“And when the female infant (Al-Maw’udah) buried alive is questioned, for what sin she was killed!” (Surah 81, al takwir: 8-9). On judgmental day, fathers will be asked for which reason they abused their daughters. Islamic teachings ended those cruel pre-Islamic practices of female infanticide “wa’d” which was common in dark ages. However, child abuse has for a long time been recorded in literature, art and science in many parts of the world. 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 physically, sexually, and emotional abused. In recent years, countries witnessed a movement towards child abuse addressing and prevention.
This concept paper aims at portraying the different types of child abuse, manifestations and consequences. Different types of child abuse are caused by many factors; those factors will be discussed also. The prevention approaches by family and health service providers will by highlighted at the end of this paper with the therapeutic approaches. Most of the available studies are concerned with aspects of physical, sexual, and/or emotional abuse, and therefore the discussion and recommendations would have the most validity when applied to such situations.
Anyone under age 18 who’s been neglected or abused by a parent or someone responsible for his care is considered a victim of child abuse. In statistics for 2002, the Department of Health and Human Services revealed that: about 896,000 American children were victims of abuse and neglect. Of all abused children, 60.5% suffered neglect; 18.6%, physical abuse; and 9.9%, sexual abuse. Some experienced more than one type. An estimated 1,400 children died from abuse or neglect; 76.1% of them were under age 4. Parents were the most common abusers. Although these numbers on child abuse are appalling, many authorities believe they’re conservative. Because abuse occurs within the family and often involves young preverbal children, many cases are never discovered or reported. Particularly, 63% of the participants were identified as victims of domestic violence on Karachi Domestic Violence Screening Scale. 36% of the victims were males and 64% of the victims were females. 35% of the victims reported facing physical abuse, 52% of the victims reported psychological abuse and 30% of the victims reported sexual abuse from their relatives. 60% of the victims had depression and 67% of the victims had anxiety. Another Study by medical students of AKU (class of 1996) in a sample of 176 children, it showed that 27% of them had suffered physical abuse.
Child abuse crosses all ethnic, racial, cultural, and socioeconomic lines. 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” (Bethea, L, 1999). Many parents who abuse their children are immature and impulsive, with low self-esteem. Sometimes family is isolated within the community and one or both parents may be a substance abuser. Environmental stressors that can trigger abuse include work problems, poverty, unemployment, illness of family members, marital tensions, and domestic violence between adults. The child consequences lead to consider child prevention as the priority in primary health care system. “The short-term consequences of abuse are the physical and behavioral indicators that led to suspect abuse in the first place in health care system”.
The role of the community, religious leaders and school teachers is vital in countering the exploitation of children, but, unfortunately, there is often ambivalence among people regarding such issues. So that there is a need to nurses to sensitize parents and teachers on the crucial issues around child abuse and mobilize them to form networks to protect children. Typically, neglect comes to light when a teacher reports a child who has poor hygiene and inappropriate clothing, appears listless, frequently complains of hunger, or frequently misses school without explanation. Neighbors may report a child being left unsupervised, or a health care provider may report that a child is missing appointments for medical care. As a health care professional, nurse role is reporting child abuse and neglect, especially when a nurse discovers it during home visitation. “Nurses who work with children and families in various health care, education, and social service settings can play a key role in stopping neglect and abuse before they begin, by promoting primary prevention procedures”. ( Kathleen ,2004)
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 the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.”
The definition given above covers a broad spectrum of abuse. This paragraph focuses primarily on manifestations and consequences of three types of child maltreatment, namely: physical abuse; sexual abuse; emotional abuse and the neglect.
Physical abuse of a child is defined as those acts that cause actual physical harm or have the potential for harm. 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.
Sexual abuse is defined as those acts where a caregiver uses a child for sexual gratification. Children may be brought to professional attention because of physical or behavioral concerns that, on further investigation, turn out to result from sexual abuse. It is not uncommon for children who have been sexually abused to exhibit symptoms of infection, genital injury, abdominal pain, constipation, chronic or recurrent urinary tract infections or behavioral problems. To be able to detect child sexual abuse requires a high index of suspicion and familiarity with the verbal, behavioral and physical indicators of abuse. Many children will disclose abuse to caregivers or others spontaneously, though there may also be indirect physical or behavioral signs.
Emotional abuse includes the failure 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 activities, ridicule, threats and intimidation, discrimination, rejection. 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.
Many risk factors are responsible on child abuse phenomena, among which: community and social factors, age and sex. Numerous studies across many countries have shown a strong association between poverty and child maltreatment. Rates of abuse are higher in communities with high levels of unemployment and concentrated poverty. Such communities are also characterized by high levels of population turnover and overcrowded housing. Research shows that “chronic poverty adversely affects children through its impact on parental behavior and the availability of community resources”. Community correlation represents the degree of cohesion and solidarity that exists within communities. “Children living in areas with less ‘‘social capital” or social investment in the community appear to be at greater risk of abuse and have more psychological or behavioral problems” (Macmillan, 1994). On the other hand, “social networks and neighborhood connections have been shown to be protective of children” (Macmillan, 1994). This is true even for children with a number of risk factors – such as poverty, violence, substance abuse and parents with low levels of educational achievement – who appear to be protected by high levels of community correlation.
Vulnerability to child abuse – whether physical, sexual or through neglect – depends in part on a child’s age. Fatal cases of physical abuse are found largely among young infants. In reviews of infant deaths in Fiji, Finland, Germany and Senegal, for instance, the majority of victims were less than 2 years of age Kathleen,M(2004). Young children are also at risk for non-fatal physical abuse, though the peak ages for such abuse vary from country to country. For example, “rates of non-fatal physical abuse peak for children at 3–6 years of age in China, at 6–11 years of age in India and between 6 and 12 years of age in the United States” (Kathleen,M(2004) ). Sexual abuse rates, on the other hand, tend to rise after the onset of puberty, with the highest rates occurring during adolescence ( ). Sexual abuse, however, can also be directed at young children.
