"You're an idiot! Why did you do that?" Smack, whack, slam . . . does this sounds like any way you would treat a child? Well, unfortunately, this is the reality for many children throughout the United States. Abuse is found in many homes, kept a secret behind closed doors. Whether they are first hand recipients of physical touch, being yelled at or witnessing the abuse of another, the effects are deep and long felt.

Rate of Child Abuse

In the U.S., there has been an increase in child abuse. The nation's economic concerns during the recent recession have not only brought hardship to many families, but the accompanying stress may also lead to an increase in physical child abuse. Scientific research and anecdotal reports have long shown that economic hardship leads to an increase in the incidence of abuse. According to information presented at the annual meeting of the American Academy of Pediatrics, there has been an increase in shaken baby syndrome for children under the age of five.

To better understand the link between economic hardship and abuse, a team of medical researchers from Children's Hospital Pittsburgh reviewed medical records of children under age 5 with abusive head trauma. The research consisted of 422 children who lived in 74 counties across four states (Washington, Pennsylvania, Ohio and Kentucky) spanning the years from 2004 to 2009. The first four years of the study preceded the recession and the last 19 months coincided with it. The study found that about 65 abusive head trauma cases occurred each year before the recession, compared to about 108 annually during the recession. The average age of children with the injury was 8.9 months; most suffered brain damage and 69 children died, though the death rate didn't appear to rise during the recession. This documentation showed that cases rose 65% with about nine per 100,000 children in pre-recession years, to almost 15 per 100,000 kids during the recession.

In January, the Centers for Disease Control and Prevention released its annual vital statistics report, and upon its release, news headlines ran celebrating that, for the first time in more than 45 years, homicide was not a leading cause of death in the U.S. Unfortunately, this wasn't the case for young children. According to the preliminary data report, assault was the third leading cause of death for children 1 to 4 years old in 2010. That means that nearly 370 of the approximately 4,300 children that died in the U.S. during 2010, died at the hands of another person. These results are heartbreaking, and present an opportunity for us to analyze how we can play a part in breaking the cycle.

Understanding Abuse Factors

In order to have a better understanding of how massage and nurturing touch can play a part in making a difference, we must first look at factors that contribute to this growing issue. There are specific risk factors associated with being a victim. According to the Centers for Disease Control and Prevention, factors include being a child under the age of four years old and having specific special health care needs that might cause an increased burden on caregivers. Children with special health care needs, including those with physical and mental differences, may even be abused in higher numbers due to the stress the caregivers feel in having to provide extra care.

Just as there are specific factors associated with being victimized, there are also marked characteristics of perpetrators. Often, parents who lack an understanding of a child's needs, child development or lack significant parenting skills might find themselves stressed and unprepared to care for a child. Many parents also possess their own history of abuse and maltreatment. Often times, parents and caregivers repeat what they have learned during their childhood.  Substance abuse and/or mental health issues including depression in the family might play a role in abusive behavior. Parental characteristics such as young age, low education, single parenthood, large number of dependent children and low income are also key factors contributing to this issue.

Why Massage

Scientific evidence supports that providing a supportive family environment and social networks contributes to breaking the cycle of child abuse. There are several additional protective factors, however, research is currently ongoing to determine whether the following factors do indeed protect children from abuse and maltreatment. Such factors include providing nurturing parent education and skills, stable family relationships, and caring adults outside of the family who can serve as role models or mentors. Communities can also contribute to childhood abuse prevention when they support parents and take responsibility for preventing abuse.

So, the question is, what do we need to think about as massage practitioners who wish to do our part to ease childhood trauma associated with abuse and provide an opportunity for breaking the cycle. If you are currently working or thinking about working hands-on in pediatric massage therapy, you need to remember to empower the child by using a structured permission process, safe positioning and giving choices. A structured permission process includes explaining the massage in terms the child will understand. Give the child phrases or code words for yes, no and stop. The reason for using a code word is not to reinforce that a child may not say "no," but rather to give them permission to say no without having to say the word "no." Many abused children will have a history of knowing they cannot say no to anything.

Safe positioning is needed to empower the child. It is recommended that you always begin with the child in a sitting up position. This is important, as laying supine feels very vulnerable, while lying prone feels vulnerable and does not provide for the pediatric client to see what is happening to them. Additionally, stay within a safe distance. Do not cross the personal bubble until the child has given you permission to do so. Give the child many choices. Not an overwhelming amount of choices. However, you want to let the child know they are in charge. Remember, they have likely never felt in charge of anything. Feeling out of control and confused does not create the best nurturing environment. It is advisable that you do not give a choice of removing clothing at the first session. This is important, as you want the child to feel safe and secure. Allowing them to keep their clothing on, even shoes and socks, provides for the safest beginning.

Not only should we provide the best environment for the child, whenever possible, we should try to include a parent who is likely also a victim of abuse. Many times, I have provided education on massage for infants and children in shelters for domestically abused women and their children. Education is important. If the parent has also been a victim of abuse, how do they know how to give and receive gentle touch appropriately?

Breaking the Cycle

During one visit at a shelter, I sat on the floor with the mothers and their children. We had a mixed group of mothers with infants, toddlers and children. One little boy, Sam, was six-years-old and sat next to his mother during the class. The director of the shelter had shared with me that Sam was quite an aggressive little boy and would lash out often. Throughout our lesson, Sam refused to have his mother massage him. As we began massage on each body area, we took time and asked permission. Every time mom asked Sam's permission, he said no. He instead asked a teddy bear's permission and would massage the bear. As it came time to massage the face, I had an idea. I suggested Sam ask mom if she would like a massage on her face. He liked this idea and scooted in front of his mom, warmed his hands and asked permission. Sam watched diligently as I demonstrated each massage stroke on my face. He lovingly placed his hands on mom's cheeks and provided gentle strokes. Sam asked her if the massage was too hard. Mom said no, it felt good, as the tears streamed down her cheeks. Together, they shared a special moment I felt privileged to witness.

Throughout the months following our class, I have kept in touch with the shelter director and am very happy to report that Sam has successfully integrated into his new school. He is no longer as aggressive and has made friends very easily. Mom is adapting well to their new life. Both mom and the shelter director have credited our massage time as the intervention that broke the cycle of abuse. The traumatizing effects of abuse might be felt for a very long time. However, using nurturing touch might be one effective tool to help break the cycle and help children to feel loved and valued. Many times it is not only our hands which provide the best care, but rather our hearts and minds sharing the information to empower others to be successful.

References:

1. Child Maltreatment: Risk and Protective Factors, retrieved January 20, 2012, from Centers for Disease Control and Prevention,website: www.cdc.gov/ViolencePrevention/childmaltreatment/riskprotectivefactors.html.
2. CDC National Vital Statistics released January 11, 2012, retrieved January 18, 2012, from Centers for Disease Control and Prevention website: www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf.
3. Berger RP, Fromkin JB, Stutz H, Makoroff K, Scribano PV, Feldman K, Tu LC, Fabio A. (2011). Abusive head trauma during a time of increased unemployment: a multicenter analysis. Pediatrics. 2011 Oct;128(4):637-43. Epub 2011 Sep 19.
4. Jones R., et. al (2008). Clinicians' description of factors influencing their reporting of suspected child abuse: report of the Child Abuse Reporting Experience Study Research Group. Pediatrics. 2008 Aug;122(2):259-66.
5. Sege R, et. al. (2011). To report or not to report: examination of the initial primary care management of suspicious childhood injuries. Academic Pediatrics, 2011 Nov-Dec;11(6):460-6. Epub 2011 Oct 12.