An Analysis on Understanding Child Abuse and Maltreatment/Neglect

Child maltreatment is a global problem which occurs in a variety of forms and settings, and in some countries it is rooted in social, economic and cultural practices. The problem is multi-faceted in some developing countries such as India in which there is little information about the magnitude, trends and socio-economic correlates of child maltreatment. The growing complexities of life and socio-economic transition increase the vulnerability of children. Certain forms of child abuse are particularly prevalent in India and recognition of child rights as primary and inviolable is still deficient. Compared with affluent countries, the prioritization of problems in a low-income country such as India is different because malnutrition, infectious diseases, chronic disabilities, poverty, housing and shelter, population explosion and illiteracy abound. Understandably, a large proportion of the country’s resources are directed towards these more immediate problems. In developed countries, where other causes of childhood morbidity and mortality are relatively rare, child maltreatment ranks high in importance among services for children. Although India’s National Policy for Children 1974 declared children to be a ‘‘supreme national asset’’, the total budget allocated to Indian children for health, education, development and protection together amounted to a mere 3.8% in 2005–2006, rising to 4.9% in 2006–2007, with an abysmally low allocation to child protection at 0.034%.3 With recent reports of increasing crimes including rape of females, especially minor (underage) girls, the problem of child maltreatment seems all the more evident. This paper summarizes the various aspects of this enormous problem in resource-poor settings with the hope that it will be helpful in planning child protection services in India and other developing countries. The World Health Organization (WHO) defines child maltreatment as ‘‘All forms of physical and/or emotional ill-treatment, sexual-abuse, neglect or negligent treatment or 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.’’ There are four types of child maltreatment: physical, sexual, emotional and psychological abuse and neglect. Very often, they occur in different combinations. A universal definition of child abuse in the Indian context is not yet available. In 2007, a working definition was proposed by the Ministry of Women and Child Development (MWCD), Government of India as ‘‘intended, unintended and perceived maltreatment of the child, whether habitual or not’’ and including psychological and physical abuse, sexual and emotional maltreatment; any act which debases the intrinsic worth and dignity of a child as a human being; unreasonable deprivation of his/her basic needs for Child maltreatment refers to the physical and emotional mistreatment, sexual abuse, neglect and negligent treatment of children, as well as to their commercial or other exploitation. It occurs in many different settings. The perpetrators of child maltreatment may be: • Parents and other family members; • Caregivers; • Friends; • Acquaintances; • Strangers; • Others in authority – such as teachers, soldiers, police officers and clergy; • Employers; • Health care workers; • Other children. Child maltreatment is a complex issue. Its dynamics and the factors that drive it, as well as effective prevention strategies, all differ markedly according to the victim’s age, the setting in which the maltreatment occurs, and the relationship between victim and perpetrator. Violence against children by adults within the family is one of the least visible forms of child maltreatment, as much of it takes place in the privacy of domestic life, but it is nonetheless widely prevalent in all societies. Child maltreatment by parents and caregivers gives rise to particular difficulties when designing strategies for prevention and victim services, since the perpetrators of the maltreatment are at the same time the source of nurture for the child. While it is not possible to make any absolute statement about the numbers of children harmed by parents and other family members, child maltreatment is recognized internationally as a serious public health, human rights, legal and social issue. The nature and the severity of both the violence itself and its consequences can vary extremely widely. In extreme cases, child maltreatment can lead to death. In the majority of situations involving maltreatment, however, the physical injury itself has a less severe effect in terms of damage to the child’s well-being than the acute psychological and psychiatric consequences, and the long-term impact on the child’s neurological, cognitive and emotional development and overall health. causally and through shared underlying risk factors. It is therefore useful to view child maltreatment within a wider categorization of violence. Following the typology presented in the World report on violence and health, violence can be divided into three broad categories, according to the context in which it is committed. • Self-directed violence refers to violence where the perpetrator and the victim are the same person. It is subdivided into self-abuse and suicide. • Interpersonal violence refers to violence between individuals. The category is subdivided into family and intimate partner violence, and community violence. The former includes child maltreatment, intimate partner violence and elder abuse. Community violence is broken down into violence by acquaintances and violence by strangers. It covers youth violence, assault by strangers, violence related to property crimes, and violence in workplaces and other institutions. • Collective violence refers to violence committed by larger groups of people and can be subdivided into social, political and economic violence. Child maltreatment often occurs alongside other types of violence. For instance, child maltreatment by adults within the family is frequently found in the same settings as intimate partner violence. Maltreated children are themselves at increased risk in later life of either perpetrating or becoming the victims of multiple types of violence – including suicide, sexual violence, youth violence, intimate partner violence and child maltreatment. The same set of factors – such as harmful levels of alcohol use, family isolation and social exclusion, high unemployment, and economic inequalities – have been shown to underlie different types of violence. Strategies that prevent one type of violence and that address shared underlying factors therefore have the potential to prevent a number of different types of 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. The historical record is also filled with reports of unkempt, weak and malnourished children cast out by families to fend for themselves and of children who have been sexually abused. For a long time also there have existed charitable groups and others concerned with children’s wellbeing 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.

