Chadwick’s Child Maltreatment 4e, Volume 3: Cultures at Risk and Roles of Professionals

Chapter 1

CULTURAL ASPECTS

Linda S. Spears

Culture surrounds us daily. Culture shapes our understanding about our lives, how we are born, grow, age, and die. Culture provides the context within which we live each day, how we learn and play, and how we form and define social connections. Culture helps us understand what is required to fulfill the aims of life, and helps us define what we do, as well as how, why, and where we do it. In these ways, culture is critical to what happens across the life span but especially during the first stages of human growth and development—childhood.

For all children in all cultures, certain conditions are required for healthy growth and development. All children need basic care including nutritious food, safe water, adequate clothing, and shelter. Children also require protection from harm, exploitation, neglect, and other forms of maltreatment. When these conditions are met, children have an opportunity to realize their full potential. When these conditions are not met, children’s physical, social, and emotional growth and development may be arrested, damaged, or reversed.

This chapter is about the cultural aspects of child maltreatment. How do culture and child maltreatment relate to each other and what are the implications for our work?

Cultures are complex and dynamic phenomena that influence the way that parents and caregivers fulfill a child’s need for love, nurturance, care, and protection. A child’s growth and development are intrinsically linked with the larger culture within which they and their caregivers live their daily lives. This cultural context offers a certain perspective on what childhood is, how childhood is characterized by the larger community, and how childhood is experienced through the children and their families. In most cultures, the nature of childhood is governed by necessity and by the relationships that exist between adults and children. When parents and communities struggle to meet basic needs, children may be viewed as property or as an asset that can help bolster the economic well-being of adults. In more affluent cultures, children may be seen as dependents with nominal responsibilities or as consumers of the resources provided by the adults upon whom they must rely. Without regard to economic determinants, children may also be cherished as symbols of a community’s legacy and as an investment in future generations. Children may be extensions of their caregivers or independent beings with rights and privileges uniquely their own. In a given culture children may also be all of these things to some measure.

Across cultures, we assign to children attributes and influences that reflect the values and imperatives in our lives. We make determinations about how we care for children in the context of our age, geographic location, religion, gender and gender identity, sexual orientation, race, ethnicity, and social class. These aspects of our lives exist in the context of our wealth and resources, inclusion and isolation, symbols, ideas, and actions that are mediated by our own status and power. Access to and exercise of power shapes what children and their families have and how they behave. It also shapes how the lives of maltreated children are studied, identified, and altered. Thus, an understanding of the relationships of power between cultural groups, between persons, and within families, communities, and institutions is essential to an understanding of how we address child maltreatment.

DEFINITIONS

CULTURES

Cultures are dynamic, large-scale human social forces that generate the structures and meanings of thought and action. Cultures enable people to define the significance of ideas, actions, experiences, places, things, and relationships.¹ Cultures are often unspoken, tacit, and below the level of consciousness. While our understanding of cultures has evolved over more than 100 years, experts today see their nature as multifaceted and broad (see Table 1-1). Culture may be reflected in our habitual behaviors. Selective use of culturally derived knowledge and understandings may help us navigate the decisions and activities of daily life. Cultures historical, situational and changeable dimensions allow us to accept certain culturally defined beliefs while at the same time reject others that may have a deleterious impact on our lives.²

CHILD MALTREATMENT, ABUSE, AND NEGLECT

Child maltreatment, abuse, and neglect are forms of physical or mental harm to human beings less than 18 years old that result from proscribed, preventable, and proximate intentional human actions by adults.⁷ In other words, child maltreatment, abuse, and neglect are the physical or psychological consequences of non-accidental violence or deprivation inflicted by adults on children. Importantly, the adult behavior must be devalued or prohibited by the culture within which the adult-child relationships exist (proscribed), committed by the child’s caregiver in the child’s immediate temporal and physical environment (proximate), and chosen instead of an alternative, non-injurious action (preventable).

CHILD MALTREATMENT, CULTURE, AND CHANGE

Child maltreatment, abuse, and neglect have existed in all cultures and in all periods of human history.⁸-¹¹ Similarly, the care and protection of children from maltreatment is omnipresent in the record of human endeavor. Professional advocacy on behalf of children is also well documented in the historical record.¹² Study in the field of child maltreatment reveals the ways in which cultures change and influence each other, and how this can generate new ideas and actions.

The 1962 publication of The Battered Child Syndrome¹³ generated an important shift in the balance of power between adults and children everywhere. For the first time in a scientific medical journal, scholars defined the concept of child abuse. The authors labeled child abuse as a recognizable phenomenon and explored its health and medical implications. An intellectual foundation was created that transformed the phenomenon from an accepted everyday reality, legitimized by a particular ideology about the natural order of private family life, into a measurable social and public health problem that requires prevention, surveillance, analysis, and intervention by multiple persons, groups, institutions, and systems.¹⁴

Subsequently, changes in relationships and institutions happened in ways that held profound implications for child growth and development, care and protection. The many forms of child maltreatment were described, categorized, and measured by a new field of study that intersected several domains of ideas and actions: medicine, public health, social work, philanthropy, politics, and law.¹⁴

As the epidemiology and medicine around child and family violence flourished, philanthropy to support action and advocacy against child abuse thrived, and legislation, particularly in the United States, evolved. In many states, legislation designed to codify child abuse definitions and to identify abusers through mandated reporting by physicians and others appeared by the late 1960s and 1970s.

