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).

Canada protects and promotes 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) occurs in all geographic areas, at all levels of socioeconomic status and family education, and in families from all ethno-cultural backgrounds.

In 2019, there were 299,171 investigations of child abuse and neglect in Canada. Of those, 34% were for substantiated maltreatment and exposure to intimate partner violence (IPV). Among confirmed cases of maltreatment, 4% resulted in physical injury to the child, and 35% involved emotional harm.^[1] Both figures probably under-represent the true prevalence of maltreatment, because most cases never come to the attention of authorities.

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 Canada. 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., inflicted bruising or burns) 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 not necessarily universally viewed as abusive include emotional abuse, exposure to pornography, and witnessing intimate partner violence (IPV).

The degree to which countries have legislation, policies, and processes related to child maltreatment varies. If a refugee or immigrant family comes from a country with laws and systems dissimilar to those in Canada, they may have no contextual lens for understanding the Canadian child welfare system, services or authorities. This may be further compounded by a number of individual, family and systemic factors, including^{[2][3][5]-[7]}:

• Language and cultural barriers between 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, unemployment
• Discrimination in the community or workplace
• Lack of awareness and access to culturally specific services Barriers to accessing health care services
• Physical and mental health issues within the family
• Parent–child conflict stemming from incompatible cultural expectations
• Norms that require family members to deal with difficulties among themselves and not share with any external party
• Lack of understanding and provision for the specialized needs of newcomer families among health and child welfare workers.

If a newcomer child needs a placement outside the family home, a “close-to-home” principle should be applied whenever possible, including matching the child’s placement as much as possible to their home language, culture and religion. Even when child welfare workers do not understand all aspects of a family’s culture, they can provide supportive services and help the family understand and access resources in many cases.

Racialized populations and the child welfare system

While there are little data specific to newcomer families in the Canadian child welfare system, studies suggest that ethnicity and culture do play a role in reporting and substantiating child maltreatment.^[8] Among the findings:

• Ethnic minorities (including but not limited to refugees or immigrants) are over- represented in reported and substantiated maltreatment cases in Canada.
• Black, Latino and Indigenous children were over-represented in child welfare reports and investigations, while White 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 White children than in other populations. This finding may indicate overidentification in cases involving White families or under-identification in other families.
• Substantiated sexual abuse and emotional maltreatment did not vary among groups in this study sample.

Possible reasons for such ethnocultural variation in the reporting and substantiation of maltreatment include^[8]:

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

Cultural perspectives on physical discipline and 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] Even within cultures, professionals and parents may disagree.

Health care providers should ask any parent they see in their practice about discipline rules 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 align with traditional cultural beliefs.^[6][7] There is a growing global recognition, however, that using physical discipline is neither effective nor healthy, and Canadian standards for parenting and child welfare involvement should be applied 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—and those 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.^[9]

Cultural healing practices

Some cultures use traditional healing practices that may raise suspicions of maltreatment in Canada^[10][11]:

• 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. “Coining” is most commonly used in Vietnamese culture, and 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 to 15 minutes to improve circulation and “draw out” illness. This practice is most common in Chinese culture and may also be used with the cup placed over an acupuncture needle. “Wet” or “bleeding” cuppinginvolves making a small incision around the cupping site after the cup is removed, then placing another cup on the area to draw out a small amount of blood. The practice can leave welts, burns, scars, ecchymoses, petechiae or transient red marks on the skin.

Traditional healing practices often do no harm, 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. If the effects are assessed to be harmful, child welfare authorities must be notified. Clinicians should try 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 denounced by global bodies such as the World Health Organization (WHO) and UNICEF. The WHO identifies four types of female genital mutilation/cutting (FGM/C).

Although Canadian laws protect against FGM/C, 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 resource on Female Genital Mutilation.

