Preventing child abuse and neglect in Saudi Arabia: are we ready?

Although child abuse and neglect (CAN) have been recognized by medical professionals for the last 20 years, child protection services and child maltreatment prevention programs are still emerging in Saudi Arabia. This paper will review the progress made in the country in terms of recognition and implementation of child protection services. Furthermore, it will draw attention to the essential steps required to start child maltreatment prevention programs, as CAN prevention is currently viewed as a global healthcare priority with an emphasis on evidence-based interventions. In addition, this paper will assess Saudi Arabia's readiness to prevent CAN and the challenges that will be faced by the professionals in implementing evidence-based CAN prevention programs.

The definitions of child protection and child maltreatment prevention are often misused, confusing or used interchangeably. Child protection as defined by the World Health Organization (WHO), are measures taken after child maltreatment has occurred, such as support and care for the traumatized child, while child maltreatment prevention refers to measures taken to prevent child maltreatment before it occurs by addressing the underlying causes, risks and protective factors, such as teaching positive parenting skills to pregnant first-time mothers.1

During the last decade, child abuse and neglect (CAN) have became more recognized in Saudi Arabia. Now that there is widespread knowledge about the occurrence of CAN, the future stands in not shifting the approach from a reactive one (child maltreatment protection) to a more proactive one (child maltreatment prevention). It is simply not enough to continue to respond to CAN after it occurs, but there is a need to tackle the problem from the root. In justifying this shift, many factors need to be taken into consideration. This paper will briefly discuss the history of child abuse and neglect in Saudi Arabia, followed by the current shift from protection to prevention, use of evidence-based approaches to prevention, lessons learned and future recommendations.

Child Abuse and Neglect in Saudi Arabia: Historical Perspective

Before 1990:

Child abuse and neglect (CAN) have been recognized in the Arabian Peninsula for centuries. Ancient Arabic scripts and anecdotes have described various forms of maltreatment that were socially acceptable, such as female infanticide. The rapid and widespread expansion of Islam in the region in the 7th century marked a landmark advancement in CAN prevention. The strictly obeyed Islamic guidelines clearly prohibited CAN and advised compassionate treatment instead.2 That led to the disappearance of infanticide cases and made children more valued not only to their families but to their communities as well. However, data on CAN afterwards was insufficient, and it is very likely that other forms of CAN were present and under-recognized.

1990-2002:

The first reported case of CAN in Saudi Arabia occurred in 1990.3 This was followed by a few case reports and review articles published during the 1990s.4–15 However, despite CAN recognition and ratification of the Convention on the Rights of the Child (CRC) in 1996,16 organized services for CAN victims did not exist throughout that decade. The support victims received was based on the individual efforts of dedicated child-advocate pediatricians.17 It is most probable that CAN was dismissed by healthcare professionals as a rare problem affecting only a small number of children and viewed as a family matter that required social intervention rather than a multidisciplinary approach.

2000-2005:

In 2002 the World Health Organization (WHO) recognized CAN as a global problem, manifested in different forms and deeply rooted in cultures.18 In Saudi Arabia it was not until 2004 that the local media made public a series of serious or fatal CAN cases uncovering the reality that such happenings exist in the conservative community of Saudi Arabia. This was considered a major turning point and consequently, governmental and non-governmental agencies specializing in child abuse prevention and the treatment of abused children were established.

Among the many positive programs and initiatives developed in the country in 2004-2005 was the formation of the General Directorate for Social Protection under the Ministry of Social Affairs to run 17 provincial Social Protection Committees. These committees are multidisciplinary, and their main undertaking is to serve victims of domestic abuse, both women and children. Furthermore, the Human Rights Commission (HRC) and the National Society for Human Rights (NSHR) were established in the same period. Among the strategies implemented as part of the conferring of human rights in the country were child protection and the prevention of CAN.19 In addition, the National Family Safety Program (NFSP) was founded by a decree of the King in November 2005. The NFSP is a quasi-governmental agency dedicated to the prevention of child abuse and neglect as well as domestic violence.20 This period in the history of CAN in Saudi Arabia was not marked with public recognition only, but also with the initiation of child protection services.

