April is National Child Abuse Prevention Month and Sexual Assault Awareness Month. The following diary samples free-access professional healthcare materials relating to violence, abuse, negligence and maltreatment of children and teens. A separate diary sampling articles on sexual assault, gender-based violence, bullying, and their origins, effects and prevention, was published earlier. Some articles applying to both topics may be in both diaries.
Research reportage and discussion within the community of healthcare professionals lends the public a working perspective for increased medical and public health literacy that news media and patient education materials often can't supply. Most of the articles below are linked at Medscape, a free fairly-plain-English email-alert and website medical research and news reportage service. For an introduction to free use of Medscape, see the large blockquote at this brief item.
Blockquotes with article links are exerpts to give an idea of the viewpoint and approach of research and reportage. Articles are numbered for the convenience of readers and are listed simply by the order in which they were found, without other significance.
The red flags that should alert the provider to possible abuse include: History that is inconsistent with the injury; No explanation offered for the injury; History that is inconsistent with the child's developmental level; and Injury blamed on another child or sibling."Blamed" on another child or sibling is a slippery slope (editorial emphasis added for clarification): ▼
2. ▼ Dating Violence by Teens Associated With Assault on Siblings, Peers
Among the [violent teen subjects] with siblings, 50.8% of the boys and 60.5% of the girls reported having physically assaulted a sibling, peer, or dating partner at least once in the past month. Only 7.9% of all violence perpetrators reported participating in dating violence only.3. ▼ Psychopaths Programmed to Be Reward Seekers (by endogenous dopamine dysfunction).
...14.1% [of the violent male teenage subjects] reported participating in physical dating violence, 84.4% in peer violence, and 49.6% in sibling violence. Only 2.3% reported perpetrating only physical dating violence ... 75% reported both dating violence and peer violence ... 55.6% reported both dating violence and sibling violence.
...44.2% [of the violent female teen subjects reported violence] against dating partners, 65.2%...against peers, and 59.8%...against siblings. ...12% reported only [dating violence], with 59.4% reporting both dating violence and peer violence, and 50.3% reporting both dating violence and sibling violence.
...physical dating violence was associated with alcohol, tobacco, and marijuana use; carrying a knife; delinquency; school failure and truancy; victimization by peers or family; and exposure to community violence...
[The authors] note that there are several possible reasons why the girls in this study reported [perpetrating] more physical dating violence... than [did] the boys. These include that the girls may have [included] playful hitting or self-defensive actions that boys often do not. Also, because the assessments did not ask about sexual violence, the boys may have underestimated their episodes of dating violence.
Psychopaths doggedly pursue rewards without particular concern about potential consequences, and this tendency seems to be due to a malfunctioning brain reward system, new data suggest. Published online March 14 in Nature Neuroscience, the findings were reported by investigators from Vanderbilt University, Nashville, Tennessee.▼ Possibly related: Toward a 'Where' and 'How' Understanding of Dopamine Dysfunction in Disorders of Attention:Amphetamine-Induced Dopamine Release and Neurocognitive Function in Treatment-Naive [i.e., never treated with drugs for at least this diagnosis]Adults With ADHD [use caution to not assume judgementalness about ADD/ADHD in this research, especially in this context of this list; that's not what is significant or valuable about this research.
"The heightened dopamine release we found in the brains of individuals with psychopathic traits suggests that psychopathy may reflect dysfunction in dopamine reward circuitry," said lead author Joshua W. Buckholtz, BS, who is studying for his doctoral degree in neuroscience, told Medscape Psychiatry. "This study identifies a new brain system as being involved in psychopathy and may lead the way for future studies that target this system as a way of reducing aggression and antisocial behavior.
