Child Abuse - A Universal Challenge
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
No country or community is untouched by violence. Child abuse has for a long time been recorded in literature, art and science in many parts of the world. Reports of infanticide, mutilation, abandonment and other forms of violence against children date back to ancient civilizations. For a long time also there have existed charitable groups and others concerned with children's well-being who have advocated the protection of children. Nevertheless, the issue did not receive widespread attention by the medical profession or the general public until 1962, with the publication of a seminal work, The battered child syndrome, by Kempe et al. The term "battered child syndrome" was coined to characterize the clinical manifestations of serious physical abuse in young children. Now, five decades later, there is clear evidence that child abuse is a global problem. It occurs in a variety of forms and is deeply rooted in cultural, economic and social practices. Since then, a wide range of public health practitioners and researchers in the United States and around the world have set themselves the task of understanding violence and finding ways to prevent it. The issue was put on the international agenda when the World Health Assembly, at its meeting in Geneva in 1996, adopted a resolution declaring violence a leading worldwide public health problem.
The purpose of this document is to address child abuse and neglect, like other forms of domestic violence. Any global approach to child abuse must take into account the differing standards and expectations for parenting behavior in the range of cultures around the world. Culture is a society's common fund of beliefs and behaviors, and its concepts of how people should conduct themselves. Culture helps define the generally accepted principles of child-rearing and care of children. This report identifies and discusses the legal and ethical concepts related to these circumstances. The report offers implementation suggestions when establishing anticipatory office procedures and training programs for staff on what to do (and not to do) in such situations to maximize the child's well-being and safety. The health sector has both a special interest and a key role to play in preventing child abuse and maltreatment.
According to the World Health Organization, there were an estimated 57,000 deaths attributed to homicide among children under 15 years of age in 2005. Global estimates of child homicide suggest that infants and very young children are at greatest risk, with rates for the 0-4-year-old age group more than double those of 5-14-year-olds. The risk of fatal abuse for children varies according to the income level of a country and region of the world. For children under 5 years of age living in high-income countries, the rate of homicide is 2.2 per 100,000 for boys and 1.8 per 100,000 for girls. In low- to middle-income countries the rates are 2-3 times higher -- 6.1 per 100,000 for boys and 5.1 per 100,000 for girls. The highest homicide rates for children under 5 years of age are found in the World Health Organization African Region -- 17.9 per 100,000 for boys and 12.7 per 100,000 for girls. The lowest rates are seen in high-income countries in the WHO European, Eastern Mediterranean and Western Pacific Regions. In the United States 3 million children were reported as having been abused in 2005 and almost 1 million children were confirmed by child protective service agencies as victims of child maltreatment. According to a 2005 survey in USA, physical abuse represented 23% of confirmed cases, sexual abuse 9%, neglect 60%, emotional maltreatment 4%, and other forms of maltreatment 5%. An estimated 11 to 17.5 million children are being raised by a substance-abuse parent or guardian. The importance of this statistic is undeniable, particularly when a patient is brought to a pediatric office by a parent or guardian exhibiting symptoms of judgment impairment. Clearly, this represents a substantial public health problem that most pediatricians will encounter at some point in their careers.
Despite the apparent widespread misclassification, there is general agreement that fatalities from child abuse are far more frequent than official records suggest in every country where studies of infant deaths have been undertaken. Among the fatalities attributed to child abuse, the most common cause of death is injury to the head, followed by injury to abdomen. Intentional suffocation has also been extensively reported as a cause of death. The Children of Alcoholic Foundation estimates that there are between 11 and 17.5 million children in the United States younger than 18 years currently living with a parent with alcoholism. The number of children living in homes with an adult who abuses drugs is unknown. According to the Boys Town National Research Hospital, children with disabilities were found to be at greater risk of becoming victims of abuse and neglect than children without disabilities. The study showed that children with disabilities are 1.8 times more likely to be neglected, 1.6 times more likely to be physically abused, and 2.2 times more likely to be sexually abused than children without disabilities.
The financial costs associated with both the short-term and long-term care of victim form a significant proportion of the overall burden created by child abuse and neglect. Available data from a few developed countries illustrate the potential financial burden. In 2005, the financial cost associated with child abuse and neglect in the United States was estimated at some 14.5 billion. This figure included estimates for future lost earnings, educational costs and adult mental health services. In the United Kingdom, and estimated annual cost of nearly 2.2 billion has been cited for immediate welfare and legal services alone. The costs of preventive interventions are likely to be exceeded many times over by the combined total of short-term costs of child abuse and neglect to individuals, families and society. A range of indirect costs are related to lost productivity, disability, decreased quality of life and premature death. There are also costs borne by the criminal justice system and other institutions, including: expenditures related to apprehending and prosecuting offenders; the costs to social welfare organizations of investigating reports of maltreatment and protecting children from abuse; costs associated with foster care; costs to the education system; costs to the employment sector arising from absenteeism and low productivity.
