INTENSIVE REVISION
COURSE
NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA
FEBRUARY 2021
ABUSES IN CHILDREN
INCLUDING CHILD TRAFFICKING
RESOURCE PERSON
NWADIUTO A. AKANI
INTRODUCTION/BACKGROUND
• Historical evidence exists that show that prior to and during the
European industrial revolution ,systematic maltreatmemt of children
for economic and ideological reasons was common.
• Growing awareness as it affected disadvantaged groups led to calls for
social reforms & policies to protect health and well being of children
especially in periods of social disruption,
• 2nd haif of the 20th century saw a growth and widespread attempt to
seek explanation of the problem, ways of systematically controlling
and preventing it as well as treating the victims/survivors.
NATURE& MAGNITUDE OF THE PROBLEM
• Inadequate data worse in developing countries
• Emerging data from countries with functional information systems,,
improved public, health and social workers awareness and a
functional reporting system show consistently , upward revision of
incidence rates
• The continued lack of legal requirements to report cases( and/ or
even prosecute offenders) make it difficult to analyse trend of events
and to successfully plan for prevention, treatment and protection
programmes especially in developing countries e.g. NIGERIA
• Non harmonization of definition of terms (professional, sociocultural).
DEFINITIONS
• The World Health Organization (WHO) defines child abuse and child
maltreatment as "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."
DEFINITION CONTC
• Centers for Disease Control and Prevention (CDC) uses the term child
maltreatment to refer to both acts of commission (abuse), which
include "words or overt actions that cause harm, potential harm, or
threat of harm to a child", and acts of omission (neglect), meaning
"the failure to provide for a child's basic physical, emotional, or
educational needs or to protect a child from harm or potential harm"
DEFINITION CONTD
• The United States federal Child Abuse Prevention and Treatment Act
defines child abuse and neglect as, at minimum, "any recent act or
failure to act on the part of a parent or caretaker which results in
death, serious physical or emotional harm, sexual abuse or
exploitation" and/or "an act or failure to act which presents an
imminent risk of serious harm
DEFINITION CONTD
• ’The physical and mental injury, sexual abuse, negligent treatment or
maltreatment of a child under the age of 18 by a person who is
responsible for the child’s welfare under circumstances which
indicate that the child’s health / welfare is harmed or threatened
thereby .” FED CHILD ABUSE AND PREVENTION ACT 1974
DEFINITION CONTD
• In 1995 the American Medical Association stated
"Child abuse occurs if a person who has the care or custody of a child
causes or allows the child to suffer any of the following: physical
harm, such as external or internal bruises, burns, fractures, wounds,
brain damage or poisoning; malnutrition (including dehydration) or
mental ill-heath of a degree that if not immediately remedied could
seriously impair growth and development or result in permanent
injury or death; or sexual molestation.
• In 1995 the American Medical Association stated
"Child abuse occurs if a person who has the care or custody of a child
causes or allows the child to suffer any of the following: physical
harm, such as external or internal bruises, burns, fractures, wounds,
brain damage or poisoning; malnutrition (including dehydration) or
mental ill-heath of a degree that if not immediately remedied could
seriously impair growth and development or result in permanent
injury or death; or sexual molestation.
TYPES OF CHILD ABUSE
• The World Health Organization recognizes four main types of child
maltreatment:
• physical abuse
• sexual abuse
• emotional and psychological abuse
• neglect
• MALTREATMENT is an area that encompasses many different things,
such as
PHYSICAL ABUSE/CHILD BATTERY/NAI
➢ physical abuse: (WHO defn) intentional use of physical force against
the child that results in or has a high likelihood of resulting in harm
for the child's health, survival, development or dignity.
Physical abuse may include the shaken baby syndrome, stabbing,
punching, hitting, beating, biting, burning and any other action that
harms a child. Though an adult may not intentionally want to cause
harm, however, it still constitutes child abuse. Physical abuse in
severe cases may lead to brain damage, disfigurement, blindness, and
even death
child neglect
➢child neglect :Child neglect is when a parent or guardian fails to
meet the needs of the child. Most cases of child neglect involve
inadequate nurturing and affection from the parent to the child.
Jill Goldman and Marsha K. Salus, 2006, define neglect as "paying
little to no attention to the child, refusal or delay in medical or
psychological care, the insufficient provision of food, clothes and
hygienic care and not providing proper education".
psychological/ emotional abuse
➢psychological/ emotional abuse : refers to an incident or a behavior
of the parent or guardian that conveys to the child that they are
worthless, flawed, unloved, unwanted, endangered or only of value in
meeting another person's requests. (1995, APSAC)
• American Psychological Association (APA 2013)
"nonaccidental verbal or symbolic acts by a child's parent or
caregiver that result, or have reasonable potential to result,
in significant psychological harm to the child.
CHILD EXPLOITATION
➢ Is a form of child abuse which yields some economic benefits to the
perpetrator or someone else. It occurs when a child is made to
engage in some gainful productive activity which is detrimental to
his/her physical, Social , psychological and emotional development.