In 1974, the US Congress passed the Child Abuse Prevention and Treatment Act (CAPTA), Public Law 93-247. This law defines child maltreatment as follows:

The physical and mental injury, sexual abuse, neglected treatment, or maltreatment of a child under 18 by a person who is responsible for the child’s welfare under circumstances which indicate the child’s health and welfare are harmed and threatened thereby as determined in accordance with regulations prescribed by the Secretary of Health, Education and Welfare.¹⁵

Over time, the concept of child abuse as a medical, public health, social work, and legal issue was globalized through publications (scholarly books and journals, as well as articles in the lay press), international conferences, popular culture (television, movies, Internet, ad campaigns, etc.), philanthropy, and advocacy on the international health and human rights stage through international organizations such as the World Health Organization and United Nations Children’s Fund (UNICEF) and documents such as the UN Convention on the Rights of the Child.

Contemporary communication technologies, including traditional and social media allow policies and practices that harm children to be publicized as human rights problems. As a result, activities that threaten child safety and well-being and are labeled as abusive in one locale are now more apt to be interpreted as a threat to human health and justice everywhere. The long-held practice of female circumcision in certain African cultures relabeled as female genital mutilation and a form of gender domination and child maltreatment, became an international human rights cause in the global public media in ways that transformed local settings, rituals, and cultural traditions.¹⁶

Thus, the history of the study of child maltreatment, abuse, and neglect reveals a basic theoretical model of culture and change. Cultures generate organized new ideas about the meaning of human phenomena like child maltreatment that make changes in values, behaviors, experiences, and relationships possible. Once advocated by powerful stakeholders and opinion-makers, these interpretations become the conventional wisdom of the day. Philanthropy and other forms of social and economic capital elevate the new interpretation of human phenomenon which then may be codified into new laws, bureaucracies, and forms of intervention (eg, public health prevention, medical screening, pediatric social work and child/family mental health systems and models of care, child protective services [CPS], and epidemiological study such as National Incidence Surveys, etc.). This further advances new ideas and alters the relationships between groups and within families, communities, and institutions in fundamental ways.

INCIDENCE/PREVALENCE

The prevalence of child abuse refers to the number of people who have experienced at least 1 episode of abuse or neglect during their lifetime. Prevalence is measured by self-report surveys of parents and victims. The incidence of child abuse refers to the number of child maltreatment cases brought each year to the attention of official agencies such as law enforcement and CPS. Incidence figures emerge from data collected by agencies mandated to respond to child maltreatment.

International estimates of the prevalence of child maltreatment are difficult to compare for methodological reasons (eg, definitions of abuse differ among countries and among states in the US). However, estimates are also problematic in places characterized by high child mortality rates or where resources to study child fatalities are limited. In such settings, neglect-related or other intentional deaths may be difficult to distinguish from threats to child survival that are beyond parental control and thus culpability.

Prevalence

In 1995, a Gallup Poll of 1000 parents revealed that 44 in 1000 Americans experienced child abuse and neglect, yielding a projected estimate of 3 million per year.¹⁷ In another study, the Adverse Childhood Experiences (ACE) study, initially conducted in 1995 and 1997 asked 17 000 adults to report on the traumatic events, including abuse and neglect, they experienced as children.¹⁸ Researchers found that 28% of those surveyed had experienced physical abuse that resulted in injuries or marks left as a result of pushing, grabbing, hitting, or a thrown object. Further, about 21% of those surveyed reported sexual abuse and nearly 11% reported that they had experienced emotional abuse. Emotional neglect was noted among nearly 15% of those surveyed, and physical neglect, including inadequate food, health care and clothing was reported by 10% of those surveyed.

Mandated by the United States Congress, the National Incidence Studies (NIS) of Child Abuse and Neglect periodically collect data from nationally representative samples of professionals and social service agencies to examine the extent and nature of child maltreatment in the population, and the characteristics of the children harmed. In the Fourth NIS (NIS-4), containing data from 2005 and 2006, it was estimated that 1.2 million children were maltreated.¹⁹ Given the child population growth, the study estimates that the rate of child maltreatment in the US has declined 26% since 1993 when approximately 1.5 million children experienced abuse or neglect.

Incidence

The National Child Abuse and Neglect Data System (NCANDS), initiated in 1990, summarizes the number, characteristics, and outcomes of child maltreatment reports to state CPS agencies. In 2011, NCANDS documented approximately 3.4 million CPS referrals involving 6.2 million children.²⁰ About 61% of these cases were screened in for a follow-up investigation or assessment. Schools, law enforcement, social services, and medical professionals were the source of 57% of referrals. Neighbors, families, and friends accounted for the remainder of reports.

The 2011 NCANDS report documents declines in the number of substantiated cases of child maltreatment in 42 states. Nationwide, the number of substantiated cases dropped significantly from 903 000 in 2001 to 681 000 in 2011.²⁰ Seventy-nine percent of the cases involved physical neglect, 18% physical abuse, 9% sexual abuse, and 10% involved other types of maltreatment including medical neglect.

While declines in reports of child maltreatment are likely the result of numerous factors, the continuing shift in our values related to child maltreatment may be a critical consideration in the way we respond to child abuse and neglect. Over a 20-year period there has been a steady increase in the number of states that have embraced less punitive and more family supportive methods for addressing abuse and neglect. Eighteen states now use some form of alternative/differential response that provides a non-investigative approach to reports of abuse and neglect that are deemed to be low-risk. In 2011, about 10% of CPS responses nationwide (361 000 cases) received an alternative response.²⁰ Practitioners posit that these responses may lead to more positive engagement of families and therefore prevent or lower the risk of re-abuse in some families.