"It also sheds light on the fact that, despite the availability of good evidence for underreactivity to some kinds of emotional stimuli, psychopaths don't have a general lack of emotional reactivity. In fact, the observed overreactivity of dopamine might cause them to pay more attention to obtaining rewards (like money, sex, or status) at the cost of attending to other things, like the potential consequences of their actions to their victims or even themselves,"
Attentional Disorders4. ▼ Proactive Aggression in Callous-Unemotional Youth May Reflect Lack of Empathy, Reuters Health Information, Apr 2014.
Disorders of attention can be conceptualized as disorders of ineffective frontal lobe processing of incoming stimuli. Parts of the frontal-subcortical circuits involved in executive function, reward, and motivation have been targeted in functional MRI studies of attentional disorders, yielding consistent patterns of abnormal frontal-striatal activation.
The dopaminergic system in particular has been consistently linked to attentional and cognitive processing abnormalities. In many cases, impulsivity is strongly associated with impaired attention and attention-deficit/hyperactivity disorder (ADHD) traits. In psychiatry, strict use of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), in making a diagnosis leads more often than not to the inclusion of different diagnoses under axis IV that may share common symptoms. If the DSM symptom criteria are strictly followed, the triad of inattention, impulsivity, and cognitive impairment can certainly be observed in disorders as phenomenologically separate as major depression, schizophrenia, bipolar disorder, and substance dependence [&etc.].
Brief Study Description
This commentary is based on a double-blind randomized study of 2 matched groups: 15 male patients with ADHD and 18 healthy male controls. Standard DSM-IV criteria were used to diagnose ADHD. The 2 main design points of the study involved use of 2 PET scans and administration of neuropsychological tests to both groups. PET was done with [11C]raclopride, a radiolabeled synthetic compound that antagonizes the dopamine receptor, in the study groups before and after lactate infusion and amphetamine administration. The main goal of this study was to further elucidate the neurochemical and structural abnormalities within the basal ganglia (the corpus striatum in particular) of the dopamine system indirectly, via measurement of binding to dopamine 2 and 3 (D2/D3) receptors.
Proactive [indicated to mean "goal-directed" in this article: violence to achieve an objective] aggression in youth with callous-unemotional traits is accompanied by amygdala hypofunction in response to...facial expressions [of fear and emotional distress], according to a case-control study [reported in] JAMA Psychiatry online (abstract).5. ▼ Psychopaths Know Right from Wrong but Don't care(editorial emphasis added for clarity)
Dr. Abigail A. Marsh, Georgetown University, Washington, DC. ...and colleagues used functional MRI to scan 16 healthy control participants and 30 juveniles [male and female... aged 10 to 17 years] with conduct problems who varied in callous-unemotional traits (16 with low callous-unemotional traits, 14 with high callous-unemotional traits), hypothesizing that differences in amygdala function could underlie these differences... The presence..of callous-unemotional traits ...(now referred to as 'limited prosocial emotions' in DSM 5)... is associated with more severe, persistent, and treatment-refractory externalizing behaviors [fighting, bullying, cursing, and other forms of violence].
"...sometimes kids with conduct problems are approached clinically as though their symptoms always reflect heightened anxiety or stress that may...result from previous trauma or maltreatment," Dr. Marsh said. "Our findings, and those of others, suggest that ...[youths] with high levels of callous-unemotional (traits) actually are not emotional enough... [they are] deficient [in] empathic responses to distress...
Adult psychopaths have deficits in emotional processing and inhibitory control, engage in morally inappropriate behavior, and generally fail to distinguish moral from conventional violations. These observations, together with a dominant tradition... which sees emotional processes as causally necessary for moral judgment, have led to the conclusion that psychopaths lack an understanding of moral rights and wrongs.6. ▼ A Single Question to Sexually Abused Children Predicts Their Trauma Symptoms
We test an alternative explanation: psychopaths have normal understanding of right and wrong, but abnormal regulation of [their] behavior. We presented psychopaths with moral dilemmas, contrasting their judgments with age- and sex-matched (i) healthy subjects and (ii) non-psychopathic delinquents. Subjects in each group judged cases of personal harms (i.e. requiring physical contact) as less permissible than impersonal harms, even [where] both types of harms led to utilitarian gains. Importantly...psychopaths' pattern of judgments...was the same as those of the other subjects. These results force a rejection of the [concept] that emotional processes are causally necessary for [moral] judgments, suggesting instead that psychopaths understand the distinction between right and wrong, but do not care about such knowledge, or the consequences that ensue from their morally inappropriate behavior.