2005-current:

In 2008, the Saudi National Health Council (NHC) approved the hospital-based child protection teams (CPTs) project proposed by the NFSP and since then, 39 CPTs have been founded in major hospitals across the 13 provinces of Saudi Arabia. The population densities and geographical breadth of these provinces were taken into account in the establishment of these centers to enable better service coverage (Figure 1). The CPTs function under the jurisdiction of the National Health Council, and the NFSP supervises the function of CPTs in addition to providing free training programs and consultations to all CPT members.21 Each CPT is composed of a core multidisciplinary team (pediatricians, social workers, psychologists) in addition to ad hoc members (surgeons, legal service providers, nurses, and others) (Table 1).

Figure 1

Distribution and number of hospital-based child protection teams (CPTs) in the 13 provinces of Saudi Arabia.

Table 1

Distribution of child protection teams in the 13 provinces of Saudi Arabia and the total number of professionals in each team

In Saudi Arabia a number of fatal cases brought the issue of CAN to the forefront in a compelling way. This provided the opportunity for a core group of pediatricians who advocated child protection, to develop a plan of action and present it to the government. The government, in turn, demonstrated the will to address the issue, which led to the majority of programs being directed towards child protection in response to the demand. As a result, the outcomes of the last decade, 2000-2010, were notable for child protection services, but with little emphasis on child maltreatment prevention programs. However, CAN prevention is currently poised to become a global health care priority with emphasis on evidence-based interventions and programs.

CAN Prevention Readiness Elements

A child protection system is currently being established in Saudi Arabia; in moving forward towards child maltreatment prevention, a few issues need to be tackled. Appropriate scientific assessments of the problem using an evidence-based public healthcare approach are necessary, which will aid professionals, leaders and decision makers in selecting prevention programs. These programs should be appropriate for the cultural context of Saudi Arabia with consideration of the human and financial resources available. Nevertheless, evidence-based interventions and programs alone may not be sufficient to prevent child maltreatment, and other conditions must be met. These conditions are often referred to as child maltreatment prevention “readiness”; or the country's willingness to support prevention, which should exist in order for a prevention program to thrive.1 These conditions and elements can be summarized in 5 main dimensions required for implementation of a prevention program in any given country. These dimensions include the following: (1) the political and public will to address the problem; (2) adequate legislations, mandates and policies; (3) institutional links and intersectoral collaborations; (4) data collection tools; and (5) CAN awareness and capacity-building, which includes enhancement of financial and technical capacity and human resources. All these conditions are necessary to implement a large-scale evidence-based child maltreatment prevention program at the national, sub-national (provincial) and local community levels. The last decade was characterized by the development of the above readiness dimensions that paved the way for implementation large-scale child maltreatment prevention programs in the coming decades. The stages of advancement each dimension has reached in Saudi Arabia vary and will be briefly discussed.

Political And Public Will

The political leadership position toward CAN was clear: in addition to the foundation of the various agencies contributing to child maltreatment protection and prevention efforts, generous financial resources have been allocated to these agencies to undertake their functions. One of the most important political movements in the history of CAN manifested in 2008, when the government cabinet of ministers issued a resolution addressing the growing concern of domestic violence and set strategic prevention and protection guidelines. These included establishing more social protection committees, promoting violence prevention through awareness and media campaigns, training of professionals, and implementing a national strategy on domestic violence and allocating funds for it.22 On the other hand, the public was already primed through the media and concerned about the issue and calling for action. Meanwhile, child advocates and advocacy agencies were aiming for an effective intersectoral multidisciplinary mechanism for recognition, management and prevention.

Child Protection Legislations And Mandates

To date there are no specific criminal laws addressing CAN in Saudi Arabia. Cases of significant physical or sexual assaults are referred to law enforcement officials for investigation, and only serious criminal cases are prosecuted in court based on General Criminal Bylaw.23 In the past 3 years, three death sentences were given for manslaughter in fatal CAN cases. The Saudi ‘Shura’ Council (legislative parliament) is currently reviewing drafts for two bylaws addressing the issue of CAN. The first is the “Child Rights and Protection Act,” which aims to enact laws protecting child rights in Saudi Arabia with an emphasis on child protection against abuse and neglect in accordance with the Convention on the Rights of the Child (CRC). The “Social Protection Act,” the other law, is more general and aims to establish multidisciplinary policies and procedures for management of domestic violence (including CAN) cases. The two bylaws are expected to be another major turning point in national child protection efforts and CAN prevention in Saudi Arabia.

