SW25B • Massachusetts LSWs and LSWAs 2025-2026

Table of Contents

SW25B • Massachusetts LSWs and LSWAs 2025-2026

How to Receive Credit

NetCE 2 Hour Course #76103 • Frontotemporal Dementia

76103 • Frontotemporal Dementia

1. INTRODUCTION

2. EPIDEMIOLOGY OF FTD

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

4. CLINICAL PRESENTATION

5. GENETICS AND FTD

6. MANAGEMENT OF FTD

7. PROGRESSION OF FTD

8. RESEARCH RELATED TO FTD

9. CASE STUDY

10. CONCLUSION

11. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

NetCE 3 Hour Course #77560 • Professional Boundaries in Mental Health Care

77560 • Professional Boundaries in Mental Health Care

1. INTRODUCTION

2. COMPETENCE

3. THE THERAPEUTIC RELATIONSHIP

4. TRANSFERENCE AND COUNTERTRANSFERENCE

5. BOUNDARIES AND LIMITS

6. BOUNDARY CROSSINGS AND VIOLATIONS

7. MULTIPLE RELATIONSHIPS

8. TECHNOLOGY AND DISTANCE THERAPY

9. CONCLUSION

10. RESOURCES

Works Cited

NetCE 10 Hour Course #97584 • Child Abuse in Ethnic Minority and Immigrant Communities

97584 • Child Abuse in Ethnic Minority and Immigrant Communities

1. INTRODUCTION

2. HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

3. DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

4. AN INTERNATIONAL PERSPECTIVE

5. CHILD ABUSE IN THE UNITED STATES AND CANADA

6. CULTURE, RACE, AND ETHNICITY

7. IMPACT OF CULTURE ON CHILDREARING

8. CULTURE AND PERCEPTION OF CHILD ABUSE

9. ECOLOGIC FACTORS

10. CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

11. CHILD ABUSE ASSESSMENT AND INTERVENTIONS

12. PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

13. CONCLUSION

Works Cited

SW25B • Massachusetts LSWs and LSWAs 2025-2026

Lauren E. Evans, MSW

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

SW25B • Massachusetts LSWs and LSWAs 2025-2026

Expiration Date: 10/31/2026

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

76103 • Frontotemporal Dementia

Lauren E. Evans, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.

Table of Contents

76103 • Frontotemporal Dementia

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. EPIDEMIOLOGY OF FTD

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

4. CLINICAL PRESENTATION

BEHAVIORAL PRESENTATION

LANGUAGE PRESENTATION

FTD OVERLAP WITH MOVEMENT DISORDERS

CLINICAL DIAGNOSIS OF FTD

5. GENETICS AND FTD

6. MANAGEMENT OF FTD

CAREGIVER SUPPORT

7. PROGRESSION OF FTD

8. RESEARCH RELATED TO FTD

9. CASE STUDY

10. CONCLUSION

11. RESOURCES

Works Cited

Evidence-Based Practice Recommendations Citations

76103 • Frontotemporal Dementia

Education Category. Psychiatric / Mental Health

Release Date. 11/01/2024

Expiration Date. 10/31/2027

Course Overview

Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.

Audience

This course is designed for psychologists who may intervene to support patients with frontotemporal dementia and their families.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 1 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 2 Clinical continuing education clock hours. NetCE designates this continuing education activity for 2 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Course Objective

The purpose of this course is to provide psychologists with current information on frontotemporal dementia (FTD). Understanding the epidemiology, pathology, clinical features, diagnostic process, genetics, symptom treatment/management, role of brain autopsy, and current research provides a foundation for the care of patients with FTD and support for their families.

Learning Objectives

Upon completion of this course, you should be able to:

1. Describe the epidemiology of frontotemporal dementia (FTD) in the United States.

2. Explain the brain changes of FTD and their general clinical manifestations.

3. Identify the three general presentations of FTD.

4. Review how a clinical diagnosis of FTD is made, including differentiation from Alzheimer disease.

5. Summarize the role of genetics in FTD.

6. Discuss strategies for managing symptoms of FTD and providing support to family caregivers.

7. Identify goals of current research on FTD.

Faculty

Lauren E. Evans, MSW, received her Master’s degree in Social Work from California State University, Sacramento, in 2008. Her focus was on political and community social work. She has also been a Registered International Instructor of Therapeutic Horseback Riding through the Professional Association of Therapeutic Horsemanship International (PATH Intl.) since 2006. She currently works as a mental health practitioner with the homeless population.

Faculty Disclosure

Contributing faculty, Lauren E. Evans, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Frontotemporal dementia (FTD) is a group of degenerative brain disorders characterized by behavior and language problems and also overlapping with some motor/movement diseases. FTD causes progressive deterioration in a person's ability to function as the result of damage to the frontal and temporal lobes of the brain. FTD is also referred to as frontotemporal degeneration, frontotemporal lobar degeneration, and Pick disease.

Dr. Arnold Pick, a Czech neurologist, psychiatrist, and neuropathologist, first described frontal and temporal lobe atrophy causing dementia and progressive aphasia in 1892 [1]. The clinical syndrome subsequently became known as "Pick disease." FTD is the third leading cause of dementia across all age groups, after Alzheimer disease (AD) and Lewy body dementia [2]. It is one of the most common causes of early-onset dementia, with onset typically between 45 and 64 years of age [2,3].

The clinical presentation of FTD can be complex, and obtaining an accurate diagnosis can be challenging. The unique clinical symptoms of FTD, neuropsychologic assessment, and brain imaging can help distinguish it from AD and other dementias. There is presently no effective treatment for FTD, and symptom management can be challenging for healthcare providers and family caregivers. Research is in progress to better understand FTD, hopefully leading to effective treatment, cure, and prevention of this devastating disease.

2. EPIDEMIOLOGY OF FTD

It is estimated that FTD affects approximately 60,000 people in the United States [3]. As noted, the age of onset for FTD is typically 45 to 64 years, with a mean of 58.5 years and a reported range between 21 and 80 years of age [2,3,4,5]. In the United States, the prevalence in people 45 to 64 years of age is estimated at 15 to 22 per 100,000 population; the incidence in this group is 2.7 to 4.1 per 100,000 [5]. It is estimated that 60% of those with FTD have onset between 45 and 64 years of age; 10% have onset before 45 years of age, and 30% have onset after 64 years of age [5]. FTD is now considered by some to be the most common form of pre-senile dementia in patients younger than age 60, even more common than AD in this group [6,7,8].

FTD affects both men and women. However, it is unclear if men and women are affected equally, or if some subtypes of FTD may be more common in one gender or the other [9]. Significant time (average: 3.6 years) often passes between symptom onset and actual clinical diagnosis [5].

The disease duration for FTD can range from 2 to 20 years from symptom onset to death, with a mean duration of 8 to 10 years [3,5,10]. Pneumonia is the most common cause of death [3].

3. PATHOGENESIS AND PATHOPHYSIOLOGY OF FTD

Patients with FTD experience a progressive loss of neurons in the frontal and anterior temporal lobes, resulting in atrophy in these areas of the brain. They may also develop gliosis in the frontal and temporal lobes where neurons have been lost or damaged.

In FTD, affected neurons have an abnormal accumulation of protein within the cell, called inclusions. Three types of intra-neuronal inclusions have been identified, based on the protein involved. In some cases, the inclusions are composed of an abnormal form of the protein tau. In other patients, the inclusions are composed of the transactive response DNA-binding protein 43 (TDP-43). In a smaller number of FTD cases, the inclusions are composed of fused in sarcoma (FUS) protein [11].

The frontal and anterior temporal lobes of the brain control executive functions (e.g., planning, organizing, abstract thinking, judgment, decision making), personality, social behavior, and language. The changes associated with FTD causes impairments in executive function, personality, behavior, and/or language. The location of the neurodegeneration correlates fairly well with the clinical presentation [11]. Changes in other areas of the brain may cause overlapping movement problems. While the cause of most cases of FTD is not known, some cases are now known to be caused by genetic mutations.

4. CLINICAL PRESENTATION

FTD causes a gradual, progressive decline in behavior and/or language; movement disorders may also be involved. Behavior or language problems are typically the first and most prominent symptoms of FTD, whereas memory problems are the first symptoms of AD [5]. Subtypes of FTD have been identified based on clinical presentation (Table 1). Behavioral variant FTD (bvFTD) is the most common form and involves changes in behavior, personality, and emotions. Language presentations are referred to as primary progressive aphasia (PPA) and can take one of three forms: nonfluent/agrammatic variant PPA (nfvPPA), semantic variant PPA (svPPA), or logopenic variant PPA (lvPPA) [12]. Nonfluent/agrammatic PPA begins with problems in speech production, while svPPA involves impaired word comprehension and object recognition and lvPPA involves word-finding problems. A movement presentation may appear as progressive supranuclear palsy (PSP), corticobasal syndrome (CBS), or motor neuron disease (MND). Some patients may present with symptoms that overlap the different subtypes of FTD or may develop symptoms of other subtypes of FTD as the disease evolves. As more is learned about FTD, the terminology and classification of the subtypes may be revised.

Table 1: FORMS OF FRONTOTEMPORAL DEGENERATION

Behavioral presentation

- Behavioral variant FTD (bvFTD)

Language presentation, variants of primary progressive aphasia (PPA)

- Nonfluent/agrammatic PPA (nfvPPA), previously called progressive non-fluent aphasia (PNFA)

- Semantic variant PPA (svPPA), previously called semantic dementia (SD)

- Logopenic variant PPA (lvPPA) (often found to have Alzheimer disease pathology at autopsy)

Associated movement disorders (not classified as FTD, but have shared symptoms)

- Corticobasal syndrome (CBS)

- Progressive supranuclear palsy (PSP)

- Motor neuron disease, also called amyotrophic lateral sclerosis (FTD/MND or FTD/ALS)

Source: Compiled by Author

BEHAVIORAL PRESENTATION

Behavioral Variant FTD

As noted, bvFTD is the most common type of FTD, estimated to account for more than half of all cases [13]. The prominent features include disinhibition, apathy/inertia, loss of empathy, compulsive behaviors, hyper-orality, and impaired executive function (Table 2) [14]. People with FTD may become socially withdrawn, inflexible, and impulsive. They may have a shortened attention span and a tendency to be easily distracted. Behavior may become socially inappropriate. People with bvFTD are usually unaware of the changes in their personality and behavior and the impact these changes have on others. Memory and visual-spatial functioning are initially relatively spared in bvFTD. Some individuals with bvFTD may develop symptoms similar to Parkinson disease, such as bradykinesia, rigidity, postural instability, and masked face.

Table 2: BEHAVIORAL VARIANT FTD

Major Clinical Features

Examples

Disinhibition

Making inappropriate comments, taking food off someone else's table at a restaurant, telling sexual jokes, shoplifting, hitting

Apathy

Less involved in old hobbies or activities, deterioration in personal hygiene

Loss of empathy

Indifferent when a family member is hurt

Compulsive behaviors

Repeating the same phrase, clapping hands in the same pattern repeatedly, checking the time repeatedly

Hyper-oral behaviors

Overeating, eating one certain type of food, eating excessive sweets

Impaired executive function

Poor performance at work, poor financial decisions, difficulty planning and preparing a meal

Source: Compiled by Author

LANGUAGE PRESENTATION

Nonfluent/Agrammatic Variant PPA

Nonfluent/agrammatic variant PPA, also referred to as progressive non-fluent aphasia (PNFA), accounts for about 25% of all FTD cases and involves problems with language expression [13]. People with nfvPPA have difficulty producing speech but retain the meaning of words and know what they want to say. As a result, speech may become hesitant, slow, and labored. Speech patterns may be "agrammatic" or "telegraphic," meaning that only the most important content words are used, without connecting words. For example, a patient might say "Tuesday…hospital…sister." Patients with nfvPPA have difficulty talking on the telephone and tend to talk progressively less. Eventually, some may become mute. While in the early stages, these patients continue to understand the speech of others, but this comprehension is eventually lost also. Reading and writing skills are better preserved than speech, although these abilities are also eventually lost. As the disease progresses, patients may develop behavioral symptoms. Some individuals with nfvPPA may develop extrapyramidal symptoms of rigidity and tremors, as seen in CBS and PSP.

Semantic Variant PPA

Semantic variant PPA, also referred to as semantic dementia, represents about 20% of FTD cases [13]. Semantic variant PPA involves the loss of understanding of the meaning of words and objects. Speech is still fluent and grammatically correct, but people with svPPA have a declining ability to comprehend the meaning of words (especially nouns) or to recognize familiar objects or faces. For example, a person with svPPA who is very familiar with vegetables might read a menu and ask: "What is broccoli?" If shown a picture of a carrot, the patient may not be able to name it and may not recognize the word when told. There are progressive word-finding problems, reading and spelling skills decline, and retrieving names becomes difficult. Later in the disease, people with svPPA may develop behavioral changes similar to those seen in patients with bvFTD.

Logopenic Variant PPA

Logopenic variant PPA is characterized by difficulty retrieving words, resulting in slow speech with frequent pauses. These patients may also have trouble repeating long phrases and understanding complex sentences. Eventually, people with lvPPA may become mute. Reading and writing skills are initially preserved, but these decline as the disease progresses. People with lvPPA have word-finding problems similar to people with AD and are often found to have AD pathology at autopsy [8].

For all patients with suspected language presentations of FTD, it is important to consider the role of culture and preferred language.

FTD OVERLAP WITH MOVEMENT DISORDERS

Progressive Supranuclear Palsy

PSP is a neurodegenerative condition characterized by problems with gait and balance, causing postural instability, falls, and difficulty with eye movement coordination. The pathophysiology of PSP shows a loss of cells in the basal ganglia, substantia nigra, subthalamus, and brainstem, and affected neurons have inclusions composed of abnormal tau protein. There are similarities between PSP and Parkinson disease, including bradykinesia, rigidity, masked face, dysarthria, dysphagia, apathy, and depression. Some people with PSP develop behavioral problems, but these are often milder than those seen in other types of FTD. Some people with PSP may develop progressive memory and language problems, and there may be a decline in executive function.

Corticobasal Syndrome

CBS is a neurodegenerative condition that may initially present with movement problems, dementia, or both. In CBS, there is atrophy in multiple areas of the brain, including the frontoparietal regions, basal ganglia, and cerebral peduncles. Neuronal inclusions are usually composed of abnormal tau protein. Signs of CBS typically begin with decreased movement on one side of the body, muscle rigidity, and tremor. A hand, arm, or leg on the affected side may demonstrate apraxia (i.e., inability to make the limb follow commands). Patients may describe the affected limb as not feeling like a part of their body, a sensation referred to as "alien limb syndrome." Symptoms may become bilateral as the disease progresses. People with CBS may also experience personality changes, executive dysfunction, and language problems as the disease progresses.

FTD with Motor Neuron Disease

Approximately 30% of people with FTD also develop problems with motor neurons that control voluntary movement [3]. This is referred to as FTD with motor neuron disease (FTD/MND) or FTD with amyotrophic lateral sclerosis (FTD/ALS). Pathologically, in addition to frontal and temporal lobe atrophy, there is also atrophy in the motor regions of the cortex and loss of motor neurons in the brain stem and spinal cord. In FTD/MND, damaged neurons usually have abnormal inclusions composed of the protein TDP-43. Patients may present with behavior or language problems, but then additionally develop muscle problems, including weakness, stiffness, twitches, cramps, and/or atrophy. Muscle problems can affect arms, legs, face, mouth, and tongue, causing patients to experience clumsiness, dysphagia, dysarthria, and hyper-reflexia. An estimated 50% of patients with MND or ALS go on to develop behavioral and executive dysfunction symptoms of FTD as their disease progresses [3].

CLINICAL DIAGNOSIS OF FTD

The diagnosis of FTD can be challenging because of the wide range of symptoms, the relatively early age of onset, and the slow progression. There is no single test to diagnose FTD, and it may be initially misdiagnosed as a psychiatric disorder (e.g., depression, schizophrenia), AD, Parkinson disease, or vascular dementia. Accurate diagnosis of FTD is important because some of the medications used to treat these other diseases may be detrimental to patients with FTD. Patients with suspected FTD are often referred to neurologists or neuropsychologists with special expertise in FTD and related neurodegenerative disorders for a comprehensive evaluation.

The clinical diagnosis of FTD is based on the clinical history, family history, neurologic examination, neuropsychologic evaluation, and neuroimaging. Other tests may also be performed for differential diagnosis. The diagnostic process may take time, and the diagnosis may change as more tests are done or as new symptoms appear.

The clinical history is obtained from the patient and his/her family or friends. It is important that family or friends provide information regarding symptoms, as patients are often unaware of their behavior changes.

The family history should focus on whether any other relatives have had a neurodegenerative disease. Any cases of dementia, language problems, or movement disorders should be noted, along with specific information about symptoms, diagnosis, age of onset, course of disease, age at death, and autopsy findings. Such background information may be valuable for both diagnosis and understanding genetic risk.

The neurologic examination typically includes assessment of the patient's general appearance and speech, mental status, cranial nerves, motor system, sensation, reflexes, and cerebellar function (coordination and balance). Consulting a neurologist who has knowledge and experience in FTD can be valuable when reaching a definitive diagnosis.

The neuropsychologic examination assesses brain function and may identify areas of the brain that have been damaged. It typically involves an interview and the administration of written tests. These tests may focus on attention and concentration, memory, orientation, language, visual-spatial abilities, and/or executive functions (e.g., reasoning, planning, organizing, problem solving). Patients with FTD may show deterioration in the areas of attention and concentration, language, and executive function, but may do relatively well on memory and visual-spatial tests.

The Neuropsychiatric Inventory (NPI) may be administered to caregivers of patients with suspected FTD. This survey helps assess behavior and psychopathology by inquiring about the patient's delusions, hallucinations, agitation/aggression, dysphoria, anxiety, euphoria, apathy, disinhibition, irritability, unusual motor activity, nighttime behavioral problems, and eating abnormalities.

Brain scans are important tools in the diagnosis of FTD. Computed tomography (CT) may be done to determine if there is a tumor, hemorrhage, or other brain injury that could account for the symptoms. Magnetic resonance imaging (MRI) provides better visualization of the brain than CT and is often done to evaluate brain atrophy when FTD is suspected. Patients with FTD have progressive frontal and anterior temporal atrophy apparent on MRI. Typically, in bvFTD, there is atrophy of the frontal lobe (involved in personality, judgment, and executive function) and the anterior temporal lobe. In nfvPPA, there is left frontal lobe atrophy (involved in speech production). In svPPA, the atrophy is focused in the anterior temporal lobe (involved in language and face recognition). In specialty or research centers, positron emission tomography (PET), single photon emission computed tomography (SPECT), or functional MRI (fMRI) brain scans may be done to further evaluate brain functioning.

While there is no laboratory test that can diagnose FTD, some tests may be ordered to rule out other diseases with symptoms similar to those of FTD. Blood work may be ordered to identify dehydration, thyroid disease, vitamin B12 deficiency, or infections affecting the brain. An electroencephalogram (EEG) may be done if there is concern that seizures might be causing the patient's symptoms. In the early stages of FTD, EEG findings are usually normal or have non-specific findings. Lumbar puncture may be done to evaluate cerebral spinal fluid and rule out rare brain infections or cancer. Electromyography may be used to identify muscle weakness or myoclonus if MND (or ALS) is being considered as a possible diagnosis. In addition, language evaluation by a speech pathologist can be an important tool in diagnosing patients with nonfluent/agrammatic, semantic, or logopenic variant PPA.

It may be challenging to clinically differentiate FTD from early AD (Table 3). The only way to establish an unquestionable diagnosis of FTD is through a brain autopsy after a patient has died. Examination of the brain tissue will show the precise location and severity of the brain atrophy, and microscopic studies can determine the protein composition of the inclusions in affected neurons.

Table 3: EARLY SIGNS AND SYMPTOMS OF FTD VERSUS ALZHEIMER DISEASE

Clinical Features

FTD

Alzheimer Disease

Hallmark

Decline in behavior, language, and/or movement; memory is retained initially

Decline in memory; socially appropriate behavior is retained initially

Initial language problems

May involve speech production, understanding words and recognizing familiar objects, or retrieving words

Word-finding or name recall

Age at onset

Usually 45 to 64 years of age

Usually 65 years of age or older

Movement problems

May have early movement disorder, with gait and balance problems, rigidity, apraxia, or muscle weakness

Usually no movement problems early in disease

Source: [3,8,15]

For families, brain autopsy can confirm the diagnosis (or identify a different cause of the dementia) and bring a measure of closure. Accurate diagnosis may be especially important if there is concern about genetic risk to other family members.

Discussion about brain autopsy should be handled delicately and with compassion at a time that is appropriate for the family; the subject may be emotionally difficult for some families. Introducing the topic ahead of time allows families to consider their feelings about brain autopsy aside from the emotional crisis of the death of a loved one and the immediate time pressure of funeral arrangements. Families may then discuss the topic among themselves and come to a consensus.

Should a family wish to have a brain autopsy done when the patient dies, the physician can help identify a pathology service experienced in neurologic disorders and preliminary logistical planning can be done ahead of time. Arrangements may be coordinated with a research center that specializes in brain autopsy for FTD. The autopsy is done as soon as possible after death, often within 6 to 24 hours. The procedure is not disfiguring, so open-casket funerals may be planned if the family so chooses.

In addition to answering families' questions regarding diagnosis, brain autopsy can also aid researchers in better understanding the correlation between the clinical signs of FTD and the pathologic changes in the brain. This may benefit future generations by improving diagnosis and advancing research on therapies for FTD.

5. GENETICS AND FTD

Understanding of the role of genetics in FTD is still evolving. Presently, it appears that most cases of FTD (approximately 60%) are sporadic, meaning one person in a family has the disease, there is no family history of any relative with the disease, and the disease does not appear to be inherited.

However, approximately 40% of those with FTD report a family history of one or more relatives with a neurodegenerative disease [6,9,11]. This is referred to as familial FTD. In some cases of familial FTD, no specific genetic mutation can be identified as the cause. The risk to family members of a person with familial FTD without an identified genetic mutation is increased over the general population, but the specific increased risk is unclear.

An estimated 10% to 20% of all FTD cases are caused by an inherited genetic mutation [6,8]. Patients with a strong family history of multiple relatives with FTD and/or MND are more likely to have an inherited form of FTD caused by a genetic mutation. Genetic mutations causing FTD are inherited in an autosomal dominant inheritance pattern, meaning each child of an affected parent is born with a 50% chance of inheriting the genetic mutation.

Several specific genetic mutations have been identified as being implicated in inherited FTD. In 1998, the first gene associated with hereditary FTD—the microtubule-associated protein tau (MAPT) gene on chromosome 17—was discovered [16,17]. Mutations in this gene cause an abnormal accumulation of tau protein in affected neurons. MAPT mutations are thought to account for 5% to 20% of familial FTD cases [18]. These mutations most commonly cause bvFTD but may also cause svPPA, PSP, and/or CBS. FTD symptoms may vary widely, even within families.

In 2006, mutations in the progranulin (GRN) gene on chromosome 17 were discovered to cause FTD [20,21]. Mutations in the GRN gene cause abnormal accumulations of TDP-43 protein in affected neurons. GRN mutations are thought to represent about 5% to 10% of all inherited FTD cases [19]. They most commonly cause bvFTD, but are also associated with nfvPPA and CBS. GRN mutations appear to have decreased penetrance, meaning that, for unknown reasons, some people with the mutation may not develop symptoms of the disease.

In 2011, the genetic mutation C9orf72 was discovered on chromosome 9 [22,23]. Mutations in C9orf72 cause an abnormal accumulation of TDP-43 in affected neurons. To date, C9orf72 mutations are the most common genetic cause of FTD, found in about 25% of familial FTD and 6% of sporadic cases [24]. C9orf72 mutations appear to cause FTD (usually bvFTD or language presentation), MND, and a combination of FTD and MND.

Other very rare genetic mutations have also been associated with FTD. Mutations in the gene valosin-containing protein (VCP) on chromosome 9, charged multivesicular body protein 2B (CHMP2B) on chromosome 3, TAR DNA-binding protein (TARDBP), FUS, TBK1, EXT2, and SQSTM1 have been associated with FTD [31].

Clinical genetic testing is available for the MAPT, GRN, and C9orf72 genetic mutations causing hereditary FTD, as well as some of the other very rare genetic mutations. Genetic testing may be ordered after informed consent and clear discussion of the implications with the patient and his/her family. For patients with FTD, identification of a genetic mutation confirms the diagnosis of FTD and provides information about risk to other family members. Each of the patient's siblings and each of the patient's children would be at 50/50 risk for having inherited the genetic mutation causing FTD. If a genetic mutation causing FTD is identified, other at-risk family members may be tested.

If a genetic mutation causing FTD is identified in a patient with FTD, unaffected at-risk family members could choose to have pre-symptomatic (predictive) genetic testing done to determine if they have inherited the genetic mutation that would someday cause FTD. Individuals considering pre-symptomatic genetic testing are referred for formal professional genetic counseling to help them make the best decision regarding whether or not to learn their FTD genetic status.

6. MANAGEMENT OF FTD

Evidence Based Practice Recommendation

According to the Royal Australian and New Zealand College of Psychiatrists, general principles of dementia care apply for the management of frontotemporal dementia, but specific issues relate to the early onset of the illness in middle life and that affected persons may lack insight into their deficits leading to occupational and social problems.

https://journals.sagepub.com/doi/abs/10.1177/1039856215582276

Last Accessed: October 14, 2024

Strength of Recommendation/Level of Evidence: Expert Opinion/Consensus Statement

There is presently no treatment to slow the progression of or cure FTD. No medication has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of FTD; however, medications used to treat other disorders may be prescribed off-label for the management of FTD symptoms. Their use may be limited by the potential adverse effects. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), may be prescribed for behavioral symptoms of FTD, and low-dose trazodone has been used for agitation and aggression [9]. While the anticholinesterase inhibitors donepezil, galantamine, and rivastigmine are beneficial for some patients with AD, they generally have not been helpful for patients with FTD [9]. The glutamate NMDA receptor antagonist memantine, used for moderate-to-severe AD, has been used for patients with FTD as well, but a 2013 study showed that it provided no benefit to patients with FTD and that it may be harmful to cognition [25]. Antipsychotics are occasionally used to treat significant agitation and behavioral symptoms, but only with caution, as antipsychotics can have serious adverse effects such as extrapyramidal adverse effects (parkinsonism), depression, sedation, falls, incontinence, and disinhibition, and patients with FTD may have an increased susceptibility to these effects [9]. Elderly patients with dementia who take antipsychotics have a 1.6- to 1.7-fold increase in mortality secondary to cardiac problems or infection, prompting the FDA to issue a warning about their use in older patients with behavioral disturbances [9]. L-DOPA has shown a minimal response for parkinsonism in patients with PSP and CBD [30]. Research is being done to further evaluate the use of available medications for the management of FTD and to find new, more effective treatments.

Management of FTD includes providing care to patients with FTD and support to their families. Caring for a person with FTD involves managing the symptoms, keeping the patient safe, and providing help in activities of daily living.