"We found that a single question - 'Sometimes, do you feel like any of this is your fault?' - predicts multiple trauma symptoms in this population," said principal investigator Dr. John D. Melville, site director of the Child Advocacy Center at Akron Children's Hospital, Mahoning Valley, in Boardman, Ohio, in an email to Reuters Health. "I was surprised by the strength of the association between self-blame and multiple trauma symptoms. Resiliency following trauma is a complicated, multifaceted process. It is unusual to have a single factor so strongly associated with so many outcomes."
The authors investigated behavioral and emotional symptoms of abuse and self-blame in [charts of 501 consecutive children aged 8 through 17 years one large urban child advocacy center, who had previously been] medically evaluated after disclosing sexual abuse, as well as family responses to disclosure ...All of the children had forensic interviews ...by either a physician or a sexual assault nurse examiner trained in assessing child sexual abuse.Clinic staff interviewed the children's parents or guardians separately, and asked them if they believed completely, partially, or did not believe the child's first claim of abuse, and whether their belief later changed."Our study...included many more Hispanic children than prior studies on self-blame. We found that Hispanic children react to sexual abuse in a way similar to their non-Hispanic peers," Dr. Melville said. Overall, 83% of the children had at least one trauma symptom such as problems with sleep, school, appetite, or sadness; 20% had one symptom and 45% reported three or more symptoms. Sixty percent of the children had difficulty sleeping, and almost 35% had thoughts of self-harm. A total of 55% reported self-blame. Children older than 12 years were almost twice as likely to blame themselves for the abuse...and girls were twice as likely as boys to blame themselves...
The children of parents who indicated disbelief at their child's disclosure of abuse were more likely to blame themselves during their medical assessment than the children of parents who completely believed their child's initial disclosure (65% vs. 51%...). In contrast, parental disbelief at the time of the medical assessment was not associated with child self-blame, according to findings published online March 11 in Child Abuse & Neglect.
Parents need to let children know that they believe what they disclose about the abuse and understand the impact their initial reaction will have on their child's emotional response to the abuse, the authors write.
Co-author Dr. James L. Lukefahr, from the University of Texas Health Science Center at San Antonio, said, "The most important thing to bear in mind when a doctor is evaluating a child who has likely been sexually abused is ...to query the child in a caring and respectful way... The vast majority of children who have been sexually abused are having [trauma]/psychosocial symptoms [but] probably won't volunteer [that information]."...
"A sexual abuse evaluation is a specialized service that comprehends more than an evidence collection or a physical examination. Physicians must diagnose and treat these emotional consequences of sexual abuse," Dr. Melville said.