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. Solving this global problem, however, requires a much better understanding of its occurrence in a range of settings, as well as of its causes and consequences in these settings.

Child maltreatment - 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. As already stated, the World report on violence and health and the 1999 WHO Consultation on Child Abuse Prevention distinguish four types of child maltreatment: • Physical abuse; • Sexual abuse; • Emotional and psychological abuse; • Neglect. Physical abuse-Physical abuse of a child is defined as the intentional use of physical force against a child that results in – or has a high likelihood of resulting in – harm for the child’s health, survival, development or dignity. This includes hitting, beating, kicking, shaking, biting, strangling, scalding, burning, poisoning and suffocating. Much physical violence against children in the home is inflicted with the object of punishing. Sexual abuse-Sexual abuse is defined as the involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violates the laws or social taboos of society. Children can be sexually abused by both adults and other children who are – by virtue of their age or stage of development – in a position of responsibility, trust or power over the victim. Emotional and psychological abuse-Emotional and psychological abuse involves both isolated incidents, as well as a pattern of failure over time on the part of a parent or caregiver to provide a developmentally mental, spiritual, moral or social development. Abuse of this type includes: the restriction of movement; patterns of belittling, blaming, threatening, frightening, discriminating against or ridiculing; and other non-physical forms of rejection or hostile treatment. Neglect-Neglect includes both isolated incidents, as well as a pattern of failure over time on the part of a parent or other family member to provide for the development and well-being 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. The parents of neglected children are not necessarily poor. They may equally be financially well-off.

In health caused by child abuse forms a significant portion of the global burden of disease. While some of the health consequences have been researched, others have only recently been given attention, including psychiatric disorders and suicidal behaviour. Importantly, there is now evidence that major adult forms of illness – including ischaemic heart disease, cancer, chronic lung disease, irritable bowel syndrome and fibromyalgia – are related to experiences of abuse during childhood. The apparent mechanism to explain these results is the adoption of behavioural risk factors such as smoking, alcohol abuse, poor diet and lack of exercise. Research has also highlighted important direct acute and long-term consequences (see Table 1).

Similarly, there are many studies demonstrating short-term and long-term psychological damage. Some children have a few symptoms that do not reach clinical levels of concern, or else are at clinical levels but not as high as in children generally seen in clinical settings. Other survivors have serious psychiatric symptoms, such as depression, anxiety, substance abuse, aggression, shame or cognitive impairments. Finally, some children meet the full criteria for psychiatric illnesses that include post-traumatic stress disorder, major depression, anxiety disorders and sleep disorders. A recent longitudinal cohort study in Christchurch, New Zealand, for instance, found significant associations between sexual abuse during childhood and subsequent mental health problems such as depression, anxiety disorders and suicidal thoughts and behaviour. Physical, behavioural and emotional manifestations of abuse vary between children, depending on the child’s stage of development when the abuse occurs, the severity of the abuse, the relationship of the perpetrator to the child, the length of time over which

