Course # 97583 • Child Abuse in Ethnic Minority and Immigrant Communities


Study Points

  1. Describe the historical emergence of child abuse and neglect.
  2. Identify federal policies in the United States to address child abuse and neglect.
  3. Define child abuse and neglect.
  4. Outline the international prevalence of child abuse and neglect and variations in defining child maltreatment.
  5. Discuss the impact of child abuse and neglect in the United States and Canada, particularly among ethnic minority groups.
  6. Analyze how race, ethnicity, and culture impacts ethnic minority families' parenting styles and disciplining.
  7. Identify the role of ecologic factors on the risk for child abuse and neglect.
  8. Describe cultural theoretical frameworks to guide practice.
  9. Discuss child abuse assessment, intervention, and training that consist of culturally sensitive best practice values.
  10. Identify self-care issues and practices for practitioners working with child abuse cases.

    1 . In the Middle Ages in Europe, children were viewed as
    A) God's creatures.
    B) miniature adults.
    C) "torchbearers" of the future.
    D) individuals with needs unique from adults.

    HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

    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]. 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]. 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].

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    2 . The first child abuse case in the United States that garnered widespread interest involved Mary Ellen Wilson, a foster child in New York City. This case took place in
    A) 1790.
    B) 1866.
    C) 1921.
    D) 1965.

    HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

    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.

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    3 . The Indian Child Welfare Act (ICWA), added to the Child Abuse Prevention and Treatment Act (CAPTA), allows
    A) practitioners better access to Native American children.
    B) Native American children to be removed from their homes and placed in non-Native American homes.
    C) the tribe, instead of the state courts, to address issues of child custody and welfare for Native American children.
    D) research projects to examine how to best integrate Native American children into the established social services framework.

    HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

    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 ICWA allows the tribe, instead of the state courts, to address issues of child custody and welfare for Native American children [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].

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    4 . Child abuse is defined at the federal level by
    A) child protective services.
    B) the Office of Child and Family Welfare.
    C) the Child Abuse Prevention and Treatment Act.
    D) the National Council on Child Abuse and Family Violence.

    DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

    The federal definition of child abuse is formally established by CAPTA, which states that child abuse is any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm [20]. A child (in this case defined as an individual younger than 18 years of age) victim of trafficking is also considered a victim of child abuse/neglect [20].

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    5 . Which of the following injuries is NOT considered a possible indicator of physical abuse?
    A) Patterned burns
    B) Bruises on multiple body areas
    C) Abrasions to the knees and elbows
    D) Multiple or spiral fractures at various stages of healing

    DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

    Physical abuse injuries can range from minor bruises and lacerations to more severe neurologic trauma and even death. Physical abuse is one of the most easily identifiable forms of abuse and the type most commonly seen by healthcare professionals. Physical injuries that may be indicative of abuse include bruises, welts, burns, fractures, abdominal injuries, lacerations/abrasions, and central nervous system trauma [187].

    Bruises and welts are of concern, particularly those appearing on:

    • The face, lips, mouth, ears, eyes, neck, or head

    • The trunk, back, buttocks, thighs, or extremities

    • Multiple body surfaces

    Patterns such as shapes of the article (a cord, belt buckle, teeth, or hand) used to inflict the bruise or welt should be noted. Cigar or cigarette burns are common, and they will often appear on the child's soles, palms, back, or buttocks. Patterned burns that resemble shapes of appliances, such as irons, burners, or grills, are of particular concern.

    Fractures that result from abuse might be found on the child's skull, ribs, nose, or any facial structure. These may be multiple or spiral fractures at various stages of healing. When examining patients, note bruises on the abdominal wall; any intestinal perforation; ruptured liver or spleen; and blood vessel, kidney, bladder, or pancreatic injury, especially if accounts for cause do not make sense. Look for signs of abrasions on the child's wrists, ankles, neck, or torso. Lacerations might also appear on the child's lips, ears, eyes, mouth, or genitalia. If violent shaking or trauma occurred, the child might experience a subdural hematoma [187].