MAKING DIFFERENCE MATTER

CULTURE, RACE/ETHNICITY, AND CHILD MALTREATMENT

Child abuse is present in all cultures and at all historical moments. Scholars estimate that nearly 60 000 children worldwide die each year as a consequence of abuse.²¹ International incidence and prevalence rates are difficult to compare for methodological reasons but appear to vary widely. However, the most comparable international data come from the World Studies of Abuse in the Family Environment project (WorldSAFE), in which a common definition and survey protocol was administered to population-based samples in four countries (Chile, Egypt, India, and the Philippines). The collaborative study was designed to assess the incidence (over 6 months before the survey) of severe and moderate forms of physical punishment of children across these countries. Caregiver behaviors toward children were assessed using the Parent-Child Conflict Tactics Scale (CTS), a tool that has been used in US studies of child maltreatment.

A 1995 study of CTS in the United States documents the rate of severe punishment (eg, hitting a child with an object, not on the buttocks) at about 49 of 1000 children. However, WorldSAFE documents that certain forms of severe punishment are over 5 times higher in Egypt, India, and the Philippines than in the United States or Chile.²¹ More moderate forms of punishment, except spanking a child on the buttocks with a hand or object (eg, slapping, pinching, shaking, or pulling hair), are also much more common in countries outside the United States. In another study using the Parent-Child Conflict Tactics Scale, the incidence of severe punishment in some communities in India was nearly three times as high as in the United States.²² A widely cited study of rates of severe punishment in China and Korea (based on school-aged children’s reports) places these countries in a range comparable to the WorldSAFE study nations with the highest rates.

In the US, the first three NIS reports bolstered a belief that there was no relationship between race/ethnicity and child maltreatment.¹⁹ However, for the first time in the 35-year history of NIS, data revealed higher rates of child maltreatment among black children than with their white counterparts. In further examining these findings, researchers found that methodological differences between study iterations, changes in the distribution of risk factors like socioeconomic circumstances among black and white children, and factors affecting the social context for children and families may all contribute to shifts in the incidence rate.

While the interrelationship between race and other risks is difficult to disentangle, the changing nature of the nation’s response to child maltreatment is apparent as states have looked to find alternative responses to foster care placement and reduce the size and cost of the foster care system. Advocates, communities and service providers have also expressed concern about the over-representation of children of color in the public child welfare systems. This has led to a significant reduction (25%) in the number of children in foster care overall along with declines in the number of children of color in care.²³,²⁴ Since 2001, African American children, who were about 15% of the child population, have moved from about 28% of the nation’s foster care population to 23%, reversing a 20-year trend (see Table 1-2).²⁴ American Indian and Alaskan Native children have also seen a decline in their rate of entry into care. However, they continue to be represented at twice the rates found in the general population.²⁵

Racial disparity in this, as for many health outcomes, is no accident or unfortunate arbitrary turn of misfortune. Reanalysis of the 1981 first NIS data¹⁹ revealed that race and class were the best predictors of whether an incident of maltreatment was reported by a hospital. Poor African American children are more likely to be reported to CPS than affluent whites, even when the severity of the abusive incident was comparable.²⁶ Differences between NIS findings and the demographics of children in foster care have historically suggested that different racial groups have received different scrutiny, sanction, and care during the social process that encompasses the professional, institutional, and bureaucratic responses to the facts of abuse.

Some researchers have argued that poverty and the challenges associated with being poor rather than race are at the root of the disparate involvement of CPS in the lives of children and families of color.²⁷ Others argue that higher levels of scrutiny and reporting of children of color is a function of under-reporting in white communities.²⁸ If these arguments are true in any measure, then it must also be acknowledged that disparate reporting by race and socioeconomic status are also a function of an individual’s access to power and, therefore, resources to care for and protect children. If under-reporting of white families actually exists, it likely reflects the inherent power of some groups to avoid involvement in a child protection system which is often viewed as punitive.

Regardless of the reasons, race in North American culture matters with regard to disparity seen in child maltreatment especially in regard to child morbidity and social outcome. This racial disparity illustrates that the manner in which cultures shape the meanings of particular kinds of behaviors among particular kinds of persons is inherently political. Differential labeling across racial groups of the same parental behaviors reveals disturbing realities about relationships of power between US racial groups.

In this as in so many other ways in American culture, the lives and competencies of African American, Native American children, and other children of color have histori cally been and continue to be devalued and stigmatized. The facts of racial disparity in response to child maltreatment resonate deeply with wider cultural meanings of racial identities and the significance they hold for opportunities, experiences, and exposures across a wide range of domains—from employment, income, and wealth, to housing, education, health, and health care.²⁹-³⁴

POVERTY, SOCIAL CAPITAL, AND CHILD MALTREATMENT

At the start of the 21st century poverty remains among the most powerful predictors of child health outcomes.³⁵ Poverty may act as an independent force in the generation of poor health outcomes or combine with other large-scale social forces such as social marginalization (unjust exclusion from essential resources on the basis, for example, of linguistic, gender, racial, or ethnic identity) to achieve its health-harming consequences.³⁶

In 2013, the United States federal poverty level for a family of four was $23 550. Families with incomes of $11 525 were considered to be living in extreme poverty.³⁷ In 2010, 22% or about 16.4 million American children lived below the federal poverty line (FPL).³⁸ Approximately 7.4% of poor children lived in extreme poverty—less than half the FPL. Official child poverty rates among African Americans and Latinos are approximately 3 times higher than rates among non-Hispanic white children.