Apathy is a common symptom in patients with bvFTD, often resulting in neglect of their personal hygiene and grooming. Supervision, encouragement, and help with bathing, dressing, and grooming may be needed. For behavioral problems, simple interventions like distraction (e.g., introducing a new activity) may help interrupt the troublesome behavior. For some patients, modification of the environment or behavior may help minimize the potential for harm. For example, if the patient is pacing, creating a safe route for him or her to walk can be helpful. Physical therapists may be able to help develop an exercise program to maintain mobility. Exercise has also been shown to improve mood and cognition and may improve behavior management in patients with dementia [26]. If behaviors such as agitation or aggression become severe, a medication may be prescribed off-label to control difficult or dangerous behaviors. Supervision may be necessary to ensure patients take medications as prescribed.

Some individuals with FTD have eating problems, such as overeating, eating just one type of food, or craving sweets. For these patients, it may be necessary to monitor weight and provide help with meal preparation to provide a balanced, nutritious diet. Access to additional foods, drinks, or sweets should be limited.

Speech pathologists or therapists may be helpful in diagnosing the specific language problems exhibited by patients with FTD, including nonfluent/agrammatic, semantic, or logopenic variant PPA. Speech therapy may also help patients to find new communication strategies, such as sign language, carrying cards with specific messages, or using a computer with pre-programmed words or phrases [27]. Such techniques may help those with language problems communicate with family and friends. Speech therapists may also be able to evaluate and address swallowing problems, if these arise.

Caring for a patient with FTD includes maintaining a safe environment for the patient and for those around him/her. A structured environment and keeping the daily routine the same is often helpful. In addition, persons with FTD should no longer drive, and safety measures should be taken at home, especially in the kitchen and bathroom. If a patient with FTD shows aggression, disinhibition, or poor judgment, close supervision is necessary when he/she is around others, especially children or the frail elderly, to prevent them from being inadvertently harmed.

It also may be necessary to monitor the patient's behavior in public places. If an individual displays inappropriate behavior, tense situations may be diffused by explaining that he or she has FTD and cannot control his/her behavior. Simple cards with this brief explanation can be made, carried, and shared with people who might be disturbed by a patient's inappropriate behavior.

If a patient with FTD has gait and balance problems, measures should be taken to prevent falls. This may include keeping the home environment free of obstacles and loose rugs and installing shower bars and a raised toilet seat. Mobility aids may be helpful. Occupational therapists should provide intervention to help patients with FTD complete activities of daily living as the disease progresses.

CAREGIVER SUPPORT

FTD places enormous burdens on the family. Most dementia care is provided at home by family caregivers, often spouses. Caregivers for those with FTD face physical, emotional, and financial challenges. FTD caregiver burden, stress, and depression are greater even than that seen with AD [28,29].

The first challenge that families of those with FTD may face is obtaining an accurate diagnosis. The process can involve years of uncertainty and stress before the correct clinical diagnosis of FTD is made. Even during the diagnosis process, support for families begins with information and education about FTD. Accurate information can lead to understanding and a greater sense of control over the stressful situation. It is important for families and caregivers to understand that the behavior changes they observe are the result of the disease. Their loved one may display behaviors that are embarrassing, offensive, self-centered, uncaring, and aggressive, with complete lack of insight about how the behavior affects others. The caregiver may feel like he/she is suddenly living with a stranger.

The aggression, disinhibition, and poor judgment associated with FTD can put family members at risk of harm. Because FTD affects people at a relatively young age, there may still be children in the home. Families should recognize the risk to others in the home and seek help creating strategies to keep themselves and other family members safe.

Language may be impaired in people with FTD, making communication difficult. This can interfere not only with communication between the patient and the caregiver, but it can also limit participation in larger social activities. Speech therapy can provide new approaches to communication, helping not only the patient but also the caregiver.

Because FTD usually begins at a relatively young age, it can cause a significant financial burden for families. There may be loss of income, and retirement benefits may be affected because the patient is unable to continue working. Financial and legal issues that should be addressed include insurance, social security disability, financial planning for the future (when additional care will be needed), power-of-attorney arrangements, and a living will. Social workers, financial advisors, and attorneys are resources available to families to help address these issues.

The demands on caregivers increase as FTD progresses. Caregivers will be required to provide more supervision and increasing assistance for activities of daily living. While providing care for an individual with FTD, the caregiver may also be grieving the loss of his or her previously healthy loved one. Family caregivers can become physically and emotionally exhausted, and they may feel isolated in their role as caregiver. Interventions to help reduce caregiver stress include an individualized patient management plan, environmental changes to promote safety and facilitate care, and strengthening caregiver coping strategies and skills. Family caregivers should be encouraged to ask for and accept help in caring for their loved one with FTD, allowing them to take time for themselves and address their own health needs. Connection with community resources may also be helpful. Community resources for FTD caregivers include national organizations such as the Association for Frontotemporal Degeneration, attorneys and financial planners, social service programs, adult day care programs, respite care, support groups, and individual or family counseling.

Family caregivers should look ahead and consider how they wish care to be provided to their loved one as FTD progresses. Patients with FTD will become more dependent and more difficult to safely manage at home by a family caregiver as the disease progresses. Social workers can be a good resource to caregivers as they consider options such as extra in-home nursing care, care communities, and long-term care facilities. Locating an appropriate care facility that accepts patients with FTD can be challenging. These patients are often younger, stronger, and more active than the typical residents of care facilities. Facility staff may need education and support to understand the unique features of FTD and to learn how to provide care to these patients while maintaining a safe environment for all residents in the facility.

Nurses play an important role in caring for those with FTD and providing support to their families. Nurses interact with patients with FTD and their families in the outpatient clinic setting, in-home care setting, and long-term care facility and may be involved in monitoring symptoms, developing and implementing individualized patient care plans, and providing direct patient care. It is important for all healthcare providers to coordinate care for the patient with FTD. All members of the interdisciplinary healthcare team can support families by listening to them, providing ongoing information and education about FTD, offering guidance to improve caregiving skills, and helping families connect to appropriate resources.

7. PROGRESSION OF FTD

The prognosis for people with FTD is poor. FTD worsens progressively, usually over several years, and patients require increasing behavioral supervision and personal care. Eventually, people with advanced FTD become mute and bedbound and require full care at home or in a care facility. As patients with FTD become more debilitated, they are vulnerable to complications such as infections and falls. The most common cause of death in people with FTD is infection (e.g., pneumonia) [3,8]. The average duration of the disease is 6 to 13 years, but it can range from 2 to 20 years [3,5].

8. RESEARCH RELATED TO FTD

The goals for research on FTD include gaining a better understanding of the pathology; identifying causes and risk factors (genetic and environmental); improving the diagnosis of FTD through enhanced neuroimaging, biomarkers, and characterization of clinical features; developing therapies to treat, cure, or prevent FTD; and exploring new ways to support family caregivers. However, research on FTD is challenging. It is an uncommon disease, so awareness is low, there are fewer potential subjects available for research studies, and there is a relatively small market for medications. FTD is a complicated disease with a wide variety of presentations (behavior, language, and movement problems) and underlying causes (sporadic and genetic). Pathologically, microscopic brain inclusions may consist of different abnormal proteins (e.g., tau, TDP-43, FUS), and up until recently, there were no good biomarkers to diagnose FTD or to monitor the progression of the disease. However, ongoing studies have begun to show promise in this area. Biomarkers such as the neurofilament light-chain protein have been shown to rise before the onset of FTD symptoms, which may help in early identification and diagnosis of asymptomatic carriers of FTD [10]. Drug development still faces the challenge of creating a medication to treat FTD that can cross the blood/brain barrier.

Despite these challenges, the pace of research on FTD has accelerated rapidly. There are an increasing number of studies and a better awareness of the varied symptoms of FTD. In the past few decades, there have been discoveries of the genetic mutations underlying some causes of FTD and a growing understanding of the changes that occur in the brain of those with FTD. Presently, there are clinical trials underway for potential medications to treat FTD. Information on clinical research studies, including participation in studies, can be found at the National Institutes of Health website https://clinicaltrials.gov.

9. CASE STUDY

Patient A was a high school homecoming queen who completed two years of college, worked in an office, then married and had three children. She was an energetic homemaker and an active community volunteer, serving as school parent-teacher association president for several years, and was fastidious about her appearance.

Patient A's mother, three maternal uncles, a maternal grandfather, and great-grandmother died with dementia; her brother and maternal aunt are living with the disease. The mean age of onset of dementia in the family is 51 years, and the mean age at death is 67 years.

When Patient A is 52 years of age, her husband notices changes in her behavior. She often appears distracted, and her impeccable grooming declines. She is less affectionate toward him and she stops participating in community activities. She has difficulty making arrangements for a planned vacation. Her previously gourmet meals become simple, functional meals. She becomes obsessed with repeatedly raking the lawn, eventually killing all the grass in the yard. When her grandchildren visit, Patient A alternates between ignoring them and playing too rough. Patient A begins to impulsively leave the house for fast-paced walks, but she always returns home and never gets lost. She frequently visits a local shopping mall, getting down on her hands and knees looking for dropped change near the cash registers. She is once stopped by mall security for shoplifting. When shopping with her husband, she approaches strangers, stands inappropriately close to them, and announces "We don't know you."

Patient A's husband brings her to a dementia clinic for evaluation. A neurologic examination and neuropsychologic testing are completed. Memory and visual-spatial performance are in the normal range, but personality, judgment, and executive function show significant decline. A brain MRI shows frontal and anterior temporal lobe atrophy, and the diagnosis of familial bvFTD is made. Clinical genetic testing identifies a mutation in the MAPT gene on chromosome 17, the believed cause of the dementia.

Patient A's husband stops working in order to care for her at home. As her disease progresses, Patient A requires increasing care and supervision. She spends much of her day watching television, writing numbers in a notebook, and pacing. She develops a craving for sweets and often rummages through kitchen cabinets looking for candy. At mealtime, Patient A stuffs her mouth with food before chewing and swallowing properly, precipitating episodes of choking. She also develops a pattern of hand-clapping that she repeats every few minutes, along with the phrase "We haven't had any phone calls lately."

Patient A's husband is encouraged to accept help from others (such as their adult children), consider local adult day care programs, and utilize respite care at a nearby nursing home. He is in monthly phone contact with nursing staff to review symptoms and develop strategies for managing symptoms. At different times during her illness, Patient A is prescribed an antidepressant and an antipsychotic medication (off label) to treat difficult behavioral symptoms, but both were eventually discontinued. The family faces financial difficulties as a result of the husband's loss of income, diminished retirement benefits, and the later cost of nursing home care. Social work support helps the family address issues such as insurance, social security benefits, adult day care programs, and selecting a nursing facility for eventual long-term care.

When Patient A is 60 years of age, her husband is no longer able to care for her at home and she is admitted to a skilled nursing facility. She is incontinent and requires full care for all activities of daily living. Her husband visits twice daily, and she always appears to recognize him. That same year, Patient A dies unexpectedly of a myocardial infarction. A brain autopsy is done and confirms the diagnosis of FTD.

Patient A's husband shares the results of her genetic testing and autopsy with their three adult children. Each of Patient A's three children is at a 50% risk for having inherited the MAPT genetic mutation. Two of the children request pre-symptomatic genetic testing. The two children who request pre-symptomatic genetic testing are referred to professional genetic counselors. After genetic counseling, they both choose to have pre-symptomatic genetic testing done. One defers getting the results for two years, underscoring the very difficult personal decision it can be to choose pre-symptomatic genetic testing.

Patient A demonstrated the typical symptoms of bvFTD and her evaluation was done at a dementia center by specialists with expertise in FTD, so her initial diagnosis was strong. The neurologic evaluation, blood tests, neuropsychologic testing, and neuroimaging together led to the clinical diagnosis of bvFTD. Patient A's family history showed a pattern of autosomal dominant inheritance. The genetic cause of her FTD was confirmed by clinical genetic testing, which documented a mutation in the MAPT gene.

10. CONCLUSION

FTD is now recognized as one of the most common causes of dementia in persons younger than 65 years of age. This course has provided an overview of FTD epidemiology, pathophysiology, clinical presentation, diagnosis, management, prognosis, and current research. Understanding FTD can help healthcare professionals provide better care to patients with FTD and support to their families.

11. RESOURCES

Association for Frontotemporal Degeneration

2700 Horizon Drive, Suite 120

King of Prussia, PA 19406

(866) 507-7222

https://www.theaftd.org

National Institute on Aging

Building 31, Room 5C27

31 Center Drive, MSC 2292

Bethesda, MD 20892-2292

(800) 222-2225

https://www.nia.nih.gov

National Institute of Neurological Disorders and Stroke

P.O. Box 5801

Bethesda, MD 20824

(800) 352-9424

https://www.ninds.nih.gov

Works Cited

1. Pick A. Ueber die Beziehungen der senile Hirnatrophie zur Aphasie. Prager Medicinische Wochenschrift. 1892;17(16):165-167.

2. Arvanitakis Z. Update on frontotemporal dementia. Neurologist. 2010;16(1):16-22.

3. Association for Frontotemporal Degeneration. Disease Overview. Available at https://www.theaftd.org/what-is-ftd/disease-overview. Last accessed October 2, 2024.

4. Hodges JR, Davies R, Xuereb J, Kril J, Halliday G. Survival in frontotemporal dementia. Neurology. 2003;61(3): 349-354.

5. Knopman DS, Roberts RO. Estimating the number of persons with frontotemporal lobar degeneration in the U.S. population. J Mol Neurosci. 2011;45(3):330-335.

6. Ghosh S, Lippa CF. Clinical subtypes of frontotemporal dementia. Am J Alzhiemers Dis Other Demen. 2015;30(7):653-661.

7. Wang X, Shen Y, Chen W. Progress in frontotemporal dementia research. Am J Alzheimers Dis Other Demen. 2013;28(1):15-23.

8. UCSF Memory and Aging Center. Frontotemporal Dementia. Available at https://memory.ucsf.edu/dementia/ftd. Last accessed October 2, 2024.

9. Seltman RE, Matthews BR. Frontotemporal lobar degeneration. CNS Drugs. 2012;26(10):841-870.

10. Snowdan J. Changing perspectives on frontotemporal dementia: a review. J Neuropsychol. 2023;17(2):211-234.

11. Sieben A, VanLangenhove T, Engelborghs S, et al. The genetics and neuropathology of frontotemporal lobar degeneration. Acta Neuropathol. 2012;124:353-372.

12. Gorno-Tempini ML, Hillis AE, Weintraub S, et al. Classification of primary progressive aphasia and its variants. Neurology. 2011;76:1006-1014.

13. Johnson JK, Diehl J, Mendez MF, et al. Frontotemporal lobar degeneration: demographic characteristics of 353 patients. Arch Neurol. 2005;62(6):925-930.

14. Rascovsky k, Hodges JR, Knopman D, et al. Sensitivity of revised diagnostic criteria for the behavioral variant of frontotemporal dementia. Brain. 2011;134(Pt 9):2456-2477.

15. Alzheimer's Association. Frontotemporal Dementia (FTD). Available at https://www.alz.org/alzheimers-dementia/what-is-dementia/types-of-dementia/frontotemporal-dementia. Last accessed October 2, 2024.

16. Hutton M, Lendon CL, Rizzu P, et al. Association of missense and 5'-splice-site mutations in tau with the inherited dementia FTDP-17. Nature. 1998;393(6686):702-705.

17. Poorkaj P, Bird TD, Wijsman E, et al. Tau is a candidate gene for chromosome 17 frontotemporal dementia. Ann Neurol. 1998;43(6):815-825.

18. Magrath Guimet N, Zapata-Restrepo LM, Miller BL. Advances in treatment of frontotemporal dementia. J Neuropsychiatry Clin Neurosci. 2022;34(4):316-327.

19. Rohrer JD, Warren JD. Phenotypic signatures of genetic frontotemporal dementia. Curr Opin Neurol. 2011;24:542-549.

20. Baker M, Mackenzie IR, Pickering-Brown SM, et al. Mutations in progranulin cause tau-negative frontotemporal dementia linked to chromosome 17. Nature. 2006;442(7105):916-919.

21. Cruts M, Gijselinck I, van der Zee J, et al. Null mutations in progranulin cause ubiquitin-positive frontotemporal dementia linked to chromosome 17q21. Nature. 2006;442(7105):920-924.

22. DeJesus-Hernandez M, Mackinzie IR, Boeve BF, et al. Expanded GGGGCC hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked FTD and ALS. Neuron. 2011;72:245-256.

23. Renton AE, Majounie E, Waite A, et al. A hexanucleotide repeat expansion in C9ORF72 is the cause of chromosome 9p21-linked ALS-FTD. Neuron. 2011;72:257-268.

24. Majounie E, Renton AE, Mok K, et al. Frequency of the C9orf72 hexanucleotide repeat expansion in patients with amyotrophic lateral sclerosis and frontotemporal dementia: a cross-sectional study. Lancet Neurol. 2012;11:323-330.

25. Boxer AL, Knopman DS, Kaufer DI, et al. Memantine in patients with frontotemporal lobar degeneration: a multicentre, randomized, double-blind, placebo-controlled trial. Lancet Neurol. 2013;12(2):149-156.

26. Ahlskog JE, Geda YE, Graff-Radford NR, et al. Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging. Mayo Clin Proc. 2011;86(9):876-884.

27. Mesulam M. Primary progressive aphasia: a dementia of the language network. Dement Neuropsychol. 2013;7(1):2-9.

28. Wong C, Merrilees J, Ketelle R. The experience of caregiving: differences between behavioral variant of frontotemporal dementia and Alzheimer disease. Am J Geriatr Psychiatry. 2012;20(8):724-728.

29. Mioshi E, Bristow M, Cook R, Hodges JR. Factors underlying caregiver stress in frontotemporal dementia and Alzheimer's disease. Dement Geriatr Cogn Disord. 2009;27(1):76-81.

30. Association for Frontotemporal Degeneration. Treating FTD. Available at https://www.theaftd.org/for-health-professionals/treating-ftd. Last accessed October 2, 2024, 2021.

31. Olney NT, Spina S, Miller BL. Frontotemporal dementia. Neuro Clin. 2017;35(2):339-374.

Evidence-Based Practice Recommendations Citations

1. Mocellin R, Scholes A, Walterfang M, Looi JCL, Velakoulis D. Clinical update on frontotemporal dementia: diagnosis and treatment. Australas Psychiatry. 2015;23(5):481-487. Available at https://journals.sagepub.com/doi/abs/10.1177/1039856215582276. Last accessed October 14, 2024.

77560 • Professional Boundaries in Mental Health Care

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Without proper boundaries and awareness, mental health professionals become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Table of Contents

77560 • Professional Boundaries in Mental Health Care

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. COMPETENCE

3. THE THERAPEUTIC RELATIONSHIP

CONGRUENCE

EMPATHY

4. TRANSFERENCE AND COUNTERTRANSFERENCE

REFLECTION

SELF-AWARENESS

5. BOUNDARIES AND LIMITS

BUILDING TRUST

THE VALUE OF FLEXIBILITY

EMPOWERING AND PROTECTING THE CLIENT

PROTECTING THE PROFESSIONAL

6. BOUNDARY CROSSINGS AND VIOLATIONS

7. MULTIPLE RELATIONSHIPS

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

GIFTS

8. TECHNOLOGY AND DISTANCE THERAPY

LEGAL AND ETHICAL CONSIDERATIONS

SOCIAL MEDIA

ARTIFICIAL INTELLIGENCE

9. CONCLUSION

10. RESOURCES

Works Cited

77560 • Professional Boundaries in Mental Health Care

Education Category. Ethics - Human Rights

Release Date. 11/01/2023

Review Date. 08/01/2026

Expiration Date. 10/31/2027

Course Overview

Without proper boundaries and awareness, mental health professionals become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Audience

This course is designed for social workers, counselors, and marriage and family therapists in all practice settings.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 1.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 3 Ethics continuing education clock hours. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program. NetCE designates this continuing education activity for 3 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course is designed to meet the New York requirement for 3 hours of education in appropriate professional boundaries every renewal period. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. NetCE designates this continuing education activity for 3 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to educate helping mental health professionals on how to provide compassionate and competent care within the boundaries of appropriate practice.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define professional competence.

2. Outline components of the therapeutic relationship.

3. Define empathy and describe the difference between empathy and sympathy.

4. Define transference and countertransference and discuss their implications for the mental health professional.

5. Identify the functions of professional boundaries in the therapeutic relationship and multiple relationships.

6. Discuss the guidance on giving and receiving gifts provided by professional ethics codes.

7. Discuss the legal and ethical considerations of providing distance therapy.

Faculty

Lisa Hutchison, LMHC, has more than 20 years of experience providing individual and group counseling with adults. She specifically focuses on teaching assertiveness, stress management, and boundary setting for empathic helpers. Ms. Hutchison graduated from the University of Massachusetts, Boston, with a Master’s degree in education for mental health counseling.

Faculty Disclosure

Contributing faculty, Lisa Hutchison, LMHC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

James Trent, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Mental health professionals can make a significant, positive impact in the lives of those with whom they work, and the practice of therapy can be highly rewarding and gratifying. However, it can also be emotionally demanding, challenging, and stressful. These professionals are at risk for occupational stress from a variety of sources, including [1]:

- The demands of clinical and professional responsibility

- The challenges of managing the client/counselor relationship

- The role characteristics that make counselors prone to burnout (e.g., high level of involvement)

- Vulnerability to vicarious traumatization

- The changing standards and business demands of the profession (e.g., increased documentation requirements, increased intrusion of legal/business concerns into therapeutic practice)

- The intersection of personal and professional demands

Healthy boundaries are a critical component of self-care. Setting boundaries can help counselors manage occupational stressors and maintain the delicate balance between their personal and professional lives. Boundaries also demonstrate competency in clinical practice and help counselors avoid ethical conflicts [2].

Please note, throughout this course the term "counselor" is used to refer to any professional providing mental health and/or social services to clients, unless otherwise noted.

2. COMPETENCE

Professional associations representing the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect both the mental health professional and the individuals with whom they work. For example, the American Psychological Association (APA), the American Counseling Association (ACA), the National Association of Social Workers (NASW), the National Board of Certified Counselors (NBCC), and the National Certification Commission for Addiction Professionals (NCCAP) each has an ethics code created to identify core values, inform ethical practice, support professional responsibility and accountability, and ensure competency among its members [3,4,5,6,7].

Competency is defined as "the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects" [8]. It is the scope of the professional's practice. According to the ethics codes of the APA, the ACA, and the NASW, members are to practice only within their boundaries of competence [3,4,5].

3. THE THERAPEUTIC RELATIONSHIP

Many situations that occur in the counseling office are not written about in textbooks or taught in a classroom setting. Counselors learn through hands-on experience, intuition, ongoing supervision, and continuing education. One constant is the therapeutic relationship. Every therapeutic relationship is built on trust and rapport. Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. In many cases, counselors are teaching self-regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people.

Bandura has described self-regulation as a self-governing system that is divided into three major subfunctions [9]:

- Self-observation: We monitor our performance and observe ourselves and our behavior. This provides us with the information we need to set performance standards and evaluate our progress toward them.

- Judgment: We evaluate our performance against our standards, situational circumstances, and valuation of our activities. In the therapeutic setting, the counselor sets the standard of how to interact by setting limits and upholding professional ethics. The client then compares the counselor's (i.e., "the expert's") modeled behavior with what they already have learned about relationship patterns and dynamics (i.e., referential comparisons).

- Self-response: If the client perceives that he or she has done well in comparison to the counselor's standard, the client gives him- or herself a rewarding self-response. The counselor should reinforce this response by delivering positive reinforcement and affirmation for the newly learned behavior. For example, if the client arrives to therapy habitually late and then makes an effort to arrive on time, the counselor can remark, "I notice that you are working hard to arrive on time for session. That is great." The counselor's positive reinforcement and acknowledgment can have a positive impact on the client's self-satisfaction and self-esteem.

According to Rogers, "individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior" [10]. To facilitate a growth-promoting climate for the client, the counselor should accept, care for, and prize the client. This is what Rogers refers to as "unconditional positive regard," and it allows the client to experience whatever immediate feeling is going on (e.g., confusion, resentment, fear, anger, courage) knowing that the professional accepts it unconditionally [10]. In addition to unconditional positive regard, a growth-promoting therapeutic relationship also includes congruence and empathy.

CONGRUENCE

Trust is built and sustained over time through consistent limits that are maintained within the sacred space of each therapeutic hour. When a counselor is observed as consistent and congruent, the client notices. Being authentic is part of being compassionate and empathic. Clients know when a counselor's words and actions do not match. These actions can be overt, such as cutting short the therapeutic time or going over the time allotted. They also can be subtle, as when leaked out and expressed through a stressed vocal tone, facial expression, or other body language indicator (e.g., arms folded across the chest). To the highly aware client, these actions can result in a loss of trust.

Nevertheless, counselors are not perfect and can err from time to time. This is why it is important for counselors to be self-aware, acknowledge when their words and actions do not match, and discuss that within the therapeutic relationship. If a client notices one of these cues of incongruence and expresses it to the counselor, it is essential that the counselor listen openly and validate the client's experience. Any defensiveness on the part of the counselor will decrease relationship trust. Conversely, this admission of human failure can actually build a stronger bond of trust. Clients see that counselors are, like themselves, human and imperfect. This presents an opportunity for clients to learn and then model this type of integrity in their own relationships. "Congruence for the therapist means that he (or she) need not always appear in a good light, always understanding, wise, or strong" [10]. It means that the therapist is his or her actual self during encounters with clients. Without façade, he or she openly has the feelings and attitudes that are flowing at the moment [10]. The counselor's being oneself and expressing oneself openly frees him or her of many encumbrances and artificialities and makes it possible for the client to come in touch with another human being as directly as possible [10]. As discussed, this involves self-observation and self-awareness on the counselor's part.

This does not mean that counselors burden clients with overt expression of all their feelings. Nor does it mean that counselors disclose their total self to clients. It means that the counselor is transparent to the client so that the client can see him or her within the context of the therapeutic relationship [11]. It also means avoiding the temptation to present a façade or hide behind a mask of professionalism, or to assume a confessional-professional attitude. It is not easy to achieve such a reality, as it involves "the difficult task of being acquainted with the flow of experiencing going on within oneself, a flow marked especially by complexity and continuous change" [10].

EMPATHY

There is great power in empathy. It breaks down resistance and allows clients to feel safe and able to explore their feelings and thoughts. It is a potent and positive force for change [10]. Empathy serves our basic desire for connection and emotional joining [12]. Empathy may be defined as the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another. It is a deeper kind of listening in which the counselor senses accurately the feelings and personal meanings that the client is experiencing and communicates this understanding to the client [10]. Empathy is not parroting back the client's words or reflecting only the content of those words. It entails capturing the nuances and implications of what the client is saying, and reflecting this back to the client for their consideration using clear, simply connotative language in as few words as possible [13]. Counselors also can show empathy in nonverbal ways to their clients by, for example, looking concerned, being attentive, leaning forward, and maintaining eye contact [13].

Empathy is a multi-level process of relating to others. It encompasses both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client's feelings), and it implies the ability to detach oneself from the client's feelings in order to maintain objectivity [14]. While engaged in empathic listening, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [14]. Empathy may be summarized by the ability to [15]:

- See the world as others see it.

- Be nonjudgmental.

- Understand another person's feelings.

- Communicate your understanding of that person's feelings.

