CHILD PROTECTION
Dr. Sally Jane Kwong-Garcia, FPPS
Handling Violence Against Children
4Rs
Recognizing
Recording
Reporting
Referral
Abuse and Neglect in Children
(Nelsons Pediatrics)
Child maltreatment encompasses a spectrum of abusive actions, or
acts of commission, and lack of actions, or acts of omission, that
results in morbidity or death.
Physical Abuse defined as intentional injuries to a child by a
caregiver that result in: bruises, burns, fractures, lacerations, punctures
or solid organ damage.
Physical neglect may result in failure to thrive, developmental or
educational delays and increased susceptibility to infection.
Nutritional neglect is most common cause of poor weight gain in
infancy.
Medical neglect results in failure of a parent to provide appropriate
medical care.
Psychologic maltreatment includes intentional verbal or behavioral
acts or omissions that result in adverse emotional or physical
consequences.
Forms of Child Abuse
Physical abuse
Sexual abuse
Psychological or emotional abuse
Neglect
Physical Abuse
WHO 2000
Results from an act of commission which produces
actual physical harm (or holds potential for harm)
which is reasonably within the control of a parent or
person in a position of responsibility, power or trust.
May be single or repeated incident.
It may include slapping, punching, shaking, kicking,
burning, shoving, grabbing, etc.
What is the most common abusive injury?
Bruising
Most Common Sites of Bruising?
Head and Neck
Signs:
Unexplained bruises or injuries on several
areas, in clusters or unusual patterns, in the shapes
of instruments used to inflict them.
New Bruise – blue, red purple
Old bruise – yellow, green or brown
“Those who don’t cruise rarely bruise.”
Bruises are uncommon in infants <6months old.
Which age group experience the highest
rate of physical abuse?
Children aged <1 year old experience the
highest rate of abuse, 21.9 per 1000
children.
www.acr.hhs.gov/programs/cb/pub/cm07/summary.htm.In
Head Injuries
Most common cause of mortality and morbidity due
to physical abuse.
Shaken Baby Syndrome
Combination of:
head injury 100%
retinal hemorrhage 80%
long bone fractures 50+% (ribs, limbs)
Early death rate 15-25%
Degree of disability 80-90%: learning disability, mental retardation, paralyses, blindness
Physical Abuse: Child’s Behavior
Aggressive, withdrawn, submissive, overly compliant,
caters to adults, hyperactive, depressed, apathetic
Easily frightened/fearful of parents, adult or any
physical contact.
Physical Abuse Parental Characteristics
Conceals the child’s injury – explanation does not fit
the injury or no explanation, dresses the child to
cover injury, keeps child from school.
Does not appear to be concerned.
Describe the child as bad, different, evil.
Believes in severe discipline.
Unrealistic expectations.
Sexual Abuse
WHO
Involves acts in which an adult uses a child for sexual
gratification
Inappropriate exposure to adult sexuality, direct sexual
contact or making a child available to others either directly
or indirectly for immoral and illegal acts such as through
pornography.
Most common presentation – states that he/she has been
abused
Sexually proactive behaviour or knowledge that is
incompatible with the child’s age & understanding.
Pregnancy, STD, psychosomatic illness, suicidal behaviour.
Sexual Abuse
Male
Female
Physical Abuse
0 1000 2000 3000 4000 5000 6000
Gender Myth
Majority of those sexually abused are girls,
The reality is that more boys are sexually abused in
the Philippines!
Distribution of Physical Findings in Sexually Abused
Children
5%
Abnormal
Normal
95%
Why exams are normal?
Nature of assault may not be damaging.
Perception of “penetration” may be in error by the
child.
Disclosure may be delayed days to years after
assault because of complete healing can occur, the
hymen can “grow” as puberty progresses, masking
prepubertal injuries.
Hymen Myths
It’s a thin covering that is broken with penetration.
It is always injured with sexual contact and cannot
heal.
Some girls are born without hymens
It can be torn by horseback riding, gymnastics or
with a tampon.
“Normal does not mean nothing
happened’”
Only 2 of the 36 adolescents had genital changes
that were diagnostic of penetrating trauma despite
definite evidence of pregnancy.
Kellog MD, Menard SW and Santos A, Pediatrics 2004: 113 (1) e67-e69
Who are the offenders? (Philippines)
1. neighbors
2. acquaintances
3. family members
How do children disclose?
Indirect or direct
Behaviour
Disclose it after participating in an intervention or
education program
Initially deny it or say they forget, only to disclose
later
Some may disclose and then retract later
Emotional Abuse
American Academy of Pediatrics
Psychological maltreatment is a repeated pattern of damaging interactions
between parent(s) and child that becomes typical of the relationship.
UN Committee on the Rights of the Child
All forms of persistent harmful interactions with child, for example,
conveying to children that they are worthless, unloved, unwanted,
endangered, or only of value in meeting another’s needs.
Scaring, terrorizing and threatening, exploiting, violating, rejecting,
ignoring,
Insults, name calling, humiliation, belittling, hurting child’s feelings
Exposure to domestic violence.
Child Neglect
Child Neglect
Means failure to provide, for reasons other than
poverty, adequate food, clothing, shelter, basic
education or medical care so as to seriously
endanger the physical, mental, social and emotional
growth and development of the child.
Two children killed when candle left A two year old boy died in a Manila
out during night caught fire and hospital late Wednesday afternoon
burned down a small house in several hours after accidentally
Nasilla Village, Davao City ingesting a silver cleaner solution.
Posted by Romeo B. 22-01-2011
Child was always alone in the house in the
afternoon when she comes home from
school. Both parents are working, She was
raped by a neighbor. She is 9 years old.
Cybersex
Potential Negative Effects of Child Abuse and
Neglect
Neurological/Medical/Physical – death, burns, brain damage,
fractures, failure to thrive, intellectual disability, physical handicaps,
STD, speech defects, chronic disease, peptic ulcer, obesity
Cognitive/Intellectual – academic skill defect, hyperactivity and
inattention, learning disorder, lowered IQ, poor reading ability,
poor school performance
Social/Behaviour – aggression, alcohol abuse, drug abuse, early
smoking, crime and violence, deliquency, promiscuity, prostitution,
running away, teenage pregnancy, truancy, intimate partner
violence, re-victimization
Psychological/Emotional – attachment disorder, anxiety, borderline
personality disorder, depression, dissociation, hostility, low self-
esteem, poor coping skills, PTSD, somatization d/o, eating d/o,
suicide attempts
Metro Manila ACE Studies
High co-occurence between domestic violence and
physical and sexual abuse.
Smoking (30%) and alcohol (36.5%) are the most
common health-risk behaviour consequences.
Sexually-abused: 12x engage in early sex, 9x have
early pregnancy, 5x commit suicide
Telemedicine