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    6 . Child sexual abuse is categorized as exhibitionism if the act involves
    A) obscene phone calls.
    B) forcing a child to observe sexual acts.
    C) watching a child get dressed or undressed.
    D) touching, fondling, or kissing the child in a provocative manner.

    DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

    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.

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    7 . A child discloses that he has not gone to school for two weeks. When questioned regarding the reason for the absences, the child states that his parents do not feel like bringing him to school. This may be reported as which type of abuse?
    A) Physical abuse
    B) Financial abuse
    C) Emotional abuse/neglect
    D) This is not an abuse case.

    DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

    The following behaviors constitute emotional abuse and neglect [20,22]:

    • Verbal abuse: Belittling or making pejorative statements in front of the child, which results in a loss or negative impact on the child's self-esteem or self-worth

    • Inadequate nurturance/affection: Inattention to the child's needs for affection and emotional support

    • Witnessing domestic violence: Chronic spousal abuse in homes where the child witnesses the violence

    • Substance and/or alcohol abuse: The parent/caretaker is aware of the child's substance misuse problem but chooses not to intervene or allows the behavior to continue

    • Refusal or delay of psychologic care: Failure or delay in obtaining services for child's emotional, mental, or behavioral impairments

    • Permitted chronic truancy: The child averages at least five days per month of school absence, and the parent/guardian does not intervene

    • Failure to enroll: Failure to enroll or register a child of mandatory school age or causing the child to remain at home for nonlegitimate reasons

    • Failure to access special education services: Refusal or failure to obtain recommended services or treatment for remedial or special education for a child's diagnosed learning disability

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    8 . Worldwide, it is estimated that approximately what percentage of children between 1 and 14 years of age have experienced physical punishment and/or psychological aggression by a caregiver in the past month?
    A) 8%
    B) 30%
    C) 50%
    D) 80%

    AN INTERNATIONAL PERSPECTIVE

    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 has been exacerbated during the coronavirus disease (COVID-19) pandemic. 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].

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    9 . The World Health Organization categorizes female genital mutilation/cutting that involves total removal of the clitoris and labia minora as
    A) incision.
    B) excision.
    C) infibulation.
    D) clitoridectomy.

    AN INTERNATIONAL PERSPECTIVE

    It is beyond the scope of this course to resolve the complex questions of culture and child abuse or to uphold one position over the other. This becomes very clear in the case of FGM/C. FGM/C generally refers to the cultural practice of cutting away a part of or all of a girl's external genitalia for a variety of cultural and social reasons [25]. However, some groups participate in ritual cutting or piercing of female genitalia that does not result in the removal of tissue. The motivation or goal does not appear to be to intentionally harm the child (although the procedure often does); rather, this practice is reflective of a set of prescribed, deeply rooted cultural norms. In some cultures, FGM/C acts as a social mechanism to control female sexuality. In other cultures, FGM/C is a ritual to initiate girls into womanhood [25]. The World Health Organization categorizes the various practices of FGM/C into four major types [34]:

    • Clitoridectomy: Partial or total removal of the clitoris and, rarely, the prepuce (the fold of skin surrounding the clitoris)

    • Excision: Partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora

    • Infibulation: Narrowing of the vaginal opening (often to the width of a matchstick) through the creation of a covering seal formed by cutting and repositioning the inner, and sometimes outer, labia, with or without removal of the clitoris

    • Other: All other harmful procedures to the female genitalia for non-medical purposes (e.g., pricking, piercing, incising, scraping, and cauterizing the genital area)

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    10 . Internationally, approximately how many children younger than 18 years of age are currently serving as soldiers?
    A) 30,000
    B) 100,000
    C) 300,000
    D) 1,000,000

