#67584: Child Abuse in Ethnic Minority and Immigrant Communities

The notion of childhood in Europe during the Middle Ages was very different from contemporary Western views. Childhood was not necessarily viewed as a distinct stage of the life cycle; rather, children were viewed as miniature adults [6,352]. Childhood was a time to teach skills to prepare children for being adults [352]. It was not until the 15th and 16th centuries, with the rise of the middle class, that childhood began to be considered a separate developmental stage [6]. John Locke, for example, argued that a child's mind was a blank slate, prime for being shaped by experiences [352]. Many Renaissance scholars argued that children had their own unique needs, which were distinct from adults; however, this perspective was primarily held by the upper middle class [7].

A dualistic perspective about children emerged during the Reformation in the 16th century. Children were viewed as God's creatures, to be loved and protected, but also as sinful humans [353]. As a result, parents, teachers, preachers, and adults who were responsible for the moral upbringing and socialization of children were encouraged to use strict discipline to correct the evilness that was part of their human nature [353].

By the mid-19th century, a romantic perspective emerged and children began to be seen as the "torchbearers" of the future [7]. There was much emphasis on education, training, and the overall nurturance of children. The increase in industrialization and urbanization of the early 20th century resulted in heightened crime, poverty, and social disorganization, all of which affected children. As a consequence, social reforms targeted to children, such as child labor restrictions and compulsory education laws, began to emerge [93]. Massachusetts was the first state to pass a child labor law in 1851, which propounded that children younger than 15 years of age were required to attend school for at least three months out of the year in order to remain working in factories [352]. During the middle of the 20th century, there was increased emphasis on the rights of children, in part because of the grassroots movements advocating for the rights of disenfranchised populations [93]. In 1938, for example, President Franklin Roosevelt signed the Fair Labor Standards Act, which addressed child labor [352].

The terms "child abuse," "child neglect," and "child maltreatment" are relatively new terms despite the fact that this social problem has existed through the ages. Records have documented cruelty to children by adults throughout the ages and across societies. Physical abuse has historically been justified because it was believed that severe physical punishment was necessary to discipline, to rid the child of his or her evil nature, and to educate children [9].

Sexual abuse of children, particularly incest (i.e., sex between family members), is very much a taboo. As early as the 16th century in England there have been concerted efforts to protect children from sexual abuse. For example, boys were protected from forced sodomy, and girls younger than 10 years of age were protected from forcible rape [9]. In the late 1890s, Sigmund Freud began seeing patients, many of whom were women and described memories of sexual abuse during their childhoods. Freud dismissed these as fantasies rooted in female psychopathology [192]. Freud's speculations contributed to later concerns about the reliability of sexual abuse reports [192]. As late as the 1920s, sexual abuse of children was described as an assault committed by "strangers" and the victim was perceived as a "temptress" rather than an innocent child [9].

The Massachusetts Adoption of Children Act of 1851 was the precursor of the modern U.S. foster care system [29]. In accordance with this Act, judges are required to determine if adoptive parents are fit to raise a child [29]. Between 1850 and 1919, the foster care movement was prominent in the United States, and it was within this landscape that the first child abuse case arose [29].

The first public case of child abuse in the United States that garnered widespread interest took place in 1866 in New York City. The child, Mary Ellen Wilson, was 10 years of age and lived with foster parents [10]. Neighbors became concerned that she was being mistreated; however, her foster parents refused to change their behaviors and said they could treat the child as they wished [9]. Because there were no agencies established to protect children specifically, Henry Berge, founder of the Society for the Prevention of Cruelty to Animals, intervened on her behalf [10]. He argued that she was a member of the animal kingdom and deserved protection. The case received much publicity, and as a result, the New York Society for the Prevention of Cruelty to Children was formed in 1874 [10]. By 1919, all but three states had juvenile courts. However, many of these nongovernmental agencies could not sustain themselves during the Depression [193]. Today, every state has a child protective services (CPS) system in place.

In 1946, a pediatric radiologist by the name of John Caffey published an article that talked about six young children he had seen with unexplained subdural hematoma and leg and arm fractures [193]. Although Caffey never used the word "abuse," it was implied, and this article generated some interest among physicians.

In 1962, Kempe and Heller published a study titled The Battered-Child Syndrome, in which they argued that battered-child syndrome consisted of traumatic injuries to the head and long bones, most commonly in children younger than 3 years of age and perpetrated by parents [11]. This is considered a seminal article in the child abuse field as it alerted both the general public and the academic community to the problem of child abuse [9].

Child abuse and neglect are now considered significant social problems with deleterious consequences. As noted, a system has been implemented in all 50 states to ensure the safety of children, with laws defining what constitutes abuse and neglect and mandated reporters of abuse.

There is some evidence of legal protection for children dating back to colonial America. For example, in 1642 in Massachusetts, there was a law that gave local magistrates the power to remove children from homes where parents were not "training up" their children [193]. In Georgia in 1735, an orphan girl was removed from a home where she was being abused sexually [193].

For the most part, in the 19th and early part of the 20th century, child protection responses were led by nongovernmental agencies [193]. Beginning in 1912, the federal government began to be involved. For example, the Children's Bureau was created, and the Sheppard-Towner Act was implemented to provide federal funds to health services for mothers and children [193].

The first major federal response can be traced to President Roosevelt's New Deal. A federal program for child welfare services was approved under the Social Security Act in 1935 [13]. The Federal Government provided grants-in-aid to states to assist in the development of state child welfare agencies and programs to deliver services to protect children. Over the years, the federal government has continued the funding, with the expectation that states will match the funds [13].

In the 1950s, there was an emphasis on maintaining children in their own families, referred to as child permanency, as studies demonstrated the negative effects of separating children from families for extended periods of time. The notion of child permanency is based on the belief that the family is paramount, the parent and child dyad is crucial for child development, and family stability has long-term positive impacts on children [14]. Ultimately, CPS must remove children from homes in some cases, and before this time, many children were in the custody of the state, without having any sense of permanency [14]. The emphasis on child permanency resulted in a move away from foster care placement and toward working with families to provide services to strengthen the family system.

In 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was authorized under the Title XX Social Services Program. This federal legislation was targeted at states' responses to child maltreatment and focused on prevention, investigation, prosecution, and the delivery of a range of social services targeted to child abuse and neglect. It also encouraged demonstration research projects to examine how best to prevent child maltreatment and to evaluate various child abuse and neglect services [15,16,17]. This act was most recently re-amended in 2003 by the Keeping Children and Families Safe Act [17].

In 1978, the Indian Child Welfare Act (ICWA) was added to CAPTA to protect Native American children in the child welfare system [15]. Congress observed that Native American children removed from their homes were often placed in non-Native American homes. Furthermore, the mainstream judicial and social work systems were not familiar with traditional Native American value systems regarding childrearing and socialization, which resulted in labeling these homes dysfunctional [18]. The emphasis of the ICWA is on reunification of the child with the family; if a child is removed, efforts should be focused on helping the family resolve issues that triggered removal [19]. Ultimately, this act was intended to help maintain the integrity of the Native American nations, cultures, and families [18]. The ICWA has been criticized for being inadequately funded, for the lack of tribal involvement, and for reverse discrimination [194].

In 1980, the Adoption Assistance and Child Welfare Act was enacted. This act emphasized that foster care was not a permanent service; rather, it was crucial to reunite families by providing services to strengthen the family system [14]. This was a federal response to three main problems in child welfare at that time: an anti-family bias, causing children to be removed from their families without exploring other options; lack of individualized case planning based on each child; and a bias in federal funding incentives toward placing children in foster care versus returning children to homes or adoption [15]. This was further expanded by the Adoption and Safe Families Act (ASFA) of 1997 [16]. This act stressed time limits for foster care, reunification of the child with the family, and better linkage between child welfare services and other supportive services [14,16].

