Child abuse: A social evil in Indian perspective.

Child abuse is a social evil which has existed in our society since a long time. The awareness regarding the same has been minimal in developing countries. Many a times, punitive measures taken by parents to discipline their children turn out to be painful scars in their childhood resulting in stunting of their mental and social growth. Doctors and other health care workers have a very important role in identifying and reporting such issues. Law has also evolved over the recent past in safeguarding the future of our children. However, awareness regarding this issue has remained to be the same as before. During the current era of COVID, parents and children have been restricted to their homes. Livelihood of many families have been at risk. These issues have burdened the caretakers at home and absence of teachers who were otherwise their guardian angels have impacted the minds of these children adversely. Hence in this article we intend to provide good clarity about this social evil, and the rights of our children. We also wish to stress upon the duties of parents, doctors, teachers in molding these tender minds so as to get the best out of them. Copyright:

Introduction

Children are vulnerable and need love, care, shelter, and protection from their caretakers for appropriate growth and development. Abuses against these tender beings often blight their childhood, leading to inability in reaching their full potential—both physically and mentally.[1] Though child maltreatment has existed for many centuries, contemporary societies have either remained in denial or have been snail-paced to acknowledge them as issues. India houses the second largest child population—India houses 19% of the total children in the world and 18% among them are below 18 years.[2] Cumulative prevalence of physical, sexual, emotional, neglect, and witnessing intimate partner violence were 5–35%, 15–30%, 4–9%, 6–12%, and 8–25% according to Gilbert R et al. in 2009.[3] A government of India survey showed that 53% of our children face some kind of abuse.[4] The last decade has seen a gradual rise in the number of child abuse victims–8,804 in 2014, 14,930 cases in 2015.[5] In a study conducted in Kerala, 35% of boys and 36% of girls below 18 had faced some kind of sexual abuse during their childhood.[6] Children between 5 and 12 years were found to be more at risk. The most vulnerable among them were those homeless on the streets, children recruited for child labor, and those in institutional care.[7]

The various kinds of abuse are:

Physical abuse

Emotional abuse

Sexual abuse

Neglect

Fabricated or induced illnesses[1]

Societal abuse[8]

Apart from the above-mentioned abuses, witnessing intimate partner violence has also been regarded as child maltreatment recently in UK.[1]

Risk Factors

A potential risk factor identified is the concept of intergenerational transmission which showed that victims of child abuse during childhood later became the perpetrators of the same in their adulthood—thus forming a vicious cycle.[9] In the same study, a childhood abuse potential (CAP) score has been deduced—taking into account their past history of child abuse.[9] A strong predictor of CAP was also thought to be post-traumatic stress caused by intimate partner violence—its severity and recency.[9]

Parenting is an art and can make or break a child. Some parents believe that physical punishment could be used to discipline their little ones—leading to another important reason for the long lasting negative impact on their children because of this evil.[7] Occasionally, parental frustration, alcoholism, mental illness, and disharmony could also add on to the list.[7]

It was also noticed that most children refused to disclose about the abusive events since the perpetrators were parents and others who were well trusted.[7] On many occasions, fear of falsely accusing parents who are well reputed and decorated in the society lead to missing the cases of child abuse and hence its continuation.[1]

Social reasons such as general preference of boys could also lead to the selective neglect of girls leading to their abuse.[8] Other common social evils such as poverty, illiteracy, caste system, lack of family planning, etc., also contribute to the intensity of the abuse and its ill effects. Increase in urbanization with a recent trend of preferring nuclear families has shown to increase the stress levels in families, and a lack of adequate support structure due to the same—leading to creating an environment amenable for abuse.[8] Female sex, physical disability, low intelligence quotient, behavioral disorders, maternal illiteracy, maladaptive maternal personality traits, young mothers, parents involved in anti-social activities such as drug abuse, and unwanted pregnancy were the recognized risk factors.[10]