Scholars have demonstrated that it actually takes about two times the FPL to meet basic material needs such as food and housing. It is estimated that 45% of American children live in low-income families, where low-income means less than 200% of the FPL. However, the burdens of low-income status are also dramatically inequitable across US racial/ethnic groups. African American, Native American, and Latino children live in low-income families at significantly higher rates than white children. Sixty-five percent of African American children, 65% of Latino children, 63% of American Indian children, and 31% of white children are in the low-income classification.³⁹

Low-income status also means greater vulnerability to economic downturns. For example, in the current American context, the official poverty rate has risen to 15%, bringing the total number of adults and children living below the poverty line to 46.2 million people.⁴⁰ However, again, racial disparities exist. From 2007 to 2011, incomes for all racial and ethnic groups declined by 8.1%. Since the recession, non-Hispanic whites saw a 7% decline in income while Asians and Latinos experienced declines of 10.6% and 10.8%, respectively. African Americans fared worst among all racial and ethnic groups, with 16.8% of families experiencing a decline in income.⁴¹ Poverty and low-income status thus represents more than inevitable misfortune randomly distributed across demographic groups. Its well-documented effects on health are cumulative, pervasive, and persistent at points along the life course. Poverty places children in an awful position of double jeopardy. They suffer both an elevated risk for health problems and a greater likelihood of harm once these problems do occur.⁴²

Unfortunately, those at greatest risk for poor health outcomes also have the least access to high-quality healthcare. Poor children are less likely to be insured. This diminishes their chances of having a consistent source of basic medical care.⁴² As a result, poor children have less screening and preventive care and receive less anticipatory guidance, safety information, and telephone consultation. Their families may not be able to afford copayments for medications, medical equipment, or doctor’s office visits. All of these factors exacerbate poor children’s double jeopardy and lower the quality of care they receive.⁴³ These social facts have a profound impact on pediatric healthcare among the poor.

Studying child maltreatment reveals a classic profile of risk. Compared with non-abusing parents, physically abusive parents are more likely to be young, single, unemployed, undereducated, and thus poor. Across both the developed and develop ing world, those at highest risk are young, single, and poor mothers. For example, the NIS-4 in the United States demonstrates that children from families with annual incomes below $15 000 as compared to children from families with annual incomes above $30 000 are 22 times more likely to be maltreated. NIS-4 strongly implicated that family-related factors in children’s risk for maltreatment are single parent status, parental substance abuse, and large family size.¹⁹ Other studies corroborate this profile of risk and harm. Rates of child maltreatment are highest in areas defined by high unemployment and concentrated poverty where there are fewer resources to meet basic needs and there is lower social capital.⁴⁴ Child maltreatment is thus suffused with the facts of power (Table 1-3).⁴⁵

International study also reveals strong associations between poverty and child maltreatment.²¹ Globally, rates of child maltreatment are higher in communities characterized by concentrated poverty, high unemployment, residential instability, substandard and overcrowded housing, and low levels of social capital—where community resources (physical, political, educational, etc.) as well as cohesion and solidarity between neighbors are lacking.²¹ On the other hand, leading scholars have also demonstrated the positive, protective power of dense social networks and elevated social capital even among children with other forms of social disadvantage such as poverty or low parental educational levels. In other words, elevating social capital in communities challenged by poverty and economic inequality is a critical countervailing force with regard to the risk of child maltreatment.⁴⁶

Strong social networks can ameliorate risk and act as a countervailing positive force when children are exposed to the toxic effects of low socioeconomic status. Dense social connections and elevating other forms of social capital can uncouple economic inequalities and prevent health-harming outcomes and create greater resilience for children and families.⁴⁶

Governments play a critical role in managing inequities that have important implications for risks of child maltreatment. In the United States, for example, despite the nation’s greater relative wealth, child poverty rates are typically two to three times higher than those in most other major Western industrialized nations. Researchers have demonstrated that in the US cuts in child care subsidy eligibility and health benefits increases the financial burdens to low-income families. On the other hand, increases in eligibility can lessen those burdens.³⁸ In 2011, it was estimated that 4.9 million children were lifted from poverty each year as a result of the federal Earned Income Tax Credit and the Child Tax Credit.⁴⁰ Government decisions such as these, and the interests of political power that shape these policies become especially important during economic downturns when household incomes decline and poverty rates climb. In these ways, political interests and exercise of power have profound implications for child maltreatment.

CHILD MALTREATMENT AND DOMESTIC VIOLENCE

Children are profoundly affected by domestic violence.⁴⁷ Over 100 studies have explored the effects of domestic violence on children.⁴⁸ However, these studies generally do not examine race or culture as mediators of risk or protection.

Children’s exposure to violence is vast. In one study of uninsured and publicly insured families registered in a large urban pediatric clinic in a low-income neighborhood, according to parental report, 10% of children had witnessed a knifing or shooting by the age of 6 years; an additional 18% had witnessed pushing, kicking, hitting or shoving.⁴⁹ Almost half of this witnessed violence occurred at home.

