A mindful approach: Assessing child maltreatment in a multicultural setting

Introduction

Child maltreatment refers to the abusive or neglectful behaviour by a caregiver that results in or places a child at risk of harm: physical, sexual and/or emotional. Maltreatment can occur as a direct result of a caregiver’s actions (e.g., hitting a child) or inaction (e.g., not providing adequate food, clothing or schooling).

Canadian society recognizes the importance of protecting and promoting the safety and well-being of children, youth and families through laws, government programs and social services, and private systems in all provinces and territories. Despite this, child and youth maltreatment (abuse and neglect) is prevalent in Canada and occurs in all geographic areas, at all levels of socioeconomic status and family education, and in families from all ethno-cultural backgrounds. In 2008, an estimated 3.9% of children in Canada were the subjects of maltreatment investigations, with maltreatment being substantiated in 1.4%  of cases that same year.¹ Both figures probably under-represent the true prevalence of maltreatment, because most cases never come to the attention of authorities. 

What is the role of child welfare authorities?

Child welfare authorities are responsible for protecting children when maltreatment or a risk of maltreatment threatens their safety, health or well-being.  They investigate reports of possible maltreatment, assess risk and intervene when harm or risk of harm exceeds a certain threshold level. All children in Canada fall within the mandate of child welfare authorities.   

The definition of a “child” in the child welfare mandate is determined by each province and territory, but includes anyone up to 16 years of age in all jurisdictions, and youth 18 or 19 years of age in some regions. The Canadian Child Welfare Research Portal provides detailed information by region.

Child welfare authorities try to work supportively with families, helping parents to meet their children’s needs in the home. Clinicians sometimes worry that reporting a case of possible child abuse will result in the child being removed from their home.  In more than 90% of reported cases, however, there is no change in the child’s living situation.  Only  about 8% of child welfare investigations lead to  changes in a child’s living situation, including about 4% that result in placement with foster care, with a relative or other residential arrangement.¹  Such changes are often temporary, with children being returned to their family home at a later date.

Provincial/territorial laws governing the actions of child welfare authorities are separate from federal criminal laws governing law enforcement (e.g., police actions) under the criminal justice system. Process and decision-making in a child welfare case may be independent from those in a concurrent, ongoing criminal investigation. Most cases investigated by child welfare authorities do not involve criminal investigation or charges.  However, child welfare authorities may consult and work collaboratively with law enforcement when there are concerns that a criminal offence may have occurred.

What role does culture play in child maltreatment?

Child maltreatment is defined according to socially accepted norms that are largely dictated by culture. As a result, some immigrant and refugee families may have different views of child rearing and child maltreatment based on the accepted practices in their country of origin (or other countries of residence) compared with the views most commonly present in Canadian society. In particular, physical punishment is still a common and socially acceptable practice in many countries.^2,3

The International Society for the Prevention of Child Abuse and Neglect undertook a global survey of “informed individuals” in 2012.⁴ Although physical abuse (e.g., beatings, burnings) and sexual abuse (e.g., incest, sexual touching) were considered to be abuse in almost all countries (97% each), only 53% of respondents indicated that physical punishment was considered to be abusive in their country. Other forms of maltreatment were not necessarily viewed as abusive, such as:

• emotional abuse (90% in the Americas, 67% in Asia and 56% in Africa)
• exposure to pornography (100% in the Americas and 56% in Africa)
• witnessing intimate partner violence (IPV) (90% in the Americas, 75% in Europe, 56% in Asia and 33% in Africa).

Several participating countries did not report having national laws or policies on child maltreatment, nor could they identify a government agency mandated to respond to cases of suspected child maltreatment at the national, state or local level. In countries with a child welfare system in place, standards of service, care and intervention were highly variable.

As a result, some refugee and immigrant families from countries with dissimilar laws and systems to those in Canada may have no experience of or contextual lens for understanding Canadian child welfare, services or authorities. This may be further compounded by a number of individual, family and systemic factors :^2,3,5-7

• Language and cultural barriers among newcomer parents and Canadian health care and child welfare professionals
• Lack of awareness, understanding or agreement with Canadian norms and laws pertaining to child-rearing
• Fear of authority, based on experience in the country of origin
• Immigration policies that discourage victims of IPV from seeking help
• Socioeconomic stress during resettlement, caused by poverty, housing problems, social isolation, employment issues
• Discrimination in the community or workplace
• Lack of awareness of and access to culturally specific services
• Barriers to health care access services
• Physical and mental health issues within the family
• Parent–child conflict stemming from discrepant cultural expectations
• An expectation that difficulties within the family should be dealt with within the family
• Lack of understanding of and provision for the specialized needs of newcomer families among health and child welfare workers.