    AN INTERNATIONAL PERSPECTIVE

    It is estimated that approximately 300,000 children younger than 18 years of age are currently serving as child soldiers [37]. Child soldiers may be responsible for digging trenches, radio communication, performing guard duty, setting land mines, manufacturing bombs, and front-line fighting [247]. The majority of these child soldiers are 15 to 18 years of age, but some are as young as 7 years [238]. In one study with a sample of 330 former child soldiers of Uganda, the mean age was 10.8 years [238]. Of these children, 41.8% served as front-line soldiers and 99.7% were recruited by force. Isolation, witnessing violence, and forced killings are mechanisms used to control and indoctrinate child soldiers [286]. The atrocities these children witness and experience are beyond comprehension. Bayer, Klasen, and Adam conducted a study that included 169 former Ugandan and Congolese child soldiers who were on average 15.3 years of age at the time of the study [38]. Almost all (92.9%) reported witnessing a shooting, 89% witnessed someone being wounded, and 84% witnessed someone being seriously beaten. A total of 54% reported having killed someone, and 27.8% reported being forced to engage in sexual activity [38]. The experience of conscription among children produces emotional and psychologic trauma and a host of cognitive and behavioral problems [39]. In the Ugandan study, 33% of the children were diagnosed with current post-traumatic stress disorder, 36% were diagnosed with current major depressive disorder, and 19% had both [238]. In one study of 19 child soldiers, 18 had volunteered for service in the army and one had been abducted. Some of the children tried to run away or disobey, which resulted in beatings and imprisonment. In some cases, they were told to commit suicide. Although most of the children volunteered into the army, their participation became involuntary. Some also reported that they received educational and supportive services that they may not have otherwise obtained [39]. In one study of child soldiers in Columbia, the majority (83%) stated they joined an illegal armed group voluntarily, with 18% citing financial motivations [287]. If child soldiers escape and attempt to reintegrate back into their communities, they often face ostracism, ridicule, and a host of mental health issues [288].

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    11 . The most common type of abuse reported in the United States is
    A) neglect.
    B) verbal abuse.
    C) sexual abuse.
    D) physical abuse.

    CHILD ABUSE IN THE UNITED STATES AND CANADA

    As of 2019, 8.9% of children in the United States have been victims of abuse and/or neglect [250]. This is the unique rate, meaning it counts each child only once regardless of the number of reports of abuse/neglect. By far, the most common type of abuse reported in the United States is neglect, which accounts for 74.9% of reported cases. This is followed by physical abuse (17.5%), and sexual abuse (9.3%) [250].

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    12 . Compared with non-Hispanic white counterparts, ethnic minority children have
    A) lower rates of reported child maltreatment.
    B) higher rates of reported child maltreatment.
    C) similar rates of reported child maltreatment.
    D) lower rates of reported neglect but higher rates of reported abuse.

    CHILD ABUSE IN THE UNITED STATES AND CANADA

    Research has shown that racial and ethnic minority children (particularly African American, Native American, and Hispanic children) have higher rates of reported child maltreatment compared to their White counterparts (Table 1) [250]. Studies examining prevalence of child sexual abuse in ethnic minority groups have yielded mixed results. These mixed results may be due to variations in definitions and methodologies used in the study of child abuse [52]. One study found that Latino and non-Latino children experienced rates of sexual abuse at 7.4% and 8.8%, respectively [52]. Another study found higher rates of child sexual abuse among African American children compared to Latinos [52]. However, there does appear to be one consistent trend: reported child sexual abuse tends to be lower in Asian countries as well as among Asian American families in the United States compared to the general population. It has been speculated that traditional norms about sexual activity or Asian cultural values such as filial piety, harmony, and collectivistic orientation impede Asian and Asian American children from reporting such abuse [52].

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    13 . Which of the following factors might contribute to the over-representation of children of color in child abuse and neglect reports in the United States?
    A) Reporter bias
    B) Lack of familiarity with cultural beliefs, norms, and practices
    C) Greater number of child abuse risk factors in ethnic minority communities
    D) All of the above