The United States has continued to pass legislation to protect children. In 2007 and 2008, several states enhanced the review process for child fatalities [234]. During this period, Maryland, Missouri, Washington, California, Delaware, Maine, and Maryland passed legislation requiring a specific and systematic child fatality review process [234]. On a national level, CAPTA was reauthorized in 2010, which assists states to continue to provide services to identify and prevent child abuse and neglect [280].

In 2014, the Preventing Sex Trafficking and Strengthening Families Act was signed into law [240]. This law ensures that states implement mechanisms for reporting and collecting data on sex trafficking and identifying children who may be at risk of becoming victims of sex trafficking [240]. It also strengthens existing laws related to adoption incentives and the provision of services to foster parents [240].

In 2015, the Justice for Victims of Trafficking Act was enacted with the goal of providing grants to organizations and programs that deliver services for victims of child pornography and domestic child human trafficking and training for law enforcement officers, child welfare, and healthcare providers in order to better identify child human trafficking victims [279]. In addition, CAPTA modified the Comprehensive Addiction and Recovery Act of 2016 to include a provision for states to develop safety plans for the follow-up care of infants affected by substance abuse, withdrawal symptoms, or fetal alcohol syndrome [280]. In 2018, the Family First Prevention Services Act allowed federal funding for services for families whose children were at risk of being removed, including the provision of mental health, substance abuse, and parenting enhancement skills services [45]. Beginning in 2020, human resource employees working in a business with five or more employees are considered mandated reporters under the Child Abuse and Neglect Reporting Act [51]. In 2023, support for kinship caregivers was enhanced. Family kinship caregivers (e.g., grandparents, aunts, uncles) can more easily step in to provide foster care for children. They are still required to undergo regulatory screening and an application process; however, the process is simplified. In addition, kinship caregivers and given the same level of financial assistance as other foster care parents [354].

There are several acts that may be considered abusive, and knowledge of what constitutes abuse is necessary for all healthcare providers and mandated reporters. In this section, specific behaviors that may be considered abuse and/or neglect will be reviewed.

Sexual Abuse/Exploitation

According to the Centers for Disease Control and Prevention, management of children who have sexually transmitted infections requires close cooperation among clinicians, laboratorians, and child-protection authorities. Official investigations, when indicated, should be initiated promptly. Certain diseases (e.g., gonorrhea, syphilis, HIV, chlamydia, and trichomoniasis), if acquired after the neonatal period, strongly indicate sexual contact.

(https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf Last Accessed: August 31, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

Sexual abuse is defined by CAPTA as, "the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or the rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children" [20]. Child sexual abuse can be committed by a stranger or an individual known to the child. Sexual abuse may be manifested in many different ways, including [21,196]:

• Verbal: Obscene phone calls or talking about sexual acts for the purpose of sexually arousing the adult perpetrator

• Voyeurism: Watching a child get dressed or encouraging the child to masturbate while the perpetrator watches

• Commercial sexual exploitation and child prostitution: Involving the child in sexual acts for monetary profit

• Child pornography: Taking photos of a child in sexually explicit poses or acts

• Exhibitionism: Exposing an adult's genitals to a child or forcing a child to observe the adult or other children in sexual acts

• Molestation: Touching, fondling, or kissing the child in a provocative manner; for example, fondling the child's genital area or long, lingering kisses

• Sexual penetration: The penetration of part of the perpetrator's body (e.g., finger, penis, tongue) into the child's body (e.g., mouth, vagina, anus)

• Rape: May involve sexual intercourse, sodomy, or penetration with a foreign object without the victim's consent, and may include violence or the threat of violence. This definition is wide in scope and does not necessarily involve physical touching, contact, or physical force. Instead, it encompasses sexual intent against an individual's will. It also takes into consideration consent, as some cannot consent due to their age, disability, fear of harm, and/ or state of consciousness or intoxication.

Worldwide, it is estimated that approximately 80% of children between 1 and 14 years of age have experienced physical punishment and/or psychological aggression by a caregiver in the past month [239]. This was exacerbated during the coronavirus disease (COVID-19) pandemic due to increased economic stress and social isolation as well as decreased services to families [355]. A systematic study involving 14,360 children found a physical abuse rate of 18% and a psychological rate of 39% during the pandemic. Researchers found a strong relationship between unemployment and physical child abuse [356].

In terms of sexual abuse, one in 10 girls younger than 18 years of age are believed to have experienced forced intercourse and other sexual acts [282]. In addition, estimates indicate that as many as 275 million (one in seven) children worldwide witness violence in the home. In a meta-analysis, 26.6% of children were found to have experienced physical abuse, 26% neglect, 19.6% emotional abuse, and 8.7% sexual abuse [283].

In some countries, child abuse and fatalities are the result of gender inequality and discrimination [24]. The United Nations Children's Fund (UNICEF) estimates there are 50 million unregistered births every year, and in some countries, particularly in some parts of South Asia, infants who are murdered within days of their birth are registered as stillbirths [25,26]. Girls are often the victims of infanticide because they are viewed as an economic liability. In India, for example, high dowry payments can make girls a financial burden for parents [242]. In China, the ratio of male to female infants is 117 to 100, an imbalance that is attributed to female infanticide [27]. China also leads the world in reports of cleft-related infanticides [245]. In some countries, girls are targeted even before they are born. Gender-specific feticide (whereby a fetus is aborted based on a sex determination test indicating the child would be a girl) is relatively common in some countries, such as China and India. In India, it is estimated that 10 million female fetuses have been illegally aborted [243].

In addition, female genital mutilation/cutting (FGM/C) is a common practice in some areas of the world, predominantly in Africa. In a Ghanaian study, the overall prevalence was 11.7%, but FGM/C trends varied significantly by region [281]. It is estimated that between 100 and 140 million girls and women in the world have experienced FGM/C [244]. A study conducted in Mali, in western Africa, almost three-quarters of the women with daughters had at least one daughter who had FGM/C [357]. Women who never read a newspaper or magazine were twice as likely to have a daughter who experienced FGM/C compared with those who read a newspaper/magazine at least once per week.

Ritual servitude is another potential form of child abuse or endangerment. In parts of Africa, mainly Ghana, Togo, and Benin, daughters younger than 10 years of age (due to their "virgin" status) are given to the priests in shrines in order to atone for sins and crimes of their dead ancestors [235]. These girls are generally expected to engage in sexual activity with the priest and elders.

Other independent studies support the UN's assertion that child abuse and neglect are common. In 2013–2014, there were 40,844 substantiated cases of child abuse and neglect in Australia [28]. A study of Iranian students 11 to 18 years of age found that more than one-third (38.5%) had experienced physical violence at home that resulted in mild-to-severe injury [30].

In a study of South African women between 15 and 49 years of age, approximately 21% disclosed having been forced to engage in sexual intercourse before the age of 15 years by a male relative [31]. One complication to obtaining data and an understanding of the extent of child sexual abuse is sanctioned forms, such as child marriages. Some countries and cultures are associated with high rates of child marriage [316].

In Western industrialized countries, it is typical to subdivide abuse and neglect into different categories, such as physical abuse, neglect, sexual abuse, and emotional abuse. All of these acts are forms of psychologic trauma and may have lifelong consequences. However, the categorization of certain social issues, such as child labor, FGM/C, honor killing, and child prostitution and trafficking, has been debated as they are not easily placed into an established abuse category [32]. The difficulty in reaching a consensus in this debate stems from several factors, including acceptability of behaviors that occur in a complex, multifaceted cultural context; variations in beliefs about childrearing and socialization; and lack of a universal method to measure child abuse and neglect [32,316]. All of these factors reflect the competing paradigms regarding universal rights and respect for cultural differences [236].