Empathy should not be confused with sympathy, which may be defined as an affinity, association, or relationship between persons wherein whatever affects one similarly affects the other. Compared with empathy, sympathy is a superficial demonstration of care. With sympathy, you feel sorry for the client; with empathy, you feel the client's pain. Although a counselor can get caught up in the client's feelings, he or she should always strive to empathically understand what the client is experiencing while maintaining emotional detachment. This potentially provides a broader perspective that extends beyond the client's situational distress. Mental health professionals want to employ the best tools in order to affect change in their clients without causing harm, and empathy surpasses sympathy in terms of effectiveness. Research has validated the importance of empathy, unconditional positive regard, and congruence for achieving an effective therapeutic relationship [16].

Compassion-focused therapy is a rapidly growing, evidence-based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [17]. According to Gilbert, the following are attributes of compassion-focused therapy [18]:

- Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client.

- Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotionally engaged with their story as opposed to being emotionally passive or distant.

- Distress tolerance: Able to contain, stay with, and tolerate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client's emotions.

- Empathy: Working to understand the meanings, functions, and origins of another person's inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not.

- Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For example, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment "as it is." This does not mean an absence of preferences.

Empathic Boundaries

Counselors strive to achieve empathy with their clients while maintaining boundaries that protect their own energies. Professionals should ''sense the client's private world as if it were [their] own, without ever losing the 'as if' quality,'' and while not becoming entangled with their perception of the client [10; 19]. It takes work to maintain a healthy distance emotionally while feeling and intuiting what the client is saying.

Too much sympathy, or working with empathy without proper boundaries in the therapeutic relationship, drains the counselor of energy and leads to burnout. In a study of 216 hospice care nurses from 22 hospice facilities across Florida, it was found that trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of compassion fatigue risk [20]. In other words, there can be too much of a good thing. In order to motivate client change, there should be a limit to the use of empathy in therapy. Empathy is but one tool that a compassionate mental health professional can use to ensure client growth.

4. TRANSFERENCE AND COUNTERTRANSFERENCE

The term transference was coined by Freud to describe the way that clients "transfer" feelings about important persons in their lives onto their counselor. As Freud said, "a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment" [21]. The client's formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [22]. Part of the counselor's work is to "take" or "accept" the transferences that unfold in the service of understanding the client's experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client's past [23]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client's own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [24]. Therapists' emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy.

REFLECTION

It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one's thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [25]:

- A questioning attitude towards one's own feelings and motives

- The recognition that we all have blind spots

- An understanding that staff are affected by clients

- An understanding that clients are affected by staff behavior

- A recognition that clients often have strong feelings toward staff

Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [26].

Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this "countertransference" as "the unconscious counter reaction to the client's transference, indicative of the therapist's own unresolved intrapsychic conflicts" [27]. Freud felt that countertransference could interfere with successful treatment [22]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treatment. Instead, it is viewed as providing important information that the professional can use in helping the client [22].

Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client's transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [28]. Good indicators of countertransference are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors' unresolved conflicts related to family issues, needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [29]. When feelings have intensity or when they persist, this is an indicator for future work and healing.

The counselor's work is to bear the client's transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the counselor's own blind spots has been engaged. As Shapiro explains, "a rough edge of our character has been 'hooked' by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference" [30]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor's anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [31]. Counselors who find themselves ruminating about a previous session's content, a client's welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and potentially harming clients [27]. One study of countertransference found that therapists' self-reported disengaged feelings over a treatment period adversely impacted the effect of transference work for all patients, but especially for patients with a history of poor, nonmutual, complicated relationships [32].

SELF-AWARENESS

Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced professionals. Clients' experiences can replicate the professional's past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client's session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client's session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client's true emotions. It also is an important component of training, development, and effectiveness [33]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [34].

As stated in the ethics codes of the ACA [4]:

Therapists are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. They respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when their values are inconsistent with the client's goals. They refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. When they become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance and determine whether they should limit, suspend, or terminate their work-related duties.

5. BOUNDARIES AND LIMITS

Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is "out of bounds" and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the "edge" of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [35,36]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.

BUILDING TRUST

An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [36]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy.

The familiarity, trust, and intensity of the therapeutic relationship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of professional care [36]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [37]:

- Is perceived as available and accessible

- Tries to understand by listening and caring

- Behaves in a professional manner (evidenced by attributes such as honesty in all interactions)

- Maintains confidentiality

- Relates to the client as another adult person rather than as an "expert"

- Remains calm and does not over-react to the issue under discussion

Only when satisfied that the clinician is sufficiently experienced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [37].

THE VALUE OF FLEXIBILITY

Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid boundaries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the "rules" are more important than his or her welfare. While rigidity and remoteness on the counselor's part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [38]. Firm, intractable boundaries may be a comfort to the helping professional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [36].

EMPOWERING AND PROTECTING THE CLIENT

Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client's understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client's best interests [39].

Boundaries begin the moment a client enters the room. Indicate which chair is yours and where it is acceptable for the client to sit. Take note of where your seat is in relation to the door should an emergency arise. Be sure to maintain an appropriate amount of space between yourself and the client. Too much space can feel impersonal and too little can feel invasive. Consider the décor of the setting. Clients may become distracted by the counselor's personal artifacts and family photographs and may place their focus on the counselor rather than on their own therapeutic work. Some clients with poor boundaries may become preoccupied with the counselor's family, which can become a source of transference.

Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships [40]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilemmas and manage them by reiterating the boundaries calmly and clearly [39]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client's primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primitive strivings and to foster and encourage adult strivings [41]. Winnicott refers to this as a "holding relationship," wherein the counselor acts as a "container" for the strong emotional storms of the client. The act of holding helps reassure the client that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [42].

Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/addictions, memory issues, personality disordered manipulations), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite knowing that it is unacceptable to arrive more than 10 minutes late to session. The first instance of a late arrival might simply warrant a reminder of the 10-minute limit, whereas repeated instances would require that the limit be enforced. The clinician who overidentifies with a client might experience a need to do things for the client rather than help the client learn to do things for him- or herself. While this behavior may appear relatively harmless, it suggests overinvolvement with a client and potential boundary problems [43]. Such behavior inhibits the client's ability to learn personal responsibility and how to resolve conflict [44]. It also may impede the reflective and investigative character of an effective helping process [45]. Mental health professionals should take reasonable steps to minimize harm to clients where it is foreseeable and unavoidable [3,4]. They also should facilitate client growth and development in ways that foster the interest and welfare of the client and promote the formation of healthy relationships [4].

PROTECTING THE PROFESSIONAL

As stated, professional associations that represent the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect the professional and the individuals with whom they work [3,4,5,6,7]. Client welfare and trust in the helping professions depend on a high level of professional conduct [3,4]. Professional values, such as managing and maintaining appropriate boundaries, are an important way of living out an ethical commitment [4].

Some situations in therapy are clear with regard to boundaries (e.g., no sexual relationships with clients). Other situations may be not as clear or may be ambiguous (e.g., receiving gifts from clients). When faced with such situations, professionals should engage in an ethical decision-making process that includes an evaluation of the context of the situation and collaboration with the client to make decisions that promote the client's growth and development [4]. Supervision and colleague support also may be necessary to reach the best decision. Such a process helps clinicians maintain justice and equity and avoid implications of favoritism in dealing with all of their clients [46].

Professionals who deliver services in nontraditional settings, such as those who have home-based practices, face unique challenges related to boundaries and limit setting. As with office-based therapy, some situations cannot be prepared for and will need to be addressed in the moment. While delivering services in nontraditional settings may benefit some clients, when working in homes or residences, the professional is advised to emphasize informed consent, particularly with regard to therapeutic boundaries. Whenever possible, the impact of crossing boundaries on therapy and on the therapeutic relationship should be considered ahead of time [47].

6. BOUNDARY CROSSINGS AND VIOLATIONS

A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [48]. Professional risk factors for boundary violations include [49]:

- The professional's own life crises or illness

- A tendency to idealize a "special" client, make exceptions for the client, or an inability to set limits with the client

- Engaging in early boundary incursions and crossings or feeling provoked to do so

- Feeling solely responsible for the client's life

- Feeling unable to discuss the case with anyone due to guilt, shame, or the fear of having one's failings acknowledged

- Realization that the client has assumed management of his or her own case

Denial about the possibility of boundary problems (i.e., "This couldn't happen to me") also plays a significant role in the persistence of the problem [49]. Lack of self-care and self-awareness also can leave the mental health professional vulnerable to boundary crossings and/or violations.

Whatever the reason the professional has to cross a boundary, it is of utmost importance to ensure that it will not harm the client. Each boundary crossing should be taken seriously, weighed carefully in consultation with a supervisor or trusted colleague, well-documented, and evaluated on a case-by-case basis. Intentional crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan that takes into consideration the client's problem, personality, situation, history, and culture as well as the therapeutic setting and context [50]. Boundary crossings with certain clients (e.g., those with borderline personality disorder or acute paranoia) are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual or multiple relationships, which always entail boundary crossing, impose the same criteria on the professional. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concerns [50].

Some counselors may consider a boundary crossing when it provides a better firsthand sense of the broader clinical context of their client, such as visiting the home of a client that is ailing, bedridden, or dying; accompanying a client to a medically critical but dreaded procedure; joining a client/architect on a tour of her latest construction; escorting a client to visit the gravesite of a deceased loved one; or attending a client's wedding [50]. Many mental health professionals will not cross these boundaries and will insist that therapy occur only in the office. Each professional should operate according to the parameters with which he or she is comfortable. As stated, the best interests of the client, including client confidentiality, and the impact to therapy should be of paramount importance when considering whether to cross a boundary.

To be in the best position to make sound decisions regarding boundary crossings, mental health professionals should develop an approach that is grounded in ethics; stay abreast of evolving legislation, case law, ethical standards, research, theory, and practice guidelines; consider the relevant contexts for each client; engage in critical thinking and personal responsibility; and, when a mistake is made or a boundary decision has led to trouble, use all available resources to determine the best course of action to respond to the problem [51]. The risk management strategy also should include discussions with supervisors, colleagues, and the client. Each step should be documented and should include supervisory recommendations and client discussion regarding the benefits versus the risks of such actions. Although minor boundary violations may initially appear innocuous, they may represent the foundation for eventual exploitation of the client. If basic treatment boundaries are violated and the client is harmed, the professional may be sued, charged with ethical violations, and lose his/her license [52].

7. MULTIPLE RELATIONSHIPS

Examples of multiple relationships include being both a client's counselor and friend; entering into a teacher/student relationship; becoming sexually involved with a current or former client; bartering services with a client; or being a client's supervisor. Even when entering into a multiple relationship seems to offer the possibility of a better connection to a client, it is not recommended. Multiple relationships can cause confusion and a blurring of boundaries and risk exploitation of the client.

The issue of multiple relationships is addressed by the codes of ethics of mental health professions. According to the APA's ethics code [3]:

A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationships could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

The ethics code of the NASW (standard 1.06 Conflicts of Interest) defines dual or multiple relationships as occurring "when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively" [5]. It also states that "social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries" [5]. The code further states that it is the professional's responsibility to "be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment" and that counselors should "inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible" [5]. In some instances, this may require "termination of the professional relationship with proper referral of the client" [5].

The ACA ethics code states that [4]:

Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective. They also are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately.

Mental health professionals who practice in small, rural communities face special problems in maintaining neutrality, fostering client separateness, protecting confidentiality, and managing past, current, or future personal relationships with clients [53]. Whether the practice is located in a small town or a big city, there will be times when counselors and clients will encounter one another outside the office. To ignore a client who is reaching out in a social setting may cause the client harm. However, it also is important to avoid violating the client's privacy. The best way to minimize the potential awkwardness of such an encounter is to prepare ahead of time. For example, a counselor might incorporate a conversation about such an encounter into the initial evaluation process by telling the client: "If I happen to be at a store or a restaurant and see you, I won't say hello because I respect your confidentiality and want to protect your privacy. However, if you want to smile or say hello to me, I will respond in kind." Explain to the client that the conversation or acknowledgment must be brief to prevent any violation of the client's privacy. After an encounter in public, address the event in your next session, discuss any feelings the client had about the encounter, and note the discussion in the client record. Such an encounter would not fall under the category of dual/multiple relationships unless, for example, the counselor and client went grocery shopping at the same time every week and interacted each time. In this instance, the counselor is advised to change his or her shopping day and/or time in order to avoid risking loss of client confidentiality.

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

Mental health professionals are forbidden to exploit any person over whom they have supervisory, evaluative, or other similar authority. This includes clients/patients, students, supervisees, research participants, and employees [3,4]. Professional ethics codes outline specific instances of behaviors and actions (some that are expressly prohibited) that have exploitative potential, including [3,4,5]:

- Bartering with clients

- Sexual relationships with students or supervisees

- Sexual intimacies with current or former clients

- Sexual intimacies with relatives/significant others of current therapy clients

- Therapy with former sexual partners or partners of a romantic relationship

- Romantic interactions or relationships with current clients, their romantic partners, or their family members, including electronic interactions or relationships

- Physical contact with clients (e.g., cradling or caressing)

There are times when a client has an emotional session and hugs the counselor unexpectedly before leaving the office. This physical contact should be noted in the client's record along with what precipitated it. It should be revisited with the client at the next session, with this discussion recorded in the client's record. While you may prefer no physical contact, you can try to respond positively to the desire for closeness. For example, make personal contact with your hand as you hold the client at a distance, make eye contact, and tell the client that while physical reaching out is positive and welcome, you cannot allow it [10].

The ACA ethics code prohibits sexual and/or romantic counselor/client interactions or relationships with former clients, their romantic partners, or their family members for a period of five years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships [4]. The APA ethics code indicates that this period should be "at least two years after cessation or termination of therapy," and that "psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances" [3]. Mental health professionals who choose to engage in relationships with former clients have the burden of demonstrating that there has been no exploitation, in light of all relevant factors [3]. Factors to consider include the amount of time passed since termination of therapy; the client's personal history and mental status; the likelihood of an adverse impact on the client; and statements or actions made by the counselor during therapy suggesting or inviting a possible sexual or romantic relationship with the client [3].

Standards regarding sexual relationships and physical contact also are addressed by the NASW ethics code [5]:

1.09 Sexual Relationships

(a) Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced.

(b) Social workers should not engage in sexual activities or sexual contact with clients' relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients' relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients' relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.

(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.

(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.

1.10 Physical Contact

Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.

The safest course of action is to continue to maintain established boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the client of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client's vulnerability in a post-termination relationship [54].

Mental health professionals who find themselves attracted to a client should seek supervision around this issue. It is normal for feelings to develop in any type of relational context. It is not the feelings of attraction that are the problem, but rather actions taken. Mental health professionals should never act on these feelings, but instead discuss them with a trusted supervisor or colleague, exploring the possibility of countertransference as well as the potential trigger for the attraction. If the attraction causes intense feelings, it is advisable to seek personal therapy. If the feelings interfere with one's ability to treat a client, the client should be transferred to another professional, and work with the client terminated.

GIFTS

It is not unusual during the course of therapy for a client to present a counselor with a token of appreciation or a holiday gift, and receiving gifts from clients is not strictly prohibited by professional ethics codes. Instead, the ethics codes advise professionals to consider a variety of factors when deciding whether to accept a client's gift.

Section A.10.f (Receiving Gifts) of the 2014 ACA Code of Ethics states that [4]:

Counselors understand the challenges of accepting gifts from clients and recognize that, in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

The National Board for Certified Counselors Code of Ethics: Directive #4 provides similar guidance to its members [6]:

National certified counselors (NCCs) shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant because of the potential confusion that may arise. NCCs shall consider the value of the gift and the effect on the therapeutic relationship when contemplating acceptance. This consideration shall be documented in the client's record.

In the code of ethics of the Association for Addiction Professionals, Principle I-40: The Counseling Relationship states that [7]:

Addiction professionals recognize that clients may wish to show appreciation for services by offering gifts. Providers shall take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

As noted in these excerpts, the effect on the therapeutic relationship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor's task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giving [55]. Counselors should consider the client's motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client's appreciation may harm the relationship [56].

If the counselor is most comfortable with a "no-gift policy," it is best that the policy be discussed at the beginning of therapy. To wait until a client is presenting a gift to state that it is your policy to decline gifts may harm the client and damage the therapeutic relationship. Clear communication, both written and spoken, of the policy with clients as they enter therapy may help avert difficult later interactions around gifts. If clients have an understanding as they begin therapy what the counselor's approach will be, misunderstandings may be avoided [57]. While restrictive guidelines might be unhelpful, confusion surrounding gifts seems to be exacerbated by a lack of professional discussion about the topic [58].

Many professionals try to keep gifts "alive" throughout client sessions. This often involves putting the gift "on hold" (including decisions about acceptance and rejection) until the best moment for exploration with the client occurs. This allows that gifts given during therapy (where possible) remain part of therapy (i.e., they stay in the room and are available for future sessions) [58]. When considering whether to discuss the gift as part of therapy, the counselor should evaluate pertinent factors, such as the client's time in therapy, the context and frequency of gifts, and client dynamics. While not all gifts warrant full discussion (e.g., those given to show appreciation or of modest financial value), some, such as repeated or expensive gifts, do. Although counselors should be careful not to make too much of a gift, especially those that clients at least initially see as being given simply as a way to say thank you, such conversations may enable both members of the dyad to attain greater insight into the gift's intention and meaning and thereby prove helpful to the continued therapy work [59].

Gifts can range from physical objects, to symbols or gestures. As stated, consider the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift [4,5,7]. If there are concerns about any of these factors, it may be best to explore the intent of the gift in session. If a gift is deemed inappropriate, the counselor is advised to decline to accept it. In these cases, counselors should express appreciation for the thought and gesture, explain why they are unable to accept the gift, return it with kindness, and note the encounter in the client's record.

Professionals who work with children have unique challenges regarding gifts. Rejecting a child's gift or trying to explain a "no-gift policy" can cause the child to feel confused or rejected; children do not have the same levels of cognition and understanding that adults have. For play counselors, potential compromises include incorporating the gift into the other materials and toys in the playroom or directly sharing the gift with the child [59]. An important factor affecting the decision to accept a gift is the kind of gift presented by the child. Artwork or something created by the child is an extension of the child and therefore can be viewed as an extension of emotional giving. Accepting non-purchased items (e.g., a flower picked by a child or a child's drawing) would be acceptable in most cases [60].

Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical picture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client's best interests [55].

Often, a small token may be given or received at the termination of therapy for a long-term client. A touchstone that has meaning for the client, such as a meditation CD, book, or greeting card, is appropriate. As with all gifts, the gift and the context in which the gift was given or received should be noted in the client's record, along with your own intent and how you think the client perceived the gift.

8. TECHNOLOGY AND DISTANCE THERAPY

We live in a rapidly changing world, especially where technology is concerned. In the past, therapy was offered only through in-person interaction in an office setting. Then, gradually, some professionals began to offer telephone sessions. Today, counseling is offered through video conferencing and online message boards, and paper client records are being replaced with electronic records. Competent counseling includes maintaining the knowledge and skills required to understand and properly use treatment tools, including technology, while adhering to the ethical code of one's profession.

The APA has created guidelines to address the developing area of psychologic service provision commonly known as telepsychology [61]. The APA defines telepsychology as the "provision of psychological services using telecommunication technologies. Telecommunication technologies include, but are not limited to, telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media)" [61]. The APA guidelines are informed by its ethics code and record-keeping guidelines as well as its guidelines on multicultural training, research, and practice. The guidelines allow that telecommunication technologies may either augment traditional in-person services or be used as stand-alone services. The guidelines also acknowledge that telepsychology involves "consideration of legal requirements, ethical standards, telecommunication technologies, intra- and interagency policies, and other external constraints, as well as the demands of the particular professional context" [61]. When one set of considerations may suggest a different course of action than another, the professional should balance them appropriately, with the aid of the guidelines [61]. The complete guidelines are available online at https://www.apa.org/practice/guidelines/telepsychology.

The 2014 ACA Code of Ethics also addresses distance counseling, technology, and social media. It states [4]:

Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

The ACA code also addresses legal considerations, informed consent and disclosure, confidentiality, security, and multicultural and disability considerations as they relate to technology.

The NBCC recognizes that distance counseling presents unique ethical challenges to professional counselors; related technology continues to advance and be used by more professionals; and that the use of technology by professionals continues to evolve. In light of this information, the NBCC revised its Internet counseling policy and developed the NBCC Policy Regarding the Provision of Distance Professional Services [62]. This policy replaces previous editions.

The revised policy includes use of the term "distance professional services" to include other types of professional services that are being used more in distance formats. The policy addresses telephone-, email-, chat-, video-, and social network-based distance professional services that may be conducted with individuals, couples, families, or group members. The policy also identifies specific actions that NCCs should take when providing distance services. The policy supplements the directives identified in the NBCC Code of Ethics [6,62]. The policy is available at https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf.

According to the NASW ethics code, social work services assisted by technology "include any social work services that involve the use of computers, mobile or landline telephones, tablets, video technology, or other electronic digital technologies [that] includes the use of various electronic or digital platforms, such as the Internet, online social media, chat rooms, text messaging, e-mail and emerging digital applications" [5]. Professionals are advised to "keep apprised of emerging technological developments that may be used in social work practice and how various ethical standards apply to them" [5]. In general, the ethical standards articulated in the NASW Code of Ethics are "applicable to all interactions, relationships, or communications, whether they occur in person or with the use of technology" [5]. Professionals who are involved in discoverable (by the client) "electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients" [5].

Professionals interested in providing online interventions also should consider the potential for boundary confusion, inappropriate dual relationships, or harm to clients [5]. For example, instant message systems can alert clients each time the professional is online, allowing the client to send chat requests. Clients might access a professional's personal webpage or sign onto online discussion groups to which the professional also belongs. Some may continue to send the professional emails after the termination of the relationship. E-counselors should consider their response to such ongoing contact. Potentially more seriously, clients may use the Internet to harass or stalk current or former counselors [63]. The best way to prevent potential problems is to discuss the boundaries with clients during the initial assessment. Being up front and clear with clients about limits and policies regarding the use of technology and social networking is recommended [64].

Miscommunication is a commonplace occurrence in the online world. Even the simplest things (e.g., punctuation marks) can be misinterpreted. Studies reveal that 7% of any message is conveyed through words, 38% through certain vocal elements, and 55% through nonverbal elements (e.g., facial expressions, gestures, posture) [65]. Some technology-based forms of communication can result in the loss of important nonverbal and vocal cues, leading to an increased risk for miscommunication between client and counselor. Interactive communication, such as texting and email, involves the loss of nonverbal social cues that provide valuable contextual information and interpretation of meaning. Loss of these physical social cues may also increase the client's tendency to project personal psychologic material onto the blankness of the communication. While this may be helpful in some forms of psychotherapeutic interventions and it may offer advantages over in-person communication, it also presents a potential risk for increased miscommunication [63].

The compassionate professional strives to communicate nonverbally to clients that he or she is listening to and in the moment with the client. Physical cues, such as nodding and eye contact, have been shown to be positively associated with the degree that clients feel the counselor is respectful and genuine [66,67]. Much attention also is paid to the voice, as it carries the verbal message and people often believe the voice to be a more reliable indicator of one's true feelings [68]. Because research exploring how empathy is experienced in an online environment is minimal, counselors should check with their clients to determine if the empathy is being transmitted in their text-based communications [10].

No matter what type of counseling is offered, a thorough initial evaluation should be completed to assess whether a client is appropriate for distance counseling. Practicing within recommended guidelines does not release counselors from the personal responsibility to be aware of, and to independently evaluate, the variety of ethical issues involved in the practice of online therapy [63]. Certain clients (e.g., those with suicidal, homicidal, or substance abuse history, clients with personality disorders) would not be suited to online therapy.

LEGAL AND ETHICAL CONSIDERATIONS

The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [69].

Providing services across state lines is one of the biggest unresolved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client's state. Providing distance therapy within one's own state is simpler, and it allows mental health professionals to reach people who would not otherwise have access to services (e.g., rural residents, people with certain disabilities) as well as those who want to receive services from home. To confidently provide distance services [70]:

- Abide by all applicable licensing requirements and professional standards of care.

- Understand the technology being used.

- Periodically check your state legislature's website for the latest telehealth laws and regulations.

- Check for a board policy statement that provides guidance on telepractice.

- Check whether your state licensing board has issued policies related to telepractice.

- Confirm that telehealth services (both in-state and across jurisdictional lines) are covered under your malpractice policy.

The COVID-19 public health emergency increased demand for mental and behavioral health services while driving most of those services to telehealth platforms. In response to this, in 2020, the APA led a campaign to maximize the availability of telepsychology services [71]. In March 2020, the federal government designated psychologists as critical, essential workers, and the Centers for Medicare and Medicaid Services (CMS) improved access to care for Medicare beneficiaries. CMS issued further guidance to waive key telehealth requirements. Because the new legislation cannot supersede state licensing laws (e.g., those that prohibit psychologists from using telehealth to provide services across state lines), the APA drafted letters to governors in all 50 states urging them to temporarily suspend state licensing laws and regulations regarding telepsychology services to ensure continuity of care. Within weeks of receiving the APA letter [71]:

- 12 states issued executive orders calling for expansion of telehealth service rates.

- 14 states issued executive orders allowing patients to receive telehealth services in their own homes.

- 16 states temporarily lifted licensing requirements.

- 22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of-state providers.

SOCIAL MEDIA

With the advent of social media, clients can now search for and find the Facebook or Twitter page of their counselor, if one exists. Counselors who accept a client's "friend request" are in essence agreeing that the counselor and client are now friends, creating a multiple relationship. As discussed, when clients have access to their counselor's social media sites, both intentional and unintentional self-disclosures can occur. Modern social networking systems (e.g., Facebook, Instagram) exemplify intentional self-disclosure without a particular client focus. In contrast, Internet search engines (e.g., Google, LexisNexis) may allow unintended disclosure of personal details of the professional's life. Professionals should be aware and cognizant of social media involvement, including what information is public. Many sites offer ways to post minimal information if a connection to other professionals is desired. Avoid posting a profile photo that includes your family or other personal details, as these are public [72].

ARTIFICIAL INTELLIGENCE

As artificial intelligence (AI) tools become increasingly integrated into health care, human oversight and thoughtful interaction between humans and technology are critical. One significant benefit of AI use is helping with administrative tasks, such as generating client case notes, creating psychoeducation materials, and developing treatment plan goals, allowing more time for direct practice and self-care [75]. However, in its current state, AI use in mental and behavioral health practice raises significant ethical issues, including transparency, bias, data security, misinformation, professional judgment, and professional liability. Since 2022, the professional organizations have begun to release guidance on the appropriate selection and use of AI tools in practice.

The APA has published Ethical Guidance for AI in the Professional Practice of Health Service Psychology, a document to help support psychologists and psychotherapists in the ethical use of AI technologies [73]. In 2025, the NASW published Practice Standards for Clinical Social Workers, which addressed artificial intelligence for the first time. Standard 12, regarding technology, states that, "Clinical social workers shall be transparent and technologically knowledgeable about using artificial intelligence (AI), as well as the use of applications, avatars, and metaverse in psychotherapy assessment and treatment" [74]. Furthermore, "clinical social workers should exercise judgment in incorporating it into practice and should also stay informed on AI advancements and their practice implications."