Mandatory reporting:

Currently, only healthcare professionals are mandated to report all suspected cases of CAN. The law of mandatory reporting of CAN cases for healthcare professionals was endoresed in 2008 by the Minister of Health and a corresponding notification was issued to all hospitals in Saudi Arabia. The law protects the identity of the reporter and preserves the confidentiality of information. Failure to report a CAN case subjects professional to penalties, including fine or work suspension or both, according to the Saudi Health Practice Bylaw.1824 To date, all other professionals who work with or for children, including educators, law enforcement officials and social workers, either do not have specific policies for mandating reporting of any CAN case in their sectors; or if such policies exist, they lack details of reporting mechanisms.

Institutional Link And Intersectoral Collaborations

According to the hospital-based child protection system and bylaws, any suspected CAN case is referred to the nearest CPT, where urgent multidisciplinary evaluation and service is provided.20 Subsequently, substantiated cases are referred to one of the 17 corresponding provincial Social Protection Committees. Each of these committees functions under the Ministry of Social Affairs and is composed of provincial representatives of social affairs, health, justice and education directorates, in addition to delegates of prosecution and law enforcement departments. These committees, which are spread across the country, are responsible for providing acute and long-term services, counseling, home visitations and rehabilitation for victims and offenders.25

National CAN Data Collection Tools

In 2009, health care professionals were mandated to report all substantiated cases to the National Family Safety Registry (NFSR) administration located in King Faisal Specialist Hospital and Research Center (KFSHRC). This web-based registry enables trained CPT members from all 13 provinces to register any confirmed CAN case to determine prevalence, demographics and recurrence of CAN, in addition to providing short-term services (Figure 2).26 The NFSR administration is expected to publish the first annual report in the year 2011.

Figure 2

National Family Safety Registry (NFSR) Web page.

One of the largest projects for the year 2010 was establishing a Child Helpline in Saudi Arabia. The (116-111) number provides an easy access and confidential outreach service for children around the country.27 In addition to direct service provision, data collected from Child Helpline is expected to provide more information about lighter forms of maltreatment, which are usually undetected, these cases do not reach the CPT like more severe cases.19

Current CAN Statistics and Research

Reports of CAN prevalence, patterns and demographics based on CPT's experiences, were published recently.1828–34 In the report from King Abdul-Aziz Medical City, National Guard Health Affairs in Riyadh (KAMC-R), of the 180 cases reviewed from the referrals to the CPT from 2000 to 2008, 70.7% were substantiated and 46.6% of these were referred for legal action.18 The reporting rate showed a 10-fold increase during the period in question, compared to earlier years marks a significant change in the awareness and attitude of the public and healthcare professionals towards the problem. The mean age of victims was 5 years, evenly represented by males and females. Physical abuse (48.9%) and neglect (32.3%) were the most common forms of maltreatment, and parents were the perpetrators in 48.9% of the cases. The overall fatality rate during that period was 8.3%.18 However, these data represent the findings of only one center and cannot be generalized to define the rate of child abuse victimization in Saudi Arabia. Nevertheless, they do provide preliminary understanding of the most common forms of abuse in the Kingdom. More general data will be published in the first National Report on CAN in Saudi Arabia, which is expected to be released by the NFSR in 2011 and will offer more informative statistics. In addition, such reports will offer data that will assist professionals, advocates, as well as policy makers in designing future maltreatment prevention strategies.