In some developing countries, the proliferation of poverty, gender inequality, political instability, and violence make it difficult to focus solely on child abuse and neglect, as these social problems are often intertwined with the issues of child welfare and protection [33]. Furthermore, social, cultural, and religious norms may hinder the ability of government or social organizations to fully implement protective policies. For example, androcentric cultural norms are deeply embedded in many countries, and to challenge the established patriarchal ideology would mean to challenge gender inequality and the structures that support this norm [33].

Culture refers to the values and knowledge of groups in a society; it consists of approved behaviors, norms of conduct, and value systems [61,62]. Culture involves attitudes and beliefs that are passed from generation to generation within a group. These patterns include language, religious beliefs, institutions, artistic expressions, ways of thinking, and patterns of social and interpersonal relations [63]. Culture can also represent worldviews, encompassing assumptions and perceptions about the world and how it works [64]. Culture helps to elucidate the reasons groups of people act as they do and respond to the environment as they do [65]. Culture is also shared among individuals in the same group across generations. It is the common ground that evokes certain feelings and ideas [200].

Kluckhohn and Strodtbeck proposed five different dimensions that comprise a worldview [66]:

Culture is not static; it is not merely inherited nor are groups of people passive recipients of culture. Rather, "culture and people negotiate and interact, thus transforming and developing each other. It is a process of continuous modification" [67].

Dividing cultural items into two categories, surface and deep structures, can assist in achieving cultural sensitivity [68]. Surface cultural dimensions include tangible and observable aspects, such as food, language, music, art, and clothing. Deep cultural dimensions, which are more difficult to identify and appreciate, include psychologic, historical, sociopolitical, and social forces [68].

The term "race" is linked to biology and is partially defined by physical markers such as hair color, skin color, and facial features. Race may also be used to describe groups of people connected to a common origin or lineage [69]. The association of race with lineage is often used to explain why people are physically and culturally different [69]. Ultimately, value judgements are often associated with race and these differences [70]. Race has social, political, and economic ramifications, as it plays a role in stereotypes, discrimination, social arrangements of different groups, and access to various societal resources [70]. When skin color is used to identify culture, it may not be an accurate measure [71].

In some ways, the term "ethnicity" refers to both culture and race [69]. Some have argued that the defining characteristic of an ethnic group is a subjective feeling of belonging. Ethnicity is closely related to culture, as ethnic groups often share common cultural traits that differentiate them from other groups [72]. However, ethnicity is now seen as more than just culture; rather, it is a category involving a group's socially constructed identity, at times based on class, politics, and sociopolitical factors [72].

Just as there are multitudes of parents, there is a vast array of different parenting styles and socialization goals. Generally, the goal of many parents is to socialize their children to become self-reliant, productive, and responsible adults. How one accomplishes these goals is influenced by cultural norms. One example is the authoritarian parenting style, which is characterized by an emphasis on controlling the child's behaviors based on absolute standards, obedience, and respect for authority [73]. In Western societies, an authoritarian parenting style is regarded more negatively, and some believe it to be associated with negative outcomes such as poor self-esteem, poor academic achievement, and greater levels of aggressive behaviors [74]. In Western cultures, such as the United States, values focusing on individualism and autonomy often promote childrearing strategies that encourage children to explore their environment more independently.

The American Academy of Child and Adolescent Psychiatry recommends that clinicians should evaluate and address in treatment the acculturation level and presence of acculturation stress and intergenerational acculturation family conflict in diverse children and families.

(https://www.jaacap.org/article/S0890-8567(13)00479-6/fulltext Last Accessed: August 31, 2024)

Level of Evidence: Expert Opinion/Consensus Statement

The issue of immigration and acculturation will inevitably influence immigrants' parenting behaviors, as values in the host country may compete with established cultural belief systems. Part of the acculturation process involves adaptation and coping. In general, studies have shown that as immigrant parents reside longer in the United States, they become less authoritative and have more open communication with their children. There is more negotiation between parent and child, and fathers become more involved in parenting [201]. However, this does not necessarily mean that traditional cultural beliefs and values disappear.

Asian parenting styles have also been described as authoritarian; yet, the authoritarian style is equated with parental concern, caring, and love in many Asian cultures [74,75]. Asian cultures also emphasize relational socialization goals, such as obeying elders and parents, maintaining harmony, and caring for others [202,329]. Many Asian parents emphasize the importance of moral training that aligns with Confucian principles, in some cases using authoritarian parenting styles (including physical punishment, guilt, and shame) [329]. As a result, Asian authoritarian parenting styles include harmony while focusing on achievement that will bring honor to the family. The parent/child relationship is predicated on hierarchal relationships and is not typically characterized as warm. Instead, parenting in many Asian homes reflects on key cultural norms that promote interdependence, social harmony, and respect [364]. Some studies have found a positive relationship between authoritarian parenting and outcomes; for example, authoritarian parenting styles were correlated with higher academic achievement in a study of Chinese students [76,253]. One study with 251 parents found that Chinese mothers tend to be more psychologically controlling of their children compared to both White and African American mothers [254]. The Chinese mothers' sense of worth was dependent on their children's performance, which may explain this tendency.

This concept may also be more fully understood if it is examined from the perspective of collectivistic cultures. Again, these are global themes and there is tremendous diversity within all cultural groups. In many collectivistic cultures, the goal is to promote harmony and relegate individual needs to that of the larger collective group (i.e., family and community) [77]. Chinese parents, for example, are charged with training their children to be cooperative, to respect their parents and elders, to learn self-control, and to value the needs of the group, all of which conform to Confucian principles [74,78]. In Chinese culture, then, it is believed that parents who do not discipline their children effectively are abusive [74]. Affectionate and highly expressive behaviors among Asian parents are not the predominant parenting styles because a major lesson for children is the value of self-control; highly expressive and emotive behaviors are considered inappropriate [78]. However, the perception of Asian American authoritative parenting may be rooted in a comparison to White/European American parenting styles in the United States. In one study, the most common parenting style among Chinese parents was a supportive style [295].

The level of adherence to authoritative parenting styles may also depend on the level of acculturation. In a qualitative study with 20 highly educated Korean parents from middle to upper-middle socioeconomic brackets, the parents described trying to strive for Western norms of autonomy and individuality in their parenting, wanting to promote their children's sense of freedom in exploring the world around them [255]. However, they do limit freedom when it comes to academic achievement [296].

In Japan, some parents strive for the mimamor approach, which means "watching and caring" [365]. Generally, the Japanese believe that it is the parent's responsibility to nurture a child, and therefore, parenting is very child-centric. Children all have potential, and the goal is to respect the wish of the child and help them reach their potential. Therefore, it is crucial for parents to watch attentively to see how they can nurture the child's innate skills [365].

Just as there is heterogeneity within specific groups, there are obviously marked differences within collectivistic cultures. Studies that show that indulgent parenting styles (high degree of parental affection, acceptance, and emotional expressiveness) in some collectivistic countries, such as Spain and Italy, yield similar results in terms of children's level of self-esteem and adjustment compared to children socialized in Asia [79]. Similarly, in Hispanic/Latino groups, which are also characterized as collectivistic, childrearing practices have been described as very nurturing and permissive, with more emphasis on interdependence versus independence [80].

These seemingly contradictory findings about collectivistic cultures may be partially explained by the diversity within collectivistic cultures; some researchers subdivide these cultures into two categories: horizontal and vertical [81]. Horizontal collectivistic cultures emphasize egalitarian relationships, while vertical collectivistic cultures focus on relationships within a hierarchical structure.