Specific issues with AI relate to its algorithmic bias; unintended harm to clients; negative impacts on privacy, confidentiality, informed consent, and client autonomy; and the potential for AI to replace human judgement and clinical decision making [73,74]. Practitioners must ensure that any use of AI is within ethical guidelines, is accurate, and does not perpetuate systemic biases. This is important, as AI models have been repeatedly shown to have considerable biases learned from consuming online content or transferred from developers during programming (e.g., gender, ethnicity, sexual orientation, other under-represented identities), whether unconscious or unintended, and then become fundamentally biased themselves. AI is also known to hallucinate, or spontaneously make up erroneous data. Due to the tendency toward bias and generating false information, care must be taken to reread and edit AI-generated work, while ensuring that statements are reflective of your own opinions, are true to facts, and adhere to all ethical principles of the profession [73,74].

9. CONCLUSION

Competent counselors are well-educated and well-versed in the ethics of their profession. They understand that trust is built over time in the therapeutic relationship, with the help of limits and boundaries, and that it is reinforced by empathic response. Competent, compassionate professionals are both self- and other-aware and able to seek appropriate supervision and consultation when necessary. They establish self-care boundaries in order to protect their own compassionate, empathic response as well as their physical, emotional, and spiritual well-being. This enables counselors to most effectively help their clients.

10. RESOURCES

American Association for Marriage and Family Therapy Code of Ethics

https://www.aamft.org/Legal_Ethics/Code_of_Ethics.aspx

APA Ethical Principles of Psychologists and Code of Conduct

https://www.apa.org/ethics/code

ACA Code of Ethics

https://www.counseling.org/resources/aca-code-of-ethics.pdf

NAADAC Code of Ethics

https://www.naadac.org/code-of-ethics

NBCC Code of Ethics

https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf

NASW Code of Ethics

https://www.socialworkers.org/About/Ethics/Code-of-Ethic

Works Cited

1. American Psychological Association Services, Inc. Professional Health and Well-Being for Psychologists. Available at https://www.apaservices.org/practice/ce/self-care/well-being. Last accessed October 16, 2023.

2. Positive Psychology Program. How to Set Healthy Boundaries: 10 Examples + PDF Worksheets. Available at https://positivepsychologyprogram.com/great-self-care-setting-healthy-boundaries . Last accessed October 16, 2023.

3. American Psychological Association. Ethical Principles of Psychologists and Code of Conduct. Available at https://www.apa.org/ethics/code. Last accessed October 16, 2023.

4. American Counseling Association. 2014 ACA Code of Ethics. Available at https://www.counseling.org/resources/aca-code-of-ethics.pdf . Last accessed October 16, 2023.

5. National Association of Social Workers. Code of Ethics. Available at https://www.socialworkers.org/About/Ethics/Code-of-Ethics . Last accessed October 16, 2023.

6. National Board of Certified Counselors. National Board for Certified Counselors (NBCC) Code of Ethics. Available at https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf . Last accessed October 16, 2023.

7. Association for Addiction Professionals. NAADAC/NCC AP: The National Certification Commission for Addiction Professionals Code of Ethics. Available at https://www.naadac.org/assets/2416/naadac-code-of-ethics-033117.pdf . Last accessed October 16, 2023.

8. Fairburn CG, Cooper Z. Therapist competence, therapy quality, and therapist training. Behav Res Ther. 2011;49(6-7):373-378.

9. Bandura A. Self-Regulation. Available at https://albertbandura.com/albert-bandura-self-regulation.html. Last accessed October 16, 2023.

10. Rogers CR. A Way of Being. Boston, MA: Houghton Mifflin; 1980: 115-116.

11. Gendlin ET. Subverbal communication and therapist expressivity: trends in client-centered therapy with schizophrenics. In: Rogers CR, Stevens B (eds). Person to Person: The Problem of Being Human: A New Trend in Psychology. Lafayette, CA: Real People Press; 1967: 121-122.

12. Jordan JV. Relational Development: Therapeutic Implications of Empathy and Shame. Wellesley, MA: Wellesley College; 1989.

13. Elliott R, Bohart AC, Watson JC, Greenberg LS. Empathy. Psychotherapy. 2011;48(1):43-49.

14. Watson JC. Role of empathy is psychotherapy: theory, research and practice. In: Cain DJ, Seeman J (eds). Humanistic Psychotherapies: Handbook of Research and Practice. 2nd ed. Washington, DC: American Psychological Association; 2002: 445-472.

15. Wiseman T. A concept analysis of empathy. J Adv Nurs. 1996;23(6):1162-1167.

16. Kirschenbaum H, Jourdan A. The current status of Carl Rogers and the person-centered approach. Psychother Theory Res Pract Training. 2005;42(1):37-51.

17. The Compassion Focused Practice Community of North America. Available at http://www.compassionfocusedtherapy.com. Last accessed October 16, 2023.

18. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15(3):199-208.

19. Arnold K. Behind the mirror: reflective listening and its tain in the work of Carl Rogers. Humanistic Psychol. 2014;42(4):354-369.

20. Abendroth M, Flannery J. Predicting the risk of compassion fatigue: a study of hospice nurses. J Hosp Palliat Nurs. 2006;8(6):346-356.

21. Freud S. Fragment of an analysis of a case of hysteria (1905 [1901). In: Freud S, Strachey J, Freud A, Strachey A, Tyson A (eds). Complete Psychological Works of Sigmund Freud. Volume VII, 1901–1905, A Case of Hysteria. London: Hogarth Press; 1953: 7-122.

22. Reidbord S. An Overview of Countertransference. Available at https://www.psychologytoday.com/us/blog/sacramento-street-psychiatry/201003/overview-countertransference. Last accessed October 16, 2023.

23. Plakun EM. Making the alliance and taking the transference in work with suicidal patients. J Psychother Pract Res. 2001;10(4):269-276.

24. Murdoch L. Psychological consequences of adopting a therapeutic lawyering approach: pitfalls and protective strategies. Seattle UL Rev. 2000;24(2):483.

25. Hughes P, Kerr I. Transference and countertransference in communication between doctor and patient. Adv Psychiatr Treat. 2000; 6(1):57-64.

26. Gabbard GO, Horowitz MJ. Insight, transference interpretation, and therapeutic change in the dynamic psychotherapy of borderline personality disorder. Am J Psychiatry. 2009;166(5):517-521.

27. Slakter E. Countertransference. Northvale, NJ: Jason Aronson; 1988.

28. Peabody SA, Gelso CJ. Countertransference and empathy: the complex relationship between two divergent concepts in counseling. J Counseling Psychol. 1982;29(3):240-245.

29. Hayes JA, McCracken JE, McClanahan MK, Hill CE, Harp JS, Carozzoni P. Therapist perspectives on countertransference: qualitative data in search of a theory. J Counseling Psychol. 1998;45(4):468-482.

30. Shapiro ER, Carr W. Lost in Familiar Places: Creating New Connections Between the Individual and Society. New Haven, CT: Yale University Press; 1991.

31. Ziegler M, McEvoy M. Hazardous Terrain: Countertransference Reactions in Trauma Groups. Available at http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.578.2804&rep=rep1&type=pdf. Last accessed October 16, 2023.

32. Dahl HSJ, Høglend P, Ulberg R, et al. Does therapists' disengaged feelings influence the effect of transference work? A study on countertransference. Clin Psychol Psychother. 2017;24(2):462-474.

33. Timm TM, Blow AJ. Self-of-the-therapist work: a balance between removing restraints and identifying resources. Contemp Fam Ther. 1999;21(3):331-351.

34. Godfrey K, Haddock SA, Fisher A, Lund L. Essential training components of curricula for preparing therapists to work with lesbian, gay, and bisexual clients: a Delphi study. J Marital Fam Ther. 2006;32(4):491-504.

35. Sommers-Flanagan R, Elliott D, Sommers-Flanagan J. Exploring the edges: boundaries and breaks. Ethics Behav. 1998;8(1):37-48.

36. Austin W, Bergum V, Nuttgens S, Peternelj-Taylor C. A re-visioning of boundaries in professional helping relationships: exploring other metaphors. Ethics Behav. 2006;16(2):77-94.

37. Langley GC, Klopper H. Trust as a foundation for the therapeutic intervention for patients with borderline personality disorder.J Psychiatr Ment Health Nurs. 2005;12(1):23-32.

38. Gabbard GO. Boundaries and Boundary Violations in Psychoanalysis. 2nd ed. Washington, DC: American Psychiatric Publishing; 2016.

39. Hermansson G. Boundaries and boundary management in counselling: the never-ending story. Br J Guid Counc. 1997;25(2):133-146.

40. Sonne JL. Nonsexual Multiple Relationships: A Practical Decision-Making Model for Clinicians. Available at https://kspope.com/site/multiple-relationships.php. Last accessed October 16, 2023.

41. Gutheil TG. Boundaries, blackmail, and double binds: a pattern observed in malpractice consultation. J Am Acad Psychiatry Law. 2005;33(4):476-481.

42. Winnicott DW. The Maturational Processes and the Facilitating Environment; Studies in the Theory of Emotional Development. New York, NY: International Universities Press; 1965.

43. Walker R, Clark JJ. Heading off boundary problems: clinical supervision as risk management. Psychiatr Serv. 1999;50(11):1435-1439.

44. Whitfield CL. Boundaries and Relationships: Knowing, Protecting, and Enjoying the Self. Deerfield Beach, FL: Health Communications; 1993.

45. Rønnestad MH, Skovholt TM. The journey of the counselor and therapist: research findings and perspectives on professional development. J Career Dev. 2003;30(1):5-44.

46. Spence SA. Patients bearing gifts: are there strings attached? BMJ. 2005;331(7531):1527-1529.

47. Knapp S, Slattery JM. Professional boundaries in nontraditional settings. Prof Psychol Res Pr. 2004;35(5):553-558.

48. Corey G, Corey MS, Corey C. Issues and Ethics in the Helping Professions. 10th ed. Stamford, CT: Brooks/Cole Cengage Learning; 2018.

49. Norris DM, Gutheil TG, Strasburger LH. This couldn't happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. Psychiatr Serv. 2003;54(4):517-522.

50. Zur O. To cross or not to cross: do boundaries in therapy protect or harm? Psychother Bull. 2004;39(3):27-32.

51. Pope KS, Keith-Speigel P. A practical approach to boundaries in psychotherapy: making decisions, bypassing blunders, and mending fences. J Clin Psychol. 2008;64(5):638-652.

52. Simon RI. Treatment boundary violations: clinical, ethical, and legal considerations. Bull Am Acad Psychiatr Law. 1992;20(3):269-288.

53. Simon RI, Williams IC. Maintaining treatment boundaries in small communities and rural areas. Psychiatr Serv. 1999;50(11):1440-1446.

54. Gabbard GO. Patient-therapist boundary issues. Psychiatr Times. 2005;22(12).

55. Gerig MS. Receiving gifts from clients: ethical and therapeutic issues. J Ment Health Couns. 2004;26(3):199-210.

56. Herlihy B, Corey G. Boundary Issues in Counseling: Multiple Roles and Responsibilities. 3rd ed. Alexandria, VA: ACA Press; 2014.

57. Knox S. Gifts in psychotherapy: practice review and recommendations. Psychotherapy. 2008;45(1):103-110.

58. Spandler H, Burman E, Goldberg B, Margison F, Amos T. "A double-edged sword:" understanding gifts in psychotherapy. Eur J Psychother Couns. 2000;3(1):77-101.

59. Knox S, Dubois R, Smith J, Hess S, Hill CE. Clients' experiences giving gifts to therapists. Psychotherapy. 2009;46(3):350-361.

60. Landreth G. Play Therapy: The Art of the Relationship. 3rd ed. New York, NY: Routledge Taylor and Francis Group; 2012.

61. American Psychological Association. Guidelines for the Practice of Telepsychology. Available at https://www.apa.org/practice/guidelines/telepsychology. Last accessed October 16, 2023.

62. National Board for Certified Counselors. NBCC Policy Regarding the Provision of Distance Professional Services. Available at https://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf. Last accessed October 16, 2023.

63. Childress CA. Ethical issues in providing online psychotherapeutic interventions. J Med Internet Res. 2000;2(1):e5.

64. Novotney A. A new emphasis on telehealth: how can psychologists stay ahead of the curve—and keep patients safe? Am Psychol Assoc. 2011;42(6):40.

65. Mehrabian A. Silent Messages: Implicit Communication of Emotions and Attitudes. 2nd ed. Belmont, CA: Wadsworth Pub Co; 1980.

66. Hill CE, Stephany A. Relation of nonverbal behavior to client reactions. J Counseling Psychol. 1990;37(1):22-26.

67. Kelly EW Jr, True JH. Eye contact and communication of facilitative conditions. Percept Mot Skills. 1980;51(3):815-820.

68. Hall JA, Harrigan JA, Rosenthal R. Nonverbal behavior in clinician-patient interaction. Appl Prev Psychol. 1996;4(1):21-37.

69. Rochlen AB, Zack JS, Speyer C. Online therapy: review of relevant definitions, debates, and current empirical support. J Clin Psychol. 2004;60(3):269-283.

70. DeAngelis T. Practicing Distance Therapy, Legally and Ethically. Available at https://www.apa.org/monitor/2012/03/virtual. Last accessed October 16, 2023.

71. Owings-Fonner N. Telepsychology Expands to Meet Demand. Available at https://www.apa.org/monitor/2020/06/covid-telepsychology. Last accessed October 16, 2023.

72. Gutheil TG. Ethical aspects of self-disclosure in psychotherapy. Psychiatr Times. 2010;27(5):39-41.

73. American Psychological Association. Ethical Guidance for AI in the Professional Practice of Health Service Psychology. Available at https://www.apa.org/topics/artificial-intelligence-machine-learning/ethical-guidance-professional-practice.pdf. Last accessed June 24, 2026.

74. National Association of Social Workers. NASW Practice Standards for Clinical Social Workers: Standard 12. Available at https://www.socialworkers.org/Practice/NASW-Practice-Standards-Guidelines/NASW-Standards-for-Clinical-Social-Work-in-Social-Work-Practice. Last accessed June 19, 2026.

75. Badillo-Diaz M. The Impact of AI Technology on the Social Work Profession: Benefits, Risks, and Ethical Considerations. Available at https://cascw.umn.edu/cw360deg-spring-2025/impact-ai-technology-social-work-profession-benefits-risks-and-ethical. Last accessed June 19, 2026.

97584 • Child Abuse in Ethnic Minority and Immigrant Communities

Alice Yick Flanagan, PhD, MSW

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Child abuse and neglect is a serious social problem. Research indicates that a significant number of children in the United States have been victims of physical abuse. The figures show that ethnic minority children (e.g., African Americans, Native American Indians/Alaskan Natives) have higher rates of reported child abuse and neglect compared to their non-Hispanic white counterparts. It has been argued that health practitioners, social workers, and mental health counselors should take into account race, ethnicity, and sociocultural factors when working with child abuse and neglect cases. This course will review the historical backdrop of the child welfare system and definitions of child abuse and neglect, including variations in definitions in various cultures internationally. An overview of the role of culture in child-rearing practices, child disciplining,and perceptions and definitions of child abuse will also be provided. Assessments and interventions based on culturally relevant theories will be reviewed. Finally, the importance of practitioners' self-care in child abuse cases is emphasized.

Table of Contents

97584 • Child Abuse in Ethnic Minority and Immigrant Communities

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

HISTORICAL VIEWS OF CHILDREN

HISTORY OF CHILD ABUSE AND NEGLECT

LEGISLATIVE RESPONSES IN THE UNITED STATES

3. DEFINITIONS AND TYPES OF CHILD ABUSE AND NEGLECT

FORMS OF CHILD ABUSE AND NEGLECT

4. AN INTERNATIONAL PERSPECTIVE

INTERNATIONAL PREVALENCE OF CHILD ABUSE AND NEGLECT

INTERNATIONAL DEFINITIONS OF CHILD MALTREATMENT

5. CHILD ABUSE IN THE UNITED STATES AND CANADA

6. CULTURE, RACE, AND ETHNICITY

CULTURE

RACE

ETHNICITY

7. IMPACT OF CULTURE ON CHILDREARING

PARENTING STYLES AND SOCIALIZATION

DISCIPLINE AND CORPORAL PUNISHMENT

8. CULTURE AND PERCEPTION OF CHILD ABUSE

9. ECOLOGIC FACTORS

MACROSYSTEM

EXOSYSTEM

MICROSYSTEM

ONTOLOGIC LEVEL

10. CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

LEININGER'S CULTURE CARE THEORY

AIRHIHENBUWA'S PEN-3 MODEL

KLEINMAN'S CULTURAL EXPLANATORY MODEL

STRENGTHS-BASED PERSPECTIVE

11. CHILD ABUSE ASSESSMENT AND INTERVENTIONS

ASSESSMENT

INTERVENTIONS AND BEST PRACTICES

INTERPROFESSIONAL COLLABORATION

PROFESSIONAL DEVELOPMENT

12. PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

TRANSFERENCE AND COUNTERTRANSFERENCE ISSUES

SECONDARY TRAUMATIZATION

BURNOUT

CONSIDERATIONS FOR CLINICAL SUPERVISION: BEST PRACTICES

13. CONCLUSION

Works Cited

97584 • Child Abuse in Ethnic Minority and Immigrant Communities

Education Category. Ethics - Human Rights

Release Date. 09/01/2024

Expiration Date. 08/31/2027

Course Overview

Child abuse and neglect is a serious social problem. Research indicates that a significant number of children in the United States have been victims of physical abuse. The figures show that ethnic minority children (e.g., African Americans, Native American Indians/Alaskan Natives) have higher rates of reported child abuse and neglect compared to their non-Hispanic white counterparts. It has been argued that health practitioners, social workers, and mental health counselors should take into account race, ethnicity, and sociocultural factors when working with child abuse and neglect cases. This course will review the historical backdrop of the child welfare system and definitions of child abuse and neglect, including variations in definitions in various cultures internationally. An overview of the role of culture in child-rearing practices, child disciplining,and perceptions and definitions of child abuse will also be provided. Assessments and interventions based on culturally relevant theories will be reviewed. Finally, the importance of practitioners' self-care in child abuse cases is emphasized.

Audience

This course is designed for physicians, nurses, social workers, therapists, mental health counselors, and other allied health professionals who may intervene in suspected cases of child abuse.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

This activity was planned by and for the healthcare team, and learners will receive 10 Interprofessional Continuing Education (IPCE) credit(s) for learning and change. NetCE designates this enduring material for a maximum of 10 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NetCE designates this continuing education activity for 10 ANCC contact hour(s). NetCE designates this continuing education activity for 10 hours for Alabama nurses. NetCE designates this continuing education activity for 5 NBCC clock hour(s). Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 10 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Completion of this course constitutes permission to share the completion data with ACCME. Social workers participating in this intermediate to advanced course will receive 10 Cultural Competency continuing education clock hours. Successful completion of this CME activity, which includes participation in the evaluation component, enables the learner to earn credit toward the CME and/or Self-Assessment requirements of the American Board of Surgery's Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Successful completion of this CME activity, which includes participation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 10 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. This activity has been designated for 10 Lifelong Learning (Part II) credits for the American Board of Pathology Continuing Certification Program. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physicians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME's "CME in Support of MOC" program in Section 3 of the Royal College's MOC Program. AACN Synergy CERP Category B. NetCE designates this continuing education activity for 10 credit(s). NetCE is authorized by IACET to offer 1 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course fulfills the Maryland requirement for 3 hours of anti-oppressive content, including cultural humility, social justice, racial equity, implicit bias, or anti-racism practices. This activity is designed to comply with the requirements of California Assembly Bill 1195, Cultural and Linguistic Competency.

Course Objective

The purpose of this course is to facilitate appropriate and culturally sensitive responses on the part of allied healthcare professionals to cases of child abuse and neglect.

Learning Objectives

Upon completion of this course, you should be able to:

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.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Ronald Runciman, MD

Mary Franks, MSN, APRN, FNP-C

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

The United States' demographic landscape is diverse and multicultural, and minority and immigrant children are projected to constitute a significant population of the school systems in the United States in the near future. In 2022, for example, 49% of the children in the United States were non-Hispanic White [8]. In 2020, non-Hispanic White children younger than 18 years of age constituted 71.6% of minor-age population [3]. Hispanic children constituted 25.5% in 2020, and it is projected they will grow to 31.9% by 2060 [3]. In 2018, the District of Columbia, Hawaii, Washington, New Mexico, and California are the states/territories that had the largest number of non-White children younger than 15 years of age [1].

As of 2019, an estimated 26% of children younger than 18 years of age in the United States (18 million) reside with at least one immigrant parent [195]. This group tends toward lower socioeconomic statuses, and as of 2021, the poverty rates for Black and Hispanic children were 27.3% and 22.4%, respectively, both of which were significantly greater than the poverty rate (8.8%) of non-Hispanic White children [8]. Almost 75% of racial and ethnic minority children live in poverty, and African American and Hispanic children are twice as likely as White children to experience food insecurity [12].

The process of immigration involves uprooting from the familiar—leaving one's homeland, family, friends, work, lifestyle, and in some cases, even value systems behind [4]. The adaptation process for immigrants often entails social, psychologic, and economic stressors. Many require new skills to navigate a new social and cultural system. Furthermore, immigrant families may be isolated, and isolation, along with the stressors, increases these families' vulnerability to child maltreatment and other problems [2]. Many immigrant families are reluctant to seek or accept formal assistance from medical and social service institutions given past experiences with oppression, fear of being deported, and general distrust of authority figures [2].

Despite these trends, the literature examining child abuse in immigrant and ethnic minority families is quite minimal when compared to the larger picture of child abuse/maltreatment research. In a meta-analysis of articles published between 1999 and 2002 on child abuse in America, researchers found that only 12% of the studies focused on ethnicity [5]. Of the 489 articles that did examine ethnicity, 52.3% found ethnicity to have a statistically significant effect on child abuse and help seeking, which emphasizes the importance of considering the role of ethnicity in child abuse and neglect.

Racial minority children are also over-represented in the child welfare system [48]. For example, in 2019, African American children constituted 14% of the child population in the United States, but they represented 23% of the foster care population [23]. In 2020, a total of 3.9 million reports came in to child welfare agencies in the United States. These reports represented 7.1 million children. Black children were twice as likely as White children to be represented in these reports [37]. After initial screening, Black children are two to five times more likely than White children to have their cases screened in for further investigation [297].

Finally, when addressing child abuse with racial and ethnic minority families, practitioners should be knowledgeable about various cultures, values, and belief systems in order to formulate interventions that are culturally sensitive and competent [2].

2. HISTORICAL OVERVIEW OF CHILD WELFARE AND PROTECTIVE SERVICES

HISTORICAL VIEWS OF CHILDREN

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].

HISTORY OF CHILD ABUSE AND NEGLECT

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.

LEGISLATIVE RESPONSES IN THE UNITED STATES

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].

3. 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].

FORMS OF CHILD ABUSE AND NEGLECT

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.

Physical Abuse

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].

Sexual Abuse/Exploitation

Evidence Based Practice Recommendation

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.

Neglect

Due to the ambiguity of definitions of neglect, the Study of National Incidence and Prevalence of Child Abuse and Neglect has attempted to standardize the definition [20,22]. According to the study, neglect may include [20,22]:

- Failure to provide adequate food, clothing, shelter, hygiene, supervision, education, and protection

- Refusal and/or delay in medical attention and care (i.e., failure to provide needed medical attention as recommended by a healthcare professional or failure to seek timely and appropriate medical care for a health problem)

- Abandonment, characterized by desertion of a child without arranging adequate care and supervision (e.g., children who are not claimed within two days or who are left alone with no supervision and without any information about their parents'/ caretakers' whereabouts)

- Expulsion or blatant refusals of custody on the part of parent/caretaker, such as ordering a child to leave the home without adequate arrangement of care by others

- Inadequate supervision (i.e., child is left unsupervised or inadequately supervised for extended periods of time)

Emotional Abuse

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

Parental Substance Abuse

Parental substance abuse falls into the category of child abuse and neglect in certain states [20]. This might include prenatal exposure due to the mother's use of an illegal substance, the manufacture of illegal substances in the presence of a child, or using substances that negatively affect caregiving abilities [20].

There has been some debate of whether exposing children to secondhand smoke is considered child abuse [241]. Some experts argue that if parents are informed by healthcare providers that the secondhand smoke is contributing to a child's illness (e.g., asthma, bronchitis) but do not make any attempts to protect the child from the smoke, it could be classified as child abuse [241].

Abandonment

In some states, abandonment is considered to be a type of child abuse or neglect [20]. CAPTA defines abandonment as, "when the parent's identity or whereabouts are unknown, the child has been left by the parent in circumstances in which the child suffers serious harm, or the parent has failed to maintain contact with the child or to provide reasonable support for a specified period of time" [20].

Trafficking

As noted, children who are the victim of trafficking are also considered child abuse victims [280]. Forms of child trafficking include forced labor, conscription, and sex trafficking. The 2015 Justice for Victims of Trafficking Act includes an amendment to CAPTA. In accordance with this amendment, states can track sex trafficking victim data. This was again expanded in 2016 to collect and report data related to infants with prenatal substance exposure. In 2018, there was a total of 27,709 infants reported in the category.

4. AN INTERNATIONAL PERSPECTIVE

When considering the implications of ethnicity and culture as they relate to child abuse, it is important to have an understanding of the global impact and experience of the problem. Particularly, there is controversy regarding whether various social problems are or should be considered child abuse and/or neglect.

INTERNATIONAL PREVALENCE OF CHILD ABUSE AND NEGLECT

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].

INTERNATIONAL DEFINITIONS OF CHILD MALTREATMENT

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].

Female Genital Mutilation/Cutting

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 match- stick) 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)

Prevalence rates of FGM/C are difficult to ascertain. Rates of recorded FGM/C are highest in Africa, where the pooled prevalence in one study was 56% [358]. One study found that rates ranged from 1% in Uganda to 98% of the female population in Somalia [284]. The highest rates of FGM/C are in Somalia [317]. It is estimated that, as of 2011, 500,000 immigrant women and girls in the European Union, Norway, and Switzerland in 2011 had experienced FGM/C [285]. There is some evidence that FGM/C rates are higher in rural areas (compared with urban areas) and in households with lower incomes [318,358]. Furthermore, a family history of FGM/C and Muslim faith are strong predictors [358]. Some countries (e.g., the United Kingdom) have laws in place making FGM/C illegal or traveling to another country for the purpose of performing FGM [284]. In some cases, physicians may be required to report FGM cases, regardless of the woman's/girl's age [284].

The question of whether FGM/C is child abuse remains. Some experts maintain that traditional cultural practices that may be unfamiliar should not necessarily be labeled as abusive [35]. In FGM/C cases, the adults do not explicitly intend to harm or punish the child; rather, the practice promotes cultural identity [35]. Similarly, male circumcision is a cultural ritual that marks a rite of passage for boys, and it is not considered abusive [36]. On the other hand, the literature demonstrates the host of negative short- and long-term repercussions associated with FGM/C, including severe scarring, infections, obstruction of urine and/or menstrual blood, infertility, postpartum hemorrhage, and death [246,318]. Adverse psychologic effects, such as post-traumatic stress disorder, are also possible [246]. If a girl's parents are cognizant of the adverse consequences of the procedure, then is it considered abuse? Can and should culture be utilized to rationalize the use of practices that are shown to have adverse physical and psychologic consequences?

