Prof.

Sujeewa Amarasena

Child Abuse

Original Definition

Acts or Omissions by a caregiver

causing Actual or Potential Damage
to the Health and Development of the
child and exposure to unnecessary
suffering

Child abuse - Epidemiology

4 die/ week in Britain

20 times increase
>35000 children on a child
protection registers
A child is treated in a way
unacceptable in a given culture
at a given time
Different Types of abuse

Prevalence

1/1000 severe physical abuse

1/10000 mortality
4% under 12 years
Other types difficult to determine
Esp. sexual abuse
Multiple types coexist
Boys and girls
First born > others
One child > others
Younger > older
Severe physical abuse <2 years
Death uncommon after 1 year

Child Abuse
Usually caused by
A related care-giver
Sex abuse usually by males, rarely
by females
Physical abuse/Sexual abuse also by
females
Common
When the father is unemployed,
Drug addict or Alcoholic
A male friend of the mother

Abuser
Parents/ Care givers
Young parents>older parents
Both in physical abuse and neglect
Sexual abuse men>women
Poisoning, suffocation and Munchausen
by proxy
mother
No mental illness usually
Personality traits
Predisposing to violent behavior or
inappropriate sexual behavior
All layers of society but more in poor
Inter generational transmission

Child Abuse

Prevalent in

In ALL Social, Economic, Ethnic and

Religious
Group
BUT More common
in poor socio-economic groups
with an
increased
number of CRISES in life; Parents who are
mostly
Unhappy & Hostile under excessive
psychological stress
Parents who had been abused during
childhood
Families with limited social assets
extended families, (esp. sex abuse)
Commonly associated with partner abuse

Types of child abuse

Physical abuse
Nutritional neglect
Sexual abuse
Intentional drugging / Poisoning
Munchausen syndrome by proxy
Neglect
Emotional abuse
Child labour & Conscription of children
in war

Physical abuse

Fist on the face vs hand on the bottom

Diagnosis is a difficult intellectual and
an emotional exercise
Needs time, experience and emotional
energy
Emotional blocks in professionals DD
not considered even in obvious cases
First case cover it up

Importance
Influence childs future
Life vs death
Permanent handicap
Emotional abuse
Deprivation will cause progressive
and permanent damage to personality
esp older children

Disordered parents/ child relationship

Symptoms of disordered parenting

Lost opportunity if missed

Diagnostic features

1.

2.

3.

No hard and fast rules

Seven classic pointers
Delay in seeking medical help or
not sought at all
Story of the accident is vague,
lack details, vary from each
telling, person to person
Account of the accident is not
compatible with the injury
observed

4. Parents behavior gives concern

Hostile, rebut accusations, leave
soon
5. Childs appearance and
interaction with the parents is
abnormal
Sad, withdrawn, frightened
6. parents affect is abnormal. No
creative anxiety to the child but
preoccupied with their problems
7. Child says different things

Physical abuse
Definition
Physical abuse may involve hitting, shaking,
throwing, poisoning, burning or scalding,
drowning, suffocating, or otherwise causing
Physical harm to a child. Physical harm may
also be caused when a parent or carer feigns
the symptoms of, or deliberately causes, ill
health to a child whom they are looking after
this situation is commonly described using
terms such as factitious illness by proxy or
Munchausen syndrome by proxy

Single injury
Multiple injuries
Patterns of injuries
Accidental vs intentional
History- story
Discrepancy
Scale and severity
Conceal
No medical treatment

Indicators

Unexplained injuries or injuries where

there are conflicting explanations
A repeated pattern of injuries which
seem unlikely to have been caused
accidentally, eg: bruises at different
stages of healing

Scaled and burns with clear outlines

Bite marks

Bruising to the face, black eye; bruising to the

buttock and torso
Finger tip bruising, hand marks, grasp marks
and marks of implements
Untreated internal injuries or broken bones
Child conceals or is reluctant to discuss
injuries
Withdrawn or aggressive behavior, loss of
confidence, social problems or lack of
achievement in school

MULTIPLE BRUISES OVER FACE &

FOREHEAD

Severe contusions over hands

inflicted with a ruler

Severe contusions over leg inflicted

with a ruler

Markedly swollen & contused ear

Fresh looped- cord marks

Scars due to beating with a looped

electrical cord

Characteristic pattern of parallel

lines due to blows with a belt

Linear contusions on thigh due to

repeated blows with a switch

Circumferential cord burn due to

attempted strangulation

Deep circumferential rope burn in

this infant who was tied to side of
her crib

Vesiculation due to mite bites

The imprint of incisors

Severe second degree deep

burns on hand

Severe second degree burns of

foot & lower leg

Cigarette lighter burns

X-rays

X-rays

X-rays

Emotional abuse

Definition
Emotional abuse is the persistent emotional ill
treatment of a child such as to cause severe and
persistent adverse effects on the child's emotional
development. It may involve conveying to children that
they are worthless or unloved, inadequate, or valued
only insofar as they meet the needs of another person.
It may feature age or developmentally inappropriate
expectations being imposed on children. It may
involve causing children frequently to feel frightened or
in danger, or the exploitation or corruption of children.
Some level of emotional abuse is involved in all types
of ill- treatment of a child , though it may occur alone.

