Child abuse

Child abuse refers to any child-rearing technique that results in physical harm or death, or
emotionally deprives the child of self-esteem through avoidable acts of omission or
commission. It can also be described as any act on the part of the parent or caregiver which
may result in death, serious physical & emotional harm, sexual abuse and exploitation of the
child. All forms of child abuse involve the element of power imbalance, exploitation and the
absence of true consent. Child abuse affects a lot of children. Over 50 000 children die each
year globally as a result of child abuse. In Zimbabwe, over 100 girls are sexually abused
every day.
Child abuse is associated with:
 Poverty & unemployment.
 Low level of parental observation.
 Single parenting.
 Poor housing.
 Domestic violence.
 Social isolation.
Other associated factors include:
 Mental illness.
 Substance misuse.
 Overcrowded housing & increased physical proximity.
 Breakdown of social & cultural norms.

Types of child abuse

The types of child abuse are:
 Physical abuse. This refers to any non-accidental physical injury to the child, even if
the perpetrator had no intention of injuring the child. This includes hitting, beating,
kicking, slapping, choking, burning, poisoning or drowning a child.
 Emotional abuse. This is persistent emotional maltreatment, resulting in severe &
persistent effects on the child’s emotional development. It includes
denigration/rejection, emotional neglect, developmentally-inappropriate
expectations, repeated separations and mid-socialisation of the child.
 Sexual abuse. This refers to sexual behaviour involving an adult and a child, or 2
children with one child being significantly older than the other & having used
coercion. The sexual behaviour involves touching genitals, buttocks & breasts;
exhibitionism; felatio; cunnilingus (stimulation of female genitals using tongue or
lips; and penetration in the vagina or anus. Developmental factors must be put into
consideration when assessing whether sexual behaviours were abusive or normative.
  Neglect. Neglect is the persistent failure to meet a child’s basic physical &
psychological needs that is likely to impact seriously on the health & development of
the child. It is the most prevalent form of child maltreatment. It includes failure to:
o Provide food, clothing, shelter and supervision for the child.
o Protect from harm or danger.
o Grant access to appropriate healthcare (medical neglect).
Neglect also includes substance abuse during pregnancy.
 Child labour. This is the use of a child in work or other activities for the benefit of
others.
There is considerable overlap between different types of abuse.

Physical abuse
This is an act resulting in non-accidental physical injury. This includes beating a child,
punching a child in the face, kicking a child, biting and poisoning. It can also be due to
neglect, in which a parent fails to provide adequate care & protection for their child. It can
also be due to factitious illnesses reported by caregivers (also called Munchausen’s
syndrome by proxy1).
The predisposing factors for physical abuse are:
 Parental factors: violence, poverty, history of abuse in the parent and low self-
esteem of the parent.
 Child factors: position in family, intellectual disability, number of children, child’s
character and requiring additional needs if disabled.
 Environmental factors: divorce, poverty, unemployment, drug abuse, poor housing
and frequent relocation.
The clinical features of physical abuse are:
 Somatic reactions. These include bed wetting, soiling, aches and pains.
 Physical signs. Unexplained bruises, marks, burns, lacerations/bruises, abdominal
injuries, bite marks and unbelievable explanations for injuries. Other signs include
multiple fractures at different ages of healing and spiral fractures in children unable
to walk.
 Behavioural changes: fearfulness, docility, mistrustfulness, guardedness,
hypervigilance and slowing down in intellectual & emotional development. Children
also develop fearfulness of going home or physical contact and they avoid seeking
physical comfort from adults. Children can also show inappropriate response to
injury, such as failure to cry after being beaten.

Neglect

1
This is a mental condition in which a caregiver/parent intentionally injures their child in order to seek medical
attention.
This is failure of a parent & guardian of a child to provide the child with adequate care &
protection. There are different types of neglect:
 Physical neglect is that in which there is actual physical separation from the child.
This includes abandonment, expulsion from home, disruptive custodial care,
inadequate supervision and reckless disregard for a child’s safety & welfare.
 Emotional neglect is not providing adequate love, affection and attention.
 Educational neglect is failure to enrol your child in a school or allowing chronic
truancy.
 Medical neglect includes refusal, delay and failure to provide medical care.
The signs & symptoms of neglect are:
 Physical manifestations: failure to thrive, signs of malnutrition, poor hygiene and
delayed immunisation.
 Suggestive behaviour: dull & inactive, excessive passitivity or sleepiness, absentism,
drug/alcohol abuse, vandalism & shoplifting and stealing/begging for food.