The financial costs associated with both the shortterm and long-term care of victims form a significant proportion of the overall burden created by child abuse and neglect. Included in the calculation are the direct costs associated with treatment, visits to the hospital and doctor, and other health services.Arange 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. Available data from a few developed countries illustrate the potential financial burden. In 1996, the financial cost associated with child abuse and neglect in the United States was estimated at some US$12.4 billion. This figure included estimates for future lost earnings, educational costs and adult mental health services. In the United Kingdom, an estimated annual cost of nearly US$1.2 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 and long-term costs of child abuse and neglect to individuals, families and society.

India is home to one-fifth of the total world child population. The number of children ,18 years rose from 428 million in 2001 to 430 million in 2006. The total number of children aged 0–6 years is 158 million, constituting 13% of the country’s total population in 2011. The five states of Uttar Pradesh, Bihar, Maharashtra, Madhya Pradesh and Rajasthan constitute one-half of this population. Boys (51.5%) slightly outnumber girls. According to a report released by the Ministry of Women and Child Development (MWCD) in 2007, more than two-thirds (69%) of children, particularly in the age-group 5–12 years, face physical abuse, mostly (89%) by parents. Sexual abuse occurs in over half of them (53%) and is severe in one-fifth (22%), and half of the abusers are known to the child or in a position of

prevalences of all forms of abuse are much lower. In developed countries, for example, physical abuse ranges from 4 to 16%, sexual abuse from 2 to 62% and approximately 10% are abused emotionally. In a study of 51 children suspected to be victims of child abuse referred to Childline Chandigarh (a 24-hour emergency outreach service for children in need of care and protection), physical abuse was the most common (84%), followed by emotional abuse (76%) and neglect (47%). Girls were significantly more affected than boys; neglect was more common in the younger age-group whereas physical and emotional abuse increased with age. Parents or close family members were the commonest perpetrators of child maltreatment.10 Similarly high prevalence of physical abuse have been reported from other settings such as child observation homes (77%) and in child domestic workers (70%). India has the dubious distinction of having the world’s largest number of sexually abused children: a child under 16 years is raped every 155th minute, a child under 10 every 13th hour and one in every ten children is sexually abused at any point of time. Communitybased studies have revealed that sexual abuse of children in India crosses all barriers of socio-economic classes and is widespread in both rural and urban areas and among boys and girls. Sexual abuse in adolescent school-children has been noted in at least one-third and is associated with poorer health and greater prevalence of risky behaviour. A higher prevalence of sexually transmitted diseases in younger children has been a surrogate indicator of probable sexual abuse/assault. We studied 100 child abuse cases handled by Childline Chandigarh over a 2-year period and found that 12% involved protection or rescue from sexual abuse, 9% were subjected to severe forms of sexual abuse and half of them (50%) had serious psychosocial sequelae. Most children belonged to socio-economically disadvantaged families, were aged 7–15 years, and the majority (10 out of 12) were girls (unpublished data). We believe a large number of cases are not reported because of a lack of awareness of the services available, inadequate knowledge about what comprises sexual abuse, and the associated shame and secrecy.

The health and social consequences of child maltreatment are more wide-ranging than death and injury alone and include major harm to the physical and mental health and development of victims. Studies These include violent victimization and the perpetration of violence, depression, smoking, obesity, high-risk sexual behaviours, unintended pregnancy, and alcohol and drug use. Such risk factors and behaviours can lead to some of the principal causes of death, disease and disability – such as heart disease, sexually transmitted diseases, cancer and suicide. Child maltreatment therefore contributes to a broad range of adverse physical and mental health outcomes that are costly, both to the child and to society, over the course of a victim’s life .