However, it is also likely that divergent cultural values may contribute to differences in parenting styles in collectivistic cultures. It has been proposed that machismo influences parenting styles in Hispanic/Latino cultures. Machismo refers to a set of ideals placed upon Hispanic/Latino men, including physical strength, virility, and bravery [82]. Men are often considered to be dominant figures in the family structure [83]. This machismo attitude may promote rigid gender role expectations and misogyny [83]. It is also speculated that machismo adherence may influence more authoritarian parenting and punitive disciplining styles in Hispanic/Latino cultures. In one study of 150 Hispanic, African American, and White parents, machismo significantly predicted use of physical punishment by fathers regardless of ethnicity [84]. This supported an earlier study of Guyanese parents in which parents who were less nurturing and who tended to use more physical punishment were associated with machismo ideals [83].

More recently, the stereotypical portrayal of machismo and its effect on Mexican fathers' parenting has been questioned. For example, the positive dimensions of machismo, known as caballerismo, consist of dignity, honor, respect, and the role of men as providers. These values can lead to greater involvement of fathers with their children in Mexican families. In one study, Mexican children whose fathers who had higher levels of caballerismo reported greater positive father involvement [203]. However, other studies have conflicted with these findings [204]. It is important to remember that no simplistic cultural generalizations can be made when working with culturally diverse groups.

The concept of raising children to be tranquilo, obediente, y respetuoso (calm, obedient, and respectful toward adults) also underlies much of childrearing among Hispanic/Latino families [85]. In Mexican families, a well-educated child has been taught to treat others with courtesy and respect [80]. As a horizontal collectivistic culture, Hispanic/Latino families highly value respect because it accords worth to individuals regardless of their social hierarchy [82]. It has been said that Hispanic/Latino parents are more likely to make unilateral decisions on the behalf of their children and the children are expected to conform to their parents' decisions in part because of the emphasis on respect [86]. In focus groups with Dominican and Puerto Rican mothers and their adolescent children, Guilamo-Ramos and colleagues found that mothers expected their children to obey them, which was expressed through cultural values revolving around respect [86]. However, this does not mean their parenting practices were harsh; rather, the children knew they were loved, but the mothers acknowledged that "tough love" was used. These ideals may be retained, in part or entirely, in Hispanic American families.

The historical legacy and the pervasiveness of racism and discrimination in the United States has led many African American families to view parenting and childrearing as preparing their children to cope, manage, and succeed in an often oppressive and hostile environment [87,88]. In a 2001 case study of two middle-class African American families, the theme of racial socialization was a key component in childrearing [89]. Racial socialization refers to the process of raising children to be healthy adults acting in a prosocial manner in a society that has a negative view of African Americans [89]. Some experts argue that this is a prominent dimension of childrearing for African American families regardless of socioeconomic class [89]. In a 2014 study with African American parents of adolescents (12 to 14 years of age), the parents reported desiring to verbally communicate with their children. For more serious situations, they tended to exhibit a firm use of disciplinary tactics [256]. It is speculated that African American parents are attuned to racism displayed by the police toward African American adolescents, and consequently, they desire to eliminate negative and perceived antisocial behaviors [256]. In families concerned with racial socialization, demanding children's respect, obedience, and proper behavior in both the public and private arenas is essential [87]. Respect is highly valued because it involves exhibiting honor to elders and authority figures and acknowledging their wisdom and past experiences. This is consistent with literature that underscores the role of elders and other responsible adults in socializing children [88]. It has also been postulated that the emphasis of respect and the use of more authoritarian parenting styles among African Americans in part stems from their experiences with racial discrimination. Focus groups with low-income African American mothers found that the women tempered their "tough love" with demonstrative caring [205]. Teaching children early on to obey their parents and to change seemingly innocent behaviors rapidly is a means to protect their children from harm [206]. In a 2010 study, African American mothers expressed concerns about spoiling their children, even as infants. They also adhered to stronger beliefs about using punishment compared to the White mother participants [207].

Raising children so they are familiar with African American historical roots and kinship ties is also an important dimension in African American families [88]. The literature has consistently documented the importance of family in African American culture. This includes not only the immediate family unit but the extended family system [90]. The extended family plays a central role in childrearing [91]. During financially difficult times, Caribbean families adhere to a concept referred to as child fostering, whereby extended family members or fictive kin step in to rear children. This allows a family member to leave the area or country to look for employment without worrying about leaving children behind. The parent who leaves is not totally absent; he or she generally continues to maintain contact and provide financial support [92].

Discipline is a set of rules, norms, and consequences established in a family system to regulate children's behaviors with the overall objective of teaching children to act in a prosocial manner and to become responsible adults [94]. Discipline methods are much debated, particularly if physical or corporal punishment is used. Corporal punishment has been defined as punishment that inflicts physical pain [95]. Legally, it has been defined as comprising "reasonable force" [208]. Corporal punishment is legally banned in 63 countries; however, it is still viewed as a common form of violence against children [366]. Worldwide, it is estimated that two-thirds of children between 2 and 4 years of age are spanked [367].

It is estimated that 71% to 99% of parents in the United States use physical punishment during the course of a child's life [96]. A 2019 study found the past-year spanking rate was 37% for children younger than 18 years of age, supporting several studies reporting a decrease in spanking between 1988 and 2011 [330]. The researchers argued that this decline may be attributed to the increasing public education and awareness promotions in the United States about the negative effects of corporal punishment. Most commonly this involves spanking. Spanking is defined as using an open hand to hit a child on the buttocks or other parts without leaving a bruise or causing physical harm [97]. However, regional differences in the acceptance of corporal punishment have been documented in the United States [368]. Respondents were asked about how much they agree that children sometimes need a good spanking. Between 1986 to 2016, generally, there was a general decline of acceptance of the statement among those from non-southern states, particularly among those from higher socioeconomic levels. However, this was not the case of individuals from southern states, regardless of socioeconomic distribution [368].

Professionals generally do not advocate the use of spanking. In a survey of psychologists, 86% felt that one should never recommend spanking to a parent, and more than 75% felt it was unethical for professionals to recommend spanking [298]. Despite practitioners, educators, and scholars advocating against the use of corporal punishment, 94% of parents of toddlers still spank [208]. In a study of 2,573 African American, Mexican American, and White low-income mothers with toddlers, 34% of the participants with children 1 year of age indicated that they or someone in the household had spanked their child within the last week [209]. This number increased to 49% for those with children 2 or 3 years of age. African American children were spanked significantly more than the White and Mexican American children, and there were no differences in frequency of spanking between White and more acculturated Mexican American families.

The decision of whether or not to spank is controversial and is associated with moral and cultural undertones. Some argue for no spanking at all, maintaining that it constitutes physical violence; others argue that it is an effective means to discipline [97]. Three perspectives on spanking have been identified [97]. The first perspective is pro-corporal punishment and embraces the belief that spanking is a necessary part of childrearing in order to teach and train children about positive behaviors. For example, some studies have found that spanking has the positive effect of gaining immediate results in cases with significant detrimental outcomes [208]. The second perspective is anti-corporal punishment. Those who fall into this category believe that violence ultimately begets violence and that harmful results will occur from spanking; they equate corporal punishment with physical abuse [210]. Some countries, such as Sweden, Germany, and Cyprus, have outlawed the use of corporal punishment and consider it abusive [95,98]. The third view is the conditional corporal punishment perspective, which advocates that it is too simplistic to make a blanketed statement about the use of spanking being positive or negative. Rather, the effects are contingent on a range of factors, such as frequency, context, intensity, and other parent-child variables, such as how the parent delivers the response and how the child understands the response [97,210]. It is important to note that healthcare workers with higher scores in terms of approval of corporal punishment have been found to be less likely to perceive and report child abuse [99].

In general, studies have found several patterns regarding attitudes toward corporal punishment. Within the United States, regional differences play a role. Individuals from the South tend to approve of the use of physical punishment, while persons in the Northeast are least likely to approve of spanking [100,330].

