Topic:- child abuse, concept, course, long & short term consequences,

measures to counteract

Concept of child abuse

According to world health organization (WHO), 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. Some studies limit
the term ‘child abuse' to “children who have received serious physical injury
caused willfully rather than by accident” (Garden & Gray, 1982:5). This
definition has not been accepted by the social scientist because of the
ambiguities in the term, ‘serious physical injury’.

Kempe and Kempe (1978) have defined child abuse as “a condition having to
do with those who have been deliberately injured by physical assault”. This
definition is limited in scope as it restricts abuse to those acts of physical
violence which produce a diagnostic injury. Thus, acts of neglect and
maltreatment of children which do not produce an injury but are equally
harmful cannot be included in this definition. No definition of child abuse can
be considered valid unless it includes non- physical acts like mental injury and
neglect and ill-treatment of child.

Burgess (1979:143) has given a wider definition of child abuse. According to

him, child abuse refers to a situation comprising “any child who receives non-
accidental physical and psychological injury as a result of act and omission on
the part of his parents or guardians or employers…” Verbal abuse, threats of
physical violence and excessive physical punishment which do not require
medical attention are also included in the definition of child abuse.

Types of abuse:-
Physical abuse:
 Physical abuse is the inflicting of physical injury upon a child.
 This may include burning, hitting, punching, shaking, kicking, beating or
otherwise harming a child. The parent or caretaker may not have intended
to hurt the child.
 It may, however, be the result of over-discipline or physical punishment
that is inappropriate to the child's age.
Sexual abuse:
 Sexual abuse is inappropriate sexual behaviour with a child. It includes
fondling a child's genitals, making the child fondle the adult's genitals,
intercourse, incest, rape, sodomy, exhibitionism and sexual exploitation.
 To be considered ‘child abuse’, these acts have to be committed by a
person responsible for the care of a child (for example a baby-sitter, a
parent, or a daycare provider), or related to the child.
 If a stranger commits these acts, it would be considered sexual assault
and handled solely by the police and criminal courts.
Emotional abuse:
● Emotional abuse is also known as verbal abuse, mental abuse, and
psychological maltreatment.
● It includes acts or the failures to act by parents or caretakers that have
caused or could cause, serious behavioural, cognitive, emotional, or
mental trauma.
● This can include parents/caretakers using extreme and/or bizarre forms of
punishment, such as confinement in a closet or dark room or being tied to
a chair for long periods of time or threatening or terrorizing a child.
● Less severe acts, but no less damaging, are belittling or rejecting
treatment, using derogatory terms to describe the child, habitual tendency
to blame the child or make him/her a scapegoat.
Neglect:
● It is the failure to provide for the child's basic needs.
● Neglect can be physical, educational, or emotional.
● Physical neglect can include not providing adequate food or clothing,
appropriate medical care, supervision, or proper weather protection (heat
or cold).
● It may include abandonment.
● Educational neglect includes failure to provide appropriate schooling or
special educational needs, allowing excessive truancies.
● Psychological neglect includes the lack of any emotional support and
love, never attending to the child, substance abuse including allowing the
child to participate in drug and alcohol use.

Indicators of child abuse

Indicators of selected forms of abuse as outlined above were identified for
verifying its different forms:
Possible indicators of physical abuse
● Physical indicators
– » any injury to an infant who is not yet mobile, especially head/facial injuries
– » injuries to a toddler or older child for which there is no explanation, the
explanation does not fit with the injuries, or the story keeps changing
– » injuries at different stages of healing
– » injuries that have a pattern or look like they may have been caused by an
object (e.g., hand, stick, buckle, stove element), and
» bruising in unusual places such as ears, trunk, neck or buttocks
Behavioural indicators
● » afraid or reluctant to go home, or runs away
● » shows unusual aggression, rages or tantrums
● » flinches when touched
● » has changes in school performance and attendance
● » withdraws from family, friends and activities previously enjoyed
● » poor self-esteem (e.g., describes self as bad, feels punishment is deserved,
is very withdrawn), and
● »suicidal thoughts or self-destructive behaviour (e.g., self-mutilation,
suicide attempt, extreme risk-taking behaviour)

Possible indicators of sexual abuse

● Physical indicators
– » unexplained or persistent pain, bleeding or unusual discharge in the genital
or anal area
– » pregnancy,
– » sexually transmitted diseases
● Behavioural indicators
– » engages in age-inappropriate sexual play or exhibits age-inappropriate
sexual knowledge
– » forces or coerces another child to engage in sexual play
– » inserts objects into vagina or rectum
– » directs sexually intrusive behaviour to adults
– » has unexplained gifts, new clothes or money
– » has changes in school performance and attendance
– » is secretive about “new” friends, activities, phone calls or internet use
– » has unexplained developmental setbacks
– » is involved in sexually exploitive activities, such as performing sex acts
for money