In another study located in a similar setting, 40% of 160 mothers sampled had filed a restraining order against a boyfriend or husband.⁵⁰ By contrast, in a study of privately insured middle-class families, only 17% of mothers reported domestic abuse.⁵¹

A third study examining children’s exposure to multiple forms of victimization including child maltreatment, domestic abuse and community violence found that, on average, children had experienced three incidents of violence during a one-year period. Boys, African Americans, and children who were poor or living in single parent households had the highest rates of exposure to multiple forms of victimization.⁵²

Intimate partner violence is one of many threats to child health and development, as well as a significant contributor to risk of child maltreatment—especially in the context of poverty and economic inequity.

Insufficient social capital experienced by poor children and exposure to many forms of violence increase a child’s risk for maltreatment and harm. Therefore, responses taken to ensure child safety should also consider the safety of all vulnerable family members.

CORPORAL PUNISHMENT AT SCHOOL AND AT HOME

Over the past 30 years, the prevalence of corporal punishment in US schools has dramatically declined due to advocacy for children. In 1976, only 2 states prohibited the use of corporal punishment in schools. Today, more than 30 states have banned corporal punishment in schools.⁵³ Corporal punishment significantly declined from about 3 million per year in the early 1980s to about 225 000 in 2006 in US schools. Still data have described disproportionate use of corporal punishment for African American children despite indications that the elimination of corporal punishment in schools does not increase children’s misbehavior.⁵⁴

Corporal punishment has always been used as a means of disciplining children by parents in the United States.⁵⁵ A great deal of scholarship reveals that both short- and long-term psychological damage and stress symptoms among children are generated by the use of corporal punishment.⁵⁶ Nevertheless, debate persists regarding the efficacy or harm of corporal punishment in the United States⁵⁷,⁵⁸ and 85% of American children have been subjected to corporal punishment by the time they reach high school.⁵⁶

Although corporal punishment in schools has declined, its persistence in society is no surprise. Some argue that the practice has deep roots in American cultural and religious traditions.⁵⁶ Notably, the practice continues despite clear scientific consensus that positive reinforcement/reward, and nonphysical punishment are well-documented and effective alternatives to corporal punishment.⁵⁹ Age, gender, race/ethnicity, and class status shape children’s risk of victimization in school. Boys are more likely than girls to be hit by an adult, and children in primary grades bear higher risks than older children.⁵⁴ Similarly, children from marginalized racial and ethnic minorities and poor white children are over four times more likely to be struck by adults in school than non-Hispanic whites and upper middle-class white students.⁵⁶ In addition, children with disabilities or in special education are more likely to suffer corporal punishment.⁵⁴ One study revealed that a wide range of implements are used to punish children in US schools—wooden paddles, leather straps, wooden switches, baseball bats, fists, and boot-clad feet.⁶⁰

Whether policies and practices regarding this profound, preventable public health problem will be determined by scientific knowledge or merely by beliefs held by groups with greater social and political power and privilege against the nation’s most vulnerable citizens remains an open and urgent question for US schools.

States that prohibit the use of corporal punishment in schools join a small but growing group of 33 nations that have also banned all forms of corporal punishment in homes, schools, and correctional institutions. These include Sweden (1979); Finland (1983); Norway (1987); Austria (1989); Cyprus (1994); Denmark (1997); Latvia (1998); Croatia (1999); Germany and Israel (2000); Iceland (2003); Venezuela, Spain, Netherlands, and Portugal (2007); Luxembourg (2008); Poland and Kenya (2010); and South Sudan (2011).⁶¹ Corporal punishment in schools has also been banned in the United Kingdom, Ethiopia, Namibia, South Africa, Zimbabwe, Uganda, New Zealand, Korea, and Thailand.

Structural Violence and Cultural Difference

Racial, ethnic, and cultural identities in themselves bear no intrinsic risks for child maltreatment. Rather, racist cultural contexts convey or distribute disparate risks on the basis of racial, ethnic, and cultural identities. North American cultural context marginalizes, devalues, and stigmatizes African American, Latino, and Native Americans as deficient and deviant and thus generates profound consequences for social status, risks, and health outcomes for these children. Current and historical discriminatory policies and practices have oppressed certain racial, ethnic, linguistic, and cultural groups in ways that position them at the bottom of the social order. This social position in turn forges disproportionate risk for child maltreatment. Moreover, differential reporting practices, even for the same severity of abuse, drives deeper racial disparities as children become entangled in the child welfare system and CPS.

Racial and ethnic identities are further imbued with meaning by the wider cultural and in the social structural context. Once within the foster care system, African American children are more likely to remain longer, are moved more often, and are less likely to be returned home and to be adopted than their white peers.²³,²⁴

Even when controlling for economic status, children in foster care suffer higher rates of chronic illnesses, psychiatric, psychological, and behavioral problems, school failure, and developmental delays than children not in foster care.⁶² Moreover, despite these elevated risks, access to high-quality healthcare is diminished among foster children compared to other poor children. Even when access to care is achieved, inadequate funding, poor coordination, and lack of continuity compromise quality. Thus exposure to society’s system of care institutions generates risks in disparate and unjust ways compounding preexisting clusters of vulnerabilities.

