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Stopping Child Abuse: A Challenge for Child and Adolescent Psychiatrists

Child Abuse is Increasing
The misery problems related to child abuse are universal. The United Nation has officially called for the world to stop ignoring this problem. WHO also passed a resolution to recognize violence to children as public health issue in 2005. Children below age 18 account for one fourth of population in Taiwan and their welfare is a big issue in this society. Recently, news of several severe fatality cases of child abuse had been reported so frequently that had attracted a great public concern. More and more children and adolescents have been abused physically, psychologically, and sexually by their parents, caregivers, teachers, friends, or even strangers. The psychiatric assessment, intervention and prevention of further abuse of victims are unavoidable responsibilities of psychiatrists and related professionals.

In Taiwan, The Child and YouthWelfare Law had been revised again in 2004.Many efforts were conducted to stop the child abuse by the Children's Bureau and Ministry of Education since 1993. Although the work of child protection has made considerable progress in the past decade, the reported incidence of child abuse is increased further. The true figure of child abuse in Taiwan was little known due to lacking of epidemiological study. From the statistics revealed on the web of Children Bureau, about ten thousand children and youths were victims of child abuse in 2005, and 6 thousand in 2000. The reported incidence was nearly double from 2000 to 2005. Although the increased incidence probably related to the effects of public education that stress the disclosure and report, the results were underreported and there was the tip of iceberg without doubt. Often more than one type of abuse or neglect occurs within families. Except stigma and reluctance to disclose victims, some types of maltreatment, such as emotional neglect and abuse, are much harder to be substantiated than physical abuse or sexual abuse.

Impacts of Child Abuse
From empirical work with adolescent and young adult psychiatric inpatients, the disclosing of childhood abuse has been increased gradually and these repeated traumatic experiences did play a significant role in their psychopathology and psychosocial function. There is ample research evidence documented that chronic traumatic experiences have devastating effects on children's developing brains and have subsequent impacts on their cognitive, psychological and social development.Many of them suffered from developmental delay and problems in attachment, attention or learning in childhood. To identify child abuse is a fundamental part at child psychiatric practice. Often the severe emotional damage to abused children does not surface until adolescence or later. They often have trouble establishing intimate and trust relationships with people. They are also at higher risk for anxiety, depression, PTSD, dissociation, substance abuse, antisocial behaviors, medical illness, and problems at school or work. Beside the biological treatment, they need tremendous work with long-term comprehensive psychotherapy and family therapy through dynamic and interactive points. There are many obstacles in providing clinical service for them. Except the low insurance coverage, multiple placements of victims, poor cooperation of family and family dysfunction, the one of biggest obstacles is the frequent neglect of psychiatrists over the issue due to shortage of manpower. The expense of dealing with the aftereffects of child abuse will be enormous if no appropriate preventive and intervention strategies were taken both for the individuals at risk and the victims as well as their families. Many studies confirmed the intensive and early interventions are keys to minimizing the longterm impacts of early trauma on children's brain and their subsequent cognitive and psychosocial development.

Family Factors of Child Abuse
Although most parents don't hurt or neglect their children intentionally, 60-70% of child abuse cases occurred within the families and strongly related to domestic violence, poverty, family disorganization, divorce, and parents with sickness, mental disorders, poor parenthood, and alcohol abuse or substance abuse. In Taiwan some social factors contributing the increasing incidences and negative outcome of abuse can not be denial, including high divorce and remarriage rates, as well as the significant economic deflation in recent few years. In the meantime, the risk of re-abuse is very high (30%) and their siblings were usually at high risk of abuse too. The familial factors are so crucial that the interventions and prevention of child abuse are proposed not only child-centered but also family-centered. At present, there are two models of family service are highly recommended, family preservation and family reunification, depending on the out-of-home placement of victims.

Insufficiency of Professionals
The identification and intervention need multidisciplinary team approach including child welfare system. Usually, health professionals are on the front line and mandated to report child maltreatment. According to the WHO, identifying the signs of abuse or children at risk should be madeas a standard part of the training of all professionals, hospital should be put in place to help doctors refer suspect cases to social services and the social services should be responsible for protection and management. Hot Line "113" is responsible for taking the reports in Taiwan, but only 14% of reported cases are referred via hospitals in 2003. Except low report rate due to low sensitivity of professionals or pediatricians and procedure obstacles, very few children and families received comprehensive services after being reported because serious shortage of resources and well trained professionals. This inadequacy highlighted the need for budgets and expert staffs who working exclusively for children, adolescents and their families in order to make workloads more manageable and effective.

Challenges to Psychiatrists
Since the child and adolescent psychiatrists are the key element of the multidisciplinary team, what can the child and adolescent psychiatrists and professionals do at present? There are some ways they can do including the followings. (1) Promoting effective skills for identifi-cation, assessment, and intervention of child abuse. (2) Collaborating with the other professionals to provide high quality services. (3) Enhancing psychiatric referrals from other physicians and professionals. (4) Providing intensive public psychoeducation for preventing and improving short and long term outcome of child abuse. (5) Conducting scientific studies over the developmental epidemiology, biology, psychopathology and outcome. Child psychiatrists also play important collaborative roles in the legal system that they help to provide objective information in forensic evaluations and dynamic psychiatric evaluations in the decision of placement and the future intervention. At the end of 2006, Taipei Juvenile Court held a conference with the Taiwanese Society of Child and Adolescent Psychiatry over the assessment and intervention of violence and child abuse which addressed the demands of increasing psychiatrists' involvements. However, the need is difficult to be met satisfactorily due to the shortage of child and adolescent psychiatrists and related professionals upto now.

Conclusions
Children and adolescents are our most valuable resource in the future. To stop child abuse and to provide them a secure, loving and warm environment for healthy development is the ultimate goal of the society. The participation of children and adolescents psychiatrists is crucial although this is a big challenge for them and for the Taiwanese Society of Child and Adolescent Psychiatry.

References
1. Anders TF. Children: Our most valuable resource. J Am Acad Child Adolesc Psychiatry. 2006;45: 1-5.
2. Arie S.: WHO takes up issue of child abuse. BMJ 2005;331:129.
3. Kaplow JB, Dodge KA, Amaya-Jackson L, Saxe GN. : Pathways to PTSD, part II: sexually abused children. Am J Psychiatry 2005;162:1305-10.
4. Ellaway BA, Payne EH, Rolfe K, Dunstan FD, Kemp AM, Butler I, Sibert JR.:Are abused babies protected from further abuse? Arch Disease Childhood 2004;89:845-6.

Ying-Sheue Chen, M.D.
Department of Psychiatry,
Taipei Veterans General Hospital
Key Word
Editorial Committe, Taiwanese Journal of Psychiatry
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