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].

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.

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 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].

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].

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:

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 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]:

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]:

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

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].

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].

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]:

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].

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].

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].

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.

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].

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].

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].

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].

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].

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].

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.

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].

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.

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

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

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].

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].

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.

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].

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].

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]:

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.

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].

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.

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.

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].

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].

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]:

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].

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]:

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.

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.

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].

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].

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].

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].

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]:

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]:

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]:

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.

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

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

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].