Hi, my name is Jordan Greenbaum. I'm the medical director of the Stephanie Blank Center for Safe and Healthy Children at Children's Healthcare of Atlanta. I specialize in child maltreatment, including abuse and neglect. Today we're going to talk about child abuse and neglect. Let's start off with this, imagine this, your nine year old daughter comes to you and says, I've got something to tell you. She goes on to say that when she spent the night with her best friend six months ago, she woke up to find the friend's father in her sleeping bag with his pants down. He was fondling her private parts and he whispered to her not to say anything. He said this was their secret. If she told her friend, the friend would be very upset. Well, she tells you, this is a man, a big man. And she was afraid of him. So she didn't want to lose her friend, so she didn't say anything. Or imagine this. A friend of yours can, confides in you that her daughter is living with a man who uses methamphetamine's. And she's worried that her daughter is using drugs too. The daughter has a 4-month-old boy. The friend tells you that she's concerned, because whenever she goes and visits them. She has to pound on the door to wakeup the parents. And when they finally come to the door they seem very groggy. And often she, when she comes in she finds the baby in a dark room, in a soaked diaper, crying and crying. Sometimes her daughter and boyfriend seem very agitated, she hears the boyfriend complain about the babies crying, and telling the mother that she's spoiling the infant by lifting him up when he's crying. Last week when the friend went, she saw bruising on the baby's face, as if someone had grabbed the baby's face. But what are we seeing here? In the first case, we're seeing a victim of child sexual abuse. In the second, circumstances strongly suggest possible, child neglect and physical abuse. What is sexual abuse? Broadly defined, it's any sexual activity that's perpetrated against a minor by threat, force, inti, intimidation or manipulation. This includes both contact and non contact activities. So for example, vaginal intercourse or fondling, touching breasts over clothing. Or non contact activities like forcing a child to watch pornography or pose for pornography. It's a broad definition. What about physical abuse? Again, the definitions vary, but legal definitions are often quite vague such as, physical abuse involves any non accidental injury to a child. Physically abusive acts include a whole lot of things like kick, or burning, or choking, or stomping on a child. In many states it includes acts or circumstance that threaten the child with harm, or the subsidiant risk of harm. You don't necessarily have to show that harm has occurred. Defining physical abuse becomes controversial. Because many states and countries allow corporal punishment. And it's difficult to define the line that separates such punishment from abuse. And people really vary on that. Child neglect occurs when a child's basic needs are not met. The reasons they aren't met may be multi-factorial, and include factors at individual level, such as the parental drug addiction that we saw with our four month old. But they also include factors at the family, community, and societal levels. For example, few, few resources for parents in a community. Or societal ills such as poverty. There are different types of neglect including lack of appropriate supervision, emotional neglect. Physical, medical, and educational neglect. And often there's more than one type of neglect, neglect in a family. Finally emotional abuse, also refered to as psychological maltreatment. Involves a repeated pattern of caregiver behavior, or one or more extreme incidents that convey to children that they are worthless, flawed, unloved, unwanted, endangered or really only of value in meeting someone elses needs. Emotional abuse is potentially devastating to children. And some people think that it is,. Emotional abuse that causes the, long term effects of child abuse and neglect. Physical wounds heal, broken bones heal, bruises heal, but the effects of constant belittling, terrorizing, or humiliating a child those effects are much harder to heal. Child abuse and neglect is extremely common in the United States, approximately 40% of American children have been maltreated in some way. Different types of abuse range from eighteen to 26% in prevalence. More than one in four females and one in 20 males will experience sexual abuse. or sexual assault as a minor. Perpetrators of sexual abuse can be adults and are often a caregiver, such as the circumstances we typically associate with sexual abuse. But they can also be peer perpetrators in circumstance we consider more typical of sexual assault. And globally the situation is fairly similar. The World Health Organization estimates that about 23% of the world's population are victims of child physical abuse. In one multinational study, the prevalence of sexual abuse was 18% for girls and nearly 8% for boys. With considerable variation among countries. There are a lot of factors that can place children at risk for child abuse and neglect. In our example, the four-month old infant, we saw caregiver drug addiction, and really, unrealistic expectations of the infant. Abuse is often intergenerational. So, an adult who has been abused as a child is at increased risk of having a child who themselves are abused. But it's important to remember that some abused kids have no risk factors, none at all. Child maltreatment