    CHILD ABUSE IN THE UNITED STATES AND CANADA

    Several factors might account for this disparity. It is possible that reporters, such as teachers, social workers, counselors, and other community workers, may be biased in the reporting of abuse [252,328]. There is some empirical indication that although ethnic minority children are less likely to be viewed as being at risk for child abuse, case workers may be more likely to view a case that is under investigation as constituting abuse when an ethnic minority child is involved [53,56]. Some experts argue that professionals have their own "professional ethnocentrism," whereby having been trained within the dominant culture's values, they see individuals from immigrant and cultural groups as being exotic, aberrant, or pathologic [46]. This perspective is also called the cultural deficit lens, which assumes that other cultures and their norms fall "short" and need correcting [198,328]. In a series of focus groups conducted with community members, legal professionals, and caseworkers from communities in which there are a disproportionate amount of African American children being removed from their homes, caseworkers admitted they often used the benchmarks of appropriate parenting based upon their own experiences. Furthermore, some caseworkers admitted being fearful of going into unsafe neighborhoods; as a result, they tended to bypass some of the normal investigative procedures and simply remove the child [57]. Some choices may also be made based on stereotypes or behaviors outside of perceived norms [58]. For example, biases may lead professionals to believe rescuing a child from an "unhealthy" environment is better than placing the child with his or her large network of extended kin because of the misperception that such a network is "chaotic" [58,328]. Related to biases, it is also possible that there is a disparity of services and resources allocated to racial and ethnic minority families, which then augments the risks for child maltreatment [252]. Practitioners' biases about kinship networks are not solely to blame; agency policies also tend to exclude willing caregivers from extended kinship networks from stepping in to care for children about to be removed [57].

    Another bias may stem from practitioners' reductionistic perspectives about child safety and what factors are responsible for placing children at risk. In a study of the over-representation of Aboriginal children in Canada's child welfare system, researchers found it was not necessarily race or poverty of the case that influenced the decision making outcome of the case [199]. Rather, it was other factors, such as substandard housing, parental substance abuse, and domestic violence, that predicted child protection decisions among practitioners. It is possible that child protective workers tend to identify individual causes (e.g., parental substance abuse, child's race, caregiver characteristics) more than structural causes (e.g., lack of access to resources). Whether biases exist on an individual level or on an agency level, it is important that the desire to help is tempered by a consideration of the role of cultural bias or racist attitudes in negatively affecting the helping process [58,328].

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    14 . As opposed to culture, race is defined by
    A) attitudes and beliefs that are passed down from generation to generation.
    B) language, religious beliefs, ways of thinking, and patterns of social relations.
    C) links to biology and physical markers such as hair color, skin color, and facial features.
    D) a group's socially constructed identity, at times based on class, politics, and sociopolitical factors.

    CULTURE, RACE, AND ETHNICITY

    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].

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    15 . In Western society, authoritarian parenting styles are
    A) associated with parental concern, caring, and love.
    B) equated with promoting individuality and autonomy.
    C) aligned with instilling a work ethic that leads to higher academic achievement.
    D) regarded more negatively and associated with negative outcomes such as poor self-esteem.

    IMPACT OF CULTURE ON CHILDREARING

    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.

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    16 . What cultural orientation is marked by an emphasis on harmony and relegating individual needs to that of the larger community?
    A) Familial culture
    B) Collectivist culture
    C) Matriarchal culture
    D) Individualist culture

    IMPACT OF CULTURE ON CHILDREARING

    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].

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    17 . What does the concept of fostering in Caribbean families involve?
    A) Socializing of children with non-related adults
    B) Social services placing at-risk children within their own families
    C) Extended family members rearing children while parents leave the area to search for employment
    D) All of the above

    IMPACT OF CULTURE ON CHILDREARING

    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].

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    18 . Corporal punishment has been defined as
    A) punishment that inflicts physical pain.
    B) discipline carried out by a patriarchal figure.
    C) punishment that relies on reasoning and lectures.
    D) discipline involving the use of shaming or publicly ridiculing.

    IMPACT OF CULTURE ON CHILDREARING

    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].

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    19 . Which of the following countries has outlawed the use of corporal punishment?
    A) Russia
    B) Barbados
    C) Germany
    D) The United States

    IMPACT OF CULTURE ON CHILDREARING

    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].

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    20 . In Asian cultures, corporal punishment is generally
    A) not utilized.
    B) considered abusive.
    C) considered a reflection of parental love.
    D) regarded as a practice of foreign cultures.