Possible indicators of emotional abuse

● Physical indicators
– » bed wetting and/or frequent diarrhea, and
– »frequent psychosomatic complaints, headaches, nausea,
abdominal pains
● Behavioural indicators
– » mental or emotional development lags
– » isolated and has no friends or complains of social isolation
– » behaviours inappropriate for age
 – » fear of failure, overly high standards, reluctant to play
– » fears consequences of actions, often leading to lying
– » extreme withdrawal or aggressiveness, mood swings
– » overly compliant, too well-mannered
– » excessive neatness and cleanliness
– » extreme attention-seeking behaviours
– » poor peer relationships
– » severe depression, may be suicidal
– » runaway attempts
– » violence is a subject for art or writing
– » forbidden contact with other children
– » shows little anxiety towards strangers,
– » unusual severe anxiety or worries

Possible indicators of neglect

Behavioural indicators
– - forages for, hoards or steals food
– - developmental delay or setbacks related to a lack of stimulation
– - poor school attendance
– - inappropriately takes on a caregiver role for a parent or siblings
– - tired or unable to concentrate at school
– - appears sad or has flat affect
– - reluctant to go home; speaks of being or appears to be left alone at
home a lot, unsupervised
– - is involved in behaviours such as misuse of drugs or alcohol, stealing,
fire-setting
– - does not respond to affection or stimulation

Child Abuse Scenario

Global level:

In 2017, the WHO estimated that up to 1 billion minors between the ages of 2
and 17 years of age have endured violence either physical, emotional, or sexual.

According to some UNICEF estimates from 2014, affected over 120 million
children, representing the highest number of victims. In 2017, the same UN
organization reported that in 38 low and middle income countries, almost 17
million adult women admitted having a forced sexual relationship during their
childhood.

Europe:

In 2013, the WHO estimated that almost 18 million children had been victims of
sexual abuse in Europe: 13.4% of all girls and 5.7% of all boys.

According to UNICEF, in 28 European countries, about 2.5 million young

women have reported sexual abuse, with or without physical contact, before the
age of 15 years (data published in 2017). In addition, 44 million (about 22.9%)
have been victims of physical violence, while 55 million (29.6%) have been
victims of psychological violence.

Asia:

In India, between 2001 and 2011, the “Asian Center for Human Rights”
reported a total of 48,338 cases of the rape of minors, with an increase of 336%
from 2,113 cases in 2001, to 7,112 cases in 2011.

Indian Scenario:

India is home to 19% of the world's children. As per the 2001 census, about 440
million individuals in India were below 18 years of age and constitute 42% of
total population.

A total of 33,098 cases of sexual abuse in children were reported in the nation
during the year 2011 when compared to 26,694 reported in 2010 which
increased by 24%. A total of 7,112 cases of child rape were reported during
2011 as equated to 5,484 in 2010 depicting a growth by 29.7%.[9,22]

India has the world's largest number of CSA cases. For every 155th minute a
child, less than 16 years is raped, for every 13th hour child under 10, and one in
every 10 children sexually abused at any point of time. Studies propose that
over 7,200 children, including infants, are raped every year and it is believed
that several cases go unreported.

It is estimated by the government that 40% of India's children are susceptible to

threats like being homeless, trafficking, drug abuse, forced labor, and crime.

In India, every second child is being exposed to one or the other form of sexual
abuse and every fifth child faces critical forms of it.
A survey by United Nations International Children Education Fund (UNICEF)
on demographic and health was conducted in India from 2005 to 2013, which
reported that ten per cent of Indian girls might have experienced sexual violence
when they were 10–14 years of age and 30% during 15–19 years of age.
Overall, nearly 42% of Indian girls have gone through the trauma of sexual
violence before their teenage.

The first study on CSA in India was conducted by Recovery and Healing from
Incest, an Indian non-government organization (NGO) in 1998. Majority (76%)
of the participants reported being abused during childhood or adolescence.

Save the Children, the international organization, and, Tulir–Center for Healing
and Prevention of Child Sex Abuse, an Indian NGO, conducted a study in 2005
among 2,211 school going children in Chennai. About 48% and 39% of the boys
and girls, respectively, reported as being sexually abused, while more than one-
tenth (15%) of the participants stated as having faced severe forms of sexual
abuse.

A study was conducted in 2007 by Ministry of women and child development in

India covering 13 states. The study reported that about 21% of the participants
were exposed to extreme forms of sexual abuse. Among the participants who
reported being abused, 57.3% were boys and 42.7% were girls, about 40% were
5–12 years of age. About half of the participants were exposed to other forms of
sexual abuse.

Prevalence of various forms of child sexual abuse in India

(An Epidemiological Overview of Child Sexual Abuse Mannat Mohanjeet Singh, Shradha S.
Parsekar, and Sreekumaran N. Nair J Family Med Prim Care. 2014 Oct-Dec; 3(4): 430–435.
doi: 10.4103/2249-4863.148139 PMCID: PMC4311357 PMID: 25657958)

Causes of child abuse

There can be multiple causes of child abuse. However, the major cause of child
abuse is additional failure or environmental maladjustment (both in family and
work place) mostly on the part of the adult perpetrators (parents, employers),
but to some extent on the part of adult’s responsible for family socialization as
well (Kewalramani, 1992:152).