When a refugee or immigrant family comes to the attention of child welfare authorities, there is concern that child welfare workers are better able to identify family deficits and have greater difficulty and lack of knowledge in identifying parental and family strengths than with non-immigrant families.⁵ It has been suggested that newcomer families may require a different approach to assessment, because many of the widely accepted ‘risk factors’ for child maltreatment (e.g., a single caregiver, living in a rented residence, few social supports) may apply to newcomer families, and are not reflective of risk in particular populations.^8-10

However, child welfare workers often integrate cultural considerations into their assessments. In the rare cases where a newcomer child needs a placement outside the family home, a “close-to-home” principle  is applied whenever possible,  including matching the child’s placement as much as possible to their native language, culture and religion. Even when  child welfare workers do not understand all aspects of a family’s culture, they are able to provide supportive services and help the family understand and access resources in many cases. More information about Canadian child welfare authorities and services is provided below.

Minority populations and the child welfare system

While there are little data specific to newcomer families in the Canadian child welfare system, one study suggests that ethnicity and culture  do play a role in reporting and substantiating child abuse:¹¹  Major findings include the following:

• Ethnic minorities (including but not limited to refugees or immigrants) are over-represented in reported and substantiated maltreatment cases in Canada.
• Relative to their population prevalence, Black, Latino and Aboriginal children were over-represented in child welfare reports and investigations, while Caucasian, Asian, and Arab children were under-represented. 
• Culture may also play a role in the investigation process.  For example, Asian children were under-represented at the case-intake stage but their cases were more likely to be investigated and substantiated as physical abuse. 
• Emotional harm from any form of maltreatment was identified more often in Caucasian children than in other populations. This finding may indicate overidentification in cases involving Caucasian families or under-identification in new Canadian families.
• Substantiated sexual abuse and emotional maltreatment did not vary among groups in the study sample.

Possible reasons for such ethnocultural variation in the reporting and substantiation of maltreatment include the following:^1,10

• Differential reporting:  Professionals appear more likely to report possible maltreatment in children from visible minorities, while nonprofessionals appear more likely to report suspected cases in Aboriginal and Caucasian children.
• Differing cultural norms regarding child rearing: Professionals are more likely to report disciplinary and parenting practices that are not viewed favourably in the majority culture.
• Lack of a culture-specific approach: Risk factors typically associated with maltreatment in Canadian-born families are disproportionately common among newcomer families due to social contextual factors independent of maltreatment (e.g., renting a home, financial challenges, single caregiver families, lack of social support).^8,9
• Discrimination: Discriminatory views held by the dominant culture and stereotyping may play a role in reporting and assessment.

Cultural perspectives on physical discipline and physical abuse

Culture, tradition, religion and familial norms influence home life and parenting practices. Certain disciplinary techniques are viewed as inappropriate in some cultures but are accepted and even promoted in others.^2,3,12 Even within cultures, professionals and parents may disagree. One Turkish study showed that certain forms of physical discipline were viewed favourably by families but abusive by professionals.¹³

Health care providers should ask any parent they see in practice about discipline at home, as part of their clinical assessment. For newcomer parents, a culturally sensitive approach is needed, with careful questions about beliefs, expectations around child behaviour and physical discipline. Conflict between parents and children may arise as the younger generation adapts to norms and expectations in their new country, while their parents may continue to identify with traditional cultural beliefs.^6,7 There is a growing global recognition, however, that using physical discipline is neither effective nor healthy,¹⁴ and Canadian standards for parenting and child welfare involvement should be applied evenly to all families living in Canada.