Other cultural considerations

While the following issues are not specific to newcomer families, clinicians should be aware that human trafficking, “honour” violence, child/early/forced marriage and war crimes against children are human rights violations. Addressing such issues requires a culturally sensitive assessment and appropriate protections if concerns arise.

How is child maltreatment defined in Canada?

In Canada, child maltreatment is commonly categorized into these types:

• physical abuse,
• sexual abuse,
• neglect,
• emotional abuse, and
• exposure to intimate partner violence (IPV).

Physical abuse

Physical abuse refers to the 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. Canadian and international entities (including the Canadian Paediatric Society), 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 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.^[12]

Under the child welfare system, case decisions are based on the “balance of probabilities,” as opposed to “beyond a reasonable doubt” used in the criminal justice system. Child welfare authorities may determine that a child needs 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 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.

Relationships 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.

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 vitally important, particularly for girls. In the case of sexual abuse, loss of virginity may be blamed on the victim, and is perceived to “bring shame” to the victim and her family. This 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.

Neglect

Neglect refers to acts of omission by a caregiver that result in actual or potential harm to the child, regardless of intention.^[13] 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 as poor access to nutritional foods; unfamiliarity with Canadian dietary practices; or exposure to messaging that 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 happens 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. Emotional harm is sometimes the primary form of maltreatment, but it more commonly co-occurs with other forms of maltreatment.

Exposure to intimate partner violence (IPV)

Children’s exposure to intimate partner violence between parents and other caregivers accounts for nearly half of all cases investigated and substantiated by child welfare authorities in Canada. IPV is directly harmful not only to the adult victim, but also to a child or youth who witnesses the violence. In addition, there is a 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. 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.

What are the obligations to report suspected child 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 matter 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 Indigenous 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 needs protection. Personal health information can be shared with child welfare authorities without a child’s or parent’s consent when it is needed for an active child maltreatment investigation. All relevant information should be shared in an objective, accurate and unbiased manner.

Sharing personal health information with law enforcement officers (i.e., the police) usually requires consent of the child (if capable of consent) or the child’s legal guardian, or a warrant or court subpoena.

What is the clinician’s role?

Clinicians have a professional and ethical responsibility to identify, prevent, and respond to child maltreatment. Asking careful, sensitive and respectful questions and being aware of different beliefs and practices can yield a clearer picture of the patient’s home life and possible risks.^[14]

Racialized populations in Canada, including immigrant and refugee families, encounter multiple barriers including discrimination within the health care system.^[10][11] Health professionals can support newcomer families’ access to health care services 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.

Health professionals should also do the following to help identify, prevent, and respond appropriately in maltreatment cases:

1. Be aware of the laws that apply to child welfare in your region. Consult the Child Welfare Research Portal for information.
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 adopt parenting practices that are healthy, beneficial and safe.
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. Read about the use of interpreters in health care settings.
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 contradict Canadian laws, child welfare and human rights standards (e.g., female genital mutilation/cutting), managing abuse within families, intimate partner violence, and early or forced marriage).
10. Identify areas of family needs and strengths, recommend and advocate for supportive resources. You can find a list of community agencies that provide services to newcomer families here and tips on a dvocating for immigrant and refugee children here.
11. Be mindful of your own values, assumptions and biases, and how they might impact clinical interactions and perceptions of maltreatment.

What is the role of child welfare authorities?

Child welfare authorities are responsible for protecting children when maltreatment or 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” under this 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. Although clinicians sometimes worry that reporting a case of possible child abuse will result in the child being removed from their home, there is no change in the child’s living situation in more than 90% of reported cases. Only about 8% of child welfare investigations lead to changes in a child’s living situation, including about 5% 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 taken place.

References

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11. Pollock G, Newbold KB, Lafrenière G, Edge S. Discrimination in the doctor’s office: Immigrant and refugee experiences. Crit Soc Work. 2012;13(2):60-79.
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14. Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: An update for 2023. Child Abuse Negl. 2023;145:106283. doi:10.1016/j.chiabu.2023.106283.