crosses all socioeconomic, religious, national, racial and ethnic boundaries. There is no community, state or country that is immune from child abuse and neglect. So how do we recognize abuse? There's some situations that may raise concerns about possible physical abuse. For example, if you see a significant injury and there's no history of any trauma to explain it, or a history that doesn't make any sense to you, that might be a red flag. Typically, young infants who have not yet learned to pull to stand and cruise, don't have any bruising. And when they do, it's typically a single injury with a very significant event, like a fall from an adult's arms. So any unexplained bruising of a very young baby is of concern. How do we learn about sexual abuse? As in our example, the nine year old girl, a child's disclosure is the most common way we learn about it. However, children may not immediately tell an adult about the abuse and delays in disclosing are very common. In our example, the child was afraid of the offender and the possibility of losing her friend. So she didn't tell anyone, until after the friend and the family moved away from town, and she felt safe. Many children never tell. Or, if they disclose, it's months, even years, later. Many parents come to our clinics with concerns that their child has been abused, based on the child's behavior. And I think it's really important to stress that there is no single behavior. That definitively identifies a child as having been sexually abused. Some children have no behavior changes. Others have some behavior changes, but they're very nonspecific and maybe related with any kind of stress, like loss of appetite or nightmares. Another thing to remember is that while it's commonly assumed that a child victim of sexual abuse will have physical changes to the genitalia. That identify a child as being abused. That is rarely the case. Not all forms of sexual abuse cause injury, and when they do cause injury typically the delay in disclosure means that those injuries have healed completely without any scarring, so by the time the child is examined there is nothing to see. The exam is completely normal. So the majority of child victims that we see in our clinic do not have physical findings th, that's diagnostic of prior trauma. Are there long term effects of child abuse and neglect? Yes. There's ample evidence that there are profound abu effects. Over the past 15 years or so, a number of studies have looked at the longterm effects of early childhood adversity, which includes the various forms of child abuse and neglect. These studies consistently show that increased early adversities substantially increases the risk of emotional, behavioral, and even physical problems. Those people who suffer early adversity, are at increased risk of significant mental health issues. They're also at risk for drug and alcohol abuse, for antisocial behavior such as juvenile delinquency, adult criminality. Adolescents who have been abused are at risk of running away from home, of teen pregnancy, and of becoming victims of human trafficking. And finally, adults with a history of early adversity are at an increased risk of major liver, lung, and heart disease. You may be asking yourself what can we, as the lay public, do to prevent child abuse and neglect. A few things. We can advocate for early childhood prevention programs that teach parents appropriate expectations for infants and children. Provide them with effective and non-violent parenting skills, those programs that foster healthy attachments with their children. We can also demand our society addresses fundamental social ills, such as poverty and widespread drug use. What about sexual abuse? There's some concrete things we can do to minimize the risk to children. We can make sure we know where our children are at any given time. We can demand that child-serving institutions have policies in place, that avoid one on one situations, in which an adult is alone with a child for a long, for a prolonged period. We can make unscheduled visits to our childcare center, or to our child's soccer practice, just so we convey the message to staff and to the coaches. That we are watching our children. We're aware of what they're doing. We can make sure that we have met and talked to the adults who may be in charge of our child, before letting our child stay with them. And finally, we can teach our children to recognize appropriate versus inappropriate touches, and tell a trusted adult when they experience something that makes them feel uncomfortable. While we'd like to prevent all child abuse and neglect, this is not likely to happen any time soon. So what should you do if you suspect abuse? If you're in the United States, call the Child Protective Services agency in the country where the child lives. Call law enforcement. If it's an emergency situation, call 911. If you're not sure what to do, call the National Child Abuse Hotline to discuss your concerns and get advice. This is a 24-hour hotline that provides resources and crisis intervention as well as advice. If you're not in the United States, I would recommend calling the Child Protective Services agency that is relevant in your country. You can call law enforcement. You can call the emergency line in your country that's equivalent to the 911 line in the United States. And if you're looking for a hotline, go online and Google Child Abuse Hotline and see what you can come up with. Whatever you do, take action. A child's life may depend on it.