developing brain which impacts learning, family life, work productivity and other economic inputs. In their paper Fox and Shonkoff note:

"The scientific knowledge around fear and anxiety points to three important implications:

1. Young children can perceive threat in their environment, but unlike adults, they do not have the cognitive or physical capacities to regulate their psychological response, reduce the threat, or remove themselves from the threatening situation. As a result, serious fear- triggering events such as family violence can have significant and long-lasting impacts on the developing child, beginning in infancy.

2. Children do not naturally outgrow early learned fear responses over time. If young children are exposed to persistent fear and excessive threat during particularly sensitive periods in the developmental process, they may not develop healthy patterns of threat or stress regulation. When they occur, these disruptions do not naturally disappear.

3. Simply removing a child from a dangerous environment will not by itself undo the serious consequences or reverse the negative impacts of early fear learning. Children who have been traumatized need to be in responsive and secure environments that restore their sense of safety, control, and predictability—and supportive interventions are needed to ensure the provision of these environments". (p.6-34).

This data has very significant implications for child protection. Clearly, children left in violent and fear inducing homes are harmed and the impact is long term. Child protection should not dither in helping those families. Getting the right interventions in place quickly is vital. Removing children needs to be done when parents are unable or unwilling to change. Failing to act is a direct price that a child pays and that price is not included in the cost of violence.

Reference:

Patel, D.M. & Taylor, R.M. (eds) (2011). Social and Economic Costs of Violence: Workshop Summary. Washington DC: National Academies Press.