Demographic and clinical features of child abuse and neglect cases: one-year experience of the hospital-based child protection team of Ege University, Turkey.
As observed historically, child abuse is a problem which occurs in all communities and has a global dimension. Child abuse is generally defined as all kinds of physical and/or emotional abuse (which is detrimental or which has a possibility of being detrimental) which affects the life, health and development of the child, sexual abuse and commercial or other kinds of exploitation (1). It was described by a radiologist named Caffey in 1946 for the first time in the medicine community (2). It is rather difficult to determine the frequency of child abuse and the frequency varies widely from country to country. In a study, the frequency of child abuse was reported to be approximatley 16.3/1000 according to the figures reported from 29 countries (3). The World Health Organization reports that 3100 children below the age of 15 lose their lives because of child abuse each year (4). The biggest problems about child abuse arise from the fact that this phenomenon is not recognized and recognized cases are managed improperly. Unrecognition of cases of child abuse may lead to chronic abuse and even death. The most appropriate approach in diagosis and management of child abuse cases can be provided by a multi-center team work. In recent years, interest and sensitivity for child abuse have increased in our country. "Child Protection Teams" have been instituted in many hospitals. A social service specialist should be incorporated in these teams in addition to various specialities related to children (pediatrician, child psychiatrist, pediatric surgeon, forensic medicine, neurosurgery, orthoapedics, ophthalmology) (5).
Ege University Child Protection Team (EUCPT) works as a multi-center unit as mentioned above. A social service specialist and a psychologist are incorporated in this team in addition to different branches of medicine including pediatrics, pediatric psychiatry, pediatric surgery, forensic medicine, neurosurgery, orthopaedics and ophthalmology. Ege University Pediatric Protection Team works to provide the recognition of cases of child abuse and management and follow-up of these cases in the most appropriate way. In this article, we aimed to evaluate the demographic and clinical characteristics of our patients who were diagnosed as child abuse between 2009 and 2012.
Material and Method
The data of 89 patients who were diagnosed as child abuse and neglect (CAN) by the multidisciplinary team of Ege University between August 2009 and 2010 were retrospectively reviewed. The sociodemographic characteristics of the patients including age, gender, place of residence, familial characteristics (economical status, education level, family type) were recorded. In addition, the type of abuse, the place where the abuse took place, the age and gender of the exploiter were determined. For determination of abuse types the following definitions were considered (1):
1. Physical abuse: all acts of another party which cause actual physical damage or which have the potential to cause physical damage in the child.
2. Sexual abuse: all acts performed on the child by another party with the aim of sexual pleasure are defined as sexual abuse. These acts are included in a wide range changing from incest, rape, making the child the object of pornography and prostitution to exhibitionism, speeches stimulating sexuality, making the child watch sexual intercourse or pornographic movies, stroking sexual organs and oral sex. In our study, a classification was made to determine the type of sexual abuse in subjects exposed to sexual abuse as follows: anal-penile penetration, vaginal-penile penetration, contact with the genital region alone, sexual abuse (stroking any part of the body or speech stimulating sexuality) and exhibitionism.
3. Emotional abuse: Behavior of the person who takes care of the child which affects the psychological health and development of the child negatively and which does not provide the proper and supportive setting for the child's healthy development.
4. Neglect: failure of the parents to meet the child's needs for healthy development, though they have the power.
Statistical assessment was done using SPSS 13 program. The definitive statistical tests were used to determine the numerical and percent values of the data.
In this study, a total of 89 children between the ages of one and seventeen 46 of whom were female (51,7%) and 48 of whom were male (48,3%) were evaluated. When familial characteristics were evaluated, 77,5% were found to reside in a province center, 57,3% had a moderate economic status and 59.6 % of the families were found to be nuclear family. 58% of the mothers of the subjects were found to be housewives and 85.4% of the fathers were found to work. 68,5% of the mothers and 78,7% of the fathers were found to be primary school graduates (Table 1).