The International Society for the Prevention of Child Abuse and Neglect recently compared definitions of abuse from 58 countries and found some commonality in what was considered abusive. In 1999, the WHO Consultation on Child Abuse Prevention drafted the following definition: "Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power." This definition covers a broad spectrum of abuse. Some definitions focus on the behaviors or actions of adults while others consider abuse to take place if there is harm or the threat of harm to the child. The distinction between behavior -- regardless of the outcome -- and impact or harm is a potentially confusing one if parental intent forms part of the definition. Some experts consider as abused those children who have been inadvertently harmed through the actions of a parent, while others require that harm to the child be intended for the act to be defined as abusive. Some of the literature on child abuse explicitly includes violence against children in institutional or school settings.
Types of child abuse and neglect:
As our understanding of child maltreatment has increased, its definition has broadened. Currently the term child maltreatment includes all intentional harm to, or avoidable endangerment of, someone under age 18. Specific acts of maltreatment fall into one of two broad categories -- abuse, which includes all actions that are deliberately harmful to a child's well-being, and neglect, which involves failure to act appropriately to meet a child's basic needs. Most professionals further divide both abuse and neglect into three sub-categories of maltreatment.
1. Physical Abuse -- deliberate, harsh injury to the body. Signs of physical abuse include broken limbs and battered bodies, as well as less obvious symptoms, such as similar abrasions on both sides of the face or body, X-rays that reveal old, poorly knit fractures, CAT-scans that show bleeding in the brain, and burn marks that are small and round (from lit cigarettes), lattice-like (from hot radiators), or that stop part-way up the body (from scalding bathwater). Available research suggests that the rates for many other countries are no lower, and may be indeed higher than the estimates of physical abuse in the United States. Data from the World Studies of Abuse in the Family Environment (WorldSAFE) project are illuminating about patterns of more "moderate" forms of physical discipline in different countries. Moderate discipline is not universally agreed to be abusive, though some professionals and parents regard such forms of discipline as unacceptable. Severe and more moderate forms of discipline are not limited to the family of home environment. A substantial amount of harsh punishment occurs in schools and other institutions at the hands of teachers and others responsible for the care of children.
2. Emotional and Psychological Abuse -- deliberate destruction of self-esteem and equanimity. The most common type is repeated verbal abuse, ranging from angry threats to incessant criticism. Another type is social isolation, such as shutting a small child in a dark closet or keeping an adolescent housebound and friendless. Psychological abuse against children has been allotted even less attention globally than physical and sexual abuse. Cultural factors appear strongly to influence the non-physical techniques that parents choose to discipline their children -- some of which may be regarded by people from other cultural backgrounds as psychologically harmful. Psychological maltreatment of children occurs when a person conveys to a child that he of she is worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs. The perpetrator may spurn, terrorize, isolate, or ignore or impair child's socialization. If severe and/or repetitious, the following behaviors may constitute psychological maltreatment: spurning (belittling, degrading, shaming, or ridiculing a child, singling out a child to criticize or punish, and humiliating a child in public); terrorizing (committing life-threatening acts, making a child feel unsafe, setting unrealistic expectations with threat of loss, harm, or danger if they are not met, and threatening or perpetrating violence against a child or child's loved ones or objects); exploiting or corrupting that encourages a child to develop inappropriate behaviors (modeling, permitting, or encouraging antisocial or developmentally inappropriate behavior, encouraging or coercing abandonment of developmentally appropriate autonomy, restricting or interfering with cognitive development); denying emotional responsiveness (ignoring a child or failing to express affection, caring, and love for a child); rejecting (avoiding or pushing away); isolating (confining, placing unreasonable limitations on freedom of movement or social interactions); unreliable or inconsistent parenting (contradictory and ambivalent demands); neglecting mental health, medical, and educational needs (ignoring, preventing, or failing to provide treatments or services for emotional, behavioral, physical, or educational needs or problems); witnessing intimate partner violence (domestic violence).