Sex is another vulnerability to child abuse. In most countries, girls are at higher risk than boys for infanticide, sexual abuse, educational and nutritional neglect, and forced prostitution. Findings from several international studies show rates of sexual abuse to be 1.5–3 times higher among girls than boys. Globally, more than 130 million children between the ages of 6 and 11 years are not in school, 60% of whom are girls (Macmillan, 1994). In some countries, girls are either not allowed to receive schooling or else are kept at home to help look after their siblings or to assist the family economically by working. Male children appear to be at greater risk of harsh physical punishment in many countries. Although girls are at increased risk for infanticide in many places, it is not clear why boys are subjected to harsher physical punishment. It may be that such punishment is seen as a preparation for adult roles and responsibilities, or else that boys are considered to need more physical discipline. Clearly, the wide cultural gaps that exist between different societies with respect to the role of women and the values attached to male and female children could account for many of these differences.
The majority of programmers focus on prevention of child abuse. Very few emphasize primary prevention approaches in the first place. Family support approaches, health service approaches, therapeutic approaches are described below.
A number of interventions for improving parenting practices and providing family support have been developed. These types of programmers generally educate parents on child development and help them improve their skills in managing their children’s behavior. As an example, Wolfe et al. evaluated a behavioral intervention to provide training in parenting, specifically designed for families considered at risk. Mother–child pairs were randomly assigned to either the intervention or a comparison group. Mothers who received the training in parenting reported fewer behavioral problems with their children and fewer adjustment problems associated with potential maltreatment compared with mothers in the comparison group. Furthermore, a follow-up evaluation by the caseworkers showed that there was a lower risk of maltreatment by the mothers who had received the training in parenting.
A number of health care organizations have developed training programmers to improve both the detection and reporting of abuse and neglect, and the knowledge among health care workers of available community services. In the United States, for example, the “American Medical Association has produced diagnostic and treatment guidelines for child maltreatment and sexual abuse”. (Kempe,1962) The detection of child abuse and neglect, however, is not always simple. Specific interview techniques and types of physical examination are generally required. I have conducted a presentation about ethical dilemma on domestic abuse last year. It was emphasized on nursing role in helping child by solving that dilemma according to teleological and deontological methods.
A review of treatment programmers for physically abused children found that “therapeutic day care with an emphasis on improving cognitive and developmental skills – was the most popular approach” ( ). Therapeutic day care has been advocated for a range of conditions related to abuse, such as emotional, behavioral or attachment related problems and cognitive or developmental delays. The approach incorporates therapy and specific treatment methods in the course of the child’s daily activities at a child care facility. Most programmers of this type also include therapy and education for the parents.
Ill 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 behavior. Importantly, there is now evidence that major adult forms of illness – including ischemic heart disease, cancer, chronic lung disease, irritable bowel syndrome and fibromyalgia – are related to experiences of abuse during childhood (99– 01). Similarly, there are many studies demonstrating short-term and long-term psychological damage. Such as depression, anxiety, substance abuse, aggression, shame or cognitive impairments. The financial costs associated with both the short term 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. In 1996, “the financial cost associated with child abuse and neglect in the United States was estimated at some US$12.4 billion.” (Kempe,1962)
From my point of view, child abuse is serious hidden problem, which I had already suffered in my childhood in side home. But the role of professionals at that age 1990 was not effective. Otherwise, I could have been protected. I believe that 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 child maltreatment are detected early on, so as to minimize the consequences for the child and to launch the necessary services as soon as possible.
As I mentioned above, I can conclude that child abuse is a serious global health problem. It has different types, and every type leads to different short and long term consequences. Many factors were responsible to increase voluntarily of child abuse. Prevention methods can be applicable on known cases which reach the clinical levels; however, we can’t predict the violence forms if they are hidden inside houses secrets.
The complex nature of child abuse doesn’t allow for easy solutions. But nurses who work with children and families in various health care, education, and social service settings can play a key role in stopping neglect and abuse before they begin. Here’s how. Primary prevention targets the general population. Public service announcements encourage positive discipline techniques, media campaigns tell people how and where to report suspected abuse. And parent-education programs teach parents about child development and parenting skills. For example, expectant and new parents may know little about the basics of child care. They typically know even less about a child’s emotional, social, and medical needs; the stages of normal development; and how critically the first 3 years of life affect development. Seize your opportunities to teach and model behaviors in clinic settings, childbirth and parenting classes, home visits, and parent support groups
I recommend we should not take a defeatist attitude toward child prevention. Despite the absence of strong evidence to guide our preventive efforts, nurses can do many things to try to prevent abuse. At the very least, showing increased concern for the parents or caregivers and increasing our attempts to enhance their skills as parents or caregivers may help save our most vulnerable patients from the nightmare of abuse and neglect. Recognition and awareness, although essential elements for effective prevention, are only part of the solution. Prevention efforts and policies must directly address children, their caregivers and the environments in which they live in order to prevent potential abuse from occurring and to deal effectively with cases of abuse and neglect that have taken place.
– Kempe,CH et al. The battered child syndrome. Journal of the American Medical
– Key,j (1999). Protecting children. New York. Continuum
– Macmillan HL, MacMillan JH, Offord DR, Griffith L, MacMillan A. Primary
prevention of child physical abuse and neglect: a critical review. Part I. J Child
Psychol Psychiatry 1994;35(5):835-56.
-Bethea,L(1999).Primary prevention of child abuse
From http://www.rcn.org rcn.org.ukww.rcn.org.uk
– Kathleen,M(2004).How to recognize and respond to child abuse
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