Child Abuse

Child Abuse

Simply refers to the ill treatment of a child by his parents or any other adult.

• Edu & Edu (1999) - willful maltreatment of a child.
• Can include acts of commission (abuse) or omission (neglect).

Flagrant abuse of children's God-given and constitution-guaranteed freedom, comfort, and peace by adults in the society.

Child Abuse

In 1999, the WHO Consultation on Child Abuse Prevention compared definitions of abuse from 58 countries and 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 the child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power."

WHO, 1999

International Convention on the Rights of a Child

Every child must be protected against all forms of exploitation, indecent, or degrading treatment including child labor, abduction, and sale (UNICEF 2000).

According to UNICEF, exploiting the labor of a child means employing a person below the age of 15 years and paying him/her less than the minimum standard wage.

WHO: There were an estimated 570,000 deaths attributed to abuse among children under 15 years of age in 2000 around the world.

ILO: 350 million children aged 5-17 are involved in abuse of all forms under child labor all over the world.

South Africa, 1995: About 400,000 children aged <15 years were working.

Ghana: 28% of children aged 14-17 years work.

Epidemiology (2001)

A.A Jekayinfa & J.A Olawepo: Incidence of Child Abuse among secondary school students in Ilorin town.

Out of 210 student respondents, 183 indicated that they've experienced one form of abuse or another.

Percentage of students who suffered Child abuse quite often is greater than those who did occasionally.

• 1 of every 3-4 girls and 1 of every 7-8 boys will be sexually assaulted by the age of 18.

• Physical Abuse
• Sexual Abuse
• Emotional Abuse
• Neglect

Physical Abuse

Physical abuse is any non-accidental injury to a child under the age of 18 by a parent or caretaker. These injuries may include beatings, shaking, burns, human bites, strangulation, or immersion in scalding water or others, resulting in bruises and welts, fractures, scars, burns, internal injuries, or any other injuries.

PHYSICAL ABUSE

Most common perpetrators of physical abuse, in descending order of frequency, are:

• Fathers
• Mothers' boyfriends
• Female babysitters
• Mothers

The term "battered child syndrome" was coined to characterize the clinical manifestations of serious physical abuse in young children. 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.

Another form is the "The shaken infant". Shaking is a prevalent form of abuse seen in very young children (less than 1 year). Most perpetrators of such abuse are males. Intracranial hemorrhages, retinal hemorrhages, and chip fractures of the child's extremities can result from very rapid shaking of an infant.

Corporal Punishment

Corporal punishment of children in the form of hitting, punching, kicking, or beating - is socially and legally accepted in most countries. In many, it is a significant phenomenon in schools and other institutions, and in penal systems for young offenders.

SEXUAL ABUSE

Involves forcing or enticing a child to take part in sexual activities including prostitution, whether or not the child is aware of what is happening.

May involve physical contact, including penetrative (e.g., rape) sex.

Aalso non-penetrative acts.

Non-contact activities such as involving children in looking at or in the production of pornographic material or watching sexual activities.

'Sexual play' occurs in the absence of coercion and involves children of the same age (separated by no more than 4 years) who engage in viewing/touching each other's genitalia because of mutual interest or curiosity. Considered normal and doesn't have the consequences of abuse.

Perpetrators mostly men, though around 10% committed by women, sometimes with men. 1/3-2/3 family members.

• Fathers account for about 50% of clinical cases.
• Stepfathers disproportionately commonly involved.
• Abusers usually known to child.
• Only 5-10% strangers.

Emotional Abuse

No consensus as to what constitutes emotional abuse.

• Often no clear intent of harm.
• Victims unlikely to complain.
• Presentation non-specific.
• No findings on physical examination.
• Some level involved in all types of maltreatment of a child though may occur alone.

EMOTIONAL ABUSE

Emotional abuse includes the failure of a caregiver to provide an appropriate and supportive environment, and includes acts that have an adverse effect on the emotional health and development of a child.

Such acts include restricting a child's movements, denigration, ridicule, threats and intimidation, discrimination, rejection, and other nonphysical forms of hostile treatment.

CHILD NEGLECT

Neglect refers to the failure of a parent to provide for the development of the child - where the parent is in a position to do so - in one or more of the following areas: health, education, emotional development, nutrition, shelter, and safe living conditions.

Neglect is thus distinguished from circumstances of poverty in that neglect can occur only in cases where reasonable resources are available to the family or caregiver.

Persistent failure to meet a child's basic physical and/or psychological needs likely to result in serious impairment of the child's health/development.

• Maternal substance abuse during pregnancy.
• Failure to provide adequate food, clothing, and shelter.
• Failure to protect a child from physical, emotional harm/danger.
• Failure to ensure adequate supervision including the use of inadequate caretakers.
• Failure to ensure access to appropriate medical care or treatment.
• Unresponsiveness to the child's basic emotional needs.