Identification of Abuse

Physical abuse

Physical abuse should be suspected when the child is seen to have injuries in un-exposed areas and posterior areas.[11] Examination of skin is of prime importance since it is the most commonly affected and visible organ.[11] Unexplained injury marks on protected parts such as buttocks, thighs, torso, frenulum, ears should raise red flags while we examine children. Similarly, babies who have not achieved the milestones of cruising or crawling cannot have bruises or abrasion on their skin unless intentionally harmed.[11] An identifiable shape or imprint on the skin could be a tell-tale sign of abuse, such as handprints, belt buckles, cord loops.[11] Other forms of physical abuse such as shaking, drowning, poisoning do not show any external skin manifestation, and hence a vigilant history taking and examination is mandated.[1]

Fracture of bones are also seen in cases of physical abuse in children, although there are no pathognomonic signs. Any child less than 1 year of age presenting with a fracture should be evaluated for abuse.[12] A thorough examination of eye and fundus is also important since a shaken baby could have retinal hemorrhages.[13] A study conducted in Bahrain showed Skin manifestations, fractures, and head injuries in 59.0%, 10.5%, and 9.7% of the victims, respectively.[14] Burns are also occasionally inflicted by those who hurt them and may be identified by the shape of imprint, for example, cigarette tip, glove and stocking shaped burns in immersion injuries.[1]

Emotional abuse

Any persistent act or conversation conveying messages of worthlessness cause emotional trauma to these children.[1] However, imposing inappropriate expectations, overprotection, and abnormal social interaction also could be considered emotional abuse, although these acts are well intentioned.[1]

Features secondary to emotional abuse are very difficult to identify and hence requires multiple focussed sessions with the victim. Children upto 5 years are more vulnerable since the relationships acquired during this period contribute to the socio-emotional development and psycho-social functioning.[15] Cognitive, motor, and language delays are seen secondary to this reason.[16] The clinical features may vary in different age groups:

Babies show delayed development, and excessive crying[1]

Toddlers show apathetic behavior, fearfulness, or violence[1]

School children show wetting, soiling, non-attendance[1]

Adolescents show self-harm, depression, oppositional, and aggressive behavior[1]

Sexual abuse

Sexual abuse involves forcing, leading, or enticing anyone below the age of 18 years to participate in sexual activity of any kind, irrespective of the awareness of consequences. Activities could range from contact activities—such as intercourse, buggery, oral sex, or could be non-contact activities—such as watching pornographic materials, or encouraging to behave in a sexually inappropriate way.[1]

In most cases, children do not complain about such events directly and comes to light when they are identified in pornographic materials, be pregnant, or have a sexually transmitted disease with no clear explanation. Head, face, and mouth should be thoroughly examined since injuries in these areas account for around 60% of the lesions noted. Within the mouth, injuries on frenulum, tongue, mucosa, and lips are the most common.[17] Vaginal bleeding, itching, discharge, or rectal bleeding could be important clues to further investigate. Children exposing excessive awareness about sexual activities which is unexpected for that age or enacting sexualized behavior should also be considered seriously.[1] Usually, these activities leave behind long lasting scars in children leading to unnecessary fears suggested by the uneasiness shown to proximity and touch of the caretakers.

Other forms of child abuse

Neglect is an act of omission resulting from the inability to acknowledge and fulfil the needs of a child—both physical and psychological which may have an impact on his/her health and development. Any failure in provision of food, shelter, clothing, protection from danger, adequate supervision, basic medical care and treatment would amount to neglect of child which is considered an abuse.[1]

Intimate partner violence (IPV) in front of the child contributes to short-term and long-term adverse effects on the behavior of the child. Many a times, children do not speak about it fearing embarrassment. It is estimated that around 15 million youngsters face this issue every year in the United States of America.[18] It could occur when the child is present in the room in which the violence is happening, when the child overhears the conversations or experiences the aftermath of the incident.[18] Depression, anxiety, hypervigilance, peer aggression, extreme separation anxiety, tantrums are the specific problems in these scenarios.[18]

Societal abuse is seen as child beggary, child labor, child marriage, etc., which are seen mostly in poorer and developing nations.[8]