Causes of physical abuse

 Psycho-pathology of the individual primary cause
 Psycho-social pathology of family interaction as the main cause,
(a) Relations between spouses,
(b) Relation between parents and children,
(c) Structural stresses, and
(d) child-produced stresses.

Causes of sexual abuse

  Family environment,
 Family structure,

 Individual predispositions

 Situational factors.

Causes of emotional abuse

 Four important causes of emotional abuse can be identified as

 Poverty,

 Deficient parental control

 Non-cordial relations within family,

Short term effects of child abuse

 Anxiety.
 Depression.
 Low self-esteem.
 Withdrawn.
 Dissociation.
 Difficulty with making and maintaining relationships.
 Experiences flashbacks.
 Hypervigilant.

Long term effects of child abuse

Depression
• 3 to 5 times more common. (beitchman et al.1992)
– Guilt and low self esteem
– Depression and withdrawal symptoms were found to be common
among children who experienced emotional, physical, or
environmental neglect. (Dubowitz, Papas, Black, & Starr, 2002).
• Lack of parental care after abuse is associated with depression in adults
(Fergussion et al, 1996; Mullen et al, 1993)
• Atypical presentation (Levitan et al, 1998)
• Earlier onset of depression, prolonged duration & treatment resistant
(Gieses et al, 1998; Zlotnick et al., 1995, 2001)

Self-mutilation, suicidality, self-defeating behavior

 30-50% of adult survivors manifest self defeating behavior (Briere, 1985)
 Internalized feelings of “I am bad and damaged”
 Withdraw from friends; engage in behaviors which lead to self
punishments.
 Compared with non-abused controls, CSA victims had significantly
higher frequency of suicide plans and/or deliberate self-harm or suicide
attempts 5% vs 0% (Bagley & Ramsay, 1986)

Anxiety disorders
• Chronic low grade anxiety.
• Phobias
• Panic disorder
• Life time prevalence- 37 % (Stein et al, 1998)
• Negative body image– Body dysmorphic disorder
(Young, 1992; Simmons, 1991; Wenniger et al, 1998; Elizabeth Maclen
1990)
PTSD
– 50-60% have a history of sexual abuse.
– Conceptualized as complex biological process
Repressed memories of abuse (Goodwin, 1985)

Dissociative disorder
• Consequence of repressed memories of trauma
• Problems in hemispheric integration
• Consequence of long standing abuse (Briere, 1984)
• DID- most extreme form of dissociation.
• 97% of DID cases have h/o CSA (Putnam et al, 1986; Schlutz et al, 1985)

Sexual problems and sexuality

• 50-60% have sexual problems (Briere, 1984; Herman, 1981)
• Promiscuity, early age of first pregnancy
• Fear of sexual experience
• Sexual dissatisfaction
• Sexual dysfunction
• Altered sexual orientation
• Consequence of internalization of “good things happen when I am
sexual” and “my sexuality means no feeling”

Revictimization & sexual offending

• Revictimization.
– Abused women are more vulnerable to revictimization in later
adulthood.
– Rates of rape are as high as 33 % in victims compared to 17%
(Russell et al, 1986)
 • Sexual offending.
– Person who experience CSA will become perpetrators in
adulthood, more in men [50 – 80%] (Marvestin, 1986; Fehrenbach,
1988)

Substance use disorders

 20-80% of patient (Goodwin, 1980)
 As a strategy of coping
 Internalization of “I am damaged”.
 Early age at initiation of injection drug use.
Inter personal relationship
 Difficulty in initiating and maintaining strong relationship needs
 Avoidance vs multiple relationship
 Internalization of lack of boundaries
 CSA was also associated with a twofold increase in risk for lifetime
domestic violence (Brown et al, 2000)
CSA v/s BPAD
Childhood abuse history is etiologically responsible for the form of presentation
of BPAD (more likely depressed than manic or mixed; more likely to be rapid
cycling at study entry) and course will be severe. (Brown et al, 2005; Bauer et
al, 1997, 2001)

Understanding of child abuse in society:

Though child abuse has been prevalent in society, especially the incidence of
physical and emotional abuse, society continues to maintain the denial of these
facts. Seshadri S, (2004), provides the framework “the iceberg phenomenon”
Management
• Psychological debriefing
• Cognitive Behaviour Therapy; such as Trauma- focused CBT (Cohen et
al., 2000; Ramchandani & Jones, 2003).
• Supportive Psychotherapy
• Client-Centered therapy
• Group therapy (Burke, 1988; Deblinger et al, 2001)

Prevention
• Child education programs
• CSA concepts and self-protection skills (Rispens et al., 1997).
• Home visitation programs
• Knowledge, skills, and supports to improve the parenting skills of
overwhelmed or at-risk parents (Olds et al., 1986)
• Early intervention & regular follow up of abused child.

Preventive measures:
World Health Organization (1999) provides a comprehensive model for the
prevention of violence and abuse against children which says that the preventive
activities can be taken up at three levels that is primary, secondary and tertiary
level.
References
1. World Health Organization. (1999). Report of the
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