Community/Societal

• High crime rate
• Lack of or few social services
• High poverty rate
• High unemployment rate

Parent-related

• Personal history of physical or sexual abuse as a child
• Teenage parents
• Single parent
• Emotional immaturity
• Poor coping skills
• Low self-esteem
• Personal history of substance abuse
• Known history of child abuse
• Lack of social support
• Domestic violence
• Lack of parenting skills
• Lack of preparation for the extreme stress of having a new infant
• History of depression or other mental health problems
• Multiple young children
• Unwanted pregnancy
• Denial of pregnancy

Child-related

• Prematurity
• Low birth weight
• Handicap

Of children who are abused, 67% are younger than 1 year of age, and 80% are younger than 3 years.

Past history of abuse - an abused child has a 50% chance of experiencing further abuse and a 10% chance of dying if not detected early.

Children with speech and language disorders, learning disabilities, conduct disorders.

Children with congenital anomalies, intellectual disabilities, or other handicaps or chronic or recurrent illnesses.

Immediate

• Anxiety
• Physical injuries

Short term

• Low self-esteem
• Anxiety
• Aggression

Long term

• Non-organic failure to thrive
• Depression
• Substance misuse
• PTSD
• Death

These are indicators of a child's need for protection

Type of Abuse	Physical Indicators	Behavioral Indicators
Physical Abuse	Unexplained bruises (in various stages of healing), welts, human bite marks, bald spots, unexplained burns (especially cigarette burns or immersion burns), unexplained fractures, lacerations, or abrasions, complains of soreness or moves uncomfortably, wears clothing inappropriate to cover body	Withdrawn & aggressive behavioral extremes, uncomfortable with physical contact, arrives at school early/stays late, chronic runaway, complains of soreness or moves uncomfortably, wears clothing inappropriate to cover body, regularly displays fatigue or listlessness; falls asleep in class
Physical Neglect	Consistent lack of supervision, unattended medical needs, consistent hunger, inappropriate dress, poor hygiene, lice; distended stomach; emaciated, torn, stained or bloody underclothing, pain or itching in genital area	Steals food; begs classmates for food; reports that no caretaker is at home, regularly displays fatigue or listlessness; falls asleep in class, frequently absent or tardy, self-destructive, school dropout, withdrawal, chronic depression
Sexual Abuse	Difficulty walking or sitting, bruises or bleeding on external genitalia, sexually transmitted infections (STI's)	Role reversal; overly concerned for sibling, poor self-esteem, self devaluation, lack of confidence, fear problems, lack of involvement, massive weight change, suicide attempts (especially adolescents), hysteria, lack of emotional control, sudden school difficulties, inappropriate sex play or premature understanding of sex, threatened by physical contact, closeness, speech disorders, habit disorders (sucking, rocking)
Emotional Abuse	Delayed physical development, substance abuse, ulcers, asthma, severe allergies	Antisocial, destructive behavior, neurotic traits (sleeping disorders, inhibition of play), passive and aggressive-behavioral extremes, delinquent behavior, developmentally delayed

Falls

In most cases, falls cause minor injuries. If a child is reported to have had a routine fall but has what appear to be severe injuries, the inconsistency of the history with the injury indicates child abuse.

Head, Facial & Oral Injuries

Head is a common area of injury.

Approximately 50% of physical abuse patients have head or facial injuries.

Injuries to the sides of the face, ears, cheeks, and temple area are highly suspicious for abuse.

Mouth/lip/teeth injuries

Multidisciplinary approach (admitting physician, pediatrician, children's forensic specialist, social workers, nursing staff, mental health professionals & law enforcement agent).

• Hospitalize suspected case
• Treat the injuries
• Carry out lab tests
• Obtain detailed facts concerning injury
• Diagnosis is the pediatrician's job
• Tell parents diagnosis & need to report (Reporting suspected child abuse is a responsible way to protect a child).

Multidisciplinary approach (admitting physician, pediatrician, children's forensic specialist, social workers, nursing staff, mental health professionals & law enforcement agent).

• Hospitalize suspected case
• Treat the injuries
• Carry out lab tests
• Obtain detailed facts concerning injury
• Diagnosis is the pediatrician's job
• Tell parents diagnosis & need to report (Reporting suspected child abuse is a responsible way to protect a child).

MANAGEMENT

Multidisciplinary approach (admitting physician, pediatrician, children's forensic specialist, social workers, nursing staff, mental health professionals & law enforcement agent).

• Hospitalize suspected case
• Treat the injuries
• Carry out lab tests
• Obtain detailed facts concerning injury
• Diagnosis is the pediatrician's job
• Tell parents diagnosis & need to report (Reporting suspected child abuse is a responsible way to protect a child).

Multidisciplinary approach (admitting physician, pediatrician, children's forensic specialist, social workers, nursing staff, mental health professionals & law enforcement agent).

• Hospitalize suspected case
• Treat the injuries
• Carry out lab tests
• Obtain detailed facts concerning injury
• Diagnosis is the pediatrician's job
• Tell parents diagnosis & need to report (Reporting suspected child abuse is a responsible way to protect a child).

