Child and youth advocacy centres: A change in practice that can change a lifetime

Abstract

While often a silent and invisible issue, childhood trauma is pervasive, and has profound individual, societal and economic impacts. Many forms of childhood trauma exist, including child physical and sexual abuse. Given the prevalence, impact and availability of prevention and intervention approaches, child abuse deserves the same level of awareness, policy priority and investment as is directed to other issues of significant public health importance. The complex issue of child abuse requires a coordinated multifaceted response, which minimizes system trauma and revictimization for the child and family. The Child and Youth Advocacy Centre (CYAC) model brings together various sectors to create an integrated, multidisciplinary response that is client-centred and trauma-informed. To ensure that all children, youth and their families who have experienced maltreatment have access to the CYAC model of care when needed, sustainable funding investment in CYACs should be a priority for government at all levels.

When you ask a paediatric clinician what they would rank as the single most impactful social determinant of health, the response is likely to be income, education, housing or social support. Childhood trauma rarely makes the list, but mounting evidence suggests that it should. Given the prevalence, scope of impact and availability of prevention and intervention approaches, we advocate that childhood trauma, and more specifically, child abuse, requires the same level of awareness, policy priority and investment as is directed to other issues of significant public health importance. As an effective model to address child abuse, we suggest that Child and Youth Advocacy Centres (CYACs) should form part of this investment.

While often an invisible issue, child abuse is pervasive, and has profound individual, societal and economic impacts. The substantial effects of childhood trauma, abuse and toxic stress are being unearthed. Diverse fields of research, including molecular genetics, neurobiology and population health are contributing to a growing base of knowledge about the significant and long-term consequences of early childhood adversity.

Perhaps in view of this, in their report to the Law Commission of Canada on the economic burden of child abuse, Bowlus et al. (1) conclude that ‘a well-planned and thoughtful investment of significant public funds in early detection, prevention and treatment of all forms of child abuse is not only a moral necessity for Canadian society, it is sound fiscal policy that will directly benefit us all’. We echo this in advocating that public policy attention and investment of resources must match the magnitude of child abuse as a pervasive public and social health issue.

In a 2014 study, Afifi et al. (2) reported the prevalence of child abuse to be 32.1% in a nationally-representative Canadian sample, which included reported childhood experiences of sexual abuse (10.1%), physical abuse (26.1%) and/or exposure to intimate partner violence (7.9%). 2.4% of respondents reported having experienced all three types of abuse.

Child abuse can have readily-apparent effects on a child’s physical, emotional and social well-being, but the impacts extend far beyond these immediate consequences. In the largest study of its kind, the ‘Adverse Childhood Experiences’ (ACEs) study found a dose–response relationship between specific types of childhood adversity (including abuse, neglect, exposure to domestic violence and household dysfunction) and poor long-term health outcomes (3).

In addition to the significant individual consequences, the economic costs of early adversity are substantial, both in health care, and across other impacted sectors (including child welfare, justice, education and employment). The lifetime cost of child abuse has been estimated at $210,012 USD per victim (2012 dollars) (4). In their 2003 study, Bowlus et al. (1) estimated the overall annual economic cost of child abuse in Canada to be $15.7 billion (1998 dollars), noting this to be a conservative estimate. Expressed in 2017 dollars, this represents an annual cost of $22.4 billion. By comparison, this is up to four times greater than the estimated annual direct and indirect costs associated with obesity (5) (estimated $5.25 to $8.4 billion in 2017 dollars), and is roughly equivalent to costs associated with tobacco use (6) (estimated $22.25 billion in 2017 dollars).

Despite the prevalence and impact of child abuse, the level of awareness and investment in this problem is substantially lower than other public health problems of similar scope. For example, in comparison to the discourse about childhood nutrition and obesity or smoking, the conversation about child abuse remains muted, with public dialogue lacking the energized, passionate tone required to effect change. In part, this is likely due to the cognitive dissonance the issue of child maltreatment creates. Acknowledging the problem of child abuse forces us to confront a difficult and uncomfortable reality: that a significant proportion of the children we encounter in our practices, schools and neighbourhoods have been or will be hurt, often by an adult who is close to them. Equally distressing is the concept that when we, as protective, rational and thoughtful adults, remain silent, we play a role in enabling ongoing victimization through a failure in education, failure of investment in public policy or failure to ask the right questions. The discomfort with the topic of child abuse is understandable, but not excusable.