3. Sexual Abuse -- children may be sexually abused by family members or non-family members and more frequently abused by males. Boys may be victimized nearly as often as girls, but may not be as likely to disclose the abuse. Sexual abuse occurs when a child is engaged in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give consent, and/or that violate the law or social taboos of society. The sexual activities may include all forms of oral-genital, genital, or anal contact by or to the child, or non-touching abuses, such as exhibitionism, voyeurism or using the child in the production of pornography. Sexual abuse includes a spectrum of activities ranging from rape to physically less intrusive sexual abuse. Healthcare providers should be aware that child sexual abuse often occurs in the context of other family problems including physical abuse, emotional maltreatment, substance abuse, and family violence. Of these problems are suspected, referral for a more comprehensive evaluation is imperative. In difficult cases, healthcare providers may find consultation with a regional child abuse specialist or assessment center helpful. All healthcare providers in the United States are required under the laws to each state to report suspected as well as known cases of child abuse.
Manifestations of child abuse and neglect:
Injuries inflicted by a caregiver on a child can take many forms. Serious damage or death in abused children is most often the consequence of a head injury or injury to the internal organs. Head trauma as a result of abuse is the most common cause of death in young children, with children in the first 2 years of life being the most vulnerable. Because force applied to the body passes through the skin, patterns of injury to the skin can provide clear signs of abuse. The skeletal manifestations of abuse include multiple fractures at different stages of healing, fractures of bones that are very rarely broken under normal circumstances, and characteristic fractures of the ribs and long bones.
The shaken baby syndrome: Shaking is a prevalent form of abuse seen in very young children. The majority of shaken children are less than 9 months old. Most perpetrators of such abuse are male, though this may be more a reflection of the fact that men, being on average stronger than women, tend to apply greater force, rather than that they are more prone than women to shaken children. Intracranial hemorrhages, retinal hemorrhages and small "chip" fractures at the major joints of the child's extremities can result from very rapid shaking of an infant. They can also follow from a combination of shaking and head hitting a surface. There is evidence that about one-third of severely shaken infants die and that the majority of the survivors suffer long-term consequences such as mental retardation, cerebral palsy or blindness.
The battered child syndrome: One of the syndromes of child abuse is the "battered child". This term is generally applied to children showing repeated and devastating injury to the skin, skeletal system or nervous system. It includes children with multiple fractures of different ages, head trauma and severe visceral trauma, with evidence of repeated infliction. Fortunately, though the cases are tragic, this pattern is rare.
Failure to thrive: It is a common problem in infancy and childhood. It is most often multifactorial in origin. Inadequate nutrition and disturbed social interactions contribute to poor weight gain, delayed development, and abnormal behavior. When failure to thrive is caused by child neglect, certain risk factors are often present. Poverty is the greatest single risk factor for failure to thrive worldwide and in the United States. The syndrome develops in a significant number to children as a consequence of child neglect. The risk factors that should alert the pediatrician to the possibility of neglect as the cause of failure to thrive include -- parental depression, stress, marital strife, divorce; parental history of abuse as a child; mental retardation and psychological abnormalities in the parent(s); young and single mothers without social support; domestic violence; alcohol or other substance abuse; previous child abuse in the family; social isolation and/or poverty; parents with inadequate adaptive and social skills; parents who are overly focused on career and/or activities away from home; failure to adhere to medical regimens; lack of knowledge of normal growth and development; and/or infant with low birth weight or prolonged hospitalization.
Munchausen Syndrome: The condition widely known as Munchausen syndrome by proxy comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. Although it is a relatively rare form of child abuse, pediatricians need to have a high index of suspicion when faced with seemingly inexplicable findings or treatment failures. The fabrication of pediatric illness is a form of child abuse and not merely a mental disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV) refers to Munchausen syndrome as "factitious disorder", and motivations for this bizarre behavior continue to puzzle both medical and mental health professionals. There is no typical presentation for this condition. It includes the following examples -- a mother takes her child to the doctor for frequent evaluations for sexual abuse, even in the absence of objective evidence or history of abuse; mothers insist their children be treated for attention-deficit/hyperactivity disorder although there is no evidence to make the diagnosis; a parent starves her child because she wrongly believes the child has multiple food allergies; physicians suspect an unusual hematological disorder after a mother repeatedly and secretly bruises her child; a parent purposely suffocates her child and kills him during a hospitalization for "apnea". Whether it is called Munchausen syndrome by proxy, pediatric symptom falsification, or simply child abuse, what remains as the central issue of importance is that caregiver causes injury to a child that involves unnecessary and harmful or potentially harmful medical care.
Prevention of Child Abuse and Neglect:
While the prevention of child abuse is almost universally proclaimed to be an important social policy, surprisingly little work has been done to investigate the effectiveness of preventive interventions. The majority of programs focus on victims or perpetrators of child abuse and neglect. Very few emphasize primary prevention approaches aimed at preventing child abuse and neglect for occurring in the first place.