Intimate partner violence (IPV) and newcomer families

IPV, also known as domestic violence, often goes unrecognized by clinicians. There are many barriers to reporting for its victims, who are usually women. It is important for health care providers to be aware that victims of IPV in newcomer families may face additional barriers to disclosing violence and seeking help. Cultural and religious beliefs, fear of authorities (e.g., police, child welfare), social isolation, dependence on the violent partner (for immigration status or economic support) and restrictive immigration laws may prevent victims of violence from coming forward.¹⁵

Cultural healing practices

Traditional healing practices are used in some cultures which may raise suspicions of maltreatment in Canada:^16,17

• Moxibustion involves burning moxa (the dried leaves of Artemisia vulgaris), wormwood or another slow-burning material on or as close to the skin as possible. It is most commonly used in Chinese and Japanese culture to improve a body function or for pain-relief, sometimes in combination with acupuncture, but can leave burns and scarring.
• Rubbing (also “coining” or “spooning”) involves vigorously or repeatedly rubbing the skin with an object (usually a coin or spoon), which can leave linear ecchymoses or welts.  The skin is often lubricated with oil or water before rubbing, and the object may be heated.  Variously used to promote blood circulation, improve metabolic function, or “release” illness from the body. Rubbing with a coin, “coining”, is most commonly used in the Vietnamese culture. The practice may also be used by Chinese, Cambodian, Laotian, Indonesian and other Asian practitioners and families.  In China, the most common form of rubbing is Gua sha, using a porcelain spoon. 
• Cupping (also dry cupping) involves suctioning the skin with one or more cups.  The suction effect is traditionally created using heat from a fire but a mechanical device (such as a pump) may also be used. Heated cups are left on the skin for 5 to15 minutes, to improve circulation and “draw out” illness. This practice is most common in Chinese culture and may be used in combination with acupuncture, with the cup placed over an acupuncture needle. “Wet” or “bleeding” cupping involves making a small incision around the cupping site after the cup is removed, then placing a second cup on the area to draw out a small amount of blood. This practice is common in many Muslim countries. Cupping is also used frequently in Finnish saunas. The practice can leave welts, burns, scars, ecchymoses, petechiae or transient red marks on the skin. 

Traditional healing practices often do no harm to a child being treated, but any practice that leaves bruises, burns or other injuries may be considered physically harmful by Canadian child welfare authorities. Clinicians should ask about a family’s use of traditional therapies as carefully as when querying other parenting practices. But when the effects, once considered, are thought to be harmful, child welfare authorities must be notified. Clinicians should make an effort to understand the cultural context for such practices, while educating families about the risk of skin injuries. They may also need to explain such practices to child welfare workers, along with the reasons for their use, the child’s general health status and expected outcomes. 

Female genital mutilation/cutting

Female genital mutilation is a practice that continues in many countries despite being condemned by global bodies such as the World Health Organization (WHO) and UNICEF. The WHO identifies four types of female genital mutilation/cutting, described elsewhere in this resource. Although Canadian laws protect against female genital mutilation/cutting, clinicians should be aware that the practice is accepted and encouraged in many cultures. Girls may be taken back to their country of origin or have a procedure performed in Canada. Girls who have already experienced genital mutilation/cutting may need special support, and child welfare authorities should be notified of such harm or risk of harm. For more information, see the section Female Genital Mutilation/Cutting in this resource.

Other cultural considerations

While the following issues are not specific to newcomer families, clinicians should be aware that human trafficking, “honour” violence, child, early or forced marriage and war crimes against children are human rights violations, and are more likely to affect the health and safety of immigrant or refugee children than children who are born in Canada. Such issues may require a culturally sensitive assessment and appropriate protections if concerns arise.

What is the health professional’s role?

Health care providers have a professional and ethical responsibility to prevent, identify and respond to child maltreatment. For families new to Canada, asking careful, sensitive and respectful questions and being aware of diverse beliefs and practices, can yield a clearer picture of home life and possible risks.  

Minority populations in Canada, including immigrant and refugee families, encounter multiple barriers including discrimination within the health care system.^18,19 Health professionals can support access to and use of health services by newcomer families, by learning about such resources themselves. They can implement more culturally responsive delivery of care by involving interpreters and providing health information in multiple languages. More information about culturally responsive care is available in this resource.