    IMPACT OF CULTURE ON CHILDREARING

    There is a common Vietnamese proverb that roughly translates to: "When we love our children, we give them a beating; when we hate our children, we give them sweet words" [117]. This idea that corporal punishment is a reflection of a parent's love is shared by many Asian cultures. Asian children are viewed as extensions of their parents, with the goal of bringing honor and pride to their families. As such, Asian children are expected to be obedient to their parents [117]. This unquestioning obedience is the foundation of parenting in many Asian cultures. Disciplinary practices commonly used among White Americans include time-outs and lecturing; however, this is not commonly practiced in Asian families. Asian parents frequently use physical disciplining, such as spanking with a hand or object [217]. In Singapore, caning is a prevalent and highly acceptable form of discipline [119]. Caning is often inflicted on a child's arm, palm, or buttocks. When used on these parts of the body, the wounds are often innocuous, but on other parts of the body or face, it may be extremely dangerous [119]. In a quantitative Chinese study, approximately half of parents reported having used corporal punishment in the past six months [334]. Mothers were more likely to use corporal punishment than fathers. Parents who had experienced corporal punishment as children were more likely to employ corporal punishment as parents. Verbal disciplining strategies may also be used, usually focusing on how the child shamed the family [217]. A survey of 89 mothers from Taiwan and Hong Kong found that the majority (91.4%) would use "power assertion," characterized as demanding immediate compliance.

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    21 . In most countries, the most severe form of abuse is identified as
    A) neglect.
    B) sexual abuse.
    C) emotional abuse.
    D) physical aggression.

    CULTURE AND PERCEPTION OF CHILD ABUSE

    In most countries, sexual abuse is considered the most severe form of abuse. Most cultural groups limit or avoid talk about sex and sexuality; for children to discuss sexual acts is considered immoral. For example, African American girls live in a culture that stresses persevering and overcoming challenges and may feel that their sexual abuse is not a legitimate cause of complaint [219]. Other cultures may consider girls who are no longer virgins to be "ruined" or "spoiled," with the blame for this change falling to the girl regardless of circumstances [219]. Sexual abuse destroys children's innocence. Some experts and laypersons have expressed the belief that sexual abuse can facilitate hypersexualization, particularly among girl victims [304]. In a 2019 study with Vietnamese American students, the majority of participants did not believe that sexual abuse perpetrators could be relatives and felt that schools and homes were safe places. They also tended to believe that boys could not be victims of sexual abuse [335].

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    22 . According to ecologic theory, parental adherence to the cultural belief that children are property is part of the
    A) exosystem.
    B) microsystem.
    C) macrosystem.
    D) ontologic level.

    ECOLOGIC FACTORS

    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. 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]:

    • Alcohol drinking culture, particularly the mother's consumption of alcohol

    • Views about corporal punishment, particularly a technique known as the "cane of love" (sarangui mae)

    • Family adherence to Confucianism regarding parent-child relationships

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    23 . Which of the following microsystem factors has been shown to correlate to an increased risk for child maltreatment?
    A) Single-parent household
    B) Family socioeconomic status
    C) Multiple children in the family
    D) All of the above

    ECOLOGIC FACTORS

    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]. 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.

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    24 . Which of the following is NOT a primary dimension of the PEN-3 model?
    A) Relationships
    B) Cultural identity
    C) Existential dilemmas
    D) Cultural empowerment

    CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

    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].

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    25 . According to Kleinman's cultural explanatory model, health or mental health assistance from an indigenous healer would be categorized in which sector?
    A) Folk
    B) Religious
    C) Professional
    D) Lay/popular

    CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

    An individual's cultural and social beliefs and value systems about health, illness, and healing are referred to as the folk sector. Religious practitioners and indigenous healers also fall into this category [145,146].

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    26 . The biculturalization of assessments and interventions involves all of the following, EXCEPT:
    A) Formulating a plan that promotes a Western approach to care
    B) Ensuring that interventions are congruent with the individual's cultural norms
    C) Identifying cultural values and beliefs to be incorporated into assessment and interventions
    D) Explaining to the individual that a Western-based intervention will not negate his or her value systems

    CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

    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]:

    • Identifying cultural values and beliefs to be incorporated into assessment and interventions

    • Ensuring that interventions are congruent with the individual's and family's cultural norms

    • Identifying indigenous interventions that can be incorporated into Western interventions