Racial, ethnic, and cultural differences and their implications for social structural inequity reveal powerful large-scale forces at work in the world. The social construction of the problem of racial disproportionality in child maltreatment and disparate institutional responses demonstrate a fundamental theoretical point. Cultures enable people to interpret the meanings of ideas, actions, experiences, places, things, and relationships,¹ thereby generating structures and meanings of thought and action in ways that profoundly affect child health.

PRACTICES: LESSONS FROM ANTHROPOLOGICAL AND CROSS-CULTURAL STUDY

Childcare and childrearing practices vary across cultures. These practices, as well as the ideas and language people use to interpret the meanings of the practices, generate different experiences yet are fundamental for human change from childhood to adulthood. No empirical cross-cultural research has identified a causal link between any particular culturally based childrearing practice and either higher or lower risk for child maltreatment and harm.

Recognizing the heterogeneity within cultural groups and the fact that cultures change over time and as a consequence of encounters with other cultures is crucial when considering culture in the context of child maltreatment practice and research.

Contemporary anthropologists, in contrast to their disciplinary predecessors, now take great pains to explain that cultures are dynamic and historical to avoid the problem of stereotyping. The prevailing wisdom is that cultural essentialism, the incorrect assumption that there are fundamental, static norms and values that define a cultural group, or characterize its immutable core or essence, may lead to misunderstanding and harm. The most productive perspective, outlined by the leading scholar in the field,⁵ is one that views culture as the crucible within which both risk and protective forces interact in complex ways.

In no contemporary culture ever studied do adults believe and act as if the abuse and neglect of children is acceptable. However, what is considered normal, responsible, and positive childrearing in one culture may have the opposite meaning in another. Scarification (ritualistic cutting or marking body parts to produce a scar in some characteristic and meaningful fashion), parent-child co-sleeping or co-bathing, touching a child’s genitalia, and certain methods of physical discipline have different meanings in different cultures.⁵ In some cultures, these behaviors are useful, salutary, and necessary whereas in others they are proscribed, deviant, and harmful. Ethnography determines whether the behavior is valued or proscribed within the culture, whether the intention of the behavior is to care or to cause harm and whether the action has a clear meaning for the child and for the child within the cultural context. The diversity of perspectives across other categories of differences (eg, across class and gender identities) is also crucial for understanding what practices are made to mean within cultures.

Childrearing practices make most sense when interpreted in light of their cultural contexts. Some culturally based healthcare practices, sometimes called folk medicine—and typically represented as done out of ignorance⁷—are actually part of larger system of meaning that has its own internal logic.

Sometimes culture is construed by the medical community too narrowly, as the exotic, irrational, innocuous (at best), and sometimes harmful beliefs and behaviors of nonwhite, non-European others. Under such circumstances, patients, families, and communities may be woefully misunderstood, and folk practices may be misidentified as the primary engines of health disparity. One consequence of this misdiagnosis or misappropriation of blame is that the political interests and exercise of power that sustain social structural inequities such as racial, gender, and class discrimination and exclusion, which is so crucial to the distribution of injury, affliction, harm, and death, remain unexamined. Moreover, culture’s influence over health practices is left hazardously unexplored in Western biomedical settings. The following practices are typically cited examples in the literature on child maltreatment. However, too often, cultural considerations in child maltreatment are limited to discussions of harmful practices interpreted out of context or cultural practices mistaken for child abuse.

—Cao gio, coining, in Vietnamese medicine is used to treat headache or fever. It involves rubbing the edge of a heated coin vigorously in downward strokes against the skin on the trunk from midline laterally. A similar therapy in Chinese medicine has also been described but more often involves use of a heated spoon rather than a coin. In both practices, symmetric linear ecchymoses over bony surfaces of the trunk are often produced.⁶³

—Cupping, in some Latino, Eastern European, and Russian cultures, is a pain-, inflammation-, and fever-control practice that involves burning small amounts of material on the skin beneath a cup or glass. Round red areas may be left on the skin and first- or second-degree burns can result.⁶⁴

—Moxibustion is practiced among some Chinese, Japanese, Cambodian, Laotian, and other Southeast Asian cultures to address a range of symptoms, including fever, abdominal pain, enuresis, and temper tantrums. The moxa herb (mugwort or Artemisia Vulgaris) is rolled into a ball, placed on the body part of interest, then ignited and burned until the moment that pain requires removal. This therapy may lead to circular or target-shaped burns.⁶⁵

—Mollera caida (fallen fontanelle), described in some Latino cultures, is caused by bouncing or dropping an infant or pulling the nipple out of a feeding infant’s mouth too quickly. The soft palate sinks in in a way that causes symptoms of poor feeding, diarrhea, fussiness, or fever. There are classic maneuvers used to address this problem that aim to reexpand the fallen fontanelle. One such maneuver involves holding the infant upside down and striking his feet. According to one report, this intervention resulted in a condition resembling shaken baby syndrome.⁶⁶

COMPLEMENTARY AND ALTERNATIVE MEDICINE

The Center for Disease Control’s 2007 National Health Interview Survey indicates that 40% of Americans use complementary and alternative medicines (CAM) in a given year (see Table 1-4).⁶⁷ Nearly 12% of children reported using CAM. Rates of CAM use for children were 5 times higher when parents also used CAM than among non-using parents. Acceptance and use of CAM is variable by race. Rates of use among white children are double that of African American children. Likewise, non-Hispanic children were one and a half times as likely as Hispanic children to use CAM therapies.