In some countries, such as Spain, FGM/C is a crime of injury [237]. Furthermore, instances in which healthcare professionals are aware of FGM/C or situations where a girl is at risk and do not intervene are considered crimes of omission, punishable by prison. The complex interaction of culture and values and the issue of rights is at the root of FGM/C. If countries implement strict control measures for FGM/C, this can have a strong impact on families. Surveillance and monitoring mechanisms, such as mandatory gynecologic exams for minors, can have negative effects on individuals' rights and dignity [237]. Clearly, the issue is complex and multiple questions arise.

Childhood Conscription

It is difficult to measure the prevalence of child conscription, but UNICEF estimates that more than 105,000 children were recruited to serve in conflict between 2005 and 2022 [359]. 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 Colombia, 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].

Again, the issue of child conscription being defined as a form of child abuse is debated. The definition of childhood and adulthood varies tremendously across different cultures in the international community [40]. Although child soldiers are clearly victims, they may be viewed and treated as perpetrators when they return home [319]. Consequently, it raises questions regarding the extent of protection that should be provided, to whom protection should be provided, and how the rights and autonomy of the individual can be achieved.

Child Labor

Child labor is defined by the International Labour Organization (ILO) as economic labor performed by a child younger than the minimum age specified for the type of work as defined by the nation (generally 15 years in the United States) and that is thus likely to impede education and/or development [188]. It is important to note the difference between child labor and child work. Child work has been defined as activities supervised by an adult that promote the development and growth of the child. Child labor does not benefit the child [41]. Essentially, child work is not considered harmful while child labor is [42].

Child labor is deeply entrenched in cultural and social norms. Early child apprenticeship is common, and parents approve these informal apprenticeships to instill a strong work ethic and, in some cases, to help perpetuate the family business [360]. Ultimately, the goal is to help improve family finances. It is also connected to gender role norms. Girls typically go into domestic work, while boys go into fishing, carpentry, or work on farms [360]. Finally, child labor is deeply rooted in poverty, the infrastructure and political stability of the country, and market forces [41]. It is also entrenched in power structures reinforced by institutional norms that perpetuate a master-servant relationship (i.e., the child laborer is considered property of the owner). The owner/adult often uses corporal punishment or abusive behaviors to instill fear in child laborers [320]. A study of child labor in the Pakistani carpet industry found that 68% of cases were attributed to poverty [289]. Often, the families did not have an adult wage laborer to provide for the family. However, some have argued that this work/labor dichotomy is too simplistic. The delineation of harmful or nonharmful work activities and range of work, and by extension the categorization of certain labor as abuse, remains a debated issue [42]. In general, forced labor and the implication of children in illicit activities are recognized as harmful [188]. However, the health consequences of child labor tend to be ambiguous, particularly if one uses the categories of hazardous and non-hazardous work [321]. For example, eradicating forms of child labor on health-related grounds may cause significant economic hardship to families, especially if the child brings in necessary income. Child labor is not a homogenous phenomenon [322].

It is difficult to estimate the scope of child labor; however, the ILO reports there are 17.2 million children worldwide engaged in paid or unpaid domestic work [248]. It has been predicted that the COVID-19 pandemic will trigger an increase in child labor [323].

A qualitative study explored the lived realities of Ghanaian children trafficked for labor to a fishing village in Lake Volta [249]. This fishing village received international attention for the extensive amount of child torture and death. One rescued child reported [249]:

When we went to the fishing village, we fished day and night, rain or shine. We were asked to dive when the net is trapped. Every day was a fishing day. There was no time set aside for sleeping. We could be called at midnight to go fishing.

Child Trafficking

Child trafficking has also been examined as a possible type of child abuse. The United Nations has defined human trafficking as [43]:

The recruitment, transportation, transfer, harbouring, or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation includes, at a minimum, the exploitation or the prostitution or other forms of sexual exploitation, forced labor or services, slavery or practices similar to slavery, servitude, or the removal of organs.

Obtaining a true understanding of the scope of child trafficking is challenging. Trafficking is a secret activity. Further, there is no universal definition or central database to monitor reports and convictions. Existing institutional corruption can also contribute to its invisibility [324]. Children are sold or kidnapped for a multitude of reasons, including labor, sexual abuse, commercial exploitation, domestic servitude, and illicit adoption [44]. Trafficking of children may be intra-regional (e.g., children from rural areas trafficked to urban areas) or inter-regional (e.g., children trafficked from one country to another) [233]. With the widespread use of Internet technology and social networking sites, chatrooms, and Internet video and voiceover communication, young children and adolescents may be trafficked after having interacted with a perpetrator on the Internet [233]. Migrant children are also at risk of being trafficked. With the migration crisis in Europe and the amount of transience, it is estimated that there are 10,000 unaccounted-for migrant children [290].

According to UNICEF, girls as young as 13 years of age, mainly from Asia and Eastern Europe, are trafficked as "mail-order brides" into Western Europe and North America. Children are also trafficked in West and Central Africa, mainly for domestic work but also for sexual exploitation and commercial labor. Nearly 90% of these trafficked domestic workers are girls. Furthermore, thousands of infants and children from Central and South America are trafficked for adoption in North America and Europe every year [25]. There have also been reports of "baby factories" in West Africa, particularly Nigeria. Young women are trafficked to produce children, and the infants are then sold for adoption. Because of the stigma of infertility among African couples, many adopt illegally [291]. In other instances, the infants are raised to a certain age then trafficked [291]. In the United States, in 2021, the National Center for Missing and Exploited Children reported that they received 17,200 cases of child sex trafficking [361]. Among those who had run away, about 17% had become sex trafficking victims. The causes of child trafficking are rooted in the political, economic, and social instabilities in many countries. In many cases, the act also reflects the gender inequalities inherent in the countries' institutional and cultural norms [44].

Like child abuse, child trafficking results in consequences to the community and the individual, which ultimately undermine child development. For example, children who are trafficked for sexual exploitation experience physical and sexual abuse, resulting in long-term psychologic trauma [324]. Several factors make children particularly vulnerable to sexual trafficking, including the cultural myth that having sex with a virgin can cure human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and the increased popularity of Internet-based child pornography and child sex tourism [25]. According to data from the 2019 National Child Abuse and Neglect Data System, substance use, living in a group home, having a disability, and residing in more rural areas predicted child sex trafficking [362]. If victims of child trafficking are rescued, reintegration back into the community is a challenge given the stigmatization [46]. Clearly there are adverse consequences to human trafficking, and the consequences may be compounded in childhood. However, questions remain regarding the categorization of this act as child abuse.

All of these social issues are complex and multifaceted. Professionals cannot simply take on a completely relativistic stance and justify all cultural practices as unharmful in the name of culture [46]. Simultaneously, it is important for professionals to avoid jumping to the conclusion that a cultural practice is deviant, bizarre, or abusive because it is outside of their own cultural experiences or beliefs.

5. CHILD ABUSE IN THE UNITED STATES AND CANADA

A study of adults in the United States indicated that 14% recalled experiencing physical abuse during childhood [47]. In 2022, there were 4.27 million referrals to CPS agencies in the United States [250]. The majority (70%) of these reports were made by professionals. Girls tended to be victims at a slightly higher rate (8.2 cases per 1,000 children) than boys (7.1 cases per 1,000 children) [250]. The most common perpetrators were parents (76%); specifically, mothers were more often perpetrators compared with fathers (37.4% vs. 24.5%) [250].

As of 2022, 7.7% 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 74.3% of reported cases. This is followed by physical abuse (17%), and sexual abuse (10.6%) [250].

There is some evidence that child abuse is on the decline in the United States. Between 2018 and 2022, the overall child maltreatment rate declined slightly from 9.4 to 7.7 per 1,000 children [250]. Approximately 1,990 children died of abuse and neglect in the United States in 2022 [250].

The accuracy of these statistical findings has been debated, with some attributing the change to a decrease in reporting, different standards for reporting, and changes in federal and state funding that have impacted child maltreatment services. One study hypothesized that the decrease in child sexual abuse cases was related to caseworkers' increased caseload size and inability to follow up adequately [50]. However, this hypothesis was not supported by analysis of data from the National Child Abuse and Neglect Data System. The researchers concluded that child sexual abuse may actually be declining. There has also been a decline in teenage suicide, juvenile delinquency, and teenage pregnancy, all of which are proxy indicators to child abuse [49]. However, it appears that cases of child neglect have increased. Compared to 1990, cases of substantiated neglect were up by 14% in 2003 [49]. The causes of the apparent decline in the prevalence of child physical abuse and the concurrent increase in child neglect have not been determined.

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].

Table 1: CHILD MALTREATMENT RATES BY RACEa

Race

Maltreatment Rate (Per 1,000 Children)

African American

12.1

Native American

14.3

Hispanic

7.0

Non-Hispanic white

6.6

Asian American

1.3

aThe rates reported are for data from 2022.

Source: [250]

Overall, children of color are more likely than White children to be over-represented in child abuse and neglect reports in many Western countries, including the United States, and this has been identified as racial disproportionality [53,251,252,325]. Aboriginal and First Nation children in Australia and Canada and African American children in the United States are over-represented in the child welfare system. For example, among African American children from birth to 18 years of age, the overall prevalence rate of child maltreatment is 21%; for White children, the rate is 11% [252,292]. Some argue that the racial disproportionality exists at the reporting phase, while other data indicate it exists at the substantiation stage [251]. It is estimated that before turning 18 years of age, 37.4% of all children in the United States will have experienced a Child Protective Services investigation; however, the rate is significantly higher for Black children (53%) [297]. Black children are also reported to be three times more likely to have their maltreatment case substantiated and be placed in foster care than White children [363].

Not only are children of color over-represented, there is also indication they may move through the system differently in terms of length of placement, type of placement (e.g., greater use of kinship foster care), and services offered (e.g., less provision of mental health services) [197]. This trend has also been reported in Canada. In a large scale study of Aboriginal and non-Aboriginal families in Canada, Aboriginal children were over-represented at all phases of the child welfare system (first reports leading to investigations, substantiated reports, cases being kept open longer, and more frequent placement in out-of-home care) [54]. In another Canadian study, Aboriginal, Black, and Latino children were 1.77 times more likely to be involved in child abuse investigations compared to White children [55]. A 2019 study found that the rate of investigations for First Nations children was three times higher than that for White counterparts in Ontario, Canada [326]. In the United States, Native American Indian families had lower reunification rates compared with White families; however, Hispanic families have higher reunification rates [327].

Evidence Based Practice Recommendation

According to the American Academy of Child and Adolescent Psychiatry, clinicians should be cognizant that cultural biases might interfere with their clinical judgment and work toward addressing these biases.

https://www.jaacap.org/article/S0890-8567(13)00479-6/fulltext

Last Accessed: August 31, 2024

Level of Evidence: Expert Opinion/Consensus Statement

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].

On the other hand, some professionals, particularly those from the same ethnic group as the family they are working with, may deny or overlook instances of abuse because the family is very much like their own family and upbringing [46]. Professionals who adopt a cultural relativism perspective are hesitant to make judgments, believing that all cultures and their practices are equally valid [198]. It is also possible for practitioners to overlook abusive behaviors in an attempt to be culturally sensitive and avoid being called racist [59].

It is possible that there are more ethnic minority children in the child welfare system because the risk factors they are exposed to are greater. Immigrant and ethnic minority families, for example, are more likely to be poor, unemployed, and live in single-parent homes, all of which are risk factors for child abuse [251]. They may also reside in neighborhoods that are characterized as more socially disorganized. When neighborhoods have lower levels of cohesion and order, families cannot rely on neighbors for assistance, which increases stress [252]. In a study of Aboriginal children in Canada, researchers found that the over-representation of Aboriginal children in the child welfare system was related to poverty, parental use of alcoholism, and lack of housing [54]. In another study using an existing dataset from Texas' National Child Abuse and Neglect Data System, financial challenges, inadequate housing, and substance abuse among caregivers were the strongest predictors to foster care placement among African American children [293]. It has been argued that the experience of colonization and oppression exacerbate these environmental stressors. In Canada, the government attempted to assimilate many Aboriginal tribes by removing young children and placing them in Christian schools, causing devastating upheaval. These schools were in existence for more than 100 years, with the last school closing in 1996 [54]. A focus group study found that complex and interwoven factors of poverty, the breakdown of the traditional community and more supportive networks, and the disintegration of families all contribute to the disproportionate number of racial minority children, particularly African American children, being removed from their homes [57].

Some have argued that, because of this connection, there should be more social services available in these neighborhoods to serve as a buffer against child abuse. In one study, researchers found that African American families who reside in areas close to mental health services had lower rates of child neglect [294]. Closer proximity to substances abuse services or poverty services was not associated with improvements in child abuse or neglect rates.

It has also been suggested that practitioners make more "false positive" identifications of child maltreatment when working with immigrant and ethnic minority families [46]. False positives can result from a lack of familiarity with cultural beliefs, norms, and practices, or it can stem from professional ethnocentrism [46]. For example, some cultural groups have restrictions on hair cutting or bathing that could lead professionals to report child neglect if they are not familiar with the cultural practices [46]. In addition, differing beliefs about sleeping arrangements with young children could lead to allegations of sexual abuse. In a study with mothers from the United States and Guatemala, American mothers tended to move their infants out of their room by 3 to 6 months of age, while Guatemalan infants generally stayed in the parents' room much longer, up to their second year in life [60].

Not only are there disparities in the proportion of minority children entering the child welfare system, but there is evidence that suggests that their length of placement is longer than their White counterparts [197]. African American and Hispanic children are also more likely to be placed with kin compared to White children [197]. Although kin foster placement can be highly beneficial, there has been some evidence that there may be unfair treatment to kinship foster care parents, with these families receiving less financial support or services compared to other foster care parents [197].

In summary, families from racial and ethnic minority groups are often expected to conform to the norms and dominant culture in which they live; yet, many desire to raise their children to appreciate and continue to perpetuate their cultural traditions. Unfortunately, misunderstandings of certain cultural practices can lead to inaccurate reports of child maltreatment.

The questions that arise about the role of culture and child abuse and neglect are complex and multifaceted [59]:

- Can culture be a legitimate explanation for abuse?

- What is considered culturally acceptable and not acceptable as child discipline?

- What are reasonable cultural explanations for behaviors, and when do they override the rights of the child?

These questions do not have simple answers, and the goal of this course is not necessarily to provide quick, easy answers, but rather to raise practitioners' awareness of the range of issues. Furthermore, these explanations should not be viewed as mutually exclusive, but synergistically, contributing to an understanding of this very complicated issue [294].

6. CULTURE, RACE, AND ETHNICITY

CULTURE

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]:

- Human nature: How individuals view human nature

- Humans and nature: How individuals view themselves in relation to nature

- Time: How individuals view the past, present, and future

- Activity: How individuals view "doing" and "being"

- Relational: How individuals view social relations such as family and other social networks

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].

RACE

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].

ETHNICITY

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].

7. IMPACT OF CULTURE ON CHILDREARING

PARENTING STYLES AND SOCIALIZATION

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.

Evidence Based Practice Recommendation

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 AND CORPORAL PUNISHMENT

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].

Effects on Children

Regardless of intent, corporal punishment has effects on the children who experience it, some of which have long-term consequences. Although a clear causal relationship between corporal punishment and the emergence of antisocial or problem behavior in children and adolescents has not been clearly established, there is some evidence of correlation. In a 2023 systematic analysis involving 34 studies that examined for associations between maternal spanking or corporal punishment and outcomes for children younger than 6 years of age, researchers found that in 94% of the studies, there were significant relationships between maternal spanking and corporal punishment practices with a decline in the child's behavior and development, either currently or at a later time [369]. In a large meta-analysis of corporal punishment and outcomes, use of physical discipline techniques was associated with one desirable outcome (immediate compliance), six undesirable outcomes in childhood (moral internalization, aggression, delinquent and antisocial behavior, quality of parent-child relationship, mental health issues, and victim of physical abuse), and four adverse outcomes in adulthood (aggression, criminal or antisocial behavior, mental health issues, and perpetrator of family abuse) [104]. Research has linked spanking and physical abuse victimization, with spanking tied to adverse outcomes [301]. In a quantitative study, researchers found that women who justified husbands hitting their wives were more likely to approve of corporal punishment for children and their children were more likely to have experienced psychologic and physical violence [257]. An analysis concluded that corporal punishment has a relationship with children's initial antisocial behavior and with changes in antisocial behavior [105]. Some speculate that when parents use more aggressive discipline, children are less likely to learn empathy, which can lead to future antisocial and aggressive behaviors [302]. Overall, research findings show that spanking has negative effects on cognitive and social/emotional development that can result in long-term developmental consequences [370].

No evidence was found for differences in the effect of corporal punishment across racial groups. In a related study, parental use of corporal punishment was associated with an increase in children's externalizing behavior problems [106]. It is important to note that in all of these studies there was not proof of cause in the relationships. A study of university students from 19 different countries found that settings in which the rate of corporal punishment experienced by university students is high tend to be settings in which the rate of students assaulting and injuring a dating partner is also high [107].

African American/Caribbean Families

Some studies have found that African American parents use spanking, harsh disciplining methods, and physical punishment more frequently than White Americans, although more research is necessary to compare discipline techniques among ethnic minority populations [91,104,108,371]. In many African American families, discipline is viewed as a teaching method and is believed to be a part of the group's cultural norms [91]. In one survey of African American parenting approaches, participants continually reiterated the necessity and essentialness of discipline in childrearing [91]. They maintained that disciplining constitutes proper childrearing; however, many acknowledged that physical punishment as disciplining is not aligned with the dominant (White) values of childrearing. Endorsement of physical punishment was not believed to be child abuse among this group of participants [91]. This is consistent with Deater-Deckard, Dodge, Bates, and Pettit's argument that African Americans' use of corporal punishment is a cultural norm and is implemented with control used to socialize children versus corporal punishment used in an emotional and impulsive manner [211]. The key is that corporal punishment is not utilized impulsively, stemming from anger and frustration. However, this was not supported by a 2011 study with 453 White, Latino, and African American couples with children 3 to 7 years of age, which did not find that African American parents used corporal punishment with less emotionality or impulsivity compared to Latino and White parents [212].

In a qualitative study of 18 African American women 18 to 49 years of age, researchers explored the use of corporal punishment and its perceived effectiveness [213]. These women indicated that corporal punishment was an expression of love, with the aim of teaching respect and promoting the child's safety, and was also considered crucial for teaching life lessons necessary for survival. It was generally used as a last resort when other disciplining tactics were not effective. In addition, within the context of African Americans' experiences with oppression and racism, corporal punishment is seen as a way of teaching children to survive in a racist environment [332]. In one study, Black parents in focus groups indicated that the changing social climate is one in which they are judged if they discipline their children in public [372]. They stated that someone will immediately interfere with their disciplining efforts. Therefore, they feel that they have to avoid disciplining their children in public or even in private, due to fears of outside (e.g., school) involvement.

Studies of African American families and disciplining patterns do not all make linear, definitive conclusions that harsh physical punishment is the sole disciplinary tactic used. In a survey study of 176 low-income African American, Latino American, and White mothers, researchers found that preferred parenting strategies were more similar than different among the three groups [109]. Mothers from all three ethnic groups preferred praising their children as their first disciplinary strategy, followed by ignoring a behavior and spanking. Overall, the mothers did not favor using harsh and punitive childrearing methods. Other studies examining the disciplinary patterns and practices of African American parents found that African American parents preferred to use rational means, such as discussions or lecturing, to physical discipline [87,110].

Metaparenting involves a systematic type of parental thinking (involving evaluation, reflection, and anticipation) to help guide children back to positive behaviors. In one study, African Americans reported more metaparenting compared with White/European American parents [303]. In addition, African Americans and Mexican Americans tended to use reflection more.

Some experts propose that families who experience high levels of stress will use more punitive and harsh disciplinary strategies, in part because childrearing and caregiving are perceived to be arduous [111]. Due to multiple stressors that commonly occur in African American families, including single parenthood, racism/oppression, and socioeconomic factors, it is possible that this group is more prone to using harsh discipline. In a longitudinal study of 139 African American mothers, researchers found that perceived discrimination predicted health and depressive symptoms, which then decreased parenting practices characterized by high levels of involvement, vigilance, warmth, and nurturance [112].

Harsh disciplining has been documented in Caribbean cultures as well. Flogging is a common disciplinary strategy used for misbehaving Jamaican children [113]. Caribbean immigrant families in the United States are over-represented in child abuse cases, and many of these parents do not understand why their parental authority is being undermined when the cases are brought forth [113]. Some have speculated that the use of harsh discipline stems from the oppressive legacy of slavery, during which time cruelties and violence were rampant [113].

It has been speculated that African cultural beliefs about respect for elders and the role of education in training children into responsible adults facilitate the acceptability of corporal punishment [114]. In some African countries, such as Botswana and Kenya, caning is a common disciplinary practice even within the school setting [114,214]. In Kenya, caning was banned in 2001, but many teachers still used it in the school setting in order to gain immediate compliance. In one study, teachers reported they felt that students misbehaved more since the ban [214].

Certain disciplining tactics are intertwined with cultural beliefs about childrearing and the symbolism attached to certain disciplining methods. In West African families, for example, suppositories of ginger root and/or pepper have also been used as forms of punishment, particularly to reduce sexually promiscuous behaviors [35]. For example, a girl who is perceived to be sexually promiscuous may be punished by inserting suppositories in her vagina, which then can result in pain and various infections [35].

Hispanic Families

Some studies have shown that Hispanic families use less corporal disciplining tactics. In focus groups, Latino participants indicated that individuals their country of origin were generally more socially accepting in their attitudes toward the use of harsh punishment and disciplining tactics than in the United States [372]. In a qualitative study with Latino mothers, many stated that they prefer not to spank but rather to first use discussion and reasoning [373]. Some have also maintained that familismo, the cultural value of the emphasis of the family and sacrificing for the family, is believed to influence this tendency [209]. Because of the collective values of family support and collectivism, there is less need for the use of physical punishments like spanking [258]. Caregivers' attitudes of machismo correlated with experiences of moderate-to-severe forms of physical punishment in a quantitative study with 736 racially/ethnically diverse undergraduate students [333].

Hispanic cultures are unique, and there are tremendous variations within the general Hispanic group. Acculturation also plays a role in these variations. In a large-scale survey study comparing foreign-born and native-born Hispanic parents, foreign-born parents were less likely to employ corporal punishment compared to their native-born Hispanic counterparts [258]. Using language as a variable to measure acculturation, Hispanic participants who answered written questions in English were less likely to respond favorably to physical punishment compared with those who responded in Spanish [332].

Native American Families

Children are considered gifts from the Creator, and Native Americans believe that parents are the guardians of this gift and must teach their children respect and to honor their elders and tribal community [215]. In Native American cultures, the extended family unit is very involved in childrearing and disciplining. As oral historians and torchbearers of cultural traditions and wisdom, grandparents and other elders in Native American families often help with the socialization of children [216]. Furthermore, elders are viewed as the oral historians, who can help pass on traditions and wisdom through storytelling [216]. In one study, Native American parents who received more support from each other and others were less likely to use corporal punishment than those with little or no support [259].

In many Native American cultures, parents and extended family adhere to a belief in noninterference when disciplining and childrearing. This is based on a deep belief in fate and maintenance of harmony and peace within the family. Young children, such as infants and toddlers, are rarely disciplined because it is believed they are unable to discern right and wrong; older siblings often use scare tactics to divert younger children's attention from engaging in misbehavior [115]. Children's misbehaviors are not ignored; rather, the goal of discipline is to teach the lessons of life, using stories, and modeling [215]. In qualitative interviews with Native American families, many parents identified the role of providing structure, rules, and guidelines to teach prosocial behaviors. They avoided using physical punishment for disciplining, instead implementing or removing rewards or privileges [374]. As children get older, particularly during adolescence, same-sex siblings and cousins employ physical disciplining or directed verbal sarcasm. However, adult caretakers then "fend off" these "hurtful" words or behaviors. By "fending off" the discipline, caretakers demonstrate that the offending child is still loved [115]. This influential role of extended family members is supported by one study that indicated family, rather than peer group, was most influential in deterring the use of illicit substances in Native American adolescents [116]. It appears the boundaries between peers and family members are more nebulous in Native American families.

Asian/Asian American Families

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. Some Asian cultures (e.g., Chinese, Korean) also use psychological control such as guilt induction, love withdrawal, and shaming to instill moral values and to teach children from right and wrong [375].

Maintaining harmony within interpersonal relationships and respecting one's elders are paramount in Asian hierarchal family structures [77]. The Korean proverb mae ga yak ida (translated as "spare the rod and spoil the child") is commonly adhered to by many Korean families [126]. Another common Korean term is sarangeei mae, which translates to "whip of love," implying that parents whip their children out of love [118]. In general, Asian immigrants tend to believe only very severe physical punishment resulting in obvious injuries (e.g., fractures) constitutes child abuse [126].

Acculturation level can affect beliefs about disciplining. In a study with first-generation Korean Americans, parents viewed disciplinary tactics such as spanking and withholding affection as consistent with the Korean culture, and using time-outs, giving and removing privileges, and the use of sticker charts as American styles of discipline [218]. However, the longer the parents lived in the United States, the more likely they were to incorporate American disciplining techniques [218].

8. CULTURE AND PERCEPTION OF CHILD ABUSE

Defining child abuse and child maltreatment is a complex matter. Hutchinson notes [120]:

Both the sociocultural and social labeling perspectives challenge the sovereign role of professionals in providing the definition of child maltreatment. The sociocultural approach points to the varying expectations of caregivers across cultures and over time and cautions that the definitions of child maltreatment need to reflect cultural norms.

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].

Abuse that involves physical aggression is also frequently viewed as abuse. In a study involving participants from the United States, Ghana, and Nigeria, the vast majority (95% to 100%) agreed that behaviors that involved a physical component and resulted in physical injury and pain (e.g., punching, kicking, burning a child with a hot object) were child abuse [260]. However, there is less agreement regarding the categorization of emotional and psychologic abuse and neglect. It becomes clear that definitions of child abuse are influenced by culture, race, and ethnicity. In one study of perceptions of child abuse among White, Chinese, and Filipino Americans, findings showed there were racial and ethnic differences in definitions [121]. In this study, White participants were more likely to rate behaviors as forms of abuse, particularly physical and emotional maltreatment, and to identify severe abuse, while the Chinese American and Filipino American participants were more concerned about parental sexual values and parental drug abuse and were more likely to view these behaviors as abusive. These differences may be attributed in part to the importance of parents' socialization of children in Asian cultures.

In a 2017 study in Beijing, participants tended to feel that the criteria for child abuse should focus on intent to harm and the severity of the harm being inflicted. They did not believe that biologic parents could abuse a child, only strangers [300]. In another survey study of 401 residents in public housing in Singapore, while more severe forms of physical punishment and physical neglect were considered to be child abuse, minor forms of physical punishment and emotional abuse were more likely to be viewed as acceptable [122]. Similarly, in a telephone survey of 1,001 Chinese participants residing in Hong Kong, the majority (80%) identified physical abuse as child abuse but often did not categorize psychologic abuse and neglect as child abuse [123]. By far, younger and more educated participants were more likely to view a behavior as abusive [123].

