INTRODUCTION

Child maltreatment has been described differently in many cultures, however, most of the definitions agreed on four types of child maltreatment i.e. physical abuse, emotional abuse, sexual abuse and neglect.^{1, 2} According to an estimate globally, around 1 billion children have suffered physical, emotional or sexual violence or neglect in the past year.³ Among all the children who experience severe violence around 64% are from South Asia. ^{4, 5} Violence on children can be observed in different settings, such as domestic, schools, workplace and community at large. ⁶

Child Abuse and Neglect (CAN) has many short and long-term effects on children. Norman et al. ⁷ reported that children, who were neglected, physically abused and emotionally abused were found to have a higher risk of anxiety and depressive disorders and suicidal behaviours as compared with non-abused children. Likewise, they reported an association between physical abuse and childhood behavioural problems and conduct disorders.

Most commonly reported perpetrators of child abuse and neglect are the caregivers, such as parents and other family members, teachers, health care workers, employers, and acquaintances. ⁸ The number of strangers is much less than presumed. Almost 80% of perpetrators of child abuse are parents. However, in cases of child sexual abuse, prevalence studies indicate that extrafamilial abuse is much more prevalent than intra familial abuse. ⁹

Zakar ⁶ reported that out of school children are most vulnerable to every type of violence. Girls are more vulnerable to psychological trauma as compared to boys, whereas boys are at a greater risk for physical abuse than girls. Such differences suggest that certain characteristics make a child more vulnerable to abuse than others. Heise ¹⁰ suggested an ecological model for understanding the risk factors of violence. World Health Organization ¹¹ and Center for Disease Control and Prevention ¹² also use this model to explain risk factors of maltreatment and violence on children. Heise ¹⁰ described certain risk factors of violence at the individual, situational/relationship, community, and societal levels. Age, gender, parental education, parents’ childhood experiences of abuse, witnessing violence at homes are a few examples of risk factors of child abuse at an individual level whereas lack of bonding between parents and child, marital conflict and unhealthy relationships in a household are situational/relationship factors contributing to child maltreatment. ^8,13 Cultural and societal factors also predispose a child to maltreatment and these include acceptance of violence, inequality in gender roles, easy access to drugs and alcohol, cultural norms that promote and glorify violence, weak legal systems and lack of implementation of the laws.¹⁴

When the cases of child abuse and neglect are presented to health services including hospitals, there are often quite complicated.¹⁵ The diagnosis of child abuse and neglect in hospitals is usually lower than expected.¹⁶

As in many countries from the South Asia region, violence against children especially physical abuse is acceptable in Pakistan and is a part of the societal norm. The concept of shame, guilt, and honour become barriers to early detection and reporting of cases of child sexual abuse.^{17, 18} Under-reporting of child abuse and neglect is the main hurdle in estimating the magnitude of the problem in Pakistan.⁶ There is no mandated system of reporting child abuse and neglect in Pakistan. There is a paucity of official data and reliable statistics on the extent of child abuse in the country.¹⁹ Unlike other major public health and social problems; it is not easy to document the incidence or prevalence of child abuse and neglect. In a conservative culture, it is difficult to obtain information on sensitive and stigmatized issues, and it becomes even more difficult when the victims are children, who either do not understand abuse or are unable to report it. In such a sociocultural setting most cases of child abuse, particularly most cases of child sexual abuse go unreported. ²⁰

Unlike developed countries managing CAN cases is extremely difficult in low-income countries, with daunting challenges in health, social welfare, education, and legal systems. In Pakistan, while many factors including lack of clarity among stakeholders, social and cultural taboos, inadequacies in legal systems, poverty, and minimal resource allocation contribute to the lack of a proper child protection system²¹, small scale efforts have been made by NGOs and local organizations.¹⁸

PAHCHAAN in collaboration with Child Rights Committee of Pakistan Paediatric Association started a Hospital-Based Child Protection initiative in 2005, which was owned by the Government’s Children Hospital Lahore, Pakistan as its Child Protection Unit (CPU) and so it became the first hospital-based Child Protection Unit in South Asia.²² Although it could not be replicated, it has managed to sustain for 10 years despite all odds with the technical support of PAHCHAAN. The objectives of this CPU include among others is to build the capacity of healthcare professionals on early detection, case management, and rehabilitation of cases of child maltreatment and to create a model for the management of CAN Cases.