There is sufficient evidence, including in the scientific literature, to state with full confidence that child maltreatment can be prevented. Despite this, little attention in terms of research and policy has been given to prevention. Many existing prevention efforts consist of the early identification of cases of child maltreatment and interventions to protect the children involved. This strategy is indeed a form of prevention and may well be beneficial to individual children and families. It will not, however, lead to a large-scale reduction in the incidence of child maltreatment that is possible using strategies that address the underlying causes and contributing factors. When choosing such strategies, it is important to know which ones – based on real evidence – have achieved their intended results. In places where resources are scarce, it is even more important to know which approaches will work. Strategies based on anecdotal information and prevailing norms may often appear as if they should work – while, when examined more closely, they do not significantly affect the numbers of new cases of child maltreatment. Prevention strategies therefore need to be based on an understanding of the risk factors as well as including a mechanism to evaluate the results. A few effective strategies for reducing child maltreatment rates have been identified through scientific outcome studies that measure the impact of prevention programmes. There are other prevention strategies where the evidence is promising and a much larger number where the evidence is unclear. These three terms, describing the extent to which strategies are known to work well, are defined as follows. • An effective prevention programme is one that reduces the incidence of child have been proposed. These include: — An evaluation of a programme using a strong research design, either experimental or quasi-experimental; — Evidence of a significant preventive effect; — Evidence of sustained effects; — Replication of the programme with demonstrated preventive effects. Few programmes meet all of these criteria. In this guide, the term “effective” is used for programmes evaluated with a strong research design that show evidence of a preventive effect. • A prevention programme is said to be promising, if it has been evaluated with a strong design, showing some evidence of a preventive effect, but requiring more testing. • The effect of a prevention programme is said to be unclear if it has been poorly evaluated or remains largely untested. Where strategies have been evaluated, almost all the outcome evaluation studies have been conducted in high-income settings. To increase the application of prevention strategies for child maltreatment in all countries, more outcome studies are urgently needed, and especially from low-income and middle-income countries. These efforts should include attempts to replicate programmes already identified as effective, adapting them to the local context, as well as outcome evaluation studies of innovative programmes designed around promising or unclear prevention strategies.

Child maltreatment is not a simple problem with easy solutions. Significant improvements in prevention, child protection and treatment, though, are not beyond reach. There is enough knowledge and experience on the subject for any country to begin addressing the problem. One of the greatest obstacles to effectively responding to child maltreatment has been the lack of information. Child abuse is a serious global health problem. Although most studies on it have been conducted in developed countries, there is compelling evidence that the phenomenon is common throughout the world. In conclusion, child maltreatment is a serious and complex problem in India with deep-rooted cultural and psycho-social causes. Management is multimodal and aims to identify and understand the causes, empower children to come forward with their concerns and towards children needs to be fostered to provide a safe environment conducive to the overall development of the child. Although the government is making efforts to tackle the problem, increased public awareness of the rights of the child and strict enforcement of the laws are crucial.

• Bross DC et al. World perspectives on child abuse: the fourth international resource book. Denver, CO, Kempe Children’s Center, University of Colorado School of Medicine, 2000.

• Browne K et al. Child abuse and neglect in Romanian families: a national prevalence study 2000. Copenhagen, WHO Regional Office for Europe, 2002.

• Butchart A, Harvey AP, Mian M, Fu¨ rniss T, Kahane T. Preventing Child Maltreatment: a Guide to Taking Action and Generating Evidence. World Health Organization and International Society for Prevention of Child Abuse and Neglect. WHO: Geneva, 2006. Available from: http://whqlibdoc.who.int/ publications/2006

• Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet. 2009;373:68–81.

• Hahm H, Guterman N. The emerging problem of physical child abuse in South Korea. Child Maltreatment, 2001, 6:169–179.

• Kacker L, Varadan S, Kumar P. Study on Child Abuse. India Ministry of Women and Child Development, Government of India and Save the children and UNICEF, 2007.

• Madu SN, Peltzer K. Risk factors and child sexual abuse among secondary students in the Northern Province (South Africa). Child Abuse & Neglect, 2000, 24:259–268.