In our study, 22 (24.7%) physical abuse cases, 44 (49.4%) sexual abuse cases, 10 (11.2%) emotional abuse cases and 13 (14.6%) neglect cases were found (Table 2). It was found that emotional abuse was also present in 10 of 22 physical abuse cases and in 9 of 44 sexual abuse cases. In 2 of 44 sexual abuse cases neglect was also present.
In our study group, the children were referred to the Child Protection Team by Pediatrics clinics (n = 42), child psychiatry clinic (n = 35), neurosurgery (n = 1), social services directorship (n = 8) and the police (n = 3).
The mean age of the exploiters was 31 [+ or -] 12 and 86.5% of them were male. It was found that 33.7% of the exploiters were fathers, 16.8% (n = 15) were addicted to drug-alcohol and a history of violence was present between the parents in 36% of the families of the exploiters. In addition, 35 (39.3%) of the exploiters were found to have abused children previously (Table 3).
66.7% of physical abuse was practiced by fathers and 59.1% of sexual abuse was practiced by a foreigner (Table 4).
When gender distribution according to abuse types was examined, physical abuse was observed with an equal rate in girls and boys, but 56.8% of the children who were abused sexually were found to be female (Table 5).
Genital contact was found in 18 (41%) of our sexual abuse subjects, abuse was found in 10 (22.7%), anal-penile penetration was found in 8 (18.1%), exhibitionism was found in 5 (11.3%) and vaginal-penile penetration was found 3 (6.8%).
When the abuse type in physical abuse was examined, it was found that punishment by slapping was present in 95% of the subjects and punishment by beating strongly without using any instrument was present in 16 subjects (17.9%). No burn, internal organ injury or sharp object injury was found in our subjects. Only one subject was diagnosed as shaken baby syndrome. Physical examination findings were found to be normal in 16 (72%) of the children who were diagnosed as physical abuse and ecchymosis was found in 6 (28%) subjects on physical examination.
No subject was hospitalized to receive medical treatment except for one subject who was diagnosed as shaken baby syndrome. The forensic procedure was continuing for four subjects who were diagnosed as sexual abuse. 60 subjects (67.4%) were reported to the Social Service Provincial Directorate and the prosecution office. The exploiter received imprisonment in the forensic process in four cases reported. In addition, the forensic procedure for two subjects and follow-up of 17 subjects by the Social Service Directorate is still continuing. One subject who was diagnosed as physical abuse was placed in a women's shelter. One subject who was diagnosed as neglect received protection order by way of the Social Service Provincial Directorate and placed in a Child Care Center.
In our country, as the number of child protection teams increase in hospitals, the frequency of publications reporting the clinical and social charactersitics of the subjects who refer to these teams increases. These studies are important in describing the general characteristics and frequency of child abuse cases in Turkey.
In the study performed by Brown et al. (6), it was emphasized that risk factors related to child abuse included broken family, low economical level and low education level of the mother. In this study, broken family was present in 37% of the children and low economic level was present in 36%. In addition, 68.5% of the mothers of these children and 78.7% of the fathers were primary school graduates. In a study performed in Turkey, nuclear family was reported to be present in 71% of the cases with a diagnosis of child abuse (7). In another study, 42% of the families of the subjects who were diagnosed as child abuse were found to be broken families, 52% of the families had a low socioeconomic level and 60% of the parents had a low education level (8). It seems that family structures of the cases of child abuse show different characteristics in different regions of our country.
The most common child abuse type is sexual abuse and physical abuse is in the second order (9). In our study, sexual abuse was in the first order with 44 subjects (49.4%) and physical abuse was in the second order with 22 (24.7%) subjects. In studies performed in Hacettepe and Gazi Universities, sexual abuse was found to be in the first order and physical abuse was found to be in the second order (4,7,10). In contrast, Oral et al. (8) found physical abuse with a rate of 60% and sexual abuse with a rate of 26% in the multi-center study they performed in Izmir.