It includes child labour and child prostitution including human
trafficking
CHILD SEXUAL ABUSE-
SEXUAL ABUSE- defined as any sexual activity which the child
➢ is developmentally unprepared for,
➢cannot comprehend, and
➢cannot give informed consent ,
➢and which violates the social and legal norms.
CHILD SEXUAL ABUSE-contd
CSA can be physical, verbal, or emotional and include
▪ actual sexual contact with a child, by penetration, masturbation
▪ physical contact e.g fondling with the child's genitals, breasts
▪ pressuring a child to engage in sexual activities
▪ Use of language that is inappropriate for the age of the child to
generate sexual excitement
▪ exposure of the genitals to a child/ viewing of the child's genitalia,
▪ displaying to a child/ using a child to produce pornography
• Sexual abuse : occurs when an adult encourages or coerces a child
to touch another person in a sexual way, encourages or coerces a
child to participate in any sexual activity or tells a child to touch
him/herself for an adult's or older child's sexual purposes.
MUNCHAUSEN BY PROXY-
➢MUNCHAUSEN BY PROXY- The falsification of illness-physical,
psychiatric, and/or psycho educational- in a child resulting from
deliberate exaggeration, fabrication or inducement of symptoms by a
parent or significant adult {esp mothers or mother surrogates}.
• American Professional Society on Abuse of Children described 2
components of MBP- the child( Paediatric Condition Falsification-
PCF)and the adult components(Factitious Disorder by Proxy)
MUNCHAUSON BY PROXY
It defined child component-Paediatric Condition Falsification (PCF)- as
a form of maltreatment in which an adult falsifies physical and/
psychological signs and/symptoms in a victim causing the victim to be
regarded as ill or impaired by others.
• MBP- caretaker simulates or produces illness in a child in order to
enhance her role. Child victims tend to make dramatic recoveries
when separated from the care giver.
EPIDEMIOLOGY OF CHILD ABUSE
• WORLD WIDE –recognized
• Exists as a spectrum of conditions with overlap between various types
• While children of all ages are at risk of child abuse, those three years
old or less are most frequently investigated for child abuse.
• SEX f>m 53% to 47%
• AGE 25% <4yrs, 50% <7yrs
EPIDEMIOLOGY – OPERATIONAL LEVELS
• OPERATIONAL LEVEL 1– GLOBAL
• LEVEL II ---CULTURAL
• LEVEL III----INDIVIDUAL
EPIDEMIOLOGY CONTD
• ABUSERS about 75% parents, 11% other relatives/friends, 14%
others- strangers .
• Males more likely to sexually abuse and females more likely to
neglect
• PREVALENCE- cannot be accurately estimated for various reasons
• FATALITY- cannot be accurately estimated
Why Does Child Abuse Happen?
• Does child abuse happen because a child has done something wrong
numerous times?
• Does it happen because of a child’s bad behaviour?
• The answers to both questions are NO!
• No child deserves to be kicked, punched, hit with objects, sworn at,
yelled at, told they aren’t good enough, sexually assaulted.
• Parents/care givers maltreat children for many reasons and a
combinations of reasons
RISK FACTORS FOR ABUSE AND NEGLECT
• In the past three decades, researchers have identified four common
co-occurring issues that are related to parenting and that lead to
child maltreatment. These are
➢parental substance abuse
➢ parental mental illness
➢domestic violence, and
➢child conduct problems—
RISK FACTORS for physical abuse
• Children with disabilities- physical or mental disability ;
• separate living arrangements from both biological parents eg a child
in foster home or with adoptive parents;
• mental illness in care giver
• hx of alcohol or drug abuse in the family;
• a parent with a hx of physical or sexual abuse as a child;
• homes with other forms of abuse,
RISK FACTORS CONTD
• Being in prostitution or transient adults.
• A Gay, lesbian or bisexual youth
• Unmarried adolescent mothers
• Unrealistic parental expectations of the child
• Preterm babies
PHYSICAL ABUSE (NAI)-RISK FACTORS
Proposed -A combination of individual, family and societal factors
“NEWBERGER”>>>.3 Types/classes of stressors
• Child produced stressors : physically ,mentally, behaviourally,
temperamentally different children
• Parent produced stressors: low self esteem, Unrealistic parental
expectations
• Social situational stressors: poverty, unemployment, excessive
mobility, isolation, attachment problems, punitive child rearing
practices
PHYSICAL ABUSE-Presenting features
• Inconsistent histories
• Injury inconsistent with history of event
• Injuries at different stages of healing
• Bruising/ injury at unusual sites
• Frequent nocturnal hospital visits
• Inappropriate parental concerns
• History of frequent accidents
• Previous injury/abuse of other siblings
MANAGEMENT OF NAI
• Adequate history taking, physical examination and documentation
• Admit for in-patient care irrespective of degree of severity of injury
• Report your suspicion
• Lab and radiological investigations
• Environmental investigation
• Definitive diagnosis and treatment
• Counseling/MDT/IDT
• Relocation
• Follow-up and adjustment programmes
• Understanding and responding to these issues is fundamental to
designing effective parenting education programs that can help
prevent abuse and neglect.