In a study of Korean mothers, participants generally felt that child abuse was a result of a parent's love toward a child [124]. As in other studies, education played a role. Mothers with higher levels of education tended to have more negative attitudes toward child abuse. Korean immigrant mothers who felt they had experienced discrimination as immigrants were more likely to approve of the use of corporal punishment [124].

A study with urban Native Americans found that the participants had very strong views regarding the classification of child neglect [220]. Overall, Native American parents rated the majority of the vignettes as violating standards of appropriate child care. In this study, the most serious style of neglect was identified as "unwholesome circumstances," such as parental substance abuse or parents' sexual behaviors and value systems. Emotional abuse is also controversial. In one study, many Chinese parents would not agree that parental control strategies that rely on psychological manipulation (e.g., withdrawing affection and love to help train children to improve school performance) would constitute as emotional abuse; those from Western societies were more likely to identify such parental behaviors as abuse [376].

It is also important to examine cultural differences in professionals' perceptions and attitudes toward child abuse, as these differences can affect reporting patterns. In a study of 80 Korean American pastors, participants stated that they were familiar with the child abuse reporting laws and felt that these laws were important to protect children [125]. However, when presented with various vignettes describing different types of maltreatment, the majority reported that they would recommend the family for pastoral counseling rather than reporting the incidents to child protective agencies. The majority (83%) also felt that the child abuse laws were at odds with childrearing practices in Korean culture.

In a survey of health visitors in England, participants were asked to rank various behaviors according to the extent of which they could be considered child neglect [127]. The top signs of child abuse included violence against the child, the family deliberately excluding the child, the child left unsupervised or a young child attending to other young children, a home environment marked by criticism, signs of human or animal excrement, an unsafe environment, a child who was not well nourished, and unmet medical needs.

9. ECOLOGIC FACTORS

Some experts have advocated for the consideration of the range of social and psychologic dimensions that contribute to social problems, including child abuse and neglect. Ecologic theory is a conceptual framework used to examine a social problem within a multi-level context: the individual, family, neighborhood, and community contexts, and sociopolitical and sociocultural structures [128]. Garbarino, who has applied the ecologic model to child abuse, argues [129]:

The overarching hypothesis generated by an ecologic analysis of child abuse is that destructive organism-environment adaptions are "permitted" by ideologic support for the use of physical force and by naturally occurring and socially engineered support systems that inadequately monitor deviance and fail to encourage effective parenting.

Ecologic theory organizes the various factors that may affect child maltreatment into four levels: macrosystem, exosystem, microsystem, and ontologic levels. It emphasizes that there is no single pathway that precipitates child abuse and neglect. The strength of ecologic theory is that it has the ability to examine many variables, exploring both their direct and indirect influences on child abuse and neglect [221].

MACROSYSTEM

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]:

- 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

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].

EXOSYSTEM

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?

MICROSYSTEM

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].

ONTOLOGIC LEVEL

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.

10. CULTURALLY RELEVANT THEORETICAL FRAMEWORKS

Cultural relevance or sensitivity is defined as behaviors, attitudes, and policies that are aligned or harmonious with a group's belief and value systems and that ultimately enable agencies, communities, practitioners, policymakers, and researchers to work effectively in a cross-cultural situation [136]. Cultural sensitivity entails the "ethic or moral imperative to value and respect the beliefs, norms, and practices of the people to be served" [137]. Culturally competent practice theories take into account how the social environment intersects at all levels [138]. Overall, cultural competence, awareness, and sensitivity are fluid processes. Each time a new patient enters a relationship with a provider, it is important to set a respectful tone and use the encounter as an opportunity to learn about his or her culture [262]. In this section, several theories will be highlighted and very briefly reviewed. It is not meant to be an exhaustive listing of all culturally relevant theories for practitioners when dealing with child abuse in ethnic minority and immigrant families. The application of these theories for child abuse assessments and interventions will be discussed in depth later in this course.

It can be argued that ecologic theory may be utilized to guide interventions when working with child abuse in immigrant families because cultural competency involves a multisystemic approach [139].

LEININGER'S CULTURE CARE THEORY

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].

AIRHIHENBUWA'S PEN-3 MODEL

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].

Cultural Identity

The cultural identity dimension is based on three components: persons, extended family, and neighborhoods and their roles in health education and interventions. As part of this category, healthcare professionals are asked to evaluate how individuals, extended family networks, and the community may be supportive or resistant toward the health education and intervention activities.

Relationships and Expectations

The concept of relationships and expectations explores the perceptions of the targeted audience for the health education and intervention programs. Identifying factors that enable and nurture health behaviors is the main task in this dimension.

Cultural Empowerment

Cultural empowerment entails examining the positive, existential, and negative components of the culture combined to empower individuals to adopt healthy behaviors. Positive behaviors involve beliefs or activities that assist in lessening the problem. Existential (neutral) behaviors are practices with no adverse health consequence. Finally, negative behaviors are beliefs and practices that are harmful and should be altered [143].

KLEINMAN'S CULTURAL EXPLANATORY MODEL

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].

Lay/Popular Sector

In many cultures, the lay/popular sector is typically the first avenue to seek help when individuals experience a problem. This sector is comprised of friends, family members, and the community. The information available in this section is typically founded on general knowledge and wisdom. Self-treatment and family care generally fall under this heading [146].

Folk Sector

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].

Professional Sector

The professional sector is closely aligned with Western approaches to health and illness. This sector involves professionals and healthcare providers who are considered "legitimate" in Western society [146].

STRENGTHS-BASED PERSPECTIVE

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 individual is viewed as the expert.

- The individual is the facilitator of change.

- The hierarchal power relationship between the individual and the practitioner should be minimized.

- Individuals should be provided the opportunity to reach self-identified goals and obtain new skills.

- Healthcare professionals should work with community stakeholders to change existing resource allocations.

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]:

- 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

11. CHILD ABUSE ASSESSMENT AND INTERVENTIONS

ASSESSMENT

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]:

- Do you know why you are here today?

- Can you tell me what happened?

- How did it begin?

- What happened next?

- Where did this happen?

- Have you been hurt lately?

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]:

- What do you believe is working well for you now?

- What difficulties are you experiencing now?

- What in your life gives you strength or a sense of meaning?

- What role does your family play in your life?

- How have you dealt with this experience in the past?

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]:

- Why did you immigrate?

- Are you a legal immigrant?

- Who was left behind? Who plans to emigrate?

- What regrets or disappointments resulted from the immigration?

- How are you coping and adjusting to your new environment? Are some having more difficulties than others? If so, who?

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].

Identifying Harmful Practices in an Ethnically Diverse Population

It is simply not feasible to ask practitioners to be informed and familiar with every cultural practice and nuance. However, it is also unethical for practitioners to explain away certain practices in the name of culture. So, how then do practitioners determine the best course of action? A model has been created to assist practitioners in conceptualizing cultural practices along a continuum [35]. On one end of the continuum there are beneficial practices, of which the practitioner should promote the continuation. On the opposite end of the continuum lie harmful practices that must cease and should be prevented by the practitioner [35]. At the center of the continuum, there are neutral practices. These are behaviors that practitioners should learn more about in order to strengthen their cultural competency. There are also potentially harmful behaviors, which are not fully understood or recognized as abusive. In these cases, practitioners should engage in a dialogue with the family to evaluate the potential negative outcomes. It may then be necessary for the practitioner to educate the family. This framework is aligned with the PEN-3 model.

INTERVENTIONS AND BEST PRACTICES

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]:

- Snacks: When children are hungry, thirsty, or tired, they are less likely to talk or remember details. However, snacks should not be used as rewards for responses provided.

- Familiar ethnic objects: Familiar pictures, books, magazines, and/or toys will reassure immigrant parents and children and make them feel more welcomed.

- Non-uniformed officials: If the police must be involved in the interviews or sessions, they should be dressed in plain clothes to avoid scaring the family/child.

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]:

- Develop a knowledge base about the demographics, values, norms, and cultural practices of ethnic minority groups. Case discussions about real life cases involving immigrant families can facilitate practitioners learning about new cultures. As part of practitioners' professional development, cultural experts may be invited to discuss real life cases of immigrant families. Of course, families should always be contacted to ask for permission, ensuring that confidentiality will be protected.

- Build relationships with stakeholders in ethnic minority communities. For example, practitioners can represent an organization or agency by attending events where immigrants and community leaders are present to begin developing relationships and alliances.

- Facilitate opportunities for practitioners and organizations to discuss stereotypes and generalizations regarding ethnic and cultural groups. For example, discussion during training workshops may reveal that practitioners hold preconceived notions that African American men are absent or marginally present in their families' lives. It is important to consider the possibility of stereotypes becoming self-fulfilling prophecy. In this example, if child welfare agencies ignore African American men as decision-makers, the men may feel as if they do not contribute in a positive manner to society. Such stereotypes should be identified and challenged.

- Form alliances with diverse communities. Many ethnic minority communities have "hidden" resources, in the sense that organizations are not familiar with the informal support networks. For example, in the African American community, churches, kinship groups, self-help groups, and voluntary associations are rich resources.

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

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.

PROFESSIONAL DEVELOPMENT

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].

Cultural Knowledge

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]. Many of these cultural practices are commonly used in Africa, Latin America, the Middle East, Southern China, and Southeast Asia, and they continue to be employed by immigrants in new homelands [383]. 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; 383].

In Hispanic culture, there is a cultural practice (hincar) whereby children are disciplined by kneeling on uncooked rice [347]. There is some controversy regarding whether this should be considered abusive. In Namibia, there is a common cultural practice called child fosterage, whereby a child is raised by an extended family member, but the child may also have to perform household duties [348].

Three questions may help practitioners determine whether a behavior is abusive or culturally specific [351]:

- Are the children and family members/ caregivers from an ethnic group?

- Does the group have such a tradition?

- Was the family member/caregiver motivated by the tradition when he or she acted?

Healthcare providers and other professionals are increasingly becoming educated about these practices in order to understand the health beliefs that surround these practices; therefore, they may be less likely to construe the marks as evidence of abuse.

Immigration Knowledge

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].

It is also important for practitioners to understand how immigration status affects the lives of their patients or clients. For example, immigration status may affect individuals' ability to access services and benefits [154,163]. When providing care for undocumented immigrants, practitioners may need to think "outside the box" to help families access informal community networks versus the traditional public benefits [154]. Immigrant groups may also be concerned regarding potential ramifications of interacting with government agencies [163]. Therefore, a basic, high-level knowledge of local and federal laws related to immigration and language access is necessary [163]. In reality, practitioners cannot know all aspects of immigration and how it affects service delivery within the context of child welfare and protection. Therefore, cross-collaboration with service delivery experts such as advocacy groups and immigration specialists is vital [226].

Law and Ethics

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].

Training Methods

The PEN-3 model can frame training for practitioners. Using the three dimensions of the model, practitioners may be encouraged to identify specific cultural values and norms and how they support or enable health education and interventions for child abuse, parent education, and childrearing. When practitioners project their own cultural values onto the patient or client, labeling "foreign" cultures as "bad" or "good," this can cause misunderstandings [165].

12. PRACTITIONER STRESS WHEN WORKING WITH CHILD ABUSE CASES

Practitioners who work on child maltreatment cases can experience a tremendous amount of stress caused by the complex problems associated with child abuse and neglect cases. The organizational characteristics of child welfare agencies can also contribute to the stress experienced by practitioners. Child welfare agencies often operate on limited resources in terms of staffing and funding, which can affect services rendered. Practitioners attempting to access services may feel frustrated by seemingly overwhelming bureaucracies, which can contribute to feelings of helplessness. Mandated reporters may feel torn between the notions of family privacy and child protection [166].

Practitioners who enter the helping professions often do so because they deeply subscribe to the notion of contributing to society. Some beliefs and expectations held when child protection professionals begin their careers include [167]:

- "Family problems can be solved."

- "I can help, and families will want my help."

- "I should always understand and be empathic."

- "I will always be safe because I am offering services to those in need."

- "My work will receive support by others (e.g., colleagues, family and friends, society in general)."

Obviously, these expectations are not always met. Child protection workers who enter the field are enthusiastic at first but can end up feeling discouraged when outcomes do not meet their expectations [168].

Ongoing and continual exposure to stressors related to child abuse cases can lead to practitioners experiencing burnout, secondary trauma, and other professional issues [167]. The following section will focus on the emotional reactions practitioners may experience when working with child abuse/maltreatment cases. There will also be a discussion of supervision issues related to child abuse cases and a review of the importance of engaging in self-care strategies.

TRANSFERENCE AND COUNTERTRANSFERENCE ISSUES

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.

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].

SECONDARY TRAUMATIZATION

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]:

- Frame of reference: The need for a stable perspective to understand the world and one's experience

- Trust: The need to depend on others and their ability to care

- Esteem: The need to be validated by others

- Safety: The need to feel safe and secure

- Independence: The need to feel in control over one's own behaviors

- Power: The need to exert control over others

- Intimacy: The need to feel connected to others

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.

BURNOUT

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.

CONSIDERATIONS FOR CLINICAL SUPERVISION: BEST PRACTICES

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]:

- Psychodynamic perspective: The goal is to assist practitioners to identify anxieties underlying parental aggression and maintain professional boundaries. The supervisor explores how the practitioner might employ defense mechanisms in the therapeutic encounter.

- Managerial perspective: The goal is for the practitioner to identify challenging concerns regarding the case and to implement goals and plans to help the victim. Outcomes are reviewed and evaluated by the clinical supervisor.

- Critical perspective: The issue of imbalance of power is at the heart of this approach to supervision. The supervisor helps the practitioner to equalize the power relations between families and the agency and to develop a partnership with families.

- Behavior perspective: The focus of super-vision is to reduce stress for the practitioner. Because stress can trigger burnout and attrition, the supervisor helps the practitioner to create positive emotional associations within the organization.

- Systemic perspective: The supervisor helps the practitioner to understand the complexities of the workplace in order to understand how different systems levels can affect child protection practices.

- Humanistic perspective: The clinical supervisor helps the practitioner to understand their feelings and emotions and how they attribute meaning to their experiences through their emotions. Practitioners are encouraged to be reflective and to identify common thoughts and emotions.

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].

13. CONCLUSION

For child welfare practices to be culturally meaningful for racially and ethnically diverse families, helping professionals in all disciplines must have a clear understanding of the multifaceted nature of oppression, marginalization, and differential access to resources and how these factors affect child abuse and maltreatment [58]. The first step in this process is for diverse groups and stakeholders to identify and name the oppression and racism affecting child welfare [58]. Second, professionals must acknowledge that best practice guidelines are often influenced by Western, Eurocentric beliefs and may not be the best course of action for racial and ethnic minority families. The third step involves restoration, "whereby dominant and culturally specific peoples take mutual responsibility for child welfare services and its outcomes" [58]. The last step is relating, which consists of all parties (e.g., families, communities, professionals, other stakeholders) recognizing reconciliation as a continual journey that can only work if everyone is committed to the process [58].

Works Cited

1. Frey WH. Less than Half of U.S. Children Under 15 Are White, Census Shows. Available at https://www.brookings.edu/research/less-than-half-of-us-children-under-15-are-white-census-shows. Last accessed August 26, 2024.

2. Williams LS, Alvarez SD, Hauck KS. My name is not María: young Latinas seeking home in the heartland. Soc Probl. 2002;49(4):563-584.

3. Vespa J, Medina L, Armstrong DM. Demographic Turning Points for the United States: Population Projections for 2020 to 2060 Population Estimates and Projections Current Population Reports. Available at https://www.census.gov/content/dam/Census/library/publications/2020/demo/p25-1144.pdf. Last accessed August 26, 2024.

4. Vecchione M, Caprara G, Schoen H, Castro JL, Schwartz SH. The role of personal values and basic traits in perceptions of the consequences of immigration: a three-nation study. Br J Psychol. 2012;103(3):359-377.

5. Miller AB, Cross T. Ethnicity in child maltreatment research: a replication of Behl et al.'s content analysis. Child Maltreat. 2006;11(1):16-26.

6. Saal CD. A historical and present-day view of the position of the child in family and society. J Comp Fam Stud. 1982;13(2):119-132.

7. Routh DK, Patton L, Sanfilippo MD. Child advocacy and clinical child psychology. J Clin Child Psychol. 1991;20(1):7-10.

8. ChildStats. America's Children: Key National Indicators of Well-Being, 2023. Available at https://www.childstats.gov/americaschildren/demo.asp. Last accessed August 27, 2024.

9. Tomison AM. A history of child protection back to the future? The maltreatment of children has occurred through history. Family Matters. 2001;60:46-55.

10. Gelles RJ. Family violence. In: Hampton RL, Gullotta TP, Adams GR (eds). Family Violence: Prevention and Treatment: Issues in Children's and Families' Lives. Newbury Park, CA: Sage Publications; 1993: 1-24.

11. Johnson JM. Horror stories and the construction of child abuse. In: Best J (ed). Images of Issues: Typifying Contemporary Social Problems. New York, NY: Aldine De Gruyter; 1989: 5-19.

12. Children's Defense Fund. The State of America's Children, 2020: Child Population. Available at https://www.childrensdefense.org/wp-content/uploads/2023/08/The-State-Of-Americas-Children-2020.pdf. Last accessed August 27, 2024.

13. Murray KO, Gesiriech S. A Brief Legislative History of the Child Welfare System. Available at http://www.pewtrusts.org/~/media/legacy/uploadedfiles/wwwpewtrustsorg/reports/foster_care_reform/LegislativeHistory2004pdf.pdf. Last accessed August 27, 2024.

14. Child Welfare Information Gateway. Permanency. Available at https://www.childwelfare.gov/topics/permanency/?top=116. Last accessed August 27, 2024.

15. Allen ML. Crafting a federal legislative framework for child welfare reform. Am J Orthopsychiatry. 1991;61(4):610-623.

16. Golden O. The federal response to child abuse and neglect. Am Psychol. 2000;55(9):1050-1053.

17. Child Welfare Information Gateway. About CAPTA: A Legislative History. Available at https://www.childwelfare.gov/pubs/factsheets/about. Last accessed August 27, 2024.

18. Jones BJ. The Indian Child Welfare Act: the need for a separate law. Compleat Lawyer. 1995;12(4):18-23.

19. Child Welfare Information Gateway. Indian Child Welfare Act. https://www.childwelfare.gov/topics/tribal-child-welfare/indian-child-welfare-act/?top=1390. Last accessed August 27, 2024.

20. Child Welfare Information Gateway. Definitions of Child Abuse and Neglect. Available at https://www.childwelfare.gov/resources/definitions-child-abuse-and-neglect/. Last accessed August 27, 2024.

21. Winton MA, Mara BA. Child Abuse and Neglect: Multidisciplinary Approaches. Boston, MA: Allyn and Bacon; 2000.

22. McDonald KC. Child abuse: approach and management. Am Fam Physician. 2007;75(2):221-228.

23. Child Welfare Information Gateway. Child Welfare Practice to Address Racial Disproportionality and Disparity. Available at https://www.childwelfare.gov/pubs/issue-briefs/racial-disproportionality. Last accessed August 27, 2024.

24. Butchart A, Phinney Harvey A, Mian M, Fürniss T. Preventing Child Maltreatment: A Guide to Taking Action and Generating Evidence. Geneva: World Health Organization; 2006.

25. UNICEF. Facts on Children: Child Protection from Violence, Exploitation, and Abuse. Available at https://data.unicef.org/wp-content/uploads/2015/12/ChildProtection_from_violence_exploitation_abuse_46.pdf . Last accessed August 27, 2024.

26. UNICEF. Violence Against Children. Available at https://www.unicef.org/protection/violence-against-children. Last accessed August 27, 2024.

27. Lai D. Sex ratio at birth and infant mortality rate in China: an empirical study. Soc Indic Res. 2005;70(3):313-326.

28. Australian Institute of Health and Welfare. Child Protection Australia, 2013–2014. Available at https://www.aihw.gov.au/reports/child-protection/child-protection-australia-2013-14/contents/table-of-contents. Last accessed August 27, 2024.

29. Nelson LR. Discourses and themes in adoption and child welfare policies and practices in the U.S. throughout the 19th and 20th centuries. Adoption Quarterly. 2020;23(4):312-330.

30. Stephenson R, Sheikhattari P, Assasi N, et al. Child maltreatment among school children in the Kurdistan Province, Iran. Child Abuse Negl. 2006;30(3):231-245.

31. Jewkes R, Levin J, Mbananga N, Bradshaw D. Rape of girls in South Africa. Lancet. 2002;359(9303):319-320.

32. Forrester D, Harwin J. Monitoring children's rights globally: can child abuse be measured internationally? Child Abuse Review. 2000;9(6):427-438.

33. Lidchi VG. Cross cultural transferability in child protection: challenges and opportunities. Child Abuse Review. 2003;12(4):238-250.

34. World Health Organization. Fact Sheet No. 241: Female Genital Mutilation. Available at http://www.who.int/en/news-room/fact-sheets/detail/female-genital-mutilation. Last accessed August 27, 2024.

35. Koramoa J, Lynch MA, Kinnair D. A continuum of child-rearing: responding to traditional practices. Child Abuse Review. 2002;11(6):415-421.

36. Taylor V. Female genital mutilation: cultural practice or child abuse? Paediatr Nurs. 2003;15(1):31-33.

37. Children's Rights. The Child Welfare System: Fact Sheet. Available at https://www.childrensrights.org/wp-content/uploads/2023/01/CR-The-Child-Welfare-System-2023-Fact-Sheet.pdf. Last accessed August 27, 2024.

38. Bayer CP, Klasen F, Adam H. Association of trauma and PTSD symptoms with openness to reconciliation and feelings of revenge among former Ugandan and Congolese child soldiers. JAMA. 2007;298(5):555-559.

39. Anwoa J, Rembea S, Odeku K. Conscription and use of child soldiers in armed conflicts. Journal of Psychology in Africa. 2009;19(1):75-82.

40. Breen C. When is a child not a child? Child soldiers in international law. Human Rights Review. 2007;8(2):71-103.

41. Otis J, Pasztor EM, McFadden EJ. Child labor: a forgotten focus on child welfare. Child Welfare. 2001;80(5):611-622.

42. McKechnie J, Hobbs S. Child labour: a global phenomenon? Child Abuse Review. 1999;8(2):87-90.

43. United Nations. Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention Against Transnational Organized Crime. Available at https://www.ohchr.org/EN/ProfessionalInterest/Pages/ProtocolTraffickingInPersons.aspx. Last accessed on August 27, 2024.

44. Rafferty Y. Children for sale: child trafficking in Southeast Asia. Child Abuse Review. 2007;16(6):401-422.

45. National Conference of State Legislatures. Disproportionality and Race Equity in Child Welfare. Available at https://www.ncsl.org/human-services/disproportionality-and-race-equity-in-child-welfare. Last accessed August 27, 2024.

46. Fontes LA. Child Abuse and Culture: Working with Diverse Families. New York, NY: The Guilford Press; 2005.

47. Moore DW. One in seven Americans victim of child abuse. Gallup Poll Monthly. 1994;5:18-22.

48. Dettlaff AJ, Rycraft JR. Factors contributing to disproportionality in the child welfare system: views from the legal community. Soc Work. 2010;55(3):213-224.

49. Finkelhor D, Jones L. Why have child maltreatment and child victimization declined? J Soc Issues. 2006;62(4):685-716.

50. Almeida J, Cohen AP, Subramanian SV, Molnar BE. Are increased worker caseloads in state child protective service agencies a potential explanation for the decline in child sexual abuse? A multilevel analysis. Child Abuse Negl. 2008;32(3):367-375.

51. National Conference of State Legislatures. Child Welfare Enacted Legislation. Available at https://www.ncsl.org/human-services/child-welfare-legislation-database. Last accessed August 27, 2024.

52. Elliott K, Urquiza A. Ethnicity, culture, and child maltreatment. J Soc Issues. 2006;62(4):787-809.

53. Dettlaffa AJ, Rivauxb SL, Baumannc DJ, Fluked JD, Rycrafte JR, James J. Disentangling substantiation: the influence of race, income, and risk on the substantiation decision in child welfare. Children and Youth Services Review. 2011;33(9):1630-1637.

54. Blackstock C, Trocmé N, Bennett M. Child maltreatment investigations among aboriginal and non-aboriginal families in Canada. Violence Against Women. 2004;10(8):901-916.

55. Lavergne C, Dufour S, Trocmé N, Larrivée MC. Visible minority, Aboriginal, and Caucasian children being investigated by Canadian Protective Services. Child Welfare. 2008;87(2):59-76.

56. Derezotes DM, Poertner J, Testa MF (eds). Race Matters in Child Welfare: The Overrepresentation of African American Children in the System. Washington, DC: Child Welfare League of America; 2004.

57. Dettlaff AJ, Rycraft JR. Deconstructing disproportionality: views from multiple community stakeholders. Child Welfare. 2008;87(2):37-58.

58. Cross TL. Disproportionality in child welfare. Child Welfare. 2008;87(2):11-20.

59. Irfan S, Cowburn M. Disciplining, chastisement, and physical child abuse: perceptions and attitudes of the British Pakistani community. Journal of Muslim Minority Affairs. 2004;24(1):89-98.

60. Morelli GA, Oppenheim D, Rogoff B, Goldsmith D. Cultural variation in infants' sleeping arrangements: questions of independence. Dev Psychol. 1992;28(4):604-613.

61. Gordon MM. Assimilation in American Life. New York, NY: Oxford University Press; 1964.

62. Lum D. Culturally Competent Practice: A Framework for Understanding Diverse Groups and Justice Issues. Pacific Grove, CA: Brooks/Cole; 1999.

63. Hodge JL, Struckmann DK, Trost LD. Cultural Bases of Racism and Group Oppression: An Examination of Traditional "Western" Concepts, Values, and Institutional Structures which Support Racism, Sexism, and Elitism. Berkeley, CA: Two Riders Press; 1975.

64. Sue DW, Sue D. Counseling the Culturally Different: Theory and Practice. New York, NY: John Wiley & Sons; 1990.

65. Jackson AP, Meadows FB Jr. Getting to the bottom to understand the top. J Couns Dev. 1991;70(1):72-76.

66. Kluckhohn F, Strodtbeck F. Variations in Value Orientations. Evanston, IL: Row, Peterson; 1961.

67. Choi H. Understanding adolescent depression in ethnocultural context. ANS Adv Nurs Sci. 2002;25(2):71-85.

68. DeBruyn L, Chino M, Serna P, Fullerton-Gleason L. Child maltreatment in American Indian and Alaska Native communities: integrating culture, history, and public health for intervention and prevention. Child Maltreat. 2001;6(2):89-102.

69. Fernando S. Mental Health, Race, and Culture. 2nd ed. New York, NY: Palgrave Macmillan; 2002.

70. Rubio M, Williams DR. The social dimension of race. In: Beech BM, Goodman M (eds). Race and Research: Perspectives on Minority Participation in Health Studies. Washington, DC: American Public Health Association; 2004: 1-25.

71. Korbin JE. Culture and child maltreatment: cultural competence and beyond. Child Abuse Negl. 2002;26(6);637-644.

72. Culley L. Transcending transculturalism? Race, ethnicity, and health-care. Nurs Inq. 2006;13(2):144-153.

73. Baumrind D. Current patterns of parental authority. Developmental Psychology Monograph. 1971;4:1-103.

74. Lieber E, Fung H, Leung PW. Chinese child-rearing beliefs: key dimensions and contributions to the development of culture-appropriate assessment. Asian J Soc Psychol. 2006;9(2):140-147.