Age and education are also predictors. Older adults and those with lower education levels tend to endorse the use of physical punishment compared to their younger and more educated counterparts [101,102]. Religion also impacts attitudes toward corporal punishment. Christian individuals who take a literal interpretation of the Bible, particularly evangelical and fundamentalist Protestants, are more likely to support corporal punishment [103]. In general, persons who identify as members of a conservative religious organization are more likely to approve of corporal punishment [100]. In a national study, researchers found that more than one-third of conservative Protestants strongly agreed that spanking is an appropriate form of discipline. Younger age and higher educational attainment were correlated with decreased likelihood to endorse corporal punishment [299].

There is also variation across countries. Strong support for corporal punishment has been documented in Russia, Jamaica, and Barbados [98]. In one cross-cultural study, university students in Asian countries tended to approve of corporal punishment at greater levels than students from European universities [98]. In China, many believe that corporal punishment is acceptable and that beating a child is not antithetical to a display of love [300]. Countries with higher levels of economic insecurity and inequality have been associated with more frequent use of violent discipline strategies [331].

The macrosystem level of ecologic theory includes the broad social and cultural values that affect the individual. Cultural norms about the justification of force or violence used to support conditions that lead to child abuse fall into this category. Norms regarding the use of social and/or mental health services were also found to predict later child neglect [377]. The lack of a consensus among professionals regarding a definitive definition of child abuse, neglect, and maltreatment can also play a role in confusing the identification, reporting, and criminal prosecution of child abuse cases [130]. Stereotypical cultural depictions can confuse definitions and perceptions of child abuse. For example, children may be simultaneously infantilized and hypersexualized. In racialized perceptions, African American girls may be viewed as "bad," overly sexual, or immoral, which can negatively affect reports of and responses to sexual abuse [337]. Overall societal attitudes about children and appropriate behavior can also affect parenting and discipline [131]. For example, if parents adhere to the cultural belief that children are the property of parents, this can breed child maltreatment [129]. Using the ecologic model to examine child maltreatment in Korea, the following macro factors were identified [222]:

Of course, the ecologic model is not meant to be deterministic or reductionistic. Cultural attitudes alone are not necessarily sufficient to lead to child maltreatment. However, coupled with a variety of other parental factors, such as lack of social support and inability to cope with the social stress, macrosystem issues can contribute to child maltreatment [129].

The influence of formal and informal social structures, such as work, peer groups, support groups, friendships, school settings, community, and neighborhoods, on larger social problems and individual behaviors is referred to as the exosystem level. As an example, some argue that a neighborhood's social organization (or lack thereof) contributes to child abuse. When neighborhoods have high rates of poverty, there are often co-occurring effects, such as high residential turnover, crime, and violence, which result in higher levels of disorganization and general decline [252]. The amount of drug use in a community or city, for example, can also impact child abuse [305]. Greater availability of drugs in a neighborhood is associated with higher reported incidences of physical child abuse and neglect.

Individuals in these communities may have more difficulty trusting and collaborating with each other, which may correspond with higher rates of victimization and violence [132]. Neighborhoods with few resources to support parents and children may experience higher incidences of child maltreatment [132]. Some experts argue that parents experience more stressors and challenges, a risk factor for child maltreatment, when raising children in impoverished neighborhood communities due to the disorder and instability impinging upon the family system.

The COVID-19 pandemic exacerbated family stressors, which contributed to the rise of child maltreatment during this period. Research indicates that 20% of parents employed more discipline on their children during the pandemic; nearly 25% reported yelling at their children more, and 26.7% disclosed that they emotionally neglected their children. Parents experiencing more financial stress also reported an increase in parent-child physical and verbal conflicts [338]. Overall, high stress levels stemming from economic hardship/deprivation and social isolation have been positively associated with all forms of child maltreatment [377].

As a second example, school systems are also considered part of the exosystem. Studies have shown that the school environment can serve as a protective buffer against the negative repercussions of child abuse. When children believe the adults in school are caring, they have positive self-esteem and self-concept, which may have been damaged by the abuse [133]. Teachers are also on the frontlines to witness children's behavior on a day-to-day basis, and when they witness behaviors or symptoms that are consistent with child abuse, how do they react?

The microsystem level refers to the family unit or the immediate context of the child. This level includes the physical characteristics of the immediate family, interactions within the family system, and the child's perception of the familial environment [131]. Families characterized by greater relational stress, marital discord, poor communication, and conflict are more vulnerable to child neglect [261,339,377]. In a Vietnamese study, a single-parent household was a strong correlate to different types of child maltreatment [378]. In a systematic study about child sex trafficking, a variety of household characteristics, including single-parent household, unrelated male member (e.g., boyfriend) of the household, households with a previous history of domestic violence, and financial hardship, were also correlated with risk of child sex trafficking [362]. A review of empirical studies that examined ecologic factors and child abuse/maltreatment concluded that there is no provable relationship between family structure and child abuse, but there are other studies that show a correlation between shorter intervals between births and child neglect [134,261]. Inconsistencies in data collection and small sample sizes may have contributed to conflicting results.

Parental unemployment has also been linked to child abuse, likely a result of financial strain on a family. However, unemployment can also allow parents to spend more time with their children and enhance their quality time [306]. In the future, more studies are needed to examine these variables.

Other studies have shown a correlation between a family's socioeconomic status and child abuse; specifically, families from lower socioeconomic brackets are more likely to use force when parenting [135,307]. It is believed economic conditions affect the quality of parent-child relationships due to the increased number of external and extenuating life stressors. Coupled with families' lack of knowledge of child development and parenting skills, this could contribute to child abuse [130]. It is possible that not having sufficient parenting skills can result in parenting stress and resultant child abuse [307].

The ontologic level refers to the factors inherent to the individual (developmental history, skill level, behavior patterns, and personality structure). Risk factors in this level that contribute to child abuse include parental substance abuse, depression, low educational levels, and experiences of interpersonal violence [130,261]. Parental/caregiver individual factors, such as substance use disorder and history of intimate partner violence, are among the strongest factors predicting child maltreatment [377]. In addition, parents' own childhood and early adult development can play a role in the perpetration of child abuse, causing the abuse to appear intergenerational [131,377]. Other ontologic risk factors include the child's age, coping skills, temperament, and personality. In one study, the greatest predictors of child neglect were related to parental factors, such as a history of antisocial behaviors, criminal offense, mental illnesses, and childhood abuse [308]. A study of children 11 to 17 years of age in Pakistan found that child maltreatment was correlated with the child's age, birth order, parental education, and maternal age [339]. A child's multiracial identity, disability diagnosis, experiences with substance abuse, and prior maltreatment are also ontological factors correlated with child sex trafficking [362].

Utilizing an ecologic model to discuss child abuse shifts the problem from being solely a parent-child issue to the true etiology and consequences of child abuse. It is important to note that the ecologic model is transactional; each level influences the others [129]. When examined in this manner, it is clear to see that child abuse is a multifaceted social problem, with ripple effects on multiple layers.

Madeline Leininger, a nursing scholar, developed a theory for transcultural nursing in the 1950s as nurses' patient populations became more diverse [140]. Leininger argues that care is the essence of nursing, and care is inevitably linked to culture [141]. Because patients are cultural beings, the goal, according to Leininger, is to provide culturally sensitive and relevant care to individuals and families that is acceptable and consistent with the individual's/group's cultural beliefs and value systems [141,263]. This theory emphasizes holism, or the idea that the whole is greater than the sum of the parts. According to the culture care theory, effective caring involves taking a range of factors into account, including the patient's religious and spiritual beliefs, language, cultural health beliefs, sociocultural milieu, and social, political, and economic environment [140,142]. Cultural care promotes the use of culturally derived acts to support an individual or group. Health is then culturally defined by the individual or group [140].

The PEN-3 model was originally developed by Airhihenbuwa for use to guide HIV prevention programs in Africa. Since then, the model has been used to understand cancer, diabetes, smoking, nutrition, domestic violence, and other social problems [264]. The PEN-3 model is a theoretical framework that places a social problem within a cultural context; culturally relevant health education and interventions can then be formulated [143].