Approach to Child Abuse

Children who are victims go through conditions of secrecy, helplessness, entrapment, and accommodation. Most of the cases of abuse happen while the perpetrator is alone with the victim, and that leads to the first condition of secrecy. The second condition of helplessness arises out of the power imbalance between the perpetrator and victim and vulnerability of the child which forces the child to go into the third and fourth conditions of entrapment and accommodation. Children may experience various kinds of feelings, including that of embarrassment, shame, guilt, helplessness, and punishment leading to delayed disclosure. These 5 conditions of secrecy, helplessness, entrapment, accommodation, and delayed disclosure together constitute child sexual abuse accommodation syndrome.[19]

Children should be interviewed in room which is silent, and provides appropriate privacy. A good rapport must be built with the child early in the interview making him comfortable and more willing to disclose.[20] Before questioning, the child should be made to understand that it is not his/her mistake to get victimized. Assurance must also be given to the child that their narrative would be accepted, and the interviewer should never be judgemental. Patient and compassionate listening over several hours and multiple sittings should be used before any conclusions are drawn. Confidentiality must also be promised.

Any injury or medical finding must be carefully noted, measured, recorded, and drawn on a body map and photographed with consent.[1] The interaction between the child and parents must be noted. History regarding siblings must be noted and their protection should also be ensured. A meeting with respective social worker, health visitor, police, general practitioner, pediatrician, teachers, and lawyers must be convened to draw a child protection plan.[1]

Ill Effects of Child Abuse

Childhood abuse leads to cyclothymic mood disorders, depression, anxiety, and irritable temperament.[21] As mentioned earlier, it adversely affects a child's physical and mental health and causes developmental delay in infants. Physical, cognitive, and reproductive adversities were results of such abuses in early childhood.[13] A study done in Britain on adults with childhood abuse showed poor physical performance in 12% of people at the age of 50. They also opined that cumulative risk increases with every episode of various types of maltreatment.[22] Kristen et al. showed that 11.4% of respondents in their study had mental or physical illness.[23] Children with adverse childhood experience had much more suicidal ideation according to a Chinese study by Kristen clemen et al.[24] Somatic complaints, asthma, recurrent infections, sleep disorders were also seen to have a significant correlation with adverse events earlier on in childhood.[13]

Reporting of Abuse and Role of Doctors, Teachers, and Parents

Safeguarding our children is one of our primary responsibility and timely intervention when there are clear events of child maltreatment is our duty toward the society. Parents, teachers should identify vulnerable children and situations and take timely action.[1] In many cases, reporting was not done by clinicians in spite of knowing about the abuse, since they thought that the repercussions it may have on the child and the family would be devastating.[25] Few clinicians also avoided reporting because of the intricacies in the legal formalities which could disrupt their smooth practice.[25] A study conducted by Inanci et al. showed that 21.5% of the primary care doctors who participated in their study had dealt with a case of abuse at least once in their career and 50% among them did not seek any guidance nor report the case. A questionnaire given to the participants showed that the most important factors leading to this act of omission was the unawareness about the formalities of notification and fear of misdiagnosis which scored a mean of 3.48 and 2.93 out of a scale of 5. The most important risk factors identified by the same group was children or parents suffering from mental disabilities, and alcohol and drug abuse among parents which scored 4.3 out of a scale of 5.[26] A study conducted on the proficiency of family physicians in identifying the cases of child abuse and correctly acting on meeting them showed that a significant 39.7% of the 375 participants were not taught about child abuse in their under graduation and post-graduation days.[27] This shows the lack of importance given to this topic in the medical curriculum, and the pressing need to inculcate the same in our system.