 As soon as a case is suspected by a doctor or a nurse, it is reported to the CPU, immediately a SCAN (Suspected Child Abuse and Neglect) case is registered. An intake form is filled which includes information regarding demographics, kind of abuse, suspected perpetrator, etc. The information is uploaded to an excel sheet, and a patient file is maintained, which includes copies of a doctor, psychologist, and social worker’s notes. It also includes challenges faced in the case and details of services provided to the child. Once the case documentation is completed and suspicion of abuse is confirmed, the cases are entered as confirmed CAN case in the data. If the suspicion is not substantiated, it is removed from the SCAN case category.²³

As there is no mandatory reporting of child abuse and neglect cases in Pakistan and there is no column for child abuse and neglect cases in any Hospital Management Information System, therefore, CAN cases are reported internally according to following criteria:

A child is suspected of emotional abuse only when there is no evidence of neglect, physical abuse or sexual abuse. A case is suspected of neglect even when there is evidence of emotional abuse whereas there is no evidence of physical or sexual abuse. He/she is reported as physical abuse even in the presence of emotional abuse or neglect but there is no evidence of sexual abuse. Sexual abuse is suspected/reported even if any or all other forms of maltreatment exists.²³

Many people get their children admitted at Children Hospital and then leave without informing anyone and abandoning their newly born babies, as well as older children for various reasons including abject poverty, the child born out of wedlock or inability to care for a chronic illness. The hospital tries to trace the parents but in most cases, they have given false information at the time of admission and therefore cannot be traced. These babies are also referred to the Child Protection Unit as Abandoned babies

OBJECTIVES

The current study presents ten years of data (2009-2018) from CPU, Children Hospital Lahore, to

•          Present case distribution for ten years for age, gender, abuse type, and the perpetrator.

•          Identify association among age, gender, type of abuse and reported perpetrator of the abuse.

METHODS

Study design

The retrospective study design was used in the present study.

Sample and Instrument

The sample included 1654 confirmed CAN cases managed at the CPU, Children Hospital, Lahore. Data was collected through intake forms used from 2009 to 2018 in the child protection unit. Although the intake forms were revised thrice during this period according to the evolving understanding of child protection during these years, the data which is presented was available in all forms from the beginning.

Procedure

The method of this study is in compliance with the Declaration of Helsinki for ethical guidelines. As we analysed retrospective data hence, no direct involvement/ manipulation of the subjects was required. However, for keeping the confidentiality and privacy of the patients; names or any other personal information were not disclosed in this research. Permission was taken from the Institution Review Board, Children Hospital, Lahore to obtain retrospective data from intake forms in the Child Protection Unit. Only those cases were included which were confirmed as CAN cases and managed in CPU, Children Hospital Lahore from 2009 to 2018. This child protection initiative was the brainchild of the primary researcher, and the team has also been involved in initiating, designing and managing the CPU forms, formats, and in case-management, therefore all records have been maintained under their supervision.

Although data for this study was collected through intake forms at Child Protection Unit Children Hospital, it was validated through the patient’s history files which include family history, doctors’ notes, and treatment plan.  The current study intended to study patterns of age and gender of CAN cases, types of maltreatment and reported perpetrator.  Only needed information was taken from intake forms.

RESULTS

Table 1:  Distribution of the cases according to age, gender, type of abuse and reported perpetrator (n=1654)

Among 1654 CAN cases, the highest reported cases were from 0 to 5 years of age, the number is 857 (51.8%), but there were 226 (13.7%) children under 1 year so a separate category was made for them as well. 58.5% of children were male whereas 41.5% were female. The majority, 70.5% of all cases suffered from severe neglect. Almost two thirds (66.1%) of the perpetrators belonged to the immediate family of the victim child.

Results show a significant relationship χ2(4, N=1654) =26.25, p<.001 between gender of the child and type of abuse the child suffered, indicating a higher frequency of male victims for neglect and physical abuse whereas the higher frequency of female child sexual abuse victimization (Table 2).

Table 2: Results of Chi-square Test and Descriptive Statistics for the type of abuse by Gender of the child (n=1654)

Results indicate statistically significant association χ2(12, N=1654) =190.62, p<.001, between the age of the child and the type of abuse he suffered. Findings show that neglect is mostly reported in 1-5 years, whereas emotional abuse is mostly reported in the age group of children older than 10 years. Physical abuse and sexual abuse are mostly reported in the age group of children older than 5 years to 10 years. Abandoned children were mostly younger than 1 year (Table 3).

Table 3: Results of Chi-square Test and Descriptive Statistics for the type of abuse by Age of the child (n=1654)

Results indicate statistically significant association χ2(9, N=1654) =35.31, p<.001 between perpetrator of abuse and age of the child. Findings indicate that frequency of perpetrators from immediate family and extended family was highest in age group of 1-5 years. Perpetrators who were acquaintances other than family, were reported more often in cases of children belonging to >5 to 10 years. Strangers were reported as perpetrators in age groups of >5 to >10 years old children (Table 4). Results show no significant association (χ2 (3, N=1654) =4.50, P=.212) between perpetrator of abuse and gender of the child.

Table 4:  Results of Chi-square Test and Descriptive Statistics for perpetrator of abuse by age of the child the child (n=1654)

Results also show a significant association χ2 (12, N=1654) =292.87, p<.001 between type of abuse and perpetrators for abuse. Findings indicate that most of the perpetrators of neglect, physical abuse and emotional abuse belong to immediate family of victim child whereas reported perpetrators of sexual abuse are strangers (Table 5).