Sexual abuse
This is the involvement of dependent developmentally immature children in sexual activities
they do not understand, with the perpetrator being gratified. It also includes sexual
exploitation of children, such as child pornography or promoting trafficking of children.
Usually, the perpetrator is a family member or a domestic worker; rarely a total stranger.
Children at risk of sexual abuse are: orphans, destitutes, disabled children, children left
unattended, step children and children left in the diaspora.
The types of sexual abuse are:
 Sexual play.
 Incest.
 Molestation.
 Exhibitionism.
 Child pornography.
 Child prostitution.
 Paedophilia.
Sexual abuse can occur within the family as well. Usually, sexual abuse from close family
members starts with small boundary violations that escalate to serious intrusions. Sexual
abuse over a long period of time involves 5 phases:
1. Engagement. In this phase, the perpetrator induces the child into a special
relationship. For example, father-daughter relationships throughout childhood and
the child may be excited at first when the father approaches her sexually.
2. Sexual interaction. The sexual interactions become a more intrusive form of abuse.
As the behaviour continues, the abused child becomes more frightened & confused
because he/she never knows whether the parent will be parental or sexual. The
 other parents may not be supportive. The other siblings may distance themselves
from the abused child, thinking that the child receives special treatment.
3. Secrecy. The perpetrator threatens the victim not to tell anyone. The
parent/guardian may interfere with the child’s normal peer relationships fearing that
the child may expose the parent.
4. Disclosure. The abuse is discovered accidentally or is reported by the child to a
responsible adult. It may also be discovered when the child is brought for medical
attention and an alert clinician asks the right questions.
5. Suppression. The child often retracts statements of the disclosure because of family
pressure or because of the child’s own mental processes (i.e. the child may perceive
violent or intrusive attention is synonymous with interest or affection). At times,
affection for the perpetrator outweighs the facts of abuse.
The signs of sexual abuse are:
 Physical: genital bruises & lacerations, torn/blood-stained underwear, pain on
urination, penile/vaginal discharge (STIs), difficulty walking, regression of milestones
(such as bed wetting), pregnancy in some cases, running away from home and
suicide ideation in some cases.
 Suggestive behaviours: lack of trust or overfamiliarity, inappropriate sexual talk &
behaviour, fantasies of sex, sleep disturbance (insomnia, nightmares), substance
misuse, compulsive masturbation and sexual promiscuity.

Emotional abuse
This is any attitude or behaviour or failure to act on the part of the caregiver that interferes
with a child’s mental health or social development. It includes verbal abuse, calling the child
names, withholding praise & love and persistent scolding. It also includes exposing the child
to domestic violence.
The suggestive findings of emotional abuse are:
 Physical findings: failure to thrive, feeding disorders and enuresis.
 Suggestive behaviours: antisocial behaviours and lags in social development
(especially delayed speech development).

Complications of physical abuse

These can be classified into physical and mental complications. The mental complications of
physical abuse are:
 Anxiety & PTSD.
 Depression.
 Substance misuse.
 Conduct disorder.
 Physical/sexual abuse of others.
Child abuse is also associated with a host of other physical illnesses in the future, such as
ischemic heart disease, liver disease, adolescent pregnancy, COPD, foetal death and skeletal
fractures.

History-taking in abuse cases

A key component of the interview also includes the child interview. The child interview is
supposed to be tailored to his/her developmental stage. Several protocols exist that are
designed to maximise the amount of accurate information and to minimise false
information provided by children. The different approaches include:
 Cognitive interview. This encourages witnesses to search their memories in various
ways, such as recalling events forward then backward.
 Step-wise interview. This is a funnel approach that starts with open-ended questions
and then moves to more-specific questions.
The initial history should be taken from the parent of the child and should include the
following:
 Whether the child had been given instructions on reporting of the incident.
 Who the perpetrator was.
 Exactly what the perpetrator did.
 Where the abuse took place.
 When it started & ended and how often it occurred.
Other information to be included is
 Symptoms & behavioural changes of the child.
 Confounding variables, such as psychiatric disorders or cognitive impairment.
 Family’s attitude towards discipline, sex and modesty.
 Developmental history from birth to present day, including any possible trauma of
child.
 Family history & social circumstances: earlier abuse of parents, spouse abuse,
substance abuse and any parent having psychiatric disorder.
 Underlying motivation & possible psychopathology of adults involved.
The investigator should obtain collateral information from: protective services (e.g. the
police), school personnel, other caregivers (e.g. baby sitters), other family members
(siblings), paediatricians and police reports.

Management of abuse
The immediate strategic intervention is to ensure the child’s safety and promote the welfare
of children. The assessment of risk and the associated interventions require a
multidisciplinary & multi-agency approach.