The PEN-3 model has three interrelated dimensions, each with three components. The three primary dimensions are cultural identity, relationships, and cultural empowerment [143,144].

Kleinman, a cross-cultural psychiatrist and researcher, argues that health behaviors are enmeshed in a cultural context [145]. How individuals make decisions about health, how they experience particular social problems and associated symptoms, and how and where they ultimately seek help are influenced by three sectors: lay/popular, folk, and professional [145].

The strengths-based perspective focuses on moving away from a client's deficits and emphasizing untapped strengths, competencies, and capabilities [147]. This perspective is based on the belief that all people have the capability for positive growth and change. Empowering individuals may assist them in accessing internal and external resources.

The central premises of the strengths-based perspective are [148]:

The strengths-based perspective emerged as a result of the tendency in many disciplines to pathologize and blame the victim [148]. The concept of "blaming the victim" was first identified in 1976 [149]. This concept recognized that social problems in America are often blamed on victims' characteristics and value systems. In taking such an approach, practitioners working with families and children with trauma and abuse histories can help their clients to realize that they are survivors and they have "survival stories" [223]. Furthermore, acknowledging clients' strengths can build rapport [340]. Resiliency, hope, and survival are emphasized. The child and the family's environment and culture are viewed in a positive manner. The goal is to create positive experiences of cultural safety, tease out protective factors to promote child and family well-being, and offer pathways for services [379].

A common theme in these theoretical frameworks is the view that an individual's culture should be at the forefront when conducting assessments and formulating interventions. For example, some experts assert that the strengths perspective is suitable in working with Muslim patients in fostering hope and delivering services that incorporate social and multicultural dimensions aligned with religious value systems [265]. Instead of making Western interventions fit into the individual's cultural context, these frameworks emphasize a biculturalization approach for assessments and interventions. The biculturalization of assessments and interventions involves [150]:

Assessment for child abuse and neglect involves the systematic collection of data and being able to assess accurately and competently with professional judgment [266]. Information should be obtained regarding the primary reason for the visit, the family health history, the child's health history, the history of illnesses, the parents' attitudes toward discipline, and the child's pattern of nutrition, sleep, and diet [189].

It is important for professionals to ask questions in a nonjudgmental manner. A nonconfrontational manner is important to ensure the parent or caregiver does not feel accused [267]. The practitioner can inform the parent/caregiver of his or her duty to explore the concerns [267]. An environment where support and concern facilitate an open, trusting relationship between the parent and the practitioner must be created. Practitioners should reinforce the idea that parents are the experts on their culture and child [341]. By providing such an environment, the parent has the opportunity to voice concerns and ask for help [189]. Questions that convey concern and can provide valuable information to the professional include, "Who helps you care for your children?" or "How do you discipline your children?" [189]. Healthcare professionals should discuss how disciplining strategies might be influenced by cultural beliefs and norms and avoid using stigmatizing language [341]. It may be necessary to interview the child and parent separately; however, by spending some time with the child and parent together, practitioners can observe interactions and communication. Finally, it is vital to remember that risk and safety are on a continuum and not necessarily dichotomous entities (e.g., safe vs. not safe) [266].

When screening and assessing children and youths who may have experienced a form of child maltreatment, a trauma-informed approach is beneficial. This approach shifts any blame from the victim, allowing the individual to tell their story in their own words and timing. A nonjudgmental first step is to simply ask: "What happened to you?" [380].

It is also important to remember that many immigrant families and their children may not be proficient in speaking English. The assessment interview is too important for individuals to struggle to convey information in a language with which they are not proficient [224]. Families and children appear more competent and less depressed and anxious and are able to provide more details when they are speaking their native language. So, it is vital that the practitioner can speak the same language as the parent and child whenever possible. If that is not possible, a well-trained professional interpreter is necessary. However, the use of an interpreter should always be discussed with the family [341].

Accuracy in record taking is also important as it ensures continuity of care and serves to enhance risk management [268]. Be sure to record the date and time of the visit, sources of any information, and the date, time, and location of the alleged abuse or assault [190]. When talking to the child, the practitioner should use developmentally appropriate language that will be easily understood. Leading questions should be avoided [190]. Asking the following questions may be helpful when interacting with children [190]:

Because studies have demonstrated a correlation between child abuse and domestic violence, there is a need for dual screening for both types of family violence [191].

Assessment guided by a strengths-based perspective focuses on an individual's or family's strengths, coping strategies, and resiliencies. This is particularly crucial when assessing racial and ethnic minorities, as they are often depicted in a negative light in society [151]. As part of the assessment process, practitioners may ask individuals involved in family violence the following questions [152]:

The goal is to give individuals the opportunity to tell their stories and frame their experiences from their own point of view. Patient-centered communication is crucial. The stories patients tell are personal and intimate, and they should have the opportunity to invite the practitioner into their lives instead of having entry demanded [309]. It is also key for the practitioner to avoid the use of jargon, which reinforces distance between the two parties.

Assessment guided by ecologic theory will address all four levels. At the exosystem level, it is important to explore how migration or immigration experience has affected the family system, childrearing, and coping ability. Immigration and migration, depending upon the circumstances, can infuse hope and new dreams with the vision of building a better life for oneself and family members. Or, it can be an experience fraught with loss, as existing social networks and supports are left behind [153].

When assessing immigrants, healthcare professionals should consider incorporating the following assessment questions of the individual and/or family [153]:

Exploring immigration experience and status is crucial. In a research study involving immigrant parents in New York City who had a recent experience (within the previous five years) with child protective services, participants consistently indicated there was a lack of caseworker knowledge of the family's immigration status [154]. This lack of knowledge had serious implications, because it affected the families' ability to access services and to meet the mandated service plans, which then delayed reunification with their child [154]. For example, one family was mandated to attend a series of psychologic evaluations, parent education training, and other services [154]. However, the caseworker was not aware that the family had immigrated illegally and therefore was not eligible for free services. After several months of attendance, the family was told that they would have to pay for these services, which they could not afford. Similarly, participants in another focus group reported that interventions are often proposed without any sense of families' understanding of the requirements or ability to access the recommended services (i.e., ability to access transportation) [57]. "Cookie cutter" interventions are made without a comprehensive assessment of families' resources; these interventions are certainly not tailored to the unique needs of the families' social realities [57].

A technique referred to as "photovoice" has been studied, whereby research participants take photographs to express their thoughts and concerns about the child welfare system [225]. Using photovoice, a 2009 study found that the philosophies of the child welfare system were often dissonant with the belief systems of parents from minority cultural groups. Refugee parents stated that resettlement and adjustment to a new country was extremely challenging, with many living in high-crime and poverty-ridden areas. As a result of their dangerous living situations, they found themselves having stricter disciplinary practices to protect their children from harm. However, they felt that the social workers they encountered judged them harshly and undermined their parenting styles. They described how they needed support services and assistance rather than the social workers' negative evaluations of how they were raising their children [225].

Assessments guided by Leininger's, Airhihenbuwa's, or Kleinman's theoretical frameworks infuse the notion of culture into all aspects of planning. For example, the folk sector of Kleinman's cultural explanatory model focuses on the cultural group's social value systems about health and healing. When ethnic minority and/or immigrant families come to practitioners for child abuse, it is necessary to momentarily put aside any established conceptualization of abuse. It is important to hear from the individual or family what circumstances brought the family to the child protective system. Questions about parenting, childrearing, and disciplining must be asked. Many immigrant families come from countries where state involvement in family affairs is minimal and may have traditional cultural beliefs about parental disciplining [154].

