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| Identification as a necessary step for prevention |
by Mr Carl-Göran Svedin, Associate Professor, M.D. in Child Psychiatry, 3/17/99
Speech
from The Stockholm Ministerial Meeting on Children at Risk in the Baltic Sea Region
17th March 1999
Paper presented at the Stockholm Ministerial Meeting on Children at Risk in the Baltic Sea Region, 17/3 1999.
Children at risk.
Identification as a necessary step for prevention
Svedin, Carl Göran, M.D., Associate professor
BUP-Elefanten, University Hospital, Linköping, Sweden
Dear delegates, I am very honoured to have been invited as speaker to this conference since it is a very important step for children in the region. My name is Carl Göran Svedin and I work as a child and adolescent psychiatrist and project leader at CAP-Elefanten in Linköping, Sweden. CAP-Elefanten is the first specialised unit for physically and sexually abused children within the child and adolescent psychiatry in Sweden. The unit is multidisciplinary in its composition and apart from treatment the unit is also a centre for education and research. I am also an Associate Professor at the Department of Child and Adolescent Psychiatry, Faculty of Health Sciences, Linköping University.
INTRODUCTION
In this first presentation I will try to focus on children at risk and prevention and in the second presentation I will try to focus on treatment and rehabilitation of child victims. It is in my view of thinking our task, that independently of wherever we work or to what profession we belong, it is our duty to make the uttermost to prevent that children are exposed to maltreatment or abuse. When an abuse already have taken place it is our duty to try to perform investigations and offer help in a way that children and families can benefit without getting into more distress than before.
AWARENESS AND RECOGNITION
It is well known that when people don?t know what to do, they don?t react on the signs of abuse or stories of abuse even if they are more or less overtly presents to them independently of the form of maltreatment, emotional/psychological abuse, physical abuse or sexual abuse. Information, policymaking and change of attitude are therefore crucial and primary steps in this community process.
I will address the problem of identification of children at risk and prevention in the following order: sexual abuse, physical abuse and emotional/psychological abuse.
Sexual abuse
The problem with estimating the prevalence and incidence of sexual abuse constitutes a
major problem. The first and overshadowing difficulty is all the unknown and unreported
cases. Other problems emanate from the difficulties with definition and sample techniques. By prevalence studies we know that approximately 10-20 % of all women and 3-10 % of all men in Europe have experienced sexual abuse before the age of 18.
Even if we looks at the lower figures as in Sweden these constitutes a great proportion of the population and if it is associated with mental illness and difficulties in the social adaptation it also constitutes a major health problem in the society. The majority of child sexual abuse offences will never come to the authorities knowledge because of non-suspicious adults or the victims unwillingness or incompetents to report.
Aetiology to sexual abuse/risk-factors
The mechanisms behind sexual crimes against children are to be seen as based on multiple factors (figure 1) identified as motivated perpetrator, and the perpetrators personality traits, factors associated with the child and factors connected wit the circumstances. A child sexual crime situation could most easily be described as a situation where an individual with a paedophilic disposition approaches an attractive child and if it results in a sexual abuse or not depends on the situation and the child?s ability to defend itself.
Basic conditions are that the perpetrator has a great emotional benefit by being with children. This is probably the reason why paedophiles often are described as very child-centred, are liked by children and have a good hand with children. Another condition is that children sexually attract the perpetrator. Yet another factor is inadequate social competence in adult relations especially in sexual relations. As a result of this the perpetrator turn to children, which can more easily be engaged, seduced and dominated. All these factors can be at hand without a potential perpetrator abuses a child. Decisive for the last step in this chain is believed to be that inner defencemechanisms such as taboo, morality and law-abidingness under certain circumstances gives away with the result of inadequate control of sexual impulses. This control can be more or less reduced by personality disturbances, pre-senility mental retardation or more temporarily for example by alcohol and substance abuse, depression or psychosocial stress.
From this perspective paedophilia can be seen as an emotional disturbance, a sexual disturbance, a relational disturbance alternatively as a disturbance of the control of inner impulses. It is probably most constructive to see paedophilia as the result of a combination of these mechanisms. The paedophilic behaviour towards the child often consists of a very careful selection of a child, a kind of courting that can go on for a very long time, motivation of the sexual activities and making the acts secret by affection, bribes and threats. This also means that some children are more attractive children than other children due to their age, sex and appearance. Some children are more easily recruited or have a diminished ability to ward of an offence due to a low self-esteem and self-confidence, social isolation, different kinds of disabilities such as psychological difficulties, mental retardation and physical handicap. These examples are consequently to be regarded as risk-factors. Children lacking peers, regular leisure activities and supervision run also a greater risk since a potential perpetrator don?t want to take the risk to be disclosed by approaching children in groups or children having a good and caring protective adult in the vicinity.