As for research, Saudi Arabia is investing more to partake epidemiological studies to identify risk factors and the consequences of child maltreatment. It is of utmost importance for the initiation of prevention programs. Various research studies and projects are ongoing, including a national surveillance study that is currently in progress to determine the impact of adverse childhood experiences on adult health status (ACE study).35 The aim of this study is to show links between negative childhood experiences and health complications or disease later in life—long-term health consequences. Another research is The Child Maltreatment Prevention Readiness Study, which measures the country's readiness to adopt prevention strategies. This study is proving to be very helpful in assessing and understanding the stance of many figures of authority and their influence on CAN. Both projects are conducted in collaboration with the Injury Prevention Department in World Health Organization (WHO). Another research project under way is The International Child Abuse Screening Tools (ICAST) series of studies developed by International Society for Prevention of Child Abuse and Neglect (ISPCAN) and UNICEF, which are expected to take place during 2010-2012. These studies will shed light on the characteristics of CAN in Saudi Arabia, which will enable professionals to implement their prevention programs on the basis of scientific evidence.

CAN Awareness and Capacity Building

Pediatricians and child rights advocates have conducted various awareness campaigns in Saudi Arabia primarily focusing on preventing maltreatment. Initially these campaigns were aimed at professionals working with children (e.g., teachers, health care workers, social workers, policemen). These campaigns coincided with a series of conferences, symposia and training courses on CAN recognition organized by the involved sectors. Afterwards, the public was approached through different media channels, such as television and radio broadcasts, videotaped television messages, newspaper columns and forums, internet websites and discussion groups, exhibitions in recreational centers and fund-raising events.

Various means were initiated in an attempt to build momentum and human resources specialized in dealing with CAN in Saudi Arabia. Members of CPTs received training on multidisciplinary approaches to CAN diagnosis and management in addition to special training for medical professionals on CAN recognition and management. Both of these training programs were designed and conducted as a joint effort between the International Society for Prevention of Child Abuse and Neglect (ISPCAN) and the NFSP as an outcome of the partnership established between these two institutions to enhance CAN prevention efforts in the country.1819 Furthermore, the National Family Safety Program (NFSP) has initiated many training programs on effectively dealing with CAN directed toward other professionals such as social workers, educators and law enforcement personnel, and to date more than 400 professionals in different disciplines have received certified training.

Reflecting on these five readiness dimensions in Saudi Arabia, it is evident that some readiness dimensions are better developed than others. Due to the importance of CAN prevention to the well being of children, Saudi Arabia should start investing in CAN prevention programs alongside the child protection efforts that began during the last decade. Child protection and child prevention should go parallel in the next decade with more emphasis on evidence-based child maltreatment prevention programs.

CAN Prevention Readiness: Challenges and Lessons Learned

Although the prevention readiness dimensions are in the process of being developed in Saudi Arabia, many challenges will be faced while moving towards CAN prevention. These include the enhancement of the multidisciplinary approach to CAN cases and the institutional links between the different related agencies. These agencies are not strongly connected, and their approaches are subject to their institutional policies. Another challenge is retaining professionals working in CPTs and preventing burn-out. The majority of these professionals joined the teams to fulfill their passion to serve victimized children, but a high turnover rate in these teams was noted within the first year of establishment of CPTs. The most likely reason was the inability of the professional to meet the demands of the CAN cases or to overcome the psychological trauma resulting from dealing with cases of that nature. Moral and financial incentives in addition to debriefing sessions might help resolve this challenge in the future. Subsequent to the challenge in retaining human resources, current efforts and resources expended on professionals’ capacity building and continuous training may not be efficient at this stage and need further evaluation. Most importantly, the legislations, mandates and policies pertaining to CAN are expected to be passed by the cabinet soon; however, the major challenge will be in the implementation phase.

In the future, the national child maltreatment prevention strategy for Saudi Arabia will be evidence-based in accordance with the recommendations of the United Nations’ independent expert study on violence against children,36 as well as the result of the child maltreatment prevention readiness study mentioned above. The strategic plan shall focus on (1) promoting prevention of CAN and implementation of the Convention on the Rights of the Child (CRC) article 19 through awareness campaigns in schools and in media, (2) enhancing the quality of social and legal support provided to CAN victims in addition to health services, (3) augmenting current data-collection systems, (4) conducting further research to determine the impact of CAN on the community and evaluation of prevention measures, (5) assisting legislators in drafting CAN-related laws for various sectors, (6) establishing further partnerships with regional and international child protection agencies, and finally (7) imparting specialized training to professionals in each discipline related to CAN to improve their skills in detection, intervention and rehabilitation of victims.