The individuals who practice child abuse are frequently the mother or the father of the child (11). In our study, it was found that the individual who practiced child abuse was the father with a rate of 33.7%. When the exploiter was examined according to abuse types, it was found that sexual abuse was most frequently practiced by a foreigner and other abuse types were practiced most frequently by the father. In a study performed in Turkey, sexual abuse was reported to be practiced frequently by a foreigner outside of the family which was similar to our study (10). In another study, sexual abuse was reported to be practiced most frequently by a familiar person outside of the family and by a foreigner in the second order of frequency (12).
In child abuse, especially sexual abuse occurs frequently in girls (6). Other abuse types occur with an equal frequency in both genders. In our subjects, 56.8% of the children who were exposed to sexual abuse were found to be girls. Also in studies performed in Turkey, sexual abuse was reported to be more frequent in girls (7,10,12). In our study, 95% of physical abuse cases were reported to be punishment by slapping. When studies about physical abuse from different countries were examined, it was found that slapping was reported to be the second punishment method (13). Some punishment methods which can be considered as child abuse (slapping, beating the hand and the gluteal area, tweaking) are sometimes considered as natural dicipline methods by parents in our country. In a study performed in Turkey, 3,1% of the families reported that they considered slapping as a behavior which can be practiced for dicipline. This rate was found to be 18.5% for beating the hand and 26,2% for beating the gluteal area (14). Therefore, parents should be educated about child raising and dicipline methods.
In our study, ecchymosis was found only in 28% of the children who were diagnosed as physical abuse. Ecchymoses are the most commonly found physical examination finding in physical abuse (15). In studies performed, it was reported that especially physical abuse cases referred to a physician with ecchymoses before the diagnosis, but this was not cared about (16). Therefore all physicians should be careful. Especially in case of ecchymoses which can not be explained by the family, child abuse should be absolutely kept in mind (15).
The highest number of cases were referred to our Child Protection Team by Pediatrics and Pediatric Psyhciatry clinics. Only one case was referred by neurosurgery clinic. No physical abuse case was found to have fracture or referred with burn. Fracture is an important finding which is found in 1/3 of physical abuse cases (17). Burns are reported to be found in 10-20% of physical abuse cases and 35% of the children hospitalized in burn units have been reported to be diagnosed as abuse (18,19). At this point, it can be thought that awareness of child abuse among all physicians is not at a sufficient level. It should be kept in mind that child abuse cases can refer to other outpatient clinics outside pediatrics clinic with different causes and different findings. Therefore, physicians who work in different divisions who are interested in child health should have more information about this subject.
A finding among our results which should be emphasized is the fact that the number of cases referred to our team by the Police and Social Service to be evaluated in terms of child abuse is rather low. In our country, a regularly functioning system has not been instituted between child protection teams of the hospitals, the Social Service and the Police to evaluate these cases. Although the number of multi-center teams was reported to be increased in a study performed in Turkey, it has been emphasized that a stronger relation should be present between these teams and other units (20). A structure in which all teams work together providing the least psychological demage to the child (for example, examination and interview for once) should be instituted and supported by legal arrangements. Our team's works to evaluate child abuse cases with these units are continuing and as a result of this the number of cases referred from these units to our team has increased in the last one year.
While evaluating child abuse cases risk factors related to the person who is thought to have practiced abuse should also be determined well. Risk factors of child abuse include drug or alcohol addiction of the exploiter, history of violence between the parents of the exploiter and previous history of child abuse practiced by the exploiter (6). In our study, it was found that 16,8% of the exploiters had drug-alcohol addiction, 36% of the exploiters had a history of violence between the parents in their families and 35 exploiters (39.3%) reported that they practiced child abuse before.
It should be kept in mind that 35% of the children who have been abused are abused again and 5-10% of these children may lose their lives (21). The most appropriate approach in the diagnosis and management of child abuse is a multi-center team work. Healthcare workers have a very improtant mission about this subject. The number of lessons about child abuse in medical faculties should be increased and education seminars should be organized for related healthcare workers with regular intervals. Conclusively, as the number of healthcare workers educated about child abuse increases, the number of child protection teams will also increase. Thus, a more appropriate approach for child abuse cases will be provided.
Conflict of interest: None declared.
