1. Preventing child maltreatment 1 |1 | A public health approach to preventing child maltreatment Dr Dinesh Sethi Violence and Injury Prevention WHO European Centre for Environment and Health, Rome

2. Preventing child maltreatment 2 |2 | Key facts and figures from the WHO European Region - 1 Almost 1,500 children aged 0-14 years died in the WHO European Region in 2002 as a result of homicide (*) The rates for children 0 – 4 years are double that for those aged 5 – 14 years. Occurrence of sexual abuse in childhood is as high as 20 % in women and 5 – 10 % in men (*) About 34 % of young people report being bullied at least once in the past 60 days (**) About 75,000 children are estimated to be involved in the sex trade in Eastern Europe (*) Available data suggest that severe physical punishment has an incidence of 5 – 8 % (*) (*) Injuries and Violence in Europe, Why they matter and what can be done (2006) WHO Regional Office for Europe (**) Young people’s health in context - Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey (2004) WHO Regional Office for Europe

3. Preventing child maltreatment 3 |3 | Standardized mortality rates for homicides in children aged 0 - 14 years for countries with more than 1 million inhabitants in the most recent year (deaths/100,000 population) Source: WHO EURO Mortality Database June 2006

4. Preventing child maltreatment 4 |4 | UN SG's Study on Violence Against Children Gap between human rights commitment and investment in evidence-based prevention programmes and services

5. Preventing child maltreatment 5 |5 | Objectives of the guide Convey knowledge of what's needed to design and implement child maltreatment prevention programmes as outcome evaluation studies Expand the evidence base to include more outcome evaluation studies from low- and middle-income countries Help prioritize child maltreatment prevention in international and national health and development agendas

6. Preventing child maltreatment 6 |6 | Guide Content overview Introduction Nature and consequences of child maltreatment Epidemiological and case-based information Prevention of child maltreatment Services for affected children and families Conclusions and recommendations Appendices

7. Preventing child maltreatment 7 |7 | Introduction Focus on child maltreatment in age 0-14 years Perpetrators mostly parents and family members Place of occurrence mostly private Professional audiences Health Social Legal Research

8. Preventing child maltreatment 8 |8 | Systematic, population-level approach Surveillance What is the Problem? Identify risk and protective factors What are the causes? Implementation Scaling up effective policy and programmes Develop and evaluate interventions What works and for whom?

9. Preventing child maltreatment 9 |9 | 1. Nature and consequences: definition

10. Preventing child maltreatment 10 | IndividualRelationship/ Family CommunitySociety 1. Nature and consequences: ecological model

11. Preventing child maltreatment 11 | 1. Nature and consequences: life course approach Adverse Childhood Experiences Social, Emotional, & Cognitive Impairment Adoption of Health-risk Behaviors Disease, Disability Early Death Birth Death Birth

12. Preventing child maltreatment 12 | 2. Epidemiological and case-based information Population-based epidemiological surveys Use of physical punishment Exposure to child maltreatment Current health risk behaviours Current health status Facility-based case information Non-fatal cases (known and suspected) Fatalities (known and suspected) Using information for advocacy

13. Preventing child maltreatment 13 | 2. Population-based epidemiological surveys Survey instruments Parent-child Conflict Tactics Scale Adverse Childhood Experiences Study questionnaires Lifetime Victimization Survey Screening questionnaire ISPCAN Child Abuse Screening Tools Adapting survey methods to local conditions Sampling strategies Ethical considerations

14. Preventing child maltreatment 14 | Categories and prevalence of Adverse Childhood Experiences Prevalence (%) Abuse, by Category Psychological (by parents)11% Physical (by parents)11% Sexual (anyone)22% Household Dysfunction, by Category Substance Abuse26% Mental Illness19% Mother Treated Violently13% Imprisoned Household Member 3% Category Felitti et al, 1998 2. Epidemiological and case-based information

15. Preventing child maltreatment 15 | 3. Prevention of child maltreatment PREVENTION IDENTIFICATION REPORTING REFERRAL TREATMENT INVESTIGATION FOLLOW-UP Address underlying causes and risk factors Child maltreatment occurs

16. Preventing child maltreatment 16 | 3. Prevention of child maltreatment Societal and community Providing early childhood education and care Reducing alcohol availability Changing norms that support child maltreatment Relationship Home visitation programmes Training in parenting Individual Reducing unintended pregnancies Increasing access to pre- and post-natal services

17. Preventing child maltreatment 17 | 3. Prevention of child maltreatment Ecological level Community/ society Parent/familyInfant/childTime from intervention to measurement Belief in acceptability of punishment Parental knowledge and expectations Infant development Educational achievement Homicide rates in children 0-4 years old Encounters with criminal justice system Adult reporting health risk behaviours Examples of outcome evaluation indicators Short Long

18. Preventing child maltreatment 18 | 4. Services for affected children and families Child maltreatment occurs PREVENTION IDENTIFICATION REPORTING REFERRAL TREATMENT INVESTIGATION FOLLOW-UP

19. Preventing child maltreatment 19 | Integrated mental/physical health and forensic assessment –Consent –History –Top-to-toe physical exam, including genito-anal exam –Documentation and treatment of injuries –Mental health assessment –Screening or treatment for STIs, HIV –Prevention of pregnancy –Forens ic examination Psychosocial support Support services for families 4. Treatment and support

20. Preventing child maltreatment 20 | Reporting laws: issues to consider Integrated assessment of families at risk Intervention for the best interest of the child 4. Protecting the child

21. Preventing child maltreatment 21 | Conclusions and recommendations Base policies, plans, programmes and services on scientific evidence Define child maltreatment cases and outcome indicators using international norms and behavioural definitions from well-tested instruments Design and implement prevention programmes and services as outcome evaluation studies Integrate wherever possible prevention and services into existing systems

22. Preventing child maltreatment 22 | Information on violence prevention in Europe www.euro.who.int/violenceinjury To obtain Preventing child maltreatment www.euro.who.int/violenceinjury Information on violence prevention in Europe www.euro.who.int/violenceinjury To obtain Preventing child maltreatment www.euro.who.int/violenceinjury Send an Email giving your name, organization, postal address and the number of copies required to: violenceprevention@who.int or download a PDF version from http://whqlibdoc.who.int/publications/2006/9241594365_eng.pdf

23. Preventing child maltreatment 23 | Zurich project on the social development of children Eisner, M. 2004. http://www.z-proso.unizh.ch/Dokumente/NEWSLETTER1en.pdf Longitudinal study –1000 children –1000 parents Prevention programme –Triple P –Paths Randomized Control Trial