It is not surprising that greater cultural competence is correlated with patient retention and satisfaction. Using a sample of 1,305 participants from a statewide family preservation program, patients who perceived higher cultural competence among their providers had higher goal attainment and satisfaction with services [269]. Developing and delivering interventions that are culturally competent is a process and "should never be treated as a one-time initiative or as an after-thought" [139]. Building rapport with families and children is important. It is vital to keep in mind that immigrant families and children are often anxious and fearful, particularly with mainstream Western social and health services. A few strategies can help put the family at ease [224]:

Building alliances and collaborative relationships with the community and other agencies and organizations is also key. Four tasks have been identified as beneficial for organizations and practitioners in order to build strong working relationships with stakeholders in ethnic communities. It is recommended that healthcare professionals should [155,156,157]:

Cultural brokers are mediators or intermediaries serving as bridges between practitioners and clients/patients. They can facilitate understanding of the individual's cultural heritage as well as typically Western paradigms of health and mental health to those who find the concepts foreign [158,341]. Cultural brokers are not usually trained in the area of health and mental health issues. In the context of this course, cultural brokers may be members of ethnic minority communities who could serve as "cultural consultants" [156]. As such, cultural brokers may be utilized in a variety of ways when dealing with individuals of a specific cultural group. Elders in ethnic minority communities could be solicited to help plan community education events sponsored by organizations or agencies. Because in many cultures, elders' experiences and wisdom are valued, the community may more readily accept events promoted by this group [155]. Cultural brokers can also assist as interpreters or translators. English language proficiency is a major barrier to accessing services for many ethnic minority patients. Because of the complexities of child abuse, it is recommended that professional interpreters be used to assist in translating communications. Cultural brokers may also be ideal for helping to translate written information and contributing to the graphic design of brochures to ensure they are culturally meaningful. Finally, cultural brokers can help in laying a foundation for practitioners from agencies to enter into the ethnic community. This may be a needed link to the "hidden" informal support networks.

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort for the common goal of improving patients' health, mental health, and social and/or family outcomes [342]. Positive outcomes have been demonstrated on the individual and organizational levels with interprofessional collaboration [343,344,345]. Because child abuse and maltreatment is complex and multifaceted, it makes sense for service providers to collaborate in order to increase access to services and reduce costs [381]. However, implementing and promoting this approach can be challenging. For example, child welfare workers rarely engage with physicians or nurses; instead, these service providers focus primarily on investigations and the home environment. Conflicting mandates or priorities for providers from different disciplines can impede effective interprofessional collaboration [381]. But understanding the patient's health context can assist in understanding family adversities [346]. Not understanding each other's roles is another barrier.

One way to support practitioners is to provide professional training and development so they have sufficient resources to handle the unique questions and issues that arise when working with diverse patients and the sensitive topic of child abuse. In reality, most individuals learn best when they have the opportunity to engage in the content and apply the information to real-life situations. Consequently, one-day training sessions may not be the most effective [270]. Coaching is one way to facilitate learning that results in sustainable change. Coaches can encourage the practitioner to question, evaluate, and reflect on specific information and can challenge the practitioner to apply new skills and reflect on their practice [270]. While organizations may not be able to offer coaching, training sessions can allocate time to ask questions that facilitate critical thinking and reflection. Agencies that invest in practitioners working in child welfare/protection by offering training, continuing education, and opportunities for professional growth will find that their staff experience less burnout and remain more committed to the agency [382].

Child abuse and neglect cases epitomize betrayal; adult caregivers have broken a child's trust, misused their power, and severely violated boundaries (particularly in child sexual abuse). This betrayal may induce clients or patients to unconsciously engage in dissociated re-enactments of the abusive relationships, in some cases with the practitioner [169]. Countertransference hostage syndrome refers to a situation in which the practitioner feels controlled by the patient and the events he or she is experiencing [170]. The practitioner ultimately feels silenced, with minimal options. Practitioners working with child abuse victims and families may take on various roles, being a rescuer, abuser, and victim [171]. In more serious cases such as working with child soldiers, Draijer and Van Zon observe that [271]:

As a result, transference and countertransference issues may arise. Identification with child abuse victims is not uncommon. Practitioners may feel as if they are in a delicate situation, similar to victims who may feel they are always on the edge of danger [172]. Child abuse victims often feel helpless, powerless, and isolated. Because the perpetrator wields the power, the victim is frequently not in the position to defend him/herself. Being exposed to these situations and emotions, practitioners can also feel helpless and powerless. In a qualitative study exploring the lived experiences of clinicians who work with sexual abuse victims, one worker stated, "'I feel disempowered in cases where I can't do anything to help…incompetent" [272]. If these feelings are ignored and not dealt with, the practitioner can inadvertently end up abandoning the client/family on an emotional level [173]. It is not uncommon for practitioners to dissociate while listening to their clients [172]. This has negative effects on the client, and it can indicate to supervisors and employers that the practitioner is incompetent and/or negligent [173]. When a practitioner is also a survivor of child abuse, detachment may be an issue [310].

Practitioners have also reported feeling exploited and manipulated, again very much like the victims' experiences [172]. Others feel angry at the perpetrator and society for failing to protect the victim, and in turn, the practitioner is motivated to rescue the victim [384]. Furthermore, victims often view the world dualistically, as good and bad or victims and perpetrators [173]. If this is the case, the practitioner may be placed into the role of victim or perpetrator by the victim/family. If not careful, the practitioner can adopt roles in which boundaries are blurred and inappropriate promises are made, such as contacting the client or family after hours [173].

Despite the horror of child abuse cases, some clients' stories may be fascinating, arousing, or exhilarating to practitioners due to their forbidden nature [168]. Although these emotions are unconscious, they can be tremendously shocking to the practitioner if brought to consciousness, provoking feelings of shame and guilt [168].

In some instances, a practitioner may avoid talking about cases with the hope that the feelings of hopelessness or frustration will disappear. Along these same lines, they may discuss cases in supervision in a removed or theoretical manner, dissociating themselves from the feelings [173].

Boundary issues are particularly relevant in child abuse cases because trust, intimacy, and power have been violated. Boundaries are the spoken or unspoken separations of the client and the practitioner [171,272]. The maintenance or dismissal of boundaries conveys messages regarding power, trust, and authority to clients [171]. For example, some practitioners use self-disclosure to promote rapport building. But, in child maltreatment cases, self-disclosure can be misinterpreted by victims and their families. If practitioners are not very clear regarding the overall intent of the self-disclosure or if they are unsure how it will affect the clinical process and the client, then there is possible risk of doing harm [171].

Similar transference and countertransference issues exist for practitioners working with abusers. In a qualitative study with nine professionals working with incest sexual abusers, the participants reported feelings of disgust and extreme anger and hostility [227]. For example, one therapist discussed having fantasies of punishing the abuser. Another therapist felt like physically stepping back from the client to avoid contact. Overidentification with an abuser can also occur. One practitioner talked about feeling sorry for the client, and another talked about having loving feelings toward the abuser [227].

Practitioners who are able to identify transference and countertransference issues specific to child abuse may use these dynamics both to help the client work through the trauma and to aid in their own professional development [173]. It is crucial that practitioners have the opportunity to self-reflect and identify various roles they may be adopting [171]. If countertransference issues are not recognized and addressed, the practitioner may begin acting out, leading to negative repercussions for the client or family, or the practitioner may experience secondary traumatization [173].