At some point in their practice, paediatric clinicians will encounter a child or family in whom there are concerns of trauma or abuse. Appropriate recognition and action are critical, yet there may be a sense that the responsibility to respond rests mainly with local child welfare and law enforcement agencies that hold the mandate to investigate, leaving the clinician in an ancillary role. In fact, the response needed may be multifaceted, requiring the intersecting involvement of child welfare, law enforcement, medical care, mental health services and victim support. These agencies all have separate mandates that address specific aspects of an overall case, but often have overlap in the information they require, their level of involvement and their interactions with the family. Working separately, this creates a fragmented system which reinforces an isolated and reductionist approach to service delivery. This can be confusing and inefficient, and places additional strain on the child, family, clinicians and agencies involved in this difficult work.

The Child and Youth Advocacy Centre (CYAC) model addresses this, by bringing these sectors together to create a more coordinated, multidisciplinary approach in a welcoming, trauma-informed and age-appropriate environment. The model seeks to minimize additional system trauma and revictimization by limiting the number of times a child must repeat their story, providing early and seamless access to services and ensuring the family has adequate support and follow-up. In addition to improving client experience, this integrated model strives to provide a more efficient and collaborative approach for the agencies involved, strengthening the collective quality of each sector’s work through timely access to information and multidisciplinary perspectives. CYACs may differ in their specific structure and scope of services based on the needs of their communities, but the core elements and goals remain consistent across the model (7).

CYACs have been shown to offer better access to forensic medical exam (48% CYAC versus 21% non-CYAC) (8) and mental health services (72% versus 31%), with more coordinated and collaborative investigations (9), and faster decision making in criminal charges (10). In addition to reduced delays and travel time for families, the CYAC model is estimated to offer better process efficiency and productivity improvements for professionals. A 2015 social return on investment study at the Sheldon Kennedy Child Advocacy Centre in Calgary estimated that the centre’s integrated approach resulted in productivity improvements equivalent to $550,000 annually (11).

The concept of a CYAC is not new—having originated in Alabama in the mid-1980’s, there are now over 800 CYACs in the USA, which last year served over 300,000 child victims of abuse (12). The model has grown internationally, and in Canada, the first CYAC (Zebra Child Protection Center) was founded in Edmonton in 2002. Creation of more CYACs progressed slowly through the early 2000’s, until a commitment of seed funding in 2010 from Justice Canada’s Victims Fund spurred accelerated expansion of the model across the country. Over 35 CYACs now exist in various stages of development across Canada, with a federal investment of $10.3 million in the past 7 years. In comparison, the National Children’s Alliance will be administering $8.1 billion in federal funds this year alone for the establishment, improvement, and expansion of CYACs in the USA.

While the increase in CYACs in Canada is changing the landscape in how we respond to child abuse, much more work is still required. Secured, sustainable funding remains an ongoing challenge for many CYACs, and further integration of the model as the community standard of practice is needed. Continued support for CYACs needs to be an ongoing priority of our federal government as an investment in the health and well-being of Canadian children and youth.

CONCLUSION

While often an invisible issue, child abuse is pervasive, and has profound individual, societal and economic impact. Public policy attention and investment of resources must match the magnitude of child abuse as a pervasive public and social health issue.

All Canadian children and youth who have disclosed abuse should have access to the comprehensive, trauma-informed response of a CYAC, regardless of where they live. In addition to improving the direct service experience for children, youth and families, CYACs can transform a community’s overall understanding and response to child abuse by becoming a hub for education, outreach, prevention, research and policy development. As a whole, CYACs offer the chance to change the lifetime trajectory for children who have experienced abuse.

The responsibility to address child abuse is not borne by any one sector alone—a concern of maltreatment will ultimately reflect back onto all aspects of society. It is a problem that we all own, and as a result, it is a problem that requires a collective response. Child and Youth Advocacy Centres present an effective, feasible public policy approach, and ongoing, sustainable funding investment should be a priority for government at all levels.

Conflict of Interest

CLS and AEO report grants from Department of Justice Canada during the conduct of the study.

Originating Institution: IWK Health Centre, Halifax, Nova Scotia.