CHAPTER 3 Child abuse and neglect by parents and other caregivers CHAPTER 3. CHILD ABUSE AND NEGLECT BY PARENTS AND OTHER CAREGIVERS . 59 Background cultures might diverge to such an extent that Child abuse has for a long time been recorded in agreement on what practices are abusive or neglectful literature, art and science in many parts of the may be extremely difficult to reach (5, 6). None- world. Reports of infanticide, mutilation, abandon- theless, differences in how cultures define what is ment and other forms of violence against children abusive have more to do with emphasizing particular date back to ancient civilizations (1). The historical aspects of parental behaviour. It appears that there is record is also filled with reports of unkempt, weak general agreement across many cultures that child and malnourished children cast out by families to abuse should not be allowed, and virtual unanimity fend for themselves and of children who have been in this respect where very harsh disciplinary practices sexually abused. and sexual abuse are concerned (7). For a long time also there have existed charitable groups and others concerned with children’s well- Types of abuse being who have advocated the protection of The International Society for the Prevention of Child children. Nevertheless, the issue did not receive Abuse and Neglect recently compared definitions of widespread attention by the medical profession or abuse from 58 countries and found some common- the general public until 1962, with the publication ality in what was considered abusive (7). In 1999, of a seminal work, The battered child syndrome,by the WHO Consultation on Child Abuse Prevention Kempe et al. (2). drafted the following definition (8): The term ‘‘battered child syndrome’’ was coined ‘‘Child abuse or maltreatment constitutes all forms to characterize the clinical manifestations of serious of physical and/or emotional ill-treatment, sexual physical abuse in young children (2). Now, four abuse, neglect or negligent treatment or commer- decades later, there is clear evidence that child abuse cial or other exploitation, resulting in actual or is a global problem. It occurs in a variety of forms potential harm to the child’s health, survival, and is deeply rooted in cultural, economic and development or dignity in the context of a social practices. Solving this global problem, relationship of responsibility, trust or power.’’ however, requires a much better understanding Some definitions focus on the behaviours or of its occurrence in a range of settings, as well as of actions of adults while others consider abuse to take its causes and consequences in these settings. place if there is harm or the threat of harm to the child (8–13). The distinction between behaviour – How are child abuse and neglect regardless of the outcome – and impact or harm is a defined? potentially confusing one if parental intent forms Cultural issues part of the definition. Some experts consider as Any global approach to child abuse must take into abused those children who have been inadvertently account the differing standards and expectations for harmed through the actions of a parent, while parenting behaviour in the range of cultures around others require that harm to the child be intended for the world. Culture is a society’s common fund of the act to be defined as abusive. Some of the beliefs and behaviours, and its concepts of how literature on child abuse explicitly includes violence people should conduct themselves. Included in against children in institutional or school settings these concepts are ideas about what acts of omission (14–17). or commission might constitute abuse and neglect The definition given above (8) covers a broad (3, 4). In other words, culture helps define the spectrum of abuse. This chapter focuses primarily generally accepted principles of child-rearing and on acts of commission and omission by parents or care of children. caregivers that result in harm to the child. In Different cultures have different rules about what particular, it explores the prevalence, causes and are acceptable parenting practices. Some researchers consequences of four types of child maltreatment have suggested that views on child-rearing across by caregivers, namely: 60 . WORLD REPORT ON VIOLENCE AND HEALTH — physical abuse; low- to middle-income countries the rates are 2–3 — sexual abuse; times higher – 6.1 per 100 000 for boys and 5.1 per — emotional abuse; 100 000 for girls. The highest homicide rates for — neglect. children under 5 years of age are found in the WHO Physical abuse of a child is defined as those acts African Region – 17.9 per 100 000 for boys and 12.7 of commission by a caregiver that cause actual per 100 000 for girls. The lowest rates are seen in physical harm or have the potential for harm. Sexual high-income countries in the WHO European, abuse is defined as those acts where a caregiver uses Eastern Mediterranean and Western Pacific Regions a child for sexual gratification. (see Statistical annex). Emotional abuse includes the failure of a Many child deaths, however, are not routinely caregiver to provide an appropriate and supportive investigated and postmortem examinations are not environment, and includes acts that have an adverse carried out, which makes it difficult to establish the effect on the emotional health and development of a precise number of fatalities from child abuse in any child. Such acts include restricting a child’s move- given country. Even in wealthy countries there are ments, denigration, ridicule, threats and intimida- problems in properly recognizing cases of infanti- tion, discrimination, rejection and other non- cide and measuring their incidence. Significant physical forms of hostile treatment. levels of misclassification in the cause of death as Neglect refers to the failure of a parent to provide reported on death certificates have been found, for for the development of the child – where the parent example, in several states of the United States of is in a position to do so – in one or more of the America. Deaths attributed to other causes – for following areas: health, education, emotional instance, sudden infant death syndrome or acci- development, nutrition, shelter and safe living dents – have often been shown on reinvestigation conditions. Neglect is thus distinguished from to be homicides (18, 19). circumstances of poverty in that neglect can occur Despite the apparent widespread misclassifica- only in cases where reasonable resources are tion, there is general agreement that fatalities from available to the family or caregiver. child abuse are far more frequent than official The manifestations of these types of abuse are records suggest in every country where studies of further described in Box 3.1. infant deaths have been undertaken (20–22). Among the fatalities attributed to child abuse, the The extent of the problem most common cause of death is injury to the head, Fatal abuse followed by injury to the abdomen (18, 23, 24). Information on the numbers of children who die Intentional suffocation has also been extensively each year as a result of abuse comes primarily from reported as a cause of death (19, 22). death registries or mortality data. According to the World Health Organization, there were an esti- Non-fatal abuse mated 57 000 deaths attributed to homicide among Data on non-fatal child abuse and neglect come from children under 15 years of age in 2000. Global a variety of sources, including official statistics, case estimates of child homicide suggest that infants and reports and population-based surveys. These very young children are at greatest risk, with rates sources, however, differ as regards their usefulness for the 0–4-year-old age group more than double in describing the full extent of the problem. those of 5–14-year-olds (see Statistical annex). Official statistics often reveal little about the The risk of fatal abuse for children varies according patterns of child abuse. This is partly because, in to the income level of a country and region of the many countries, there are no legal or social systems world. For children under 5 years of age living in with specific responsibility for recording, let alone high-income countries, the rate of homicide is 2.2 responding to, reports of child abuse and neglect per 100 000 for boys and 1.8 per 100 000 for girls. In (7). In addition, there are differing legal and CHAPTER 3. CHILD ABUSE AND NEGLECT BY PARENTS AND OTHER CAREGIVERS . 61 BOX 3.1 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 infant 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 shake children. Intracranial haemorrhages, retinal haemorrhages and small ‘‘chip’’ fractures at the major joints of the child’s extremities can result from very rapid shaking of an infant.