The terms secondary traumatization, secondary traumatic stress, secondary victimization, vicarious traumatization, and compassion fatigue all refer to the psychologic trauma experienced by those in close contact with trauma victims. This includes, but is not limited to, families, friends, and helping practitioners, such as nurses, mental health counselors, therapists, and social workers [174]. Secondary traumatic stress is defined as "the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" [174]. Secondary trauma can affect practitioners' beliefs about the world, others, and self, including concepts of safety, trust, control, and intimacy [175]. It has been argued that trauma caused by another person (i.e., abuse) may be difficult for practitioners to deal with because it brings up the issue of human evilness. This may affect existing beliefs and ideals more than trauma caused by natural events (e.g., natural disasters) [175]. Seven psychologic areas may be negatively affected by trauma or secondary trauma [228]:

In a systematic review of child protection and welfare workers, many workers reporting having lost trust in the world and in the goodness of other people [336]. In a survey study with 310 professionals who worked with clients who experienced various traumas, researchers found that 60% of the research participants indicated that their beliefs about the world changed as a result of their work, particularly to beliefs about the world being a dangerous and unjust place [229]. About 20% felt they lost a sense to the meaning of life and that they may not recover from what they heard from their clients.

Practitioners with large caseloads of clients with a history of trauma and those who have minimal clinical experience in working with traumatized clients are vulnerable to secondary or vicarious traumatization. In these situations, it is easy to suppress one's emotions and begin distancing oneself from clients [230].

However, it is important to remember that it is not all negative. In a quantitative study with 255 social workers who work with abused children, there was a positive relationship between secondary traumatic stress and vicarious post-traumatic growth [385]. In other words, while the work was extremely stressful, there were opportunities for growth and satisfaction.

Practitioners involved in child maltreatment cases are at risk for burnout. Burnout refers to the extreme stress experienced by practitioners that depletes emotional, mental, physical, and psychologic resources [176]. Signs of burnout include depression, physical and mental exhaustion, anger, cynicism, acting out, frustration, lack of productivity at work despite working longer hours, and difficulty controlling feelings [167]. A practitioner experiencing burnout often feels drained or tired and at times emotionally detached from clients [176]. Burnout can result from occupational characteristics, such as long work schedules, case overload, low staffing patterns, feelings of lacking power and control, lack of reward structures, poor management, and poor interpersonal relationships among colleagues [177,311]. A survey study of 170 home visitors found that sense of empowerment and a positive organization climate positively affected workers' feelings of burnout [273]. A study of child welfare caseworkers showed that job stress and time pressure predicted burnout [312]. In a 2020 study, there was a positive relationship between secondary traumatic stress and burnout [349]. A sense of hope and finding meaning in one's work are mitigating factors. Supervisor and peer support, the accessibility of client services, and the caseworker-client relationship can also be protective against burnout [312]. However, these factors alone, or in combination, do not necessarily predict burnout; some practitioners may experience one or more factors but not burn out.

Clinical supervision serves several functions, ensuring the delivery of high-quality, client-centered care [178,179,274]. Supervision can be delivered by self-facilitated peer groups, individual discussion with an experienced specialist who can assist with emotionally difficult cases, or individual discussion with a specialist [180].

Supervision of practitioners who work with child abuse cases has an inquisitorial nature [178]. This stems in part from the tremendous amount of follow-up necessary in child abuse cases; therefore, supervisors may assist in prioritizing cases [178,181]. Supervision also involves monitoring practitioners' emotional well-being, especially given the distressing nature of the cases [178,181]. In a study that examined the underlying theoretical/conceptual underpinnings of how clinical supervision is conceptualized in child welfare/protection, six different approaches emerged [278]:

There are several established best practice recommendations for clinical supervision of child abuse cases. Supervision should take place in an environment where practitioners feel safe to identify and label the feelings they are experiencing. Having a safe space to vent frustrations and to discuss and manage countertransference issues without feeling judged is important [350]. If supervision is delivered via a group format, the group should be small enough to allow each member the opportunity to adequately discuss his or her work and the issues that have emerged in specific cases [181]. Managers who facilitate supervision groups may feel conflicted, wanting to be a supporter while being held to the organization's mission and policies [182]. However, additional studies are needed to explore this further. It is important to ensure the members of the group are not further traumatized by hearing other members' stories. Practitioners may need to be reminded that empathic listening can exacerbate secondary traumatization [174]. Clinical supervisors help practitioners find the words to capture their experiences and feelings [168]. Furthermore, clinical supervisors should be mindful that a supervisory session can unconsciously mimic the trauma triangle of "victim/victimizer/bystander" [275]. Spiritual/religious consultants may help practitioners through grief reactions, if necessary [168]. Clinical supervisors should be aware of personal life circumstances that could negatively affect practitioners' work, for example, life crises, bereavement, and personal stressors [180]. Finally, clinical supervisors should operate from a resiliency model, with a caveat that seemingly resilient individuals should not be expected to take on all difficult cases [313].

Because of the power given to them by the state to make decisions about child abuse cases, practitioners have tremendous responsibilities. They must constantly navigate between power and compassion; therefore, in supervision, it is important to allow practitioners to explore how the issue of power emerges in their daily practice and how it affects their relationships [183].

Finally, supervisors must ensure they are engaging in self-care to avoid burnout, particularly because they model these positive behaviors to their supervisees [184]. Self-care is integral to the prevention of negative symptoms in practitioners, including burnout, secondary traumatization, and compassion fatigue. As discussed, practitioners experience the stressors associated with emotionally charged cases in addition to the normal stressors of daily life [185]. Yet practitioners may be more likely to overwork and neglect to adequately care for themselves [185,314].

An effective self-care plan may include cognitive and stress management techniques, including relaxation techniques, meditation, biofeedback, and hypnosis [186]. Good nutrition and diet, regular physical exercise, and maintaining social and familial relationships are also important. Self-awareness and mindfulness are incorporated into many self-care plans. Self-awareness refers to knowledge about one's self, and mindfulness has been defined as one's knowledge and awareness of one's experience at and in the present moment [231]. Mindfulness-based stress reduction interventions teach individuals to attend to emotions, thoughts, and feelings as they arise and to be aware of the present moment experience [232]. Mindfulness has been found to play a mediating role in the relationship between self-care and well-being among mental health professionals [231]. Instead of practicing self-care, child welfare workers tend to engage in unhealthy behaviors to manage their stress [315].

Some argue that trauma-informed self-care is particularly pertinent for practitioners who work with patients who have experienced trauma such as child abuse [276]. The focus of trauma-informed self-care is on helping practitioners to deal with patients who have been traumatized and are learning to use strategies to mitigate stress [276]. The National Child Traumatic Stress Network has developed self-care training, which is available online at https://www.nctsn.org/resources/child-trauma-toolkit-educators.

Self-care can be described as a continuum, with proactive planning and reactive intervention on either end [176]. Self-care activities include an array of behaviors involving physical (e.g., exercise, nutrition, sleep), recreational (e.g., play activities, vacation time, hobbies), social (e.g., interaction with friends and family members), and spiritual/religious (e.g., prayer, meditation) support [176]. The concept of self-compassion has also been proposed as an integral component in self-care practice. This approach emphasizes human imperfection and may be particularly pertinent for practitioners who feel inadequate and powerless in the face of witnessing patients' adversity and trauma [277]. Practitioners should not merely consider these activities in passing but should spend some time exploring the activities in which they are engaged and whether they are practicing effective self-care [176].

Monitoring ongoing self-care is as important as promoting and developing it. To achieve this, self-care check-ins, whereby a practitioner is assigned to one of his or her peers so they can hold each other accountable to a self-care plan, may be established [184,350]. Collegial support can also help to minimize burnout. Colleagues can help by alleviating work task stress, providing insight and comfort, and offering humor to lighten the mood [230]. Another option is for the supervisor to incorporate this monitoring into regular supervision.

When providing education to practitioners regarding self-care and secondary traumatization, it is important to avoid conveying a message of blame or weakness [166]. Along the same lines, organizations should consider whether their culture and environment may hinder practitioners from engaging in self-care activities. For example, practitioners who take vacation time or who decline to work overtime should not feel they will be perceived as less motivated than their colleagues [182]. Things like a coffee maker, relaxing photos, comfortable furniture, and soft music can provide opportunities for practitioners to take breaks after emotionally difficult meetings with clients and their families [182].