Family Support Approaches: These types of programs generally educate parents on child development and help improve their skills in managing their children's behavior. While most of these programs are intended for use with high-risk families or those families in which abuse has already occurred, it is increasingly considered that providing education and training in this area for all parents or prospective parents can be beneficial. The principal aim is to prevent further abuse, as well as other negative outcomes for the child, such as emotional problems or delayed development. Home visitation programs bring community resources to families in their homes. This type of intervention has been identified as one of the most promising for preventing a number of negative outcomes, including youth violence and child abuse. During the home visits, information, support and other services to improve the functioning of the family are offered. A number of different models for home visitation have been developed and studied. In some, home visits are provided to all families, regardless of their risk status, whereas others focus on families at risk for violence, such as first-time parents or single and adolescent parents living in communities with high rates of poverty. Intensive family preservation services are designed to keep the family together and to prevent children from being placed in substitute care. Targeted towards families in which child maltreatment has been confirmed, the intervention is short (lasting a few weeks or months) and intense, with generally 10-30 hours a week devoted to a particular family, either in the home or somewhere else that is familiar to the child. A broad array of services are usually offered, according to the needs of the family, including various forms of therapy and more practical services such as temporary rent subsidies.
Health Services Approaches: The detection of child abuse and neglect is not always straightforward. Specific interview techniques and types of physical examination are generally required. Health care professionals have a key part to play in identifying, treating and referring cases of abuse and neglect and in reporting suspected cases of maltreatment to the appropriate authorities. It is vital that cases of maltreatment are detected early on, so as to minimize the consequences for a child and to launch the necessary services as soon as possible. To maintain a continuing dynamic process of education, some researchers have suggested multi-component, structured curricula for health professionals, according to their particular level of involvement with child abuse cases. Separate but integrated courses of training would be developed for medical students and physicians in training, and for those with a specific interest in child abuse. Evaluations of training programs have focused principally on the health care worker's knowledge of child abuse and behavior. Because pediatricians are concerned with physical and emotional welfare of children, they are in a unique position to recognize and report psychological maltreatment. The pediatrician may be the only professional who has regular contact with maltreated children before they enter school. Early recognition and reporting of suspected psychological maltreatment to proper authorities, with the provision of therapeutic services, may prevent or ameliorate the consequences of psychological maltreatment.
Therapeutic Approaches: Maltreated preschool children are usually highly withdrawn socially. Review of treatment programs for physically abused children found that therapeutic day care -- with an emphasis on improving cognitive and development skills is the most popular approach. It has been designed throughout the world. As with physical abuse, the manifestations of sexual abuse can vary considerably, depending on a number of factors, such as the individual characteristics of the victim and the relationship of the perpetrator to the victim and the circumstances of the abuse. Consequently, a wide variety of intervention approaches and treatment methods have been adopted to treat child victims of sexual abuse, including individual, group and family therapy. One of more recent additions to the collection of intervention strategies is services for children who witness domestic violence. Research has shown that such exposure may have numerous negative consequences. For instance, children who witness violence are more likely to reproduce, as adults, dysfunctional relationships within their own families. A number of studies have found a link between a history of child abuse and a range of conditions, including substance abuse, mental health problems and alcohol dependence. In addition, victims of child abuse may not be identified as such until later in life and may not have symptoms until long after the abuse has occurred. For these reasons, there has been a recent increase in services for adults who were abused as children, and particularly in referrals to mental health services.
Community-based interventions often focus on a selected population group or are implemented in a specific setting, such as in schools. There may also be conducted on a wider scale -- over a number of population segments, for instance, or even the entire community -- with the involvement of many services.
School Programs: To prevent child sexual abuse are one of the most widely applied preventive strategies and have been incorporated into the regular school curriculum in several countries. These programs are generally designed to teach children how to recognize threatening situations and to provide them with skills to protect themselves against abuse. The concepts underlying the programs are that children own and can control access to their bodies and there are different types of physical contact. Children are taught how to tell an adult if they are asked to do something they find uncomfortable. School programs vary widely in terms of their content and presentation and many also involve parents or caregivers. Widespread prevention and educational campaigns are another approach to reducing child abuse and neglect.
National Policies and Programs: Most prevention efforts for child maltreatment focus on victims and perpetrators without necessarily addressing the root causes of the problem. It is believed, though, that by successfully tackling poverty, improving educational levels and employment opportunities, and increasing the availability and quality of child care, rates of child abuse and neglect can be significantly reduced. Other policies that can indirectly affect levels of child abuse and neglect are those related to reproductive health. It has been suggested that liberal policies on reproductive health provide families with a greater sense of control over the size of their families and that this, in turn, benefits women and children. Such policies, for instance, have allowed for more flexibility in maternal employment and child care arrangements. The nature and scope of these policies is, however, also important. Some researchers have claimed that policies limiting the size of families, such as the "one child" policy in China, have had the indirect effect of reducing rates of child abuse and neglect, though others point to the increased numbers of abandoned girls in China as evidence that such policies may actually increase the incidence of abuse.