75. Chao RK. Beyond parental control and authoritarian parenting style: understanding Chinese parenting through the cultural notion of training. Child Dev. 1994;65:1111-1119.

76. Cheung CS, McBride-Chang C. Relations of perceived maternal parenting style, practices, and learning motivation to academic competence in Chinese children. Merrill-Palmer Quarterly. 2008;54(1).

77. Chung DK. Asian cultural commonalities: a comparison with mainstream American culture. In: Furuto S, Biswas R, Chung DK, Murase K, Ross-Sheriff F (eds). Social Work Practice with Asian-Americans. Newbury Park, CA: Sage Publications; 1992: 27-44.

78. Chen X, Wu H, Chen H, Wang L, Cen G. Parenting practices and aggressive behavior in Chinese children. Parent Sci Pract. 2001;1(3):159-184.

79. Martínez I, García JF. Internalization of values and self-esteem among Brazilian teenagers from authoritative, indulgent, authoritarian, and neglectful homes. Adolescence. 2008;43(169):13-29.

80. Zuniga ME. Families with Latino roots. In: Lynch EW, Hanson MJ (eds). Developing Cross-Cultural Competence: A Guide to Working with Children and Their Families. 2nd ed. Baltimore, MD: Paul H. Brooks Publishing, Co.; 1998: 209-250.

81. Triandis HC. Individualism-collectivism and personality. J Pers. 2001;69:907-924.

82. Glass J, Owen J. Latino fathers: the relationship among machismo, acculturation, ethnic identity, and paternal involvement. Psychology of Men and Masculinity. 2010;11(4):251-261.

83. Deyoung Y, Zigler EF. Machismo in two cultures: relation to punitive child-rearing practices. Am J Orthopsychiatry. 1994;64(3): 386-395.

84. Ferrari AM. The impact of culture upon child rearing practices and definitions of maltreatment. Child Abuse Negl. 2002;26(8): 793-813.

85. Dixon SV, Graber JA, Brooks-Gunn J. The roles of respect for parental authority and parenting practices in parent-child conflict among African American, Latino, and European American families. J Fam Psychol. 2008;22(1):1-10.

86. Guilamo-Ramos V, Dittus P, Jaccard J, Johansson M, Bouris A, Acosta N. Parenting practices among Dominican and Puerto Rican mothers. Soc Work. 2007;52(1):17-30.

87. Bradley CR. Child rearing in African American families: a study of the disciplinary practices of African American parents.J Multicult Couns Devel. 1998;26(4):273-281.

88. Willis W. Families with African American roots. In: Lynch EW, Hanson MJ (eds). Developing Cross-Cultural Competence: A Guide for Working with Children and Their Families. 2nd ed. Baltimore, MD: Paul H. Brookes Publishing Co.; 1998: 165-202.

89. Carter-Black J. The myth of "the tangle of pathology:" resilience strategies employed by middle-class African American families. Journal of Family Social Work. 2001;6(4):75-100.

90. Hill RB. Understanding black family functioning: a holistic perspective. J Comp Fam Stud. 1998;29(1):15-25.

91. Mosby L, Rawls AW, Meehan AJ, Mays E, Pettinari CJ. Troubles in interracial talk about discipline: an examination of African American child rearing narratives. J Comp Fam Stud. 1999;30(3):489-521.

92. Yearwood EL. "Growing up" children: current child-rearing practices among immigrant Jamaican families. J Child Adolesc Psychiatr Nurs. 2001;14(1):7-16.

93. Hart SN, Pavlovic Z. Children's rights in education: an historical perspective. School Psych Rev. 1991;20(3):345-358.

94. Holden GW. Perspectives on the effects of corporal punishment: comment on Gershoff (2002). Psychol Bull. 2002;128(4):590-595.

95. Hilarski C. Corporal punishment: another form of school violence. J Evid Based Soc Work. 2004;1(2-3):59-75.

96. Schenck ER, Lyman RD, Bodin SD. Ethical beliefs, attitudes, and professional practices of psychologists regarding parental use of corporal punishment: a survey. Child Serv Soc Policy Res Pract. 2000;3(1):23-38.

97. Kazdin AE, Benjet C. Spanking children: evidence and issues. Curr Dir Psychol Sci. 2003;12(3):99-103.

98. Douglas EM. Familial violence socialization in childhood and later life approval of corporal punishment: a cross-cultural perspective. Am J Orthopsychiatry. 2006;76(1):23-30.

99. Ashton V. The relationship between attitudes toward corporal punishment and the perception and reporting of child maltreatment. Child Abuse Negl. 2001;25(3):389-399.

100. Flynn CP. Regional differences in attitudes toward corporal punishment. J Marriage Fam. 1994;56(2):314-324.

101. Straus MA. Beating the Devil Out of Them: Corporal Punishment in American Families and Its Effects on Children. New Brunswick, NJ: Transaction Publishers; 2001.

102. Giles-Sims J, Straus MA, Sugarman DB. Child, maternal, and family characteristics associated with spanking. Fam Relat. 1995;44:170-176.

103. Ellison CG, Bradshaw M. Religious beliefs, sociopolitical ideology, and attitudes toward corporal punishment. J Fam Issues. 2009;30(3):320-340.

104. Gershoff ET. Corporal punishment by parents and associated child behaviors and experiences: a meta-analytic and theoretical review. Psychol Bull. 2002;128(4):539-579.

105. Grogan-Kaylor A. Corporal punishment and the growth trajectory of children's antisocial behavior. Child Maltreat. 2005;10(3): 283-292.

106. Grogen-Kaylor A. Relationship of corporal punishment and antisocial behavior by neighborhood. Arch Pediatr Adolesc Med. 2005;159:938-942.

107. Douglas EM, Straus MA. Assault and injury of dating partners by university students in 19 countries and its relation to corporal punishment experienced as a child. Eur J Criminol. 2006;3(3):293-318.

108. Day RD, Peterson GW, McCracken C. Predicting spanking of younger and older children by mothers and fathers. J Marriage Fam. 1998;60:79-94.

109. Medora NP, Wilson S, Larson JH. Attitudes toward parenting strategies, potential for child abuse, and parental satisfaction of ethnically diverse low-income U.S. mothers. J Soc Psychol. 2001;141(3):335-348.

110. Horn IB, Cheng TL, Joseph J. Discipline in the African American community: the impact of socioeconomic status on beliefs and practices. Pediatrics. 2004;113(5):1236-1241.

111. Dietz TL. Disciplining children: characteristics associated with the use of corporal punishment. Child Abuse Negl. 2000;24(12):1529-1542.

112. Brody GH, Chen YF, Kogan SM, Murry VM, Logan P, Luo Z. Linking perceived discrimination to longitudinal changes in African American mothers' parenting practices. J Marriage Fam. 2008;70(2):319-331.

113. Smith DE, Mosby G. Jamaican child-rearing practices: the role of corporal punishment. Adolescence. 2003;38(150):369-381.

114. Tafa EM. Corporal punishment: the brutal face of Botswana's authoritarian schools. Educational Review. 2002;54(1):17-26.

115. White JM, Godfrey J, Moccasin BI. American Indian fathering in the Dakota nation: use of Akicita as a fatherhood standard. Fathering. 2006;4(1):49-69.

116. Swaim RC, Oetting ER, Thurman PJ, Beauvais F, Edwards RW. American Indian adolescent drug use and socialization characteristics. J Cross Cult Psychol. 1993;24(1):53-70.

117. Segal UA. Exploring child abuse among Vietnamese refugees. J Multicult Soc Work. 2000;8(3/4):159-191.

118. Hahm HC, Guterman NB. The emerging problem of physical child abuse in South Korea. Child Maltreat. 2001;6(2):169-179.

119. Chan JS, Elliott JM, Chow Y, Thomas J. Does professional and public opinion in child abuse differ? An issue of cross-cultural policy implementation. Child Abuse Review. 2002;11(6):359-379.

120. Hutchinson E. Child maltreatment: can it be defined? In: Barth R, Duerr Berrick J, Gilbert N (eds). Child Welfare Review. Vol 1. New York, NY: Columbia University Press; 1994: 3-27.

121. Gong SM. Child Abuse and Neglect: Perceptions Held by Asian Americans. [Unpublished doctoral dissertation]. Boston University; 1985.

122. Elliott JM, Tong CK, Tan PM. Attitudes of the Singapore public to actions suggesting child abuse. Child Abuse Negl. 1997;21(5):445-464.

123. Lau JTF, Liu JLY, Yu A, Wong CK. Conceptualization, reporting and underreporting of child abuse in Hong Kong. Child Abuse Negl. 1999;23(11):1159-1174.

124. Park MS. The factors of child physical abuse in Korean immigrant families. Child Abuse Negl. 2001;25(7):945-958.

125. Rhee S, Chang J, Youn S. Korean American pastors' perceptions and attitudes toward child abuse. Journal of Ethnic & Cultural Diversity in Social Work. 2003;12(1):27-46.

126. Rhee S, Chang J. Child Abuse: Characteristics and Patterns among Cambodian, Chinese, Korean, and Vietnamese American Families. An Empirically-Based Curriculum. Berkeley, CA: University of California, California Social Work Education Center; 2006.

127. Lewin D, Herron H. Signs, symptoms, and risk factors: health visitors' perspectives of child neglect. Child Abuse Review. 2007;16(2):93-107.

128. Bronfenbrenner U. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press; 1979.

129. Garbarino J. The human ecology of child maltreatment: a conceptual model for research. J Marriage Fam. 1977;39(4):721-731.

130. Little L, Kaufman Kantor G. Using ecological theory to understand intimate partner violence and child maltreatment. J Community Health Nurs. 2002;19(3):133-145.

131. Sidebotham P. An ecological approach to child abuse: a creative use of scientific models in research and practice. Child Abuse Review. 2001;10(2):97-112.

132. Coulton CJ, Korbin JE, Su M. Neighborhoods and child maltreatment: a multi-level study. Child Abuse Negl. 1999;23(11):1019-1040.

133. Zielinski DS, Bradshaw CP. Ecological influences on the sequelae of child maltreatment: a review of the literature. Child Maltreat. 2006;11(1):49-62.

134. Freisthler B, Merritt DH, LaScala EA. Understanding the ecology of child maltreatment: a review of the literature and directions for future research. Child Maltreat. 2006;11(3):263-280.

135. Baumrind D. Child Maltreatment and Optimal Caregiving in Social Contexts. New York, NY: Garland Publishing; 1995.

136. Cross T, Bazron B, Dennis K, Isaacs M. Towards A Culturally Competent System of Care. Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center; 1989.

137. Flaskerud JH. Cultural competence: what is it? Issues Ment Health Nurs. 2007;28(1):121-123.

138. Morelli PT, Fong R, Oliveira J. Culturally competent substance abuse treatment for Asian/Pacific Islander women. J Hum Behav Soc Environ. 2001;3(3/4):263-280.

139. McPhatter AR, Ganaway TL. Beyond the rhetoric: strategies for implementing culturally effective practice with children, families, and communities. Child Welfare. 2003;82(2):103-124.

140. Tourville C, Ingalls K. The living tree of nursing theories. Nurs Forum. 2003;38(3):21-30.

141. McCance TV, McKenna HP, Boore JRP. Caring: theoretical perspectives of relevance to nursing. J Adv Nurs. 1999;30(6):1388-1395.

142. Leininger M. Future directions in transcultural nursing in the 21st century. Int Nurs Rev. 1997;44(1):19-23.

143. Airhihenbuwa CO. Health and Culture: Beyond the Western Paradigm. Thousand Oaks, CA: Sage; 1995.

144. Airhihenbuwa CO, Webster JD. Culture and African contexts of HIV/AIDS prevention, care, and support. SAHARA J. 2004;1(1):4-13.

145. Kleinman A. Patients and Healers in the Context of Culture. Berkley, CA: University of California Press; 1981.

146. Kleinman A, Eisenberg L, Good B. Clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978;88:251-258.

147. Saleebey D. The Strengths Perspective in Social Work Practice. White Plains, NY: Longman; 1997.

148. Browne C, Mills C. Theoretical frameworks: ecological model, strengths perspective, and empowerment theory. In: Fong R, Furuto S (eds). Culturally Competent Practice: Skills, Interventions, and Evaluations. Boston, MA: Allyn and Bacon; 2001: 10-32.

149. Ryan W. Blaming the Victim. New York, NY: Vintage Books; 1976.

150. Fong R, Boyd C, Browne C. The Gandhi technique: a biculturalization approach for empowering Asian and Pacific Islander families.J Multicult Soc Work. 1999;7:95-110.

151. McPhatter AR. Cultural competence in child welfare: what is it? How do we achieve it? What happens without it? Child Welfare. 1997;76(1):255-278.

152. Westbrooks KL, Starks SH. Strengths perspective inherent in cultural empowerment: a tool for assessment with African American individuals and families. In: Fong R, Furuto S (eds). Culturally Competent Practice: Skills, Interventions, and Evaluations. Boston, MA: Allyn and Bacon; 2001: 101-131.

153. Negroni-Rodriguez LK, Morales J. Individual and family assessment skills with Latino/Hispanic Americans. In: Fong R, Furuto S (eds). Culturally Competent Practice: Skills, Interventions, and Evaluations. Boston, MA: Allyn and Bacon; 2001: 132-146.

154. Earner I. Immigrant families and public child welfare: barriers to services and approaches for change. Child Welfare. 2007;86(4): 63-91.

155. Woodroffe A, Spencer M. Culturally and ethnically diverse communities: building blocks for working relationships. Child Welfare. 2003;82(2):169-183.

156. Pine BA, Drachman D. Effective child welfare practice with immigrant and refugee children and their families. Child Welfare. 2005;84(5):537-562.

157. Gray SS, Nybell LM. Issues in African-American family preservation. Child Welfare. 1990;69(6):513-523.

158. Singh NN, McKay JD, Singh AN. The need for cultural brokers in mental health services. J Child Fam Stud. 1999;8(1):1-10.

159. Buchwald D, Panwala S, Hooton TM. Use of traditional health practices by Southeast Asian refugees in a primary care clinic. The Western Journal of Medicine. 1992;156(5):507-512.

160. Nuttall P, Flores FC. Hmong healing practices used for common childhood illnesses. Pediatr Nurs. 1997;23(3):247-254.

161. Taylor L, Willies-Jacobo LJ. The culturally competent pediatrician: respecting ethnicity in your practice. Contemp Pediatr. 2003;20(6):83-105.

162. Davis RE. Cultural health care or child abuse? The Southeast Asian practice of cao gio. J Am Acad Nurse Pract. 2000;12(3):89-95.

163. Chahine Z, Van Straaten J. Serving immigrant families and children in New York City's child welfare system. Child Welfare. 2005;84(5):713-723.

164. Indell R, Vidal de Haymes M, Francisco D. A culturally responsive practice model for urban Indian child welfare services.Child Welfare. 2003;82(2):201-217.

165. Bates L, Baird D, Johnson DJ, Lee RE, Luster T, Rehagen C. Sudanese refugee youth in foster care: the "lost boys" in America.Child Welfare. 2005;84(5):631-648.

166. Nelson-Gardell D, Harris D. Childhood abuse history, secondary traumatic stress, and child welfare workers. Child Welfare. 2003;82(1):5-26.

167. Azar ST. Preventing burnout in professionals and paraprofessionals who work with child abuse and neglect cases: a cognitive behavioral approach to supervision. J Clin Psychol. 2000;56(5):643-663.

168. Dane B. Child welfare workers: an innovative approach for interacting with secondary trauma. J Soc Work Educ. 2000;36(1):27-38.

169. Pearlman LA, Saakvitne KW. Trauma and the Therapist: Counter-Transference and Vicarious Traumatisation in Psychotherapy with Incest Survivors. London: WW Norton and Co. Ltd.; 1995.

170. Kaufmann CM. Countertransference Hostage Syndrome in the Treatment of Trauma Survivors. Paper presented at the annual meeting of the International Society for Traumatic Stress Studies. Los Angeles, CA. September 1992.

171. Harper K, Steadman J. Therapeutic boundary issues in working with childhood sexual abuse survivors. Am J Psychother. 2003;57(1):64-79.

172. Etherington K. Supervising counselors who work with survivors of childhood sexual abuse. Couns Psychol Q. 2000;13(4):377-389.

173. Walker M. Supervising practitioners working with survivors of childhood abuse: counter-transference, secondary traumatization, and terror. Psychodynamic Practice. 2004;10(2):173-193.

174. Figley CR. Compassion fatigue: toward a new understanding of the costs of caring. In: Stamm BH (ed). Secondary Traumatic Stress: Self-care Issues for Clinicians, Researchers, and Educators. 2nd ed. Lutherville, MD: Sidran Press; 1999: 3-28.

175. Cunningham M. Impact of trauma work on social work clinicians: empirical findings. Soc Work. 2003;48(4):451-459.

176. Patrick PKS. Stress-induced challenges to the counselor role: burnout, compassion fatigue, and vicarious traumatization. In: Patrick PKS (ed). Contemporary Issues in Counseling. Boston, MA: Allyn and Bacon; 2007: 210-250.

177. Kilfedder CJ, Power KG, Wells TJ. Burnout in psychiatric nursing. J Adv Nurs. 2001;34(3):383-396.

178. Rushton A, Nathan, J. The supervision of child protection work. Br J Soc Work. 1996;26:357-374.

179. Davis G, Cockayne D. Peer support in child protection practice. Br J Community Nurs. 2005;19(10):18-21.

180. Scott L. The nature and structure of supervision in health visiting with victims of child sexual abuse. J Adv Nurs. 1999;29(3):754-763.

181. Lister PG, Crisp BR. Clinical supervision in child protection for community nurses. Child Abuse Review. 2005;14(1):57-72.

182. Bell H, Kulkarni S, Dalton L. Organizational prevention of vicarious trauma. Fam Soc. 2003;84(4):463-481.

183. de Boer C, Coady N. Good helping relationships in child welfare: learning from stories of success. Child Fam Soc Work. 2007;12(1):32-42.

184. Aten JD, Madson MB, Rice A, Chamberlain AK. Postdisaster supervisor strategies for promoting supervisee self-care: lessons learned from Hurricane Katrina. Training and Education in Professional Psychology. 2008;2(2):75-82.

185. Coster JS, Schwebel M. Well-functioning in professional psychologists. Prof Psychol Res Pr. 1997;28(1):5-13.

186. Twemlow SW. Interviewing violent patients. Bull Menninger Clin. 2001;65(4):503-521.

187. Gonzalez D, Mirabal AB, McCall JD. Child Abuse and Neglect. Available at https://www.ncbi.nlm.nih.gov/books/NBK459146. Last accessed August 27, 2024.

188. International Labour Organization. Child Labour Statistics. Available at https://www.ilo.org/international-programme-elimination-child-labour-ipec/child-labour-statistics. Last accessed August 27, 2024.

189. Humphreys J, Ramsey AM. Nursing care of abused children. In: Campbell J, Humphreys J (eds). Nursing Care of Survivors of Family Violence. St. Louis, MO: Mosby; 1993: 211-247.

190. Leder R, Knight JR, Emans SJ. Sexual abuse: when to suspect it, how to assess for it. Contemporary Pediatrics. 2001;18:59-74.

191. Bullock K. Child abuse: the physician's role in alleviating a growing problem. Am Fam Physician. 2000;61(10):2977-2980.

192. Bala N. An historical perspective on family violence and child abuse: comment on Moloney et al., Allegations of family violence. J Fam Stud. 2008;14(2/3):271-278.

193. Myers JEB. A short history of child protection in America. Fam Law Q. 2008;42(3):449-463.

194. Hogan PT, Sau-Fong S. Minority children and the child welfare system: an historical perspective. Soc Work. 1988;33(6):493-498.

195. Batalova J, Hanna M, Levesque, C. Frequently Requested Statistics on Immigrants and Immigration in the United States. Available at https://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states#Children. Last accessed August 27, 2024.

196. Murray LK, Nguyen A, Cohen JA. Child sexual abuse. Child and Adolescent Psychiatric Clinics of North America. 2014;23(2):321-337.

197. Azar ST, Goff PA. Can science help Solomon? Child maltreatment cases and the potential for racial and ethnic bias in decision making. St Johns Law Rev. 2007;81:533-573.

198. Chand A. Every child matters? A critical review of child welfare reforms in the context of minority ethnic children and families. Child Abuse Review. 2008;17:6-22.

199. Stokes J, Schmidt G. Race, poverty and child protection decision making. Br J Soc Work. 2011;41(6):1105-1121.

200. Zou X, Tam KP, Morris MW, et al. Culture as common sense: perceived consensus versus personal beliefs as mechanisms of cultural influence. J Pers Soc Psychol. 2009;97(4):579-597.

201. Nesteruk O, Marks LD. Parenting in immigration: experiences of mothers and fathers from Eastern Europe raising children in the United States. J Comp Fam Stud. 2011;42(6):809-825.

202. Raval VV, Martini TS. "Making the child understand:" socialization of emotion in urban India. J Fam Psychol. 2011;25(6):847-856.

203. Cruz RA, King KM, Widaman KF, et al. Cultural influences on positive father involvement in two-parent Mexican-origin families.J Fam Psychol. 2011;25(5):731-740.

204. Glass J, Owen J. Latino fathers: the relationship among machismo, acculturation, ethnic identity, and paternal involvement. Psychol Men Masc. 2010;11:251-261.

205. West-Olatunji C, Sanders T, Mehta S, Behar-Horenstein L. Parenting practices among low-income parents/guardians of academically successful fifth grade African American children. Multicultural Perspectives. 2010;12(3):138-144.

206. Deater-Deckard K, Dodge KA. Externalizing behavior problems and discipline revisited: nonlinear effects and variation by culture, context, and gender. Psychological Inquiry. 1997;8(3):161-175.

207. Burchinal M, Skinner D, Reznick JS. European American and African American mothers' beliefs about parenting and disciplining infants: a mixed-method analysis. Parent Sci Pract. 2010;10(2):79-96.

208. Hicks-Pass S. Corporal punishment in America today: spare the rod, spoil the child? A systematic review of the literature. Best Practice in Mental Health. 2009;5(2):71-88.

209. Berlin LJ, Ispa JM, Fine MA, et al. Correlates and consequences of spanking and verbal punishment for low-income White, African American and Mexican American toddlers. Child Dev. 2009;80(5):1403-1420.

210. Oas PT. Current status on corporal punishment with children: what the literature says. Am J Fam Ther. 2010;38(5):413-420.

211. Deater-Deckard K, Dodge KA, Bates JE, Pettit GS. Physical discipline among African American and European American mothers: links to children's externalizing behaviors. Dev Psychol. 1996;32:1065-1072.

212. Lorber MF, O'Leary SG, Slep AMS. An initial evaluation of the role of emotion and impulsivity in explaining racial/ethnic differences in the use of corporal punishment. Dev Psychol. 2011;47(6):1744-1749.

213. Taylor CA, Hamvas L, Paris R. Perceived instrumentality and normativeness of corporal punishment use among Black mothers. Fam Relat. 2011;60(1):60-72.

214. Mweru M. Why are Kenyan teachers still using corporal punishment eight years after a ban on corporal punishment? Child Abuse Rev. 2010;19(4):248-258.

215. Bigfoot DS, Funderburk BW. Honoring children, making relatives: the cultural translation of parent-child interaction therapy for American Indian and Alaska Native families. J Psychoactive Drugs. 2011;43(4):309-318.

216. Cross SL, Day AG, Byers LG. American Indian grand families: a qualitative study conducted with grandmothers and grandfathers who provide sole care for their grandchildren. J Cross Cult Gerontol. 2010;25(4):371-383.

217. Larsen S, Kim-Goh M, Nguyen TD. Asian American immigrant families and child abuse: cultural considerations. Journal of Systemic Therapies. 2008;27(1):16-29.

218. Kim E, Hong S. First-generation Korean-American parents' perceptions of discipline. J Prof Nurs. 2007;23(1):60-68.

219. Fontes LA, Plummer C. Cultural issues in disclosures of child sexual abuse. J Child Sex Abus. 2010;19(5):491-518.

220. Evans-Campbell T. Perceptions of child neglect among urban American Indian/Alaska native parents. Child Welf. 2008;7(3):115-142.

221. Afifi TO. Child abuse and adolescent parenting: developing a theoretical model from an ecological perspective. J Aggress Maltreat Trauma. 2007;14(3):89-105.

222. Hong JS, Lee NY, Park HJ, Faller KC. Child maltreatment in South Korea: an ecological analysis. Child Youth Serv Rev. 2011;33(7):1058-1066.

223. MacArthur J, Rawana EP, Brownlee K. Implementation of a strength-based approach in the practice of child and youth care. Relational Child & Youth Care Practice. 2011;24(3):6-16.

224. Fontes LA. Interviewing immigrant children for suspected child maltreatment. J Psychiatry Law. 2010;38(3):283-305.

225. Dumbrill GC. Your policies, our children: messages from refugee parents to child welfare workers and policymakers. Child Welf. 2009;88(3):145-168.

226. Dettlaff AJ, de Haymes MV, Velazquez S, et al. Emerging issues at the intersection of immigration and child welfare: results from a transnational research and policy forum. Child Welf. 2009;88(2):47-67.

227. Friedrich M, Leiper R. Countertransference reactions in the therapeutic work with incestuous sexual abusers. J Child Sex Abus. 2006;15(1):51-68.

228. McCann IL, Pearlman LA. Psychological Trauma and the Adult Survivor: Theory, Therapy and Transformation. New York, NY: Brunner/Mazel; 1990.

229. Tehrani N. The cost of caring: the impact of secondary trauma on assumptions, values and beliefs. Couns Psychol Q. 2007;20(4):325-339.

230. Newell JM, MacNeil GA. Professional burnout, vicarious trauma, secondary traumatic stress, and compassion fatigue: a review of theoretical terms, risk factors, and preventive methods for clinicians and researchers. Best Practice in Mental Health. 2010;6(2):57-68.

231. Richards KC, Campenni CE, Muse-Burke JL. Self-care and well-being in mental health professionals: the mediating effects of self-awareness and mindfulness. Journal of Mental Health Counseling. 2010;32(3):247-264.

232. Schure MB, Christopher J, Christopher S. Mind-body medicine and the art of self-care: teaching mindfulness to counseling students through yoga, meditation, and qigong. J Couns Dev. 2008;86:47-56.

233. Larsen JJ. The trafficking of children in the Asia-Pacific. Trends and Issues in Crime and Criminal Justice. 2011;415:1-6.

234. Cole J, Sprang G. Sex trafficking of minors in metropolitan, micropolitan, and rural communities. Child Abuse Negl. 2015;40:113-123.

235. Sossou MA, Yogtiba JA. Abuse of children in West Africa: implications for social work education and practice. Br J Soc Work. 2009;39(7):1218-1234.

236. Kaime T. "Vernacularising" the convention on the rights of the child: rights and culture as analytic tools. International Journal of Children's Rights. 2010;18(4):637-653.

237. Kaplan-Marcusán A, Rio NF, Moreno-Navarro J, et al. Female genital mutilation: perceptions of healthcare professionals and the perspective of the migrant families. BMC Public Health. 2010;10:193-201.