Health professionals should also take the following actions to prevent, help identity, and respond appropriately in maltreatment cases: 

1. Be aware of the laws that apply to child welfare in your region. Information is available on the Child Welfare Research Portal.
2. Strive to understand child-rearing customs, disciplinary practices and child behaviour expectations for all families, including those new to Canada.
3. Encourage parents and other caregivers to use child-rearing practices, such as positive parenting, that are healthy, beneficial and safe in the Canadian context.
4. Counsel parents and other caregivers on Canada’s laws and accepted norms in child rearing, as well as unacceptable practices.
5. Discourage all forms of physical punishment and provide practical advice on alternative disciplinary strategies.
6. Appreciate diversity across and within cultures and consider using language and/or cultural interpreters as appropriate. Information about the use of interpreters in health settings is available in this resource.
7. Apply Canadian standards to parenting practices and child welfare involvement evenly for all the families you see in your practice.
8.  Build awareness, knowledge and skills around possible maltreatment. Identify and report any concerns about a child’s safety or well-being to child welfare authorities.
9. Learn more about cultural practices that conflict with Canadian laws, child welfare and human rights standards (e.g., female genital mutilation/cutting, managing abuse within families, intimate partner violence, and child, early or forced marriage).
10. Identify areas of family need —and strength—and recommend and advocate for supportive resources. A list of community agencies that provide services to newcomer families and tips on advocacy for immigrant and refugee children are available in this resource.
11. Consult with paediatricians specializing in child maltreatment as needed.  Each paediatric centre in Canada and many community paediatricians can provide expert advice in this area.
12. Consult with child welfare authorities whenever you have a concern for maltreatment (whether the case is clear or unclear). 
13. Be mindful of your own values, assumptions and biases, and how they might  impact clinical interactions and perceptions of maltreatment.

What are the obligations to report suspected maltreatment?

All Canadian provinces and territories have mandatory reporting laws which state that anyone with reasonable grounds to suspect that a child has been maltreated or is at risk of maltreatment has a legal responsibility to report the possibility to child welfare authorities. Professionals are legally required to make such reports and should consult with child welfare authorities even when it is unclear whether a report is warranted. Clinicians may also consult with other professionals with more expertise (e.g., hospital-based child maltreatment paediatricians, social workers, psychologists) but this does not remove the responsibility to report concerns directly to child welfare authorities. 

In general, clinicians should contact the child welfare authority for the region where maltreatment might have occurred and/or where the child lives.  In some provinces and territories, child welfare authorities are distributed geographically or based on religion or culture (e.g., Catholic, Jewish and Aboriginal child welfare authorities exist in some regions).

It is the role of child welfare authorities, not the health care professional, to determine the level of risk and whether the child is ‘in need of protection’. Personal health information can be shared with child welfare authorities without a child’s or parent’s consent when it is relevant for an active child maltreatment investigation. All relevant information should be shared with child welfare authorities in an objective, accurate and unbiased manner. Sharing personal health information with law enforcement officers (i.e., the police) is covered by different laws and usually requires consent of the child (if capable of consent) or the child’s legal guardian, or a warrant or court subpoena.

How is maltreatment defined in Canada?

In Canada, child maltreatment is commonly divided into the following types: physical abuse, sexual abuse, neglect, emotional abuse and exposure to intimate partner violence (IPV). Each of these is discussed in more detail below.

Physical abuse

Physical abuse refers to the deliberate use of physical force which results in harm or risk of harm to the child’s health, safety or well-being. Most substantiated physical abuse cases occur in a disciplinary context, as corporal or physical punishment. In Canada, physical punishment was considered an appropriate tool in child-rearing until relatively recently. However, there is increasing acceptance here and around the world that corporal punishment causes harm to children, is not effective and violates children’s rights.¹⁴ Eminent Canadian and international entities (including the Canadian Paediatric Society [CPS], the United Nation’s Committee on the Rights of the Child, the Parliamentary Assembly of the Council of Europe, and many governments and high courts around the world) now strongly advocate against the use of physical punishment. 

In the Canadian child welfare system, any physical act that leaves a visible mark on a child or causes physical or emotional harm (e.g., bruising or a fear of caregivers) is generally considered to be physically abusive, even when the act was intended to correct behaviour or punish. This includes direct actions (e.g., spanking, slapping) and indirect actions (e.g., requiring a child to kneel on a grate). In Canada, the most common form of physical abuse is hitting with a hand.²⁰

Under the child welfare system, case decisions are based on the ‘balance of probabilities’, as opposed to the ‘beyond a reasonable doubt’ rule used in the criminal justice system.  Child welfare authorities may determine that a child is ‘in need of protection’ and take legal action without laying criminal charges.