History Taking

• Don't keep repeating questions
• Open-ended questions initially
• Questions directed to the child first if he/she can speak. Refusal to permit child is considered a "red flag" for abuse.

Factors that raise suspicion of abuse:

• History inconsistent with injuries of the child
• History vague or lacking in details
• Conflicting histories by different family members/History changes in repeated versions

• Injury attributed to actions of young siblings (Cover story/sibling rivalry, inadequate supervision, or violence in the home)
• No history offered: 'I don't know what happened; her leg was just suddenly broken'.
• History inconsistent with developmental stage of child.
• Implausible history (reported bite by an insect on the thigh, radiographs reveal a spiral # of the femur).

History taking is very important in sexual abuse - less than 10% have physical findings on examination.

Physical Examination

• Injuries that are consistent with history
• Multiple fractures in various stages of healing, or different types of injuries coexisting (bruises, burns)
• Injuries that are likely to be inflicted (patterned bruises)
• Evidence of poor caretaking (dirty or inadequately clothed). Abuse may be present in the absence of this.
• Bruising to the pinna, neck, or abdomen.
• Rectal or genital bleeding and/or STIs not acquired perinatally.

Hymen: One of the most challenging aspects of female genitalia examination.

Significance of notches or clefts in the hymen depends upon location & extent of defect. Superficial notches can occur in the absence of abuse, whereas, deep notches >50% of hymen diameter are more concerning for abuse.

Laboratory Evaluation

• Hematologic: CBC + diff, platelet count, PT & PTT
• Anemia with an abnormal peripheral smear & cell indices - neglect associated nutritional anemia.
• Chemistries: Serum levels of ALT & AST are elevated in those with injury to the liver. Amylase & lipase in pancreatic injury.
• Serum electrolyte & osmolality: dehydration or water intoxication.
• Urinalysis: hematuria in abdominal or urogenital system trauma.

Radiological Evaluation

• Neuroimaging
• Ophthalmoscopy

Intervention

Aims:

• To prevent further abuse.
• To mitigate the effects of what has happened.
• To meet the child's needs in the longer term.
• Treatment of psychiatric disorders where present.

Assessment of the parent

• Nature of psychiatric disorder
• Risk posed
• Likely response to treatment
• Capacity to change
• Likely compliance with & benefits from intervention

Assessment of the child

• Vulnerability to future abuse
• Level of disturbance
• Care & therapeutic needs
• Resilience

Treatment

• Treatment of parental mental disorder
• Treatment of family
• Treatment of child

Parental psychiatric disorder is an important risk factor in child abuse.

Child abuse & neglect can have severe long-term consequences for the mental health of children.

Bruises

• Bleeding disorders
• Dermatologic disorder
• Accidental bruise
• Genetic disorder e.g. Ehlers-Danlos

Burns

• Accidental burn
• Dermatitis
• Steven Johnson Syndrome

Fracture

• Accidental Fracture
• Birth trauma
• Rickets
• Osteogenesis imperfecta

Head trauma

• Accidental trauma
• Birth trauma

Although child abuse occurs in Nigeria, it has received little attention.

Probably due to emphasis placed on more prevalent childhood problems of malnutrition & infection. General assumption that extended family provides love, care & protection to all children.

Poverty has made more children live &/or work on the street & has increased their vulnerability to trafficking. Also, some traditional child rearing practices adversely affect some children.

Various other types of child abuse have been identified particularly in urban areas.

Abandonment of normal infants by unmarried or very poor mothers, increase child labor & exploitation of children from rural areas to urban elite families & abuse of children in urban nuclear families by child minders.

Almajiri Syndrome

Has remained worrisome in the minds of Northern elites because it's a form of embarrassment to the region.

They are children who, irrespective of gender, beg for assistance on the street or from house to house.

Children between the ages of 7 and 20 who attend informal religious schools but equally roam about with the purpose of getting assistance or engaging in some form of labor to earn a living.

Another form of child abuse in the sense that they are exposed to laborious work at a tender age.

Child labor is a fundamental factor of child abuse.

Also being denied their right to Western education.

Once the basic needs of a child are provided, there is no doubt that they can perform wonderfully in their undertakings and can deliver as leaders of tomorrow.

Recommendations

• Provision of infrastructural facilities & employment opportunities in rural areas to prevent the drift of young population to cities.
• Effective legal protection for the handicapped child.
• Create greater awareness of the existence of child abuse in the community by health & social workers through education.
• Adoption and signing into law of the Child Right Act of 2003 by all states of the federation.
• Government should make primary education free for all children.

Conclusion

Child abuse is a common problem in our society. Children injured through abuse are at significant risk for future psychiatric disorders.

Health care providers of all types must be alert to the indicators of abuse and must be willing to report their suspicions to the appropriate child protective agencies.

Only in this manner can we protect our children and facilitate their development into capable young adults who will become competent, caring parents.