Table 5: Results of Chi-square Test and Descriptive Statistics for type of abuse and perpetrator of abuse (n=1654)   

DISCUSSION

The current study is carried out to identify patterns of age, gender, type of abuse and perpetrator of the abuse of all the cases managed at Child Protection Unit, Children Hospital, Lahore from 2009 to 2018. The literature reports neglect as the most common form of child maltreatment. ^{24, 25} Findings of the current study also indicate that the majority of the cases reported in CPU suffered from neglect. A report on the prevalence of violence in Pakistan suggested that psychological and physical violence are the most prevalent forms of violence in Pakistan with varying proportions in different settings but this data was from a sample of 948 children aged 5-12 in schools and out of school setting, from all provinces of Pakistan and it is difficult to consider as a representative sample to draw such conclusions.⁶

Findings reveal that perpetrators in the majority of the cases belong to the immediate family of the child. Perpetrators of neglect, physical abuse, and emotional abuse belong to the immediate family of the abused child whereas reported perpetrators of sexual abuse are strangers. These findings are consistent with Sedlak et al.²⁶ they reported that in majority of the cases of neglect and emotional abuse, perpetrators were one of the biological parents of the child. Likewise, Esernio-Jenssen, Tai & Kodsi ²⁷ reported biological parents as the most common perpetrators of physical abuse of the children. Sahin et al.¹⁷ reported that the relationship between perpetrators to the child and different abuse types was significant. The alleged perpetrator varied according to the type of abuse but overall, more than 50% of the cases reported that the perpetrators were family members, around 30% were extra familial acquaintances and around 21% were strangers. Cruel numbers ²⁸ indicated that acquaintances remain the highest category of perpetrators for child sexual abuse and constitute 85% of the total cases reported in newspapers.

Current findings show that neglect is mostly reported in under 5 years, whereas emotional abuse is mostly reported in the age group of children older than 10 years. Physical abuse and sexual abuse are mostly reported in the age group of children between 5 years to 10 years. These findings are similar to the findings of a study conducted in a hospital-based multidisciplinary team for protection in Turkey, it was found that neglect was more common in the 0-5 year’s age group and the mean age for sexual abuse was around 6-14 years, physical abuse peaked around 2-14 years and neglect. However findings of the current study are not consistent with Wauchope and Straus ²⁹ as they reported in their study that physical abuse is more common in younger children and decreases as the child matures. According to Cruel Numbers, a report published by an NGO Sahil ²⁸ most vulnerable age bracket for child sexual abuse is 6-10 years and 11 to 15 years. Boys are more vulnerable than girls of this age. In the other age brackets (0-5 years and 16-18 years) girls are more vulnerable to abuse than boys for CSA. A significant relationship between gender and age of the victim was also found in cases of sexual abuse in another study from Turkey. ³⁰

Findings indicate a higher frequency of male victims for neglect and physical abuse whereas the higher frequency of female child sexual abuse victimization. These findings are consistent with the findings of Meng and D’Arcy ³¹; Zakar ⁶ as they reported that male children were more vulnerable towards physical abuse whereas females reported frequent sexual abuse victimization.

CONCLUSIONS AND RECOMMENDATIONS

This study provides insights into child abuse and neglect cases reported in the Child Protection Unit, Children Hospital Lahore from 2009 to 2018.  Neglect is the most common form of child maltreatment reported in CPU cases and in a majority of the cases perpetrator belonged to the immediate family of the child. This indicates negligence on part of caretakers’ roles and responsibilities. Findings lead to a reaffirmation of gender norms in society indicating a higher percentage of male children towards physical abuse victimization whereas a higher percentage of female children towards sexual abuse victimization.

To date, there is only one CPU in Pakistan and due to severe human resource and financial constraints, only the most severe cases of CAN were reported here. This shows that Child Abuse and Neglect is a grossly under-reported and unrecognized common problem which needs urgent attention.

The current study is focused on four variables. As it was retrospective data for ten years so variables with missing data were not included. However, future research should include more variables in detail.

The authors feel that there is a need for multidisciplinary hospital-based child protection units in at least every teaching hospital in Pakistan

Pakistan needs to establish strong child protection systems, mandatory reporting and management mechanisms for CAN victims.

There is a strong need for creating awareness on child abuse and neglect in the society, this becomes more pertinent in developing countries like Pakistan where child protection mechanisms are still not well established or in the process of establishing.

ACKNOWLEDGMENTS

Hospital-Based Child Protection Unit of Children Hospital Lahore could not have been possible without un-wavering support of the administration of Children Hospital and Institute of Child Health especially the successive Deans of the Institution. The staff of Children Hospital has been voluntarily taking care of the abused and neglected children and has provided relentless support to the CPU. PAHCHAAN administration and staff have been providing technical support to this initiative and its interns have been of immense assistance in data collection and data entry continuously for the last ten years.

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