    • Formulating a plan that promotes an individual's values and belief systems

    • Explaining to the individual (and family) that the Western-based intervention will not negate the client's value systems but can work in harmony with indigenous interventions

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    27 . An area for professional development for practitioners involved in the care of ethnic minority and immigrant individuals is
    A) cultural knowledge.
    B) immigration knowledge.
    C) legislation pertaining specifically to racial and ethnic minority groups.
    D) All of the above

    CHILD ABUSE ASSESSMENT AND INTERVENTIONS

    Some behaviors and practices are universally unacceptable (e.g., teaching a child to steal), but other behaviors may be culturally idiosyncratic or existential behaviors (from the third dimension of the PEN-3 model). These culturally rooted behaviors are neutral, with no negative health ramifications, but may be unfamiliar to practitioners. Examples are the use of coining, cupping, and cao gio, all of which are practiced by many Southeast Asians. Very briefly, coining, cupping, and cao gio are all traditional dermabrasion therapies intended to reduce the phong or "wind" in the body. Coining consists of a coin or metal piece being rubbed against the client's/patient's skin in order to remove the phong[159,160]. Cupping is an intervention whereby one applies warm cups to the ailing individual's skin to draw the phong out [161]. Cao gio involves rubbing an ointment comprised of various oils including camphor, menthol, and wintergreen oil onto the body [162]. A spoon edge or a coin is then used to firmly rub the ointment on the body area for about 15 to 20 minutes, until a red mark is produced [162]. Based on yin-yang principles, moxibustion involves putting a piece of material (e.g., yarn, string) on the painful area of a patient's body and lighting the material on fire [347]. Healthcare professionals have at times misinterpreted marks from these therapies as being abusive. Teachers who notice red marks on their students' arms or back have attributed them to child abuse and have reported it as such [162,347].

    Practitioners working with racial and ethnic minority families require some understanding of the stages of migration for different immigrant groups and the complex issues related to immigration status. It is important to understand that not all immigrant groups are the same. The variables that influence the pre-migration stage (prior to leaving their homeland), the transit or intermediate stage (the time before settling in their new homeland, which may include detention centers or refugee camps), and the resettlement stage will vary tremendously among immigrant groups [156]. Continuing education or independent study focusing on various nations and immigrant groups may be useful. Reviewing the migration journey for these groups can provide practitioners with a basis on which to build cultural knowledge [156].

    Practitioners should be familiar with appropriate child welfare legislative policies and their historical foundations, particularly the laws pertaining to racial and ethnic minority groups. For example, practitioners who work with Native American families should be familiar with the ICWA. A basic understanding of this act is needed to understand the services for which Native American families are eligible [164]. It is also crucial for practitioners to understand the historical backdrop that led to the legislation, as it may help practitioners understand the reluctance to accept government assistance [164].

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    28 . Countertransference hostage syndrome refers to a situation in which the practitioner
    A) severely violates professional boundaries.
    B) abandons the patient on an emotional level.
    C) becomes overly involved with the patient and family.
    D) feels controlled by the patient and the events he or she is experiencing.

    PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

    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]:

    Clinicians are confronted with oppression and dissociation in and outside of psychotherapy. Relatively minor stressors can trigger classic fight, flight, or freeze reactions, manifested by severe aggression and/or regressed dissociative states…Clinicians are pulled into the reenactments of old trauma scenarios and become part of a wild therapeutic dance of approach and avoidance that can feel like war.

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    29 . Which of the following is NOT a best practice recommendation for clinical supervision of child abuse cases?
    A) Practitioners' emotional well-being should be monitored.
    B) Spiritual/religious consultants are not appropriate experts to assist with grief reactions.
    C) Supervision should take place in an environment where practitioners feel safe to identify the feelings they are experiencing.
    D) If supervision is administered via a group format, steps should be taken to ensure that group members are not further traumatized by hearing other members' stories.

    PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

    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].

    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].

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    30 . As practitioners involved with child abuse cases are at an increased risk for burnout, it is vital that they engage in self-care to prevent negative symptoms. An effective self-care plan includes
    A) regular physical exercise.
    B) stress management techniques.
    C) maintenance of social relationships.
    D) All of the above

    PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

    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].

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