Indicators

Chronic lack of self- esteem and low selfconfidence

Emotional responses, regression and neurotic
behaviour.
Demanding behaviour, attention-seeking ,
inappropriate behaviour towards non-parental
adults.

Withdrawn behaviour, failure to make friends o

Fear of new task, not wanting to

experiment or join in.
Developmental and learning
delays.
Outbursts of anger or distress.
Indifferent or negative
relationship with parents.
Over- compliance behaviour,
excessive desire to please.

Sexual abuse

Definition
Sexual abuse involves forcing or enticing a
child or young person to take part in sexual
activities , whether or not the child is aware of
what is happening. The activities may involve
physical contact, including penetrative (eg: rape or
buggery) or non-penetrative acts. They may
include non contact activities, such as involving
children in looking at , or in the production of ,
pornographic materials or watching sexual
activities, or encouraging children to behave in
sexually inappropriate ways.

Indicators

Inappropriate sexual behaviour

towards adults and/or other children
Unusual bleeding or discharge from
the genitals
Sexual knowledge inappropriate for
the childs age
Selfharming
Eating and sleeping disturbances
Depression, low self- esteem, suicidal
behaviour
Poor achievements in school

Tourist Vs Domestic sex abusewhich is bigger?

Abuse by Tourists - Easily seen and exposed
Easy to recruit

Hardly seen

Domestic sexual
abuse of boys

Iceberg phenomenon

Why is male sexual abuse

more common in Sri Lanka?

Not mainly due to tourist paedophile activity

Virginity in females is important at marriage
Traditionally blood stained bed sheetproduced at the
"home-coming ceremony. Females relatively
protected
Pre-marital sex in traditional society is uncommon
Boys have little protection.- Many Misconceptions.
Cannot happen, Little physical damage
(ships dont leave tracks) Boys dont
become pregnant
Vicious cycle of todays abused becoming
tomorrows abuser

Long term Consequences of Sexual

Abuse

Depression and other psychiatric problems

Devalued self-esteem
Problems in sexual relationships
Polygamy / Polyandry (Adultery)
Prostitution / Promiscuity
Homosexuality
Sexual abuse of children /paedophilia /incest
Increased vulnerability to further abuse
Problems with spouse, parents, relatives
Isolating oneself from society
Males sexually abused during childhood by
mother/
other women- there is a high incidence of being
rapists

Sexual Abuse
Conclusions
Commonly Prevalent
Common among relatives, Incest
In lower social classes, the
incidence of sexual abuse is high

In Sri Lanka, the incidence of

sexual abuse is high among
boys, than girls

Severe genital trauma in a

prepubescent girl after rape

Perianal laceration, abrasions &

burns in a prepubescent

Neglect
Definition

Neglect is the persistent failure to

meet a child's basic physical and/ or

psychological needs, likely to results in
the serious impairment of the child
health or development. It may involve
a parent or carer failing to provide
adequate food, shelter and clothing,
failing to protect a child from physical
harm or danger, or the failure to
ensure access to appropriate medical
care or treatment. It may also include
neglect of, or unresponsiveness to a
childs basic emotional needs.

Indicators

Poor growth and development, failure to

thrive without an organic cause
Failing to achieve in school, learning delays
Poor hygiene, inadequate clothing
Untreated medical conditions
Poor self-esteem
Chronic tiredness and hunger, falling to a
sleep in class, voracious eating
Mottled purplish skin, sores, poor hair
condition
Lateness to school, frequent non attendance
Poor social relationships, indiscriminate
attention-seeking with adults
High level of accidents

Long term outcomes

Measurable deficits
Eg: polio
Vs CAN
Developmental delay
Personality problems
Conduct disorder
Psychiatric illnesses
eg: Depression
Sexual disorders
sexual dysfunction, sexualized behaviour,
prostitution, self mutilation
Eating disorders

A badly neglected case of irritant

diaper dermatitis

Psychosocial failure to thrive as

a result of neglect

Growth chart of a child with

psychosocial failure to thrive

Wasting of upper arm

Childhood
experience

Possible outcome

Understimulation

Developmental delay

Emotional neglect

Indiscriminate over friendliness, overactivity,

and aggression
Problems in making and sustaining Intimate
personal relationships

Emotional abuse

Excessive
punitiveness

Disturbed feeding behaviour, wetting, and

soiling
Poor social adjustment
Anti social behaviour
Passive frozen behaviour
Disorganized aggression

Family violence

Conduct disorders

Sexual abuse

Sexualized behaviour
self mutilation
Eating disorders
Depression

Child Labour
Definition

All forms of commercial or other

exploitation resulting in actual or
potential harm to children.