International Treaties: In November 1989, the United Nations General Assembly adopted the Convention on the Rights of the Child. A guiding principle of the Convention is that children are individuals with equal rights to those of adults. Since children are dependent on adult, though, their views are rarely taken into account when governments set out policies. At the same time, children are often the most vulnerable group as regards government-sponsored activities relating to the environment, living conditions, healthcare and nutrition. The Convention on the Rights of the Child provides clear standards and obligations for all signatory nations for the protection of children. The Convention on the Rights of the Child is one of the most widely ratified of all the international treaties and conventions. Its impact, though, in protecting children from abuse and neglect has yet to be fully realized.
Legal and Related Remedies:
The reporting by health professionals of suspected child abuse and neglect is mandated by law in various countries, including Argentina, Finland, Israel, Kyrgyzstan, the Republic of Korea, Rwanda, Spain, Sri Lanka and the United States. Various types of voluntary reporting systems exist around the world, in countries such as Barbados, Cameroon, Croatia, Japan, Romania and the United Republic of Tanzania. In the Netherlands, suspected cases of child abuse can be reported voluntarily to one or two separate public agencies -- the Child Care and Protection Board and the Confidential Doctor's Office. All pediatricians in the United States are required under the laws of each state to report suspected as well as known cases of child sexual abuse. The legal issues confronting pediatricians in evaluating sexually abused children include mandatory reporting with penalties for failure to report; involvement in the civil, juvenile, or family court systems; involvement in divorce or custody proceedings in divorce courts; and involvement in criminal prosecution of defendants in criminal court. In addition, there are medical liability risks for pediatricians who fail to diagnose abuse or who misdiagnose other conditions as abuse.
Criminal justice policies vary markedly, reflecting different views about the role of the justice system with regard to child maltreatment. The decision whether to prosecute alleged perpetrators of abuse depends on a number of factors, including the seriousness of the abuse, the strength of evidence, whether the child would make a competent witness and whether there are any viable alternatives to prosecution. Court-mandated treatment for child abuse offenders is an approach recommended in many countries. Mandatory treatment follows from the belief that, in the absence of legal prosecutions, some offenders will refuse to undergo treatment. Against that, there is the view that enforced treatment imposed by a court could actually create resistance to treatment on the part of the offenders, and that the willing participation of offenders is essential for successful treatment.
Child abuse is a serious global health problem. As a healthcare professional we are aware of the frequency and severity of crimes against children. Unfortunately, the general public is unaware of the extent of child abuse. These children, victims of outrageous crimes, too often are unable to speak about or against their abusers. Their rage and pain is then turned on themselves or others close to them, and the cycle continues. We are beginning to hear more about child abuse. We hope our publication enlightens and educates. Millions of our children, our most precious natural resource, are being victimized by a tragic and unconscionable epidemic of child abuse and neglect. Both the level and intensity of child maltreatment have increased dramatically in the last decade. We hope our efforts will help people understand that our child abuse crisis goes far beyond excessive spanking. Each year hundreds of thousands of helpless children are being brutalized and tortured physically, emotionally and sexually. Each act of child abuse reverberates into the future; when a child gets hurt, we may all suffer the consequences. Few children survive their childhood abuse, and these stories are a triumphant and inspiration to all of us. We must never forget, however, the tens of thousands of children who do not survive their ordeals, and the millions who are still suffering. The only cure of child abuse is prevention; and we at Women's Health and Education Center (WHEC) hope this article will help to build our growing movement of people working to prevent child abuse in all its forms.
Physicians and other health care personnel have an ethical, moral, and legal obligation to diagnose and treat abused or neglected children. Although there are major gaps in knowledge and a pressing need for more research, experience to date has taught some important lessons about preventing violence and mitigating the consequences. Violence is often predictable and preventable. Understanding the context of violence is vital in designing interventions. Women's Health and Education Center (WHEC) has made a substantial contribution by providing a global perspective on all forms of violence. As long as humanity continues to rely on violence to resolve conflicts, the world will enjoy neither peace nor security, and our health will continue to suffer. A stronger commitment to increase global violence prevention efforts is desperately needed. National health system as a whole should aim to provide high-quality care to victims of all types of violence, as well as the rehabilitation and support services needed to prevent further complications.