In addition to these interweaving factors, sexually exploited children are found to come from underprivileged homes, lacking in childcare. This also means that children coming from underprivileged circumstances, for example children running away from home, are vulnerable to becoming economically dependant, selling their bodies for sex and pornography. This group currently forms the core of those children in different countries that become street prostitutes and is the group targeted in the expanding sex-tourism trade.
Child physical abuse
Aetiology
As with sexual abuse many factors are usually also present in a specific case of child physical abuse. These factors could be divided to factors connected with the perpetrator, the child or the environment (figure 2). These factors can also be viewed as risk factors that in special circumstances for example the addition of a stressful situation triggers the abuse. Many studies have shown that parents that themselves as children have experienced neglect and physical abuse are more prone to neglect, physically punish or physically abuse their children. A personality with an aggressive/explosive character, low tolerance of frustration and lacking the ability to resolve conflict situations is associated with an increased risk for child physical abuse. Mental illness as for example affective disorders and substance abuse risk to reduce both the threshold for stress tolerance but even the threshold for executing an aggressive behaviour towards the child. Unrealistic expectations towards the child or a negative perception of the child?s behaviour might lead to aggressive punishments as well as a general harsh mode of upbringing. A failing parent during the infancy of the child can be compensated by support from the partner or other peoples in the network but if this support is missing or the parent is not able to ask for help it increases the risk for child maltreatment-physical abuse. Shortcomings in the ability to plan and foresee difficulties have also been noted.
Prematurity and different forms of child disabilities/handicaps are the most usually cited contributive factors in the child that are connected with child physical abuse. Environmental factors is also to be seen as stress factors that not directly but indirectly influences the parents abilities to deal with their difficulties.
Child neglect and psychological abuse
Child neglect have different meaning for different people and varies also if you see it from a legal, medical, psychological, social or lay perspective. Common for all neglect is that the child has seriously or for a long time been exposed to physical as well as psychological neglect in care and protection. Neglect can be either intentional or unintentional but usually we mean a more passive form compared with child psychological or emotional abuse that we more often see as a more active act from one or both of the parents.
Different kind of subtypes of child neglect has been identified (figure 3). Physical neglect is perhaps the most obvious form an includes that the child is not properly protected from different kind of dangerous situations and don?t get it?s basic need for shelter, housing, food, hygiene and clothing provided for. Emotional neglect is more difficult to proof and document since the physical signs are missing. Aggravating circumstances are often that this kind of neglect is subtle, occurs in the private area of the home and often affects the smallest children without verbal capacity to tell somebody. ''Non-organic failure to thrive'' is understood as the most extreme form of emotional neglect. Medical neglect is defined as the caregivers insufficient ability to seek medical care in time or to complete medical ordinations or vaccination programme. Mental health neglect is similar to medical neglect in the way that the caregiver doesn?t seek or refuses to comply with psychiatric or psychological helps when the child has severe emotional or behaviour problems. Educational neglect could mean that the caregiver doesn?t comply with the requirements of school attendance and accepts or promotes truancy. Another example could be to refuse a child with learning difficulties to get special education.
Psychological/emotional abuse is usually used when a more active pattern of behaviour is observed. The caregiver uses repeatedly a behaviour that gives the child a feeling of being worthless, unloved, or unwanted. Other examples of psychological abuse can be spurning-hostile rejection, terrorising, isolating, exploiting/corrupting and denying emotional responsiveness.
Aetiology
Most vulnerable are children to parents that acute or in more chronic way fails in their obligations as parents. A common trait is that the caregiver lacks an understanding of the emotional interaction in human relations, especially in the parent-child relation. An inability to enter into the child?s situation and needs and difficulties in confirming the child?s unique characters. The reason to this can be personality disorders, mental retardation, mental illness or substance abuse. But also factors associated with the child such as temperament (or the parents perception of their child?s temperament) and factors in the environment such as poverty, unemployment, marital discord, stressful life events, lack of social support and network are important for understanding the mechanism behind child neglect and psychological abuse. In order to prevent child abuse we need knowledge about children at risk. We need help from all citizens but especially from professionals working with children on a daily basis. In order to achieve this professionals need education and training in identifying these children but we also need adequate resources to give these children protection, treatment and rehabilitation, hopefully in the majority of the cases together with their parents.
| Published by |
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Sweden, , Seyfert Helena(Sweden) |
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28.02.2001 |
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