In the US, child advocacy centers are multidisciplinary facilities that have increasingly taken on the responsibility of providing legal intervention and psychotherapy for children who are [alleged victims of crimes, and non-offending family members]... In 2012, 286,457 US children received services at C.A. centers, and of these, 197,902 (69%) were [assessed as having been] victims of child sexual abuse. study abstract (scroll down past reprint purchase information)
11. ▼ Poverty, Maltreatment and Attention Deficit Hyperactivity Disorder, from Archives of Disease in Childhood, 2013. Sections: Abstract • Background • Impact of Exposure to Conflict and Violence on Brain Development and Function • Testing the Hypothesis • Problems for Diagnosis, Management and Research Diagnosis • Conclusions • References
Abstract: Attention deficit hyperactivity disorder (ADHD) is a common condition affecting many thousands of children. It is a condition that can have adverse health, social and educational outcomes. It also exacts significant societal costs, economically and socially. This paper hypothesises that the population of children receiving a clinical diagnosis of ADHD is aetiologically heterogeneous: that within this population, there is a group for whom the development of ADHD is largely genetically driven, and another who have a 'phenocopy' of ADHD as a result of very adverse early childhood experiences, with the prevalence of this phenocopy being heavily skewed towards populations living with poverty and violence. A third group will have a high genetic risk and have been exposed to violence. These groups will overlap, with epigenetic phenomena and other environmental factors, for example, preterm birth, poor intrauterine growth, foetal exposure to teratogens, playing an important role for all affected children in determining the severity of their functional difficulties. ...12. ▼ Shaken Baby Syndrome Nickolaus J. Miehl Disclosures J Foren Nurs. 2005
Impact of Exposure to Conflict and Violence on Brain Development and Function:The infant human brain at birth is relatively immature in comparison to other mammals. Consequently, the first two years of life, especially the first, see marked growth and development of the brain, including the establishment or loss of cellular interconnections and cell culling. The direction and pattern of these processes is partly genetically, partly environmentally driven although, of course, these factors are not independent. The emerging science of epigenetics is providing some explanation as to how they inter-relate. However they do, it does not alter the undeniable conclusion that our children's brains are sculpted irrevocably by their early life experiences, and that these impacts last into adulthood.
Shaking generally is attributed to the perpetrator's level of tension and frustration, often generated by an infant's crying or irritability. Risk factors for nonaccidental injuries in children and infants include... Negative childhood experiences including neglect or abuse... Additionally, parents or caretakers who have been involved with substance abuse and/or domestic violence may be at a higher risk for inflicting SBS. Societal factors, such as the general acceptance of violence on television, radio, and video games may also have a strong correlation with child maltreatment (Thomas, Leicht, Hughes, Madigan, & Dowell, 2003).13. ■ Children in Lesbian Families Less Likely to be Abused by Parent, Other Caregiver Deborah Brauser November 18, 2010
...Parents may not be aware of the basic needs and normal development of their infant. This can lead to a role strain due to unrealistic expectations of the infant and a poor understanding of the infant's developmental level and abilities. Fulton (2000) notes that infants can spend up to 20% of their awake time crying. To the parents and caretakers of the infant, he or she may seem inconsolable, and frustration can quickly build. This may lead to the physical shaking of the infant in an attempt to calm the baby. Episodes of shaking are directly proportional to the degree of frustration felt by the parent or caretaker, and parents are often the perpetrators of abuse resulting in a child fatality (Tenney-Soeiro & Wilson, 2004). Men outnumber women as perpetrators of shaking by a 2:1 ratio, including fathers, step-fathers, and boyfriends (Keenan & Runyan, 2001). Caretakers, including babysitters, are now being examined as possible contributors to SBS (Fulton, 2000). Risk factors of caretakers contributing to SBS include immaturity, young age, and lack of life experience.
14. ■ Emotional Maltreatment
Significant neglect or abuse during childhood adversely affects levels of the hormones leptin and irisin, suggesting a link between adversity in early years and metabolic disorders later in life, according to a new study.27. ▼ Childhood Abuse Linked to Food Addiction
This is the first known report of early-life adversity influencing levels of adipomyokines (hormones released from adipose tissue) in adult life, say the investigators. It adds to the growing body of data regarding the potential impact of early-life adversity on obesity, diabetes, and metabolism in later life.
Analysis of more than 57,000 women who participated in the Nurses' Health Study II (NHSII) showed that those who experienced physical or sexual abuse as children and/or adolescents were twice as likely to have a current food addiction as the women who did not suffer past abuse. The risk for food addiction was even greater for the women who had experienced both physical and sexual abuse...28. ▼ Abandoned Time and Time Again: (Part of a series, "The Child Exchange: Inside America's underground market for adopted children") The complete article is highly recommended - please consider reading in full.