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Feyza Koc, Sadik Aksit, Arda Tomba, Cahide Aydin *, Guldane Koturoglu, Saniye Korkmaz Cetin *, Asli Aslan, Oya Halicioglu, Yusuf Ersahin **, Tuncer Turhan **, Ahmet Celik ***, Ender Senol ****, Sinan Kara *****, Ufuk Solak
Ege University Medical Faculty, Department of Pediatrics, izmir, Turkey
* Ege University Medical Faculty Child and Adolescence Psychiatry, ?zmir, Turkey
** Ege University Medical Faculty, Neurosurgery, ?zmir, Turkey
*** Ege University Medical Faculty, Pediatric Surgery, ?zmir, Turkey
**** Ege University Medical Faculty, Forencis Medicine, ?zmir, Turkey
***** Ege University Medical Faculty, Trauma and Orthoapaedics, ?zmir, Turkey
Address for Correspondence: Feyza Koc MD, Ege University Medical Faculty Department of Pediatrics, Izmir, Turkey Phone: +90 232 390 13 69 Fax: +90 232 388 18 80 E-mail: email@example.com Received: 06.14.2011 Accepted: 07.21.2011
Turkish Archives of Pediatrics, published by Galenos Publishing
Table 1. The sociodemographic characteristics of the child abuse cases n=89 % Gender Female 46 51.7 Male 43 48.3 Age (years) (the least-the highest) 1-17 Place of residence Province center 69 77.5 County 14 15.7 Village 6 6.7 Economic status High 6 6.7 Moderate 51 57.3 Low 32 36 Education level of the mother Primary school 61 68.5 Secondary school 10 11.2 High school 10 11.2 University 8 9 Education level of the father Primary school 70 78.7 Secondary school 5 5.6 High school 12 12.4 University 2 3.4 Family type Nuclear 53 59.6 Large 3 3.4 Broken 33 37 Place where the abuse took place House 66 74 School 3 3.4 Street 17 19 Dormitory 2 2.2 Table 2. Child abuse types n=89 % Physical abuse 22 24.7 Physical and emotional abuse 10 11.2 Sexual abuse 44 49.4 Sexual and emotional abuse 9 10.1 Sexual abuse and neglect 2 2.2 Emotional abuse 10 11.2 Neglect 13 14.6 Table 3. General characteristics of the exploiters Age (Mean [+ or -] SD) (years) 31 [+ or -] 12 n=89 % Gender Male 77 86.5 Female 12 13.5 Alcohol-drug addiction 15 16.8 Presence of violence between 32 36 the parents in the family Previous history of abuse 35 9.3 Exploiter Father 30 33.7 Foreigner 28 31.5 Relative 9 10.1 Mother 6 6.7 Partner or boyfriend 4 4.5 of the mother Baby sitter 3 3.4 Stepmother 1 1.1 Stepfather 1 1.1 Sibling 5 5.6 Table 4. Exploiter according to abuse type Physical Emotional Sexual Neglect n % n % n % n % Father 15 66.7 4 40 4 9.1 7 53.8 Foreigner 1 4.8 1 10 26 59.1 0 0 Relative 0 0 2 20 7 15.9 0 0 Mother 1 4.8 2 20 0 0 3 23.1 Partner or 2 9.5 0 0 2 4.5 0 0 boyfriend of the mother Baby sitter 0 0 0 0 3 6.8 0 0 Stepmother 1 4.8 0 0 0 0 0 0 Stepfather 0 0 0 0 0 0 3 23.1 Sibling 2 9.5 1 10 2 4.5 0 0 Table 5. Gender distribution of the children according to abuse types Female Male n % n % Physical abuse 11 50 11 50 Sexual abuse 25 56.8 19 43.2 Emotional abuse 6 60 4 40 Neglect 5 38.5 8 61.5
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|Title Annotation:||Original Article|
|Author:||Koc, Feyza; Aksit, Sadik; Tomba, Arda; Aydin, Cahide; Koturoglu, Guldane; Cetin, Saniye Korkmaz; Asl|
|Publication:||Turkish Pediatrics Archive|
|Date:||Jun 1, 2012|
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