The National Institutes of Health now include as many as 36 interventions and 45 product categories in its definition of CAM, all of which are used to treat everything from stress and depression to the common cold and pain. While many of these approaches are often seen as an alternative to conventional treatment, the majority of individuals used both methods of treatment.

Faith healing and prayer are perhaps the most well accepted and, at the same time, controversial forms of CAM. It is estimated that when faith healing and prayer are considered, rates of CAM use increases to more the 60% of individuals annually.⁶⁸ Faith healing and prayer use have been described in a wide range of Christian traditions and in Christian Scientism. In certain cases, engaging in these practices delayed exposure to more efficacious Western biomedical scientific assessment and therapy. Negligent behavior on the part of caregivers was considered if children’s lives were endangered. In some cases, parental rights and custody were curtailed or terminated.

THE CHANGING CONTEXT

With an increasingly complex cultural context how can professionals meet their responsibilities both as mandated reporters and as culturally responsive clinicians when children present with findings consistent with injuries from abuse or neglect? Clinical practice has never been so fraught with complexity and thus risk for misinterpretation and alienation between doctor and patient during clinical encounters. Many have commented on the profound demographic shifts in the US population. Increasing religious and cultural diversity has elevated the likelihood that clinical encounters will also be cross-cultural encounters.

These changes in sociocultural context may increase the chances that conflicts or difficulties in clinical interpretation and decision-making may arise when physical findings that result from culturally or religiously based healing practices like those already discussed are revealed in medical settings.

The high stakes of such encounters demand clarity in clinical communication, access to high-quality scholarship, and consultation regarding the range of practices used in communities, transparency in clinical decision-making, and accountability to all the relevant stakeholders in the process (children, families, communities, and the state). The theoretically based practical definition of abuse discussed earlier⁷ elucidates a way toward rigorous, valid clinical interpretations and a way out of conflicts that may arise.

Leading scholars define child abuse as harm that results from adult actions that are proscribed by the cultures and communities in which they take place, are proximate in time and space to the harm, and are preventable, that is, viable and available alternative actions would have avoided the harm. In each example discussed, the well-documented culturally and religiously based practices are acceptable and appropriate (even required) by those who self-identify with the given cultural group. Sorting these issues of identity and intention properly requires careful and respectful listening during the medical interview, scholarly investigation, consultation with insider informants or cultural brokers, and ultimately imagination and artful clinical judgment within community networks. Open, honest communication between families and clinicians about the issues at stake and the process of decision-making is a key component of success.

Difficult clinical interpretations require careful attention, time, and expertise. Considering child abuse or maltreatment in the differential diagnosis is no exception to this rule.

The material, physical signs both of harm/injury and of therapeutic intervention (which include culturally and religiously based practices like those already discussed) must be interpreted in light of the social and cultural context they exist within to uncover their meanings. In the final analysis, these meanings of complex signs determine whether abuse or maltreatment has occurred.

Those who bear the burdens and responsibilities of clinical interpretation also hold the professional privilege of legal protection. One advantage of the professional role is that clinical curiosity is legally protected. In the United States, the Child Abuse Prevention and Treatment Act Amendments of 1996⁶⁹ provides the legal foundations and minimum standards on which various state definitions of abuse and neglect are built. In turn, each state crafts its own definitions to comply with these standards as well as its own civil and criminal codes. A key provision of both federal and state laws is immunity from prosecution or liability for individuals making good faith reports of suspected or known occurrences of child abuse or neglect.

On the other hand, religious freedom and cultural pluralism are also legally protected in the United States. In almost every state, religious exemptions provide that no child shall be considered abused or neglected solely because treatments chosen by parents/guardians are based on religious or spiritual means or practices. The Child Welfare Information Gateway is an accessible and comprehensive reference on specific national and state specific laws on reporting, immunity, and relevant data and policies; see https://www.childwelfare.gov/.

Fortunately, scholarship on child abuse and maltreatment has informed both national and state law in ways that support possibilities for the valid interpretation of clinical findings. Protections for clinical professional curiosity, imagination, and rigor, and protections of religious and cultural freedom exist side by side. In this way, the rights, safety, and dignity of all citizens, lay and professional, are preserved.

Despite the varieties of meaningful practice, cross-cultural study of child maltreatment reveals some important unifying themes that explain risk. Certain kinds or categories of child and social context elevate or diminish risks for child maltreatment.⁷

—Children and families with greater social supports, denser social networks, and less social isolation have less risk for maltreatment.

—Children of single parents or in foster care bear elevated risks of physical abuse and neglect.

—Children with chronic illnesses, disabilities, or birth defects or those who are apathetic as a consequence of malnourishment bear higher risks.⁷⁰

—Children with little economic usefulness as laborers (who are more likely economic consumers rather than producers) bear elevated risks of maltreatment.

—Children with devalued gender identities in cultural contexts characterized by gender inequities and clear gender preferences bear greater risk of maltreatment.

—Lesbian, Gay, Bisexual, Transgender, and Questioning youth whose gender identity or sexual orientation may increase vulnerability to rejection and maltreatment by family members and in the community.⁷¹

—Excess or unwanted children bear great risks of maltreatment.

