Hi, my name is Jordan Greenbaum.

I'm the medical director of

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