Pierce et al. had suggested a mnemonic—“TEN-4” which stands for Torso, ears, neck, and 4 stands for the age of 4 years. According to this, any bruises in these areas occurring during the first four years of life should raise suspicion in the minds of primary physicians. It was further enhanced to “TEN FACE sp,” whereby any injury to Frenulum, Angle of jaw, Cheeks, Eyelids along with Sub-conjunctival hemorrhage and Patterned bruises were also added. This rule of thumb was 97% sensitive and 87% specific in predicting abuse.[28] Abuse of children could be missed in a busy emergency department, and it is very important to set up “child protection service” units specialized in dealing with such cases. A study conducted by Tiyyagura et al. showed that when Community emergency departments, referred cases to dedicated child protection team, on identifying any of the above-mentioned TEN-FACE-sp injuries, an increased reporting of child abuse occurred (from 10.7% to 32.6%).[29]

Apart from identifying these tell-tale signs, it is also important for a primary care physician to take an elaborate history from the parents and the child—both together and individually. Any discrepancy could be an alarm toward a possibility of maltreatment. Observing the family relationship could also provide few clues. Socioeconomic status is never a factor, since children from all strata of society have been noticed to be victims of this evil.[26]

Teachers and parents are the guardian angels of these children and school should be their second home. Any small change in behavior or wellbeing in children could be picked up by these people and should be investigated by them by taking these children into confidence. It is the professional responsibility of a teacher to prevent future harm of their young student who will be an asset of the nation in future.[30] Fear that reporting will affect the relationship between teacher, student, and family, adverse consequences of wrong reporting of a sensational issue, possibility of increase of torture and abuse with reporting, and the inefficiency of the foster homes, hold teachers back from reporting.[31] Training of teachers to improve their skill and accuracy in detecting this evil and awareness of the various laws to safeguard children will also enhance their confidence in this regard. Prompt action from doctors, police, and legal experts is also essential to ensure smooth running of the safeguarding machinery.

Child Abuse and Law

Protection of children from sexual offences was an act framed by the Indian parliament in 2012.[32] It is a gender neutral act and encompasses all kinds sexual acts—sexual intercourse, non-penetrative sexual assault, sexual harassment, using child for pornographic purpose, and trafficking of children for sexual purposes.[33] There are further provisions in this act to preserve the confidentiality and to conduct trial through camera. It also asks for special courts for speedy trials. Failure to reporting a case by a clinician is also punishable—with 6 years of imprisonment and a fine under section 21 of the POCSO act and if a doctor or a hospital staff is involved in rape—a 7 year punishment will be given.[33]

The duties of a doctor while coming across abuse victims are:

Thorough medical examination and documentation of evidences

Treat the injuries

Age evaluation of the child

Providing prophylaxis for diseases which could be sexually transmitted or offer contraceptives if penetrative sexual assault has occurred

Monthly follow-up till 6 months and look for any mental health issues

Family counselling

Assist the court in their proceedings

However, there are few flaws in this law:

In case the victim is an adolescent, consent should be given by both parents and the child. If the child does not give consent, then the law does not provide a clear guidelines for further action.[34]

If both victim and perpetrator are adolescents, then there are no provisions or clear instructions.[34]

The law has made it mandatory for a medical centre to provide free treatment to a victim. However, if the state does not bear the cost of the treatment and procedures, it will lead to centres providing sub-standard treatment.[34]

Conclusion and Summary

Children are dependent on their parents along with other caretakers for their appropriate growth and development. These guardians are also duty-bound to provide them with love, care, shelter, and protection. Abuse during this period leads to long lasting effects, which if not picked up at the right time, could continue for a longer time causing non-healing scars in the minds of these children.

Many a times these victims are later seen to be perpetrators of this evil. Systematic approach toward patients with usage of easy to remember checklist such as “TEN-4-FACEsp” should be used to screen children with injuries, and suspicious cases should be reviewed by a dedicated child protection team.

Doctors along with teachers and parents are at many times the first to identify these vulnerable children and have a primary responsibility of championing the drive toward soothing the inflicted physical and mental wounds of the victims, as well as eradicating this evil from our societies. Makers, guardians, and enforcers of law have a role of providing with the adequate checks and balances in the system.

Though there are many laws to prevent abuse, they are mostly confined to sexual abuse. The other forms of abuse including societal abuse and neglect are still hidden in our society hurting our future demographic dividend. They can be uprooted only through strict legislations and collective vigilance of all the sections of society. Apart from reporting such incidents and bringing the perpetrators to light, we need to heal their present and nurture their future so that they could lead a normal life.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.