238. Klasen F, Oettingen G, Daniels J, Adam H. Multiple trauma and mental health in former Ugandan child soldiers. J Trauma Stress. 2010;23(5):573-581.

239. UNICEF. How COVID-19 is Changing the World. Available at https://data.unicef.org/resources/how-covid-19-is-changing-the-world-a-statistical-perspective. Last accessed August 27, 2024.

240. Child Welfare Information Gateway. Preventing Sex Trafficking and Strengthening Families Act of 2014. Available at https://www.childwelfare.gov/resources/preventing-sex-trafficking-and-strengthening-families-act-pl-113-183/. Last accessed August 27, 2024.

241. Goldstein AO. Is exposure to secondhand smoke child abuse? Yes. Ann Fam Med. 2015;13(2):103-104.

242. Almond D, Edlund L, Milligan K. Son preference and the persistence of culture: evidence from South and East Asian immigrants to Canada. Popul Dev Rev. 2014;39(1):75-95.

243. Akhter T. A case study of female foeticide in Jammu and Kashmir. EXCEL International Journal of Multidisciplinary Management Studies. 2013;3(6):188-194.

244. Wood CJ. International crisis: female genital mutilation. American Diplomacy. 2015;3:17-28.

245. Stewart BT, Hatcher KW, Sengupta A, Burg RV. Cleft-related infanticide and abandonment: a systematic review of the academic and lay literature. Cleft Palate-Craniofacial Journal. 2018;55(1):98-104.

246. Reisel D, Creighton SM. Long-term health consequences of female genital mutilation (FGM). Maturitas. 2015;80(1):48-51.

247. De Silva H. The use of child soldiers in war with special reference to Sri Lanka. Paediatr Int Child Health. 2013;33(4):273-280.

248. International Labour Organization. Child Labour and Domestic Work. Available at https://www.ilo.org/international-programme-elimination-child-labour-ipec/sectors-and-topics/child-labour-and-domestic-work. Last accessed August 27, 2024.

249. Hamenoo ES, Sottie CA. Stories from Lake Volta: the lived experiences of trafficked children in Ghana. Child Abuse Negl. 2015;40:103-112.

250. U.S. Department of Health and Human Services. Child Maltreatment 2022. Available at https://www.acf.hhs.gov/cb/data-research/child-maltreatment. Last accessed August 27, 2024.

251. Krase KS. Differences in racially disproportionate reporting of child maltreatment across report sources. J Public Child Welf. 2013;7(4):351-369.

252. Nadan Y, Spilsbury JC, Korbin JE. Culture and context in understanding child maltreatment: contributions of intersectionality and neighborhood-based research. Child Abuse Negl. 2015;41:40-48.

253. Frewen AR, Chew E, Carter M, et al. A cross-cultural exploration of parental involvement and child-rearing beliefs in Asian cultures. Early Years (Stoke-on-Trent). 2015;35(1):36-49.

254. Ng FFY, Pomerantz EM, Deng C. Why are Chinese mothers more controlling than American mothers? "My child is my report card." Child Dev. 2014;85(1):355-369.

255. Kim L, Knudson-Martin C, Tuttle A. Toward relationship-directed parenting: an example of North American born second-generation Korean-American mothers and their partners. Fam Process. 2014;53(1):55-66.

256. Adkison-Bradley C, Terpstra J, Dormitorio BP. Child discipline in African American families: a study of patterns and context. Fam J. 2014;22(2):198-205.

257. Lansford JE, Deater-Deckard K, Bornstein MH, et al. Attitudes justifying domestic violence predict endorsement of corporal punishment and physical and psychological aggression towards children: a study in 25 low-middle-income countries. J Pediatr. 2014;164(5):1208-1213.

258. Lee SJ, Altschul I. Spanking of young children: do immigrant and U.S.-born Hispanic parents differ? J Interpers Violence. 2015;30(3):475-498.

259. Limb GE, White C, Holgate M. Strengthening American Indian couples' relationship quality to improve parenting. J Hum Behav Soc Environ. 2014;24(2):92-104.

260. Fakunmoju SB, Bammeke FO, Antwi Bosiakoh T, et al. Perception and determination of child maltreatment: exploratory comparisons across three countries. Child Youth Serv Rev. 2013;35(9):1418-1430.

261. Bartlett JD, Raskin M, Kotake C, et al. An ecological analysis of infant neglect by adolescent mothers. Child Abuse Negl. 2014;38(4):723-734.

262. Waite R, Nardi D, Killian P. Examination of cultural knowledge and provider sensitivity in nurse managed health centers. J Cult Divers. 2014;21(2):74-79.

263. Christensen S. Enhancing nurses' ability to care with the culture of incarceration. J Transcult Nurs. 2014;25(3):223-231.

264. Iwelunmor J, Newsome V, Airhihenbuwa CO. Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethn Health. 2014;19(1):20-46.

265. Abdullah S. An Islamic perspective for strengths-based social work with Muslim clients. J Soc Work Pract. 2015;29(2):163-172.

266. Pecora PJ, Chahine Z, Graham JC. Safety and risk assessment frameworks: overview and implications for child maltreatment fatalities. Child Welfare. 2013;92(2):143-160.

267. Kodner C, Wetherton A. Diagnosis and management of physical abuse in children. Am Fam Physician. 2013;88(10):669-675.

268. Barnett JE, Molzon CH. Clinical supervision of psychotherapy: essential ethics issues for supervisors and supervisees. J Clin Psychol. 2014;70(11):1051-1061.

269. Damashek A, Bard D, Hecht D. Provider cultural competency, client satisfaction, and engagement in home-based programs to treat child abuse and neglect. Child Maltreat. 2012;17(1):56-66.

270. Hatton-Bowers H, Pecora PJ, Johnson K, et al. Evaluating training to promote critical thinking skills for determining children's safety.J Soc Work Educ. 2015;51(2):298-314.

271. Draijer N, Van Zon P. Transference-focused psychotherapy with former child soldiers: meeting the murderous self. J Trauma Dissociation. 2013;14(2):170-183.

272. Capri C, Kruger LM, Tomlinson M. Child sexual abuse workers' emotional experiences of working therapeutically in the Western Cape, South Africa. Child Adolesc Social Work J. 2013;30(5):365-382.

273. Lee E, Esaki N, Kim J, et al. Organizational climate and burnout among home visitors: testing mediating effects of empowerment. Child Youth Serv Rev. 2013;35(4):594-602.

274. Cookson J, Sloan G, Dafters R, et al. Provision of clinical supervision for staff working in mental health services. Mental Health Pract. 2014;17(7):29-34.

275. Miehls D. Neuroscience insights that inform clinical supervision. Smith Coll Stud Soc Work. 2014;84(2/3):367-384.

276. Salloum A, Kondrat DC, Johnco C, Olson KR. The role of self-care on compassion satisfaction, burnout and secondary trauma among child welfare workers. Child Youth Serv Rev. 2015;49:54-61.

277. Devenish-Meares P. Call to compassionate self-care: introducing self-compassion into the workplace treatment process. Journal of Spirituality in Mental Health. 2015;17(1):75-87.

278. Karpetis G. Clinical supervision in child protection practice: a review of the literature. Trauma, Violence, & Abuse. 2021;22(4):689-701.

279. Child Welfare Information Gateway. Major Federal Legislation Concerned with Child Protection, Child Welfare, and Adoption. Available at https://www.childwelfare.gov/pubPDFs/majorfedlegis.pdf. Last accessed August 27, 2024.

280. Child Welfare Information Gateway. About CAPTA: A Legislative History. Available at https://www.childwelfare.gov/pubPDFs/about.pdf. Last accessed August 27, 2024.

281. Alhassan AR, Anyinzaam-Adolipore JN. Female genital mutilation in Ghana: prevalence and socioeconomic predictors. BioMed Research International. 2021;6675579:1-6.

282. United Nations Children's Fund. Hidden in Plain Sight: A Statistical Analysis of Violence Against Children. New York, NY: UNICEF; 2014.

283. Ji K, Finkelhor D. A meta-analysis of child physical abuse prevalence in China. Child Abuse Negl. 2015;43:61-72.

284. Malik Y, Rowland A, Gerry F, Phipps FM. Mandatory reporting of female genital mutilation in children in the UK. British Journal of Midwifery. 2018;26(6):377-386.

285. Van Baelen L, Ortensi L, Leye E. Estimates of first-generation women and girls with female genital mutilation in the European Union, Norway and Switzerland. Eur J Contracept Reprod Health Care. 2016;21(6):474-482.

286. Kelly JTD, Branham L, Decker MR. Abducted children and youth in Lord's Resistance Army in northeastern Democratic Republic of the Congo (DRC): mechanisms of indoctrination and control. Conflict & Health. 2016;10:1-11.

287. Hurtado M, Iranzo Dosdad Á, Gómez Hernández S. The relationship between human trafficking and child recruitment in the Colombian armed conflict. Third World Quarterly. 2018;39(5):941-958.

288. Van Leeuwen JM, Miller L, Zamir M, et al. Community reintegrating former child soldiers in Northern Uganda: a qualitative study on the road to recovery. Journal of Psychology in Africa. 2018;28(2):105-109.

289. Anjum F, Zafar MI, Maann AA, Ahmad M. Health issues and wellbeing: working children in carpet industry in Punjab, Pakistan. Professional Medical Journal. 2015;22(5):640-647.

290. Obertová Z, Cattaneo C. Child trafficking and the European migration crisis: the role of forensic practitioners. Forensic Sci Int. 2018;282:46-59.

291. Makinde OA. Infant trafficking and baby factories: a new tale of child abuse in Nigeria. Child Abuse Review. 2016;25(6):433-443.

292. Wildeman C, Emanuel N, Leventhal JM, Putnam-Hornstein E, Waldfogel J, Lee H. The prevalence of confirmed maltreatment among U.S. children, 2004 to 2011. JAMA Pediatrics. 2014;168(8):706-713.

293. Kahn NE, Hansen ME. Measuring racial disparities in foster care placement: a case study of Texas. Children & Youth Services Review. 2017;76:213-226.

294. Maguire-Jack K, Cao Y, Yoon S. Racial disparities in child maltreatment: the role of social service availability. Children & Youth Services Review. 2018;86:49-55.

295. Kim SK, Wang Y, Orozco-Lapray D, Shen Y, Murtuza M. Does "tiger parenting" exist? Parenting profiles of Chinese Americans and adolescent developmental outcomes. Asian American Journal of Psychology. 2013;4:7-18.

296. Kang H, Shih K. "Actions speak louder than words:" Korean American emerging adults' perceptions and meaning making of their parents' instrumental aspects of parenting. Journal of Family Issues. 2018;39(3):644-667.

297. Children's Rights. Racism at the Front End of Child Welfare: Fact Sheet, January 2023. Available at https://www.childrensrights.org/wp-content/uploads/2023/12/CR-Racism-at-the-Front-End-of-Child-Welfare-2023-Fact-Sheet.pdf. Last accessed August 27, 2024.

298. Miller-Perrin C. A Survey of Ethical Beliefs, Attitudes, and Professional Practices of Psychologists on Parental Use of Spanking. Paper presented at: Annual Conference of the American Psychological Association.

299. Hoffmann JP, Ellison CG, Bartkowski JP. Conservative Protestantism and attitudes toward corporal punishment, 1986–2014. Social Science Research. 2017;63:81-94.

300. Qiao DP, Xie QW. Public perceptions of child physical abuse in Beijing. Child & Family Social Work. 2017;22(1):213-225.

301. Gershoff ET, Grogan-Kaylor A. Spanking and child outcomes: old controversies and new meta-analyses. J Fam Psychol. 2016;30(4):453-469.

302. Burkhart K, Knox M, Hunter K. Changing health care professionals' attitudes toward spanking. Clin Pediatr (Phila). 2016;55(11):1005-1011.

303. Holden GW, Hawk CK, Smith MM, Singh JP, Ashraf R. Disciplinary practices, metaparenting, and the quality of parent–child relationships in African-American, Mexican-American, and European-American mothers. International Journal of Behavioral Development. 2017;41(4):482-490.

304. Böhm B. She got "spoiled:" perceptions of victims of child sexual abuse in Ghana. J Child Sex Abus. 2017;26(7):818-838.

305. Freisthler B, Wolf JP, Wiegmann W, Kepple NJ. Drug use, the drug environment, and child physical abuse and neglect. Child Maltreat. 2017;22(3):245-255.

306. Raissian KM. Does unemployment affect child abuse rates? Evidence from New York State. Child Abuse Negl. 2015;48:1-12.

307. Espinosa A, Ruglass LM, Nicholson R, Dambreville N, Shevorykin A, Sykes KM. Correlates of child abuse potential among African American and Latina mothers: a developmental-ecological perspective. Child Abuse Negl. 2017;70:222-230.

308. Mulder TM, Kuiper KC, van der Put CE, Stams GJM, Assink M. Risk factors for child neglect: a meta-analytic review. Child Abuse Negl. 2018;77:198-210.

309. Dolan CM, Raber MS. Responding to child sexual abuse disclosure. Nurse Pract. 2017;42(12):18-27.

310. Shah R. Broken mirror: the intertwining of therapist and client stories of childhood sexual abuse (CSA). European Journal of Psychotherapy & Counselling. 2017;19(4):343-356.

311. Tavormina M, Clossey L. Exploring crisis and its effects on workers in child protective services work. Child & Family Social Work. 2017;22(1):126-136.

312. He AS, Phillips JD, Lizano EL, Rienks S, Leake R. Examining internal and external job resources in child welfare: protecting against caseworker burnout. Child Abuse Negl. 2018;81:48-59.

313. Goddard C, Hunt S. The complexities of caring for child protection workers: the contexts of practice and supervision. Journal of Social Work Practice. 2011;25(4):413-432.

314. Miller JJ, Donohue-Dioh J, Niu C, Shalash N. Exploring the self-care practices of child welfare workers: a research brief. Children & Youth Services Review. 2018;84:137-142.

315. Griffiths A, Royse D, Walker R. Stress among child protective service workers: self-reported health consequences. Children & Youth Services Review. 2018;90:46-53.

316. Sanjeevi J, Houlihan D, Bergstrom KA, Langley MM, Judkins J. A review of child sexual abuse: impact, risk, and resilience in the context of culture. Journal of Child Sexual Abuse. 2018;27(6):622-641.

317. UNICEF. Female Genital Mutilation/Cutting: A Global Concern. Available at https://data.unicef.org/resources/female-genital-mutilationcutting-global-concern. Last accessed August 27, 2024.

318. Geremew TT, Azage M, Mengesha EW. Hotspots of female genital mutilation/cutting and associated factors among girls in Ethiopia: a spatial and multilevel analysis. BMC Public Health. 2021;21(1):186.

319. Garbarino J, Governale A, Nesi D. Vulnerable children: protection and social reintegration of child soldiers and youth members of gangs. Child Abuse and Neglect. 2020;110(Pt 1):104415.

320. Ahad MA, Parry YK, Willis E. The prevalence and impact of maltreatment of child laborers in the context of four South Asian countries: a scoping review. Child Abuse and Neglect. 2021;117:105052.

321. Posso A. The health consequences of hazardous and nonhazardous child labor. Review of Development Economics. 2019;23(2):619-639.

322. Burrone S, Giannelli GC. Child labour, gender and vulnerable employment in adulthood: evidence for Tanzania. Journal of Development Studies. 2020;56(12):2235-2250.

323. Lal N. India's child-trafficking nightmare deepens in the pandemic. Global Asia. 2021;16(1):82-87.

324. Greenbaum J. A public health approach to global child sex trafficking. Annual Review of Public Health. 2020;41:481-497.

325. Kokaliari ED, Roy AW, Taylor J. African American perspectives on racial disparities in child removals. Child Abuse and Neglect. 2019;90:139-148.

326. Ma J, Fallon B, Richard K. The overrepresentation of First Nations children and families involved with child welfare: findings from the Ontario incidence study of reported child abuse and neglect 2013. Child Abuse and Neglect. 2019;90:52-65.

327. LaBrenz CA, Findley E, Graaf G, Baiden P, Kim J, Choi MJ, Chakravarty S. Racial/ethnic disproportionality in reunification across U.S. child welfare systems. Child Abuse and Neglect. 2021;114:104894.

328. Fix RL, Nair R. Racial/ethnic and gender disparities in substantiation of child physical and sexual abuse: influences of caregiver and child characteristics. Children and Youth Services Review. 2020;116:105186.

329. Cho HS, Cheah CSL, Vu KTT, et al. Culturally shared and unique meanings and expressions of maternal control across four cultures. Developmental Psychology. 2021;57(2):284-301.

330. Finkelhor D, Turner H, Wormuth BK, Vanderminden J, Hamby S. Corporal punishment: current rates from a national survey. Journal of Child & Family Studies. 2019;28(7):1991-1997.

331. Beatriz E, Salhi C. Child discipline in low- and middle-income countries: socioeconomic disparities at the household- and country-level. Child Abuse and Neglect. 2019;94:104023.

332. Toure D, Do K, Ramos AK, Su D. Assessing racial and ethnic differences in attitudes towards the use of physical discipline in parenting: a mixed-methods approach. Journal of Social Service Research. 2019;45(4):455-465.

333. Lin J. Values and beliefs as risk and protective factors for physical punishment. Journal of Child & Family Studies. 2018;27(10): 3413-3425.

334. Wang F, Wang M, Xing X. Attitudes mediate the intergenerational transmission of corporal punishment in China. Child Abuse and Neglect. 2018;76:34-43.

335. Do HN, Nguyen HQT, Nguyen LTT, et al. Perception and attitude about child sexual abuse among Vietnamese school-age children. International Journal of Environmental Research and Public Health. 2019;16(20):3973.

336. Molnar BE, Meeker SA, Manners K, et al. Vicarious traumatization among child welfare and child protection professionals: a systematic review. Child Abuse and Neglect. 2020;110(Pt 3):104679.

337. Martinello E. Applying the ecological systems theory to better understand and prevent child sexual abuse. Sexuality and Culture. 2020;24(1):326-344.

338. Rodriguez CM, Lee SJ, Ward KP, Pu DF. The perfect storm: hidden risk of child maltreatment during the Covid-19 pandemic. Child Maltreatment. 2021;26(2):139-151.

339. Lakhdir MPA. Factors associated with child maltreatment among children aged 11 to 17 years in community settings of Karachi, Pakistan, using Belsky ecological framework. Journal of Interpersonal Violence. 2021;36(1/2):297-313.

340. Oliver C, Charles G. Which strengths-based practice? Reconciling strengths-based practice and mandated authority in child protection work. Social Work. 2015;60(2):135-143.

341. Santa-Sosa E, Runyon M. Addressing ethnocultural factors in treatment for child physical abuse. Journal of Child & Family Studies. 2015;24(6):1660-1671.

342. Bridges DR, Davidson RA, Odegard PS, Maki IV, Tomkowiak J. Interprofessional collaboration: three best practice models of interprofessional education. Medical Education Online. 2011;16.

343. Gilles I, Filliettaz SS, Berchtold P, Peytremann-Bridevaux I. Financial barriers decrease benefits of interprofessional collaboration within integrated care programs: results of a nationwide survey. International Journal of Integrated Care. 2020;20(1).

344. Hale GM, Joseph T, Maravent S, et al. Effect of interprofessional collaboration on quality of life in elderly patients with cardiovascular disease. Journal of Interprofessional Education & Practice. 2018;12:25-28.

345. Weinberg DB, Miner DC, Rivlin L. "It depends:" medical residents' perspectives on working with nurses. American Journal of Nursing. 2009;109:34-43.

346. Campbell KA, Wuthrich A, Norlin C. We have all been working in our own little silos forever: exploring a cross-sector response to child maltreatment. Academic Pediatrics. 2020;20(1):46-54.

347. Chen L. Cultural competency in mandated reporting among healthcare professionals. Southern California Review of Law & Social Justice. 2019;28(2):319-347.

348. Sharley V. Conceptualising child neglect in Namibia: challenges and strategies. International Social Work. 2019;62(3):1159-1164.

349. Passmore S, Hemming E, McIntosh HC, Hellman CM. The relationship between hope, meaning in work, secondary traumatic stress, and burnout among child abuse pediatric clinicians. Journal of Applied Communications. 2020;24(1):29-34.

350. Wymer B, Guest JD, Deaton JD, Newton TL, Limberg D, Ohrt JH. Early career clinicians' supervision experiences related to secondary traumatic stress when treating child survivors of sexual abuse. Clinical Supervisor. 2020;39(2):284-305.

351. Renteln AD. Corporal punishment and the cultural defense. Law and Contemporary Problems. 2010;73:253-279.

352. Kibler T. Unpacking the History of American and International Child Rights. Available at https://home.heinonline.org/blog/2020/08/unpacking-the-history-of-american-and-international-child-rights. Last accessed August 27, 2024.

353. Lang D. 1600s: Autocratic Parenting. Available at https://iastate.pressbooks.pub/parentingfamilydiversity/chapter/autocratic. Last accessed August 27, 2024.

354. Administration for Children and Families. HHS Announces Historic Child Welfare Package to Expand Support and Equity in Child Welfare System. Available at https://www.acf.hhs.gov/media/press/2023/hhs-announces-historic-child-welfare-package-expand-support-and-equity-child. Last accessed August 27, 2024.

355. Marmor A, Cohen N, Katz C. Child maltreatment during COVID-19: key conclusions and future directions based on a systematic literature review. Trauma, Violence, & Abuse. 2023;24(2):760-775.

356. Lee H, Kim E. Global prevalence of physical and psychological child abuse during COVID-19: a systematic review and meta-analysis. Child Abuse & Neglect. 2023;135:1-10.

357. Ahinkorah BO, Budu E, Seidu A-A, et al. Female genital mutilation/cutting among girls aged 0–14: evidence from the 2018 Mali Demographic and Health Survey data. BMC Women's Health. 2024;24(1):1-9.

358. Ayenew AA, Mol BW, Bradford B, Abeje G. Prevalence of female genital mutilation and associated factors among women and girls in Africa: a systematic review and meta-analysis. Systematic Reviews. 2024;13(1):1-16.

359. UNICEF. Children Recruited by Armed Forces or Armed Groups. Available at https://www.unicef.org/protection/children-recruited-by-armed-forces. Last accessed August 27, 2024.

360. Abdullah A, Huynh I, Emery CR, Jordan LP. Social norms and family child labor: a systematic literature review. International Journal of Environmental Research and Public Health. 2022;19(7):4082.

361. National Center for Missing and Exploited Children. Child Sex Trafficking Overview. Available at https://www.missingkids.org/content/dam/missingkids/pdfs/CST%20Identification%20Resource.pdf. Last accessed August 27, 2024.

362. Branscum C, Richards TN. The wrong rite of passage: comparing sex trafficking to other types of child maltreatment using the National Child Abuse and Neglect Data System (NCANDS). Victims & Offenders. 2023;18(3):399-422.

363. Briggs HE, Huggins-Hoyt KY, Teasley ML, Gary Hopps J. Poverty or racism? Determinants of disproportionality and disparity for African American/Black Children in child welfare. Research on Social Work Practice. 2022;32(5):533-538.

364. Zhao X, Dale C, Hare M, et al. Measurement invariance in the assessment of parenting practices: a cross-cultural comparison of China and the United States. Journal of Family Psychology. 2023;37(6):774-785.

365. Porter N, Tanabe K. The mimamoru approach in contemporary Japanese parenting magazines: strategies for disciplining young children. Early Childhood Education Journal. 2023;51(7):1241-1252.

366. Global Initiative to End All Corporal Punishment of Children. Global Progress. Available at https://endcorporalpunishment.org. Last accessed August 27, 2024.

367. Bhatia A, Fabbri C, Cerna-Turoff I, et al. Violence against children during the COVID-19 pandemic. Bulletin of the World Health Organization. 2021;99(10):730-738.

368. Hines CT, Kalil A, Ryan RM. Differences in parents' attitudes toward spanking across socioeconomic status and region, 1986–2016. Social Indicators Research. 2022;160(1):133-158.

369. Avezum M, Pisani Altafim ER, Martins Linhares MB. Spanking and corporal punishment parenting practices and child development: a systematic review. Trauma, Violence & Abuse. 2023;24(5):3094-3111.

370. Cuartas J. Estimating the association between spanking and early childhood development using between- and within-child analyses. Psychology of Violence. 2024;14(2):77-86.

371. Duong HT. Childhood experiences and attitudes toward corporal punishment: the mediating role of perceived efficacy of alternative discipline strategies among low-income Black, Hispanic, and White parents. Journal of Interpersonal Violence. 2022;37(19/20):NP18266-NP18290.

372. Duong HT, Monahan JL, Mercer Kollar LM, Klevens J. Examining sources of social norms supporting child corporal punishment among low-income Black, Latino, and White parents. Health Communications. 2022;37(11):1413-1422.

373. Navarro-Cruz G, Kouyoumdjian C, Arias L. 'There's not one way to do it:" Latina mothers' discipline techniques. Journal of Family Issues. 2021;42(5):908-930.

374. McKinley C, Knipp H, Lilly J. "A learning experience:" disciplinary and parenting practices among Native American families. Child & Family Social Work. 2022;27(2):185-194.

375. Cho HS, Cheah CSL, Vu KTT, et al. Culturally shared and unique meanings and expressions of maternal control across four cultures. Developmental Psychology. 2021;57(2):284-301.

376. Woudstra MIJ, Emmen RAG, Alink LRA, Wang L, Branger MCE, Mesman J. Attitudes about child maltreatment in China and the Netherlands. Child Abuse & Neglect. 2021;112:104900.

377. Younas F, Gutman LM. Parental risk and protective factors in child maltreatment: a systematic review of the evidence. Trauma, Violence, & Abuse. 2023;24(5):3697-3714.

378. Tran NK, van Berkel SR, van IJzendoorn MH, Alink LRA. Child and family factors associated with child maltreatment in Vietnam. Journal of Interpersonal Violence. 2021;36(5-6):NP2931-NP2953.

379. Larter N, Jersky M, Ryan L, et al. Strengths-based approaches to providing an Aboriginal community child health service. International Journal of Indigenous Health. 2024;19(1):1-14.

380. VanGraafeiland B, Chiocca E, Perks D, Dietzman H, Horner G. Overview of recognition and prevention of child sex trafficking in the primary care setting: a primer for nurse practitioners. Journal for Nurse Practitioners. 2022;18(3):285-288.

381. Seekamp S, Ey L-A, Wright S, Herbert J, Tsiros MD. Service delivery goals and underlying interprofessional practices: a scoping review to support interprofessional collaboration in the field of child protection. Children and Youth Services Review. 2022;143:1-10.

382. Bowman ME. Child welfare worker wellness: an ethical imperative in the service of children. Child Abuse Review. 2022;31(5):1-12.

383. Wadji DL, Oe M, Cheng P, et al. Associations between experiences of childhood maltreatment and perceived acceptability of child maltreatment: a cross-cultural and exploratory study. Child Abuse & Neglect. 2023;143:1-12.

384. Tlali T. Therapeutic tool or a hindrance? A phenomenological investigation into the experiences of countertransference in the treatment of sexually abused children. Indo-Pacific Journal of Phenomenology. 2022;22(1):1-12.

385. Weiss-Dagan S, Ben-Porat A, Itzhaky H. Secondary traumatic stress and vicarious post-traumatic growth among social workers who have worked with abused children. Journal of Social Work. 2022;22(1):170-187.