EDITOR'S NOTE: This story contains language that some readers may find offensive.29. ■ Essential Information About Patterns of Victimization Among Children With Disabilities
...of the roughly quarter-million foreign children brought to this country through adoption since the late 1990s...their fate in America has never been systematically examined. ...A Reuters investigation has revealed how Americans who adopt from overseas can easily offload troubled children to virtual strangers they meet on the Internet. Through a practice called "private re-homing," parents market their unwanted kids online and pass them along to others - quickly, often illegally, and almost always without consequence for the adults.
In a single Internet bulletin board examined for this series, a child was offered to strangers once a week, on average. Most of the children - 70 percent - were listed as foreign-born. They came from at least 23 foreign countries, including Russia, Ethiopia, China and Ukraine. (Yahoo took down the bulletin board in response to what Reuters found.)
Adoptive parents say they turn to Internet groups because they have no alternative. In an interview with the Associated Press in 2001, Priscilla Whatcott said life was so bad that she wondered whether Inga [the pre-teen Russian girl adopted by the Whatcott's through Nightlight Christian Adoptions], would simply be better off dead. "Some days I think that the very best answer is for God to take her," she told the AP. "Release her and be done with it. There is no happy ending here."
Whatcott's solution was tougher liability laws. "Clearly, we would have avoided much of this heartache and tragedy if consumer protection laws pertaining to international adoption had been in place," she wrote in testimony submitted to Congress in 1999. ... Today, 16 years on, Whatcott still compares adopting Inga to buying "a pig in a poke" or being "sold a bill of goods."
Stephen Pennypacker, a child welfare official in Florida, says adoptive parents aren't consumers and their troubled children can't be treated like faulty products...
Trafficking in persons is a human rights violation that occurs around the world. Human trafficking involves the recruitment and movement of individuals—generally by force, coercion, or deception—for the purposes of criminal exploitation or abuse... the International Labor Organization has estimated that approximately 12.3 million people are in situations of forced or bonded labor, half of whom are believed to be women and girls... Although men, women, and children are trafficked and exploited in such economic sectors as construction, farming, fishing, textiles, and mining, the trafficking of women and girls for forced prostitution is among the most well-recognized forms of trafficking. Because of the often extreme sexual, physical, and psychological abuses associated with this form of gender-based violence, women and girls who are trafficked and sexually exploited through forced sex work or in other circumstances such as domestic servitude, are a population of particular concern for mental health specialists. Researchers and advocates continue to call for urgently needed psychological support services for trafficked persons—and for sexually abused women and girls in particular... Some trafficked girls and women do not suffer extraordinary levels of abuse; nevertheless, assault, coercion, threats of harm to themselves and their families, and severely restricted freedom are common... many of the menacing tactics used to control trafficked girls and women are readily comparable with the characteristics of abuse described in the literature on torture
34. ■ Forced Female Genital Cutting Female Genital Cutting. J Obstet Gynaecol Canada 2013 Nov;35(11):1028-45. Abstract. Reported at length in Guideline format, with evidence quality rating descriptions, in Agency for Healthcare Quality & Research, National Guidelines Clearinghouse, NIH, U.S. Dept. of Health & Human Services
...Female genital cutting (FGC) is internationally recognized as a harmful practice and a violation of girls' and women's rights to life, physical integrity, and health. The immediate and long-term health risks and complications of FGC can be serious and life threatening. ...Global migration patterns have brought FGC to Europe, Australia, New Zealand, and North America, including Canada...There is concern that FGC continues to be perpetuated in receiving countries, mainly through the act of re-infibulation... Performing or assisting in FGC is a criminal offense in Canada. Reporting to appropriate child welfare protection services is mandatory when a child [is found to have] been subjected to FGC or is at risk of being subjected to the procedure... There is a perception that the care of women with FGC is not optimal in receiving countries...35. ■ Trauma-Focused CBT Effective for Pediatric PTSD possibly versus No Long-term Benefit of Trauma Treatments in Kids