Sexual abuse

Sexual abuse occurs when a person in a caregiving role or position of power engages in any activity with a child for sexual purposes. This includes sexual contact (e.g., oral, anal, genital), as well as activities not involving physical contact, such as voyeurism, exhibitionism or exploitation. Canadian laws protect children from sexual abuse and sexual exploitation.

Child welfare authorities should be notified of sexual abuse when:

• an adult engages in any form of sexual activity with a child (including sexual touching by the adult or inviting the child to sexually touch the adult) and does not fit the ‘close-in-age’ exceptions.  In some jurisdictions, child welfare authorities would only become involved if the sexual abuse involved a caregiver or person of authority. 
• a child or youth under 18 years of age is involved in exploitative sexual activity (subject to the provincial or territorial age mandate for the child welfare authority)
• a child or youth is sexually assaulted by a peer (i.e., non-consensual sexual activity regardless of age of the involved parties).  In some regions, the protocol is to involve child welfare authorities only if the caregivers are not supportive or protective of the child or youth. In other regions, all sexual assaults are reported.
• child or youth siblings are involved in sexual behaviour together (non-consensual or consensual)
• a child or youth exhibits concerning sexualized behaviours or verbalizations that raise concerns for sexual abuse.

Relationship and sexual practices vary throughout the world, and  culture plays a pivotal role in dictating what is acceptable and what is not in any given culture. 

However, under the Criminal Code of Canada, any sexual contact involving a child under the age of 12 is considered sexual assault. At age 16, a youth may consent to sexual activity as long as it is not exploitative (as described below). Sexual activity without consent remains an offence at any age.

‘Close-in-age’ exceptions exist such that children below the age of 16 years may consent to sexual activity with peers under the following conditions:

• 12- and 13-year-olds may legally consent to sexual activity with peers within a 2-year age range (e.g., a 12-year-old and a 14-year-old).
• 14- and 15-year-olds may consent with those within 5 years of their age (e.g., a 14-year-old and a 19-year-old).

Any sexual activity between an adult and a child under 16 years of age (when the ‘close-in-age’ exceptions do not apply) is considered sexual assault.

Child welfare authorities should be notified of sexual abuse when:

• an adult engages in any form of sexual activity with a child (including sexual touching by the adult or inviting the child to sexually touch the adult) and does not fit the ‘close-in-age’ exceptions.  In some jurisdictions, child welfare authorities would only become involved if the sexual abuse involved a caregiver or person of authority. 
• a child or youth under 18 years of age is involved in exploitative sexual activity (subject to the provincial or territorial age mandate for the child welfare authority)
• a child or youth is sexually assaulted by a peer (i.e., non-consensual sexual activity regardless of age of the involved parties).  In some regions, the protocol is to involve child welfare authorities only if the caregivers are not supportive or protective of the child or youth. In other regions, all sexual assaults are reported.
• child or youth siblings are involved in sexual behaviour together (non-consensual or consensual)
• a child or youth exhibits concerning sexualized behaviours or verbalizations that raise concerns for sexual abuse.

Although youth can consent to sexual activity at 16 years of age, they may not consent to exploitative sexual activity until they are 18 years of age. Exploitative sexual activity includes:

• pornography
• prostitution 
• engaging in a sexual relationship with a person of authority (e.g., a teacher, coach, pastor or community leader)

In some cultures, sexual experience and practices impact perceptions of family honour and status within the community, as well as legal and social rights.  The concept of virginity is understood differently across and within cultural groups. For some, maintaining virginity (in the traditional sense) until marriage is considered of vital importance, particularly for girls. In the case of sexual abuse, loss of virginity may be blamed on the victim, is perceived to ‘bring shame’ to the victim and her family, may exclude the victim from future relationships or marriage possibilities, and may even place her at risk of physical harm. 