Child labour

Sending
Community
4076 families
1022 children employed
Estate, rural, armed conflict, inner
city slums
Estate 51.8%
Agriculture 19.2%
Labour 11.2%
Other

Child labour

8% in Galle
4% in admissions
2.5% (<14 years) 7574 children
(NCPA indirect survey)

Child labour
Working children

248 females 146

males - 99
87% were happy at work place

Management
Rehabilitation / follow up
Care plan

Judiciary
case conference
Police, Judicial Medical officer
probation, Paediatrician , Psychiatrist

Detection & Reporting

Average

Maximum 110 cases per year in

2001
Last year 51 cases
Now evenly distributed
Some do not get admitted
>120 cases in Galle district

Hospital admissions
Paediatrics ward
Surgery ward

Gynecology

Obstetrics &
wards.

Attendance

Paediatrician
AJMO/ JMO
Probation officer
Police officer
Psychiatry registrar or written
opinion
Paediatric
Registrar/Registrars/House officer
Parents, guardian , some times child
One medical student

Detail discussion
Probation report
Decisions in the best interest of
the child
50% within 4 weeks in 2002

Placement

27% institutionalization GMA 2002

Support, protection, monitoring
Cases of complex nature takes
time

Follow up

Childrens home
Relatively easy
Home
Difficult
Compliance poor
Ground realities & logistics
difficult

CRPO / PO
Access difficult
Workload heavy
6 PO
20 now
better
Three wheelers
Motor bicycles

STD Follow up
1.
2.
3.

VDRL positive
1 case
Gonococcus
1 case
Herpes
1 case
Over 8 years rare.

Education follow up
Childrens home
Birth certificate
Leaving certificate
PO / CRPO need to attend
Principal give it to the guardian
Court orders are needed
Case story
Teacher with 3 children
Father ran away to Italy. Sold the house
Big - National school .
Did not give the leaving certificate
Court order

Basic needs - For abused

children

Provision was difficult

At the time of detection

Dirty clothes, no slippers / shoes
Hungry
Not combed hair, not brushed teeth
poor personal hygiene
Hat collection of staf
Now 2006
Rs. 3500/ per case from DCPC.
Buy - Basic needs
- Educational items
100 children supported so far.

Monitoring

Monthly interviews of parents and

children
Monitoring records on financial
expenditure
Monitoring school attendance and
learning progress.
Reports from principal, teachers
Field assistants visits to the family.
PSSW Pre intern

Children's homes

Basic needs /education & 2 graduates now.

Dancing & music group

It is a victory
Reintegration expedited.
Eg. 14 year old boy with AGN/scabies
Kataragama. Parents available
magistrate lost shoes

All street children arrested

Send to remand home

Case conference held
Lawyer arranged
Handed over to parents
21 children send home last year.

ROLE OF POLICE
OFFICERS

1. AS A

POLICE OFFICER

2. AS A PARENT

3. AS A CITIZEN

SEXUALLY ABUSED GIRL

IN HOSPITAL FOR ASTHMA.

CARED BY STAFF OF A HOME
TAKEN AWAY BY A NURSE
A CHILD DOMESTIC KEPT BY A
DOCTOR
NOBODY REPORTS UNTIL THE
CHILD RUNS AWAY

AS A police officer

HAVE PRINCIPLES
CANNOT TAKE A SIDE
DO NOT TAKE PART IN
UNETHICAL CONDUCT
BE FREE OF PERSONAL ,
POLITICAL BIASES

AS A PARENT

DO YOU CARE FOR YOUR CHILD ?

DO YOU EMOTIONALLY ABUSE
THEM ?

DO YOU CONTROL YOUR ANGER ?

DO YOU OVER PROTECT THEM ?

AS A CITICIZEN
WHAT WILL YOU DO

WHEN YOU SEE A CHILD

DOMESTIC HELPER ?
WHEN YOU WITNESS ABUSE /
RAPE
CONDUCT YOURSELF LIKE A
PROFESSIONAL IN ANY SETTING

Reality
Case detection
1996 - Personal intervention
A 13 yr old boy sexually abused by 2
adults.
Paid Rs. 20/-,
I took him to police station in my
car
Severe anal trauma, VDRL
positive.
Evidence in courts, Fined Rs 1500/=

2002 School
teacher

Drawing of a child ,
CRPO
Referred to police by
me.

I reported to
police. Pending
on 19/3/2007

2006 - Community
A child physically abused by the
father
Head hit on the wall
Neighbor intervened
Father cut the penis.
The child ran bleeding and
collapsed.
Estate watcher picked up & ES
drove to
hospital

E.g.: 06.03.2007

13 yr old girl CSA - uncle

Parents separated at 3 yrs. IDP
Fathers elder sister cared
unmarried , govt. worker,
well, live separately
Kept with younger sister+ husband
from 3 yr. of age
Caring uncle abused her over the last
2 years
Mother not available for 10 yrs
Lives with aunt
Father not traceable

Provision of support
Case : A 13 yr old girl with RAP in a medical
ward.
Referred to me due to P/H CSA.2002 at 8 y
Handled by us.

Court case concluded. Verdict pending.

Changed school after case conference due to
stigma.
School 6 km away instead of km.
Mother gives money to bus fare EOD (Rs 10/-)
She attends school EOD. School, friends teachers
support for that.