ON CULTURAL COMPETENCE AND CULTURAL HUMILITY

The concept of cultural competence in medicine has developed new meaning over the past two decades. The term has been used by a vast array of scholars, writers, and consultants in a multitude of programs, conferences, and curricula and in professional standards, training, and marketing materials. Since the publication of the seminal article in the medical literature, Culture, Illness and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research,⁷² the diversity industry in medicine has become a multi-million dollar business with representation across the profession (in research and practice) and among corporations in the medical marketplace. Cultural competence standards have implications for child maltreatment and have been discussed by several prominent scholars.¹,⁴,⁷³,⁷⁴

Encyclopedic mastery of the vast cultural varieties of childcare and childrearing practices that medical professionals may encounter is impossible. Cultural forces also interact with other social forces (eg, economic, psychological, and political forces) in extremely complex ways that elevate or diminish a child’s risk of exposure or harm by intentionally violent adults. Cultural competence, therefore, cannot be achieved by mere attendance at a seminar or perusal of an article or text.

Cultural competence requires a professional capacity for disciplined imagination and action to help manage the health, illness, and care for patients, families, and communities.

Disciplined imagination is curiosity motivated and informed by a fundamental insight of scholarship on health. Social position and the cultural capital associated with that position critically shape one’s health vulnerabilities, opportunities, resilience, and agency, that is, an individual’s ability to make choices and take action.⁷⁴

Building on these professional capacities, the literature also suggests a greater focus on cultural humility. This approach suggests that through mutual respect, self-reflection, and humble inquiry, professionals can enhance their understanding of how culture is manifested in the lives of their patients. Patient-focused interviewing and care can obviate the need for extensive knowledge of specific cultures and replace it with the real world cultural context that their patients experience.⁷⁵ In any culture, questions of who is afflicted or harmed, who suffers or dies from child maltreatment, when, why, and by what means are forged by power relations between social groups. Cultures shape the meanings of ideas, identities, and actions through which power is exercised in social structural contexts. For child maltreatment, cultural considerations in explore how risks and protection are determined by cultures in societies. The purpose of cultural competence and cultural humility in the field of child maltreatment is to use best-practice to uncouple social inequities from their health-harming outcomes. This perspective is derived from the work of scholar Paul Wise reflecting on racial disparities in infant mortality.⁷⁶ Cultural competence and humility uses disciplined imagination to engage individual patients and their families to discover the role of culture in their lives and determine what is important for their health, illness, and care.⁷⁷

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Chapter 2

RISK OF THE INTERNET

Daniel D. Broughton, MD, FAAP

Krishna Dandamudi, Esq

Justin Fitzsimmons

INTRODUCTION

To say that the Internet and technological advances in digital communication devices have transformed the world is an understatement. The Internet itself has undergone radical transformation since it first came into commercial public use in the late 1980s and early 1990s. Today, access to information has become not only instant, but constant. Gone are the days of dial-up connections via a desktop computer, long waits and prohibitive costs of accessing the Web. Practically every new device that is produced today—mobile phones, laptops, tablet computers, cameras, music players, video game consoles—is Internet-ready, and Americans are heavily engaging with these devices.¹

It is no surprise, then, that according to recent estimates, almost 2.27 billion people, or one out of every three human beings on the planet is connected to the Internet.² This worldwide surge in Internet use is largely caused by technological advances in mobile devices and big data, and the digital revolution is supplemented by the rise of social media sites such as Facebook, YouTube, and Twitter that connect millions of people worldwide.

The benefits of the Internet are undeniable. The digital world abounds with opportunities for learning, channels for creativity and productivity, tools to communicate with people from around the world, and even possibilities to create national and international movements for social change.³ For individuals of all ages and backgrounds, especially children, adolescents, and young adults, the Internet is an important forum for socialization, education, and entertainment.

For all its benefits of transforming the quality of life for billions, however, this hyper-connectivity comes at a cost. Widespread use of the Internet is raising growing concerns about security, cyber-crime, privacy, the flow of personal data, individual rights, access to information, and child sexual exploitation.⁴ Children are particularly vulnerable to the risks of the Internet, and any discussion about child maltreatment must address the role of the Internet and mobile technology in facilitating various forms of child exploitation and harm.

Those interested in issues of child maltreatment and Internet risks must pay close attention to numerous areas of concern. Broadly, the harms to children facilitated by the Internet and digital media fit generally into two categories: sexual and non-sexual. Sexual harms are the ones most established in public consciousness, and perhaps rightfully so. The potential for the Internet to be used as a tool for child sexual exploitation of various forms is ever-present, and crimes like child trafficking, forced pornography, and various forms of Internet-based sexual abuse continue to brutally victimize children worldwide. Other harms, however, such as cyber-bullying, sexting, and exposure to self-harm, suicide, hate, and eating disorder sites must also be addressed. Whether sexual or non-sexual, these potential harms are not to be taken lightly. Research shows that they too have serious health, developmental, and psychological consequences, and may affect a broader population of children given the ubiquity of the Internet.⁵

Parents, service providers and law enforcement must continue to educate and reeducate themselves of the various ways in which both children and adults use the Internet, and all the ways in which it can harm children. The goal should be to stay on par with, if not one step ahead of, technological and social changes.

INTERNET USAGE

ADULTS

Consider the transformation in Internet use within the adult population of the United States in the last decade. In the year 2000, less than half (46%) of all adults used the Internet and slightly over half (53%) owned cell phones. Almost no adults (0%) used social networking sites or connected to the Internet wirelessly. Fast forward to the year 2012, and more than 8 out of every 10 (82-85%) American adults over the age of 18 years use the Internet in some form, 88% own cell phones, 46% own