Clinicians may be asked by a family to examine a girl or young woman as a ‘virginity check’.  They should advise families that physical examinations are private, confidential and only done to verify that a  child or young woman is in good health and does not require any treatment. In most cases of sexual abuse, the examination is normal and can neither confirm nor exclude the possibility of abuse.²¹

Neglect

Neglect refers to acts of omission by a caregiver that result in actual or potential harm to the child, regardless of intention.²² In Canada, 34% of substantiated maltreatment investigations were related primarily to neglect in 2008.¹ Types of neglect include:

• Physical neglect (e.g., not providing adequate food, hygiene, clothing, shelter)
• Supervisory neglect (e.g., not adequately supervising a child, resulting in harm)
• Emotional neglect (e.g., failing to provide the emotional nurturing needed for healthy psychosocial development)
• Medical or dental neglect (e.g., failing to provide recommended and necessary medical, dental or psychological assessment and/or treatment)
• Educational neglect (e.g., not assisting the child to obtain adequate schooling).

Immigrant and refugee families may have additional vulnerabilities that could lead to neglect, such poor access to foods that they are used to preparing and unfamiliarity with Canadian dietary practices, and previous public messaging which discouraged certain vaccinations.  Such issues are not unique to families new to Canada but cultural barriers and practical difficulties to providing appropriate care need to be considered. 

Emotional abuse

Emotional abuse occurs when the actions of a caregiver cause, or have the potential to cause, emotional harm, through verbal assault, belittling or treating the child in a way that undermines development, confidence, self-esteem or self-worth. Emotionally harmful behaviour takes many forms, including rejecting, isolating, ignoring, terrorizing, corrupting or exploiting the child.²³ Emotional harm is sometimes the primary form of maltreatment, but it more commonly co-occurs with other forms of maltreatment.¹

Exposure to intimate partner violence (IPV)

In 2008, the most common form of substantiated maltreatment in Canada was exposure to IPV.¹ IPV is directly harmful not only to the adult victim, but also to a child or youth who witnesses the violence. In addition to the risk of physical harm if a child or youth comes between  two adults– unintentionally or in an attempt to intervene­– children exposed to IPV appear to experience mental health problems and other adverse outcomes similar to children who have been the direct victims of abuse.^24-27 In all regions of Canada, IPV is reportable to child welfare authorities when there is risk of harm to a child or youth. In some regions, the presence of IPV in the home of a child or youth is, on its own, reportable.

Suggested resources

• Public Health Agency of Canada, 2001. A booklet for service providers who work with immigrant families on issues relating to child discipline, child abuse and child neglect.
• Canadian Department of Justice. About family violence.
• Child Welfare League of Canada. Resources for parents. Includes resources on positive discipline and parenting.
• Criminal Code of Canada, Section 43. PRB-05-10E. Revised June 20, 2008.
• Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA 2002;288(13):1603-9.
• Fontes, Lisa A. Child abuse and culture: Working with diverse families. The Guildford Press. 2008.
• Public Health Agency of Canada , 2012. Family violence in refugee and immigrant communities, 2012.
• United Nations. UN World Report on Violence and Health. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. Geneva; 2002.

References

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4. International Society for the Prevention of Child Abuse and Neglect (ISPCAN). Dubowitz H (Ed.). World Perspectives on Child Abuse, 10th Edition. Aurora, CO: ISPCAN. 2012.
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21. Adams JA. Medical evaluation of suspected child sexual abuse: 2011 update. J Child Sexual Abus 2011;20(5):588-605.
22. Dubowitz H, Poole G. Child neglect: An overview. Encyclopedia of early child development, 2012.
23. Hart SN, Brassard M, Davidson HA, et al. Psychological maltreatment. In: Myers JEB, Ed. The Society on the Abuse of Children (APSAC) Handbook on Child Maltreatment, 3rd edn. Thousand Oaks, CA: Sage, 2006.
24. Afifi TO, MacMillan HL, Boyle M et al. Child abuse and mental disorders in Canada. CMAJ 2014;186(9):E324-32.
25. Evans SE, Davies C, DiLillo D. Exposure to domestic violence: A meta-analysis of child and adolescent outcomes. Aggression and Violent Behavior 2008;13:131-40.
26. Kitzmann KM, Gaylord NK, Holt AR, Kenny ED. Child witnesses to domestic violence: A meta-analytic review. J Consult Clin Psychol 2003;71(2):339-52.
27. Wolfe DA, Crooks CV, Lee V, et al. The effects of children’s exposure to domestic violence: A meta-analysis and critique. Clin Child Fam Psychol Rev 2003;6(3):171-87.