Sexual Victimization- Risk factors
The primary markers for increased risk for child sexual abuse for girls are
having:
• few friends
• absent or unavailable parents
• Living with a stepfather and
• conflict with or between parents
Other risk factors for CSA (as for NAI)
• physical or mental disability;
• separate living arrangements from both biological parents;
• mental illness
• alcoholic or drug abuse in the family;
• a parent who was physically or sexually abused as a child;
• homes with other forms of abuse,
• prostitution or transient adults.
• Gay, lesbian or bisexual youth
EFFECTS OF SEXUAL ABUSE
• Survivors are at higher risk for mental health and social functioning
problems resulting from feelings of
✓ powerlessness,
✓ guilt, shame,
✓ stigmatization and
✓ low self-esteem.
Survivors therefore Face Severe Negative Effects
Consequences of CSA on victim
• Powerlessness damages coping skills and reduces ability to protect oneself
from further abuse
• Chronic /repeat victimization
• low self-esteem, depression, anxiety, fear, hostility, chronic tension
• eating disorders
• sexual dysfunction
Consequences of CSA on victim contd
• self-destructive or suicidal behavior
• post traumatic stress disorder
• dissociation, multiple personality disorder
• Academic problems
• running away, criminal behavior, substance abuse and prostitution
(behaviors in conflict with the law)
The sexually exploited child
• Commercial sexual exploitation of children fall into 3 categories
➢Prostitution
➢Trafficking
➢Sale of children
• Most at risk are CEDC esp the poor and abandoned
Common health problems are related to injuries from accidents and
working conditions and structure eg long working hours, lack of
sleep, substance use, non use of contraception including barrier
methods.
Consequences of neglect
• Neglect can often result in psychological/mental diseases, the most
common being post-traumatic stress and depression.
• Moreover, children who did not receive the loving care and support
from their parents have a hard time having healthy relationships.
• If they have never experienced a healthy relationship, they are not
able to have one, and
• they cannot communicate normally.
• Neglect often leads to other types of abuse, mostly psychological
STEPS IN MX OF CHILD ABUSE
• Good history, physical examination &
• documentation of findings(see - concerns of the doctor in CSA )
• Completion of reporting form/confidentiality
• Consultation request (may involve interdisciplinary management/MDT)
• Investigations-HIV screening, Hep B,VDRL, HVS, urine mcs and others as
indicated eg pregnancy test
• Initial treatment including counseling/options-like PEP,emergency
contraception
• Follow up care
• Management of relationships
• Preparation for court
Management PRIORITIES
• - safety,
• -stabilization (emotional trauma),
• -working relationship for CBT (GROUP OR INDIVIDUAL)
• environmental(social) support
INITIAL APPROACH TO TREATMENT
IDENTIFY/NOTE
• 1. Age at time of presentation
• 2.Circumstances of presentation
• 3. Co-morbid conditions
• GOAL OF RX- Not only to treat current mental health issues but to
also prevent future ones.
MAJOR MODALITIES OF TREATMENT
• Family therapy
• Group therapy
• Individual therapy
MAJOR FACTORS THAT AFFECT PATHOLOGY
AND RESPONSE TO TREATMENT
• TYPE AND SEVERITY OF ABUSE
• FREQUENCY OF ABUSE
• AGE AT WHICH IT OCCURRED
• FAMILY OF ORIGIN
CSA-concerns of the physician
• BODY IMAGE CONCERNS
• INTERPRETATION OF RESIDUAL LESIONS
• MEDICAL FOLLOW UP FOR STIs ,HIV/AIDS
• CONDITIONS OF GUS &GIT ASSOCIATED WITH THE SEXUAL ABUSE
• FORMULATION OF A FINAL MEDICAL DIAGNOSIS
NB .IMPORTANCE OF A THOROUGH PE,PROPER DOCUMENTATION
AND ITS LEGAL IMPLICATIONS
PREVENTION OF ABUSE AND NEGLECT
• IMPROVED PARENTING IS THE MOST IMPORTANT GOAL OF CHILD
ABUSE PREVENTION.
ACTIONS
• CHILD CENTERED
• PARENT FOCUSED
• ENVIRONMENTAL ISSUES
PREVENTION OF CHILD ABUSE
• INTERSECTORAL COLLABORATION----Health , legal, social welfare
• ADVOCACY to trad rulers, legislators, women
• AWARENESS CREATION –about available legal/ human rights instruments ,ILO, CHILD RIGHTS ACT
-- child rights organizations,
----WOTCLEF
Trainings—Parenting skills, comprehensive sexuality education
Universal basic Education,skills acquisition
Good national governance and effective judicial system
Conclusion
• Child abuse- very common in our society .
• Sexual abuse has assumed an epidemic proportion (females and
males).
• Females are now an endangered species
• Concerted efforts and appropriate responses of Civil society, legal
officers and health workers are necessary to mitigate this societal ill.
• Judicial system, the Legislature and law enforcement agents should
live up to the expectations as enshrined in our laws.
• CHURCHES/ SCHOOLS SHOULD CONTINUE TO TEACH MORALS
• THANK
• YOU
