What shall we do about: Preventing Child abuse and neglect?

Like doctors and other healthcare professionals worldwide, many of us see children with injuries caused by physical violence and girls who have been raped. Sometimes we know that a child is malnourished, sick or traumatised because of abuse or neglect.

The aim of this article is to raise the issue of child abuse and neglect and to start a dialogue on how healthcare and other professionals can better protect South Sudan's children. So please send us your views and suggestions for tackling this problem.

Extent and Causes

Child abuse and neglect occur almost everywhere - but receive relatively little attention ¹. The extent of the problem is not known but international data indicate that worldwide:

• At least 40 million children are abused or neglected.
• 12.7% of injury deaths are the result of abuse.
• Approximately 0.6–1.8% of children in high HIV-incidence countries in Southern Africa experience penetrative sexual abuse by an AIDS/HIV infected person before 18 years of age².
• More than 80% of children are physically punished.

86% of mothers in 29 developing countries said they used some form of violent discipline, 19% report severe physical punishment and often the children punished are very young¹.

Child abuse and neglect is often linked to:

• Children being separated from their families because of war or exile and/or living in areas of insecurity.
• Domestic violence, divorce of parents, parents sending children to live with relatives because they cannot take care of them.
• Children living with step-parents (who are often the biggest offenders of child physical abuse).
• Parents/carers being ill (physically or mentally), disabled, or misusing alcohol or other substances.
• Children being forced to work long hours or late in the night.
• Children leaving home (e.g. due to poverty) and living on the streets
• Teachers bullying, beating or abusing (physically, verbally or sexually) pupils at school.
• Girls being forced into underage marriage, genital mutilation and/or initiation with tribal marks (e.g. the Mundari and Dinka)

In turn these situations may occur because of:

• Insecurity and the aftermath of the war.
• Traditional methods of discipline at home and at school
• Traditional beliefs about female genital mutilation
• Traditional beliefs on roles and behaviour of girls. This is especially occurs when girls are 12-13 years old and become adolescents. A girl may try to express the confusion inside her by being depressed or self-conscious, and refusing to work, answering parents incorrectly or talking loudly. But her parents are likely to become angry. Most parents do not accept any challenge from girls although they do from boys. It is worse where the girl is not living with her biological mother.
• Traditions related to early marriage and pregnancy
• Lack of knowledge by families, teachers and health/social workers of children's rights (for food, shelter, schooling, etc.), and of the consequences of abuse.
• Beliefs related to how to avoid AIDS/HIV
• Extreme poverty when families may need child wages or for children to leave home.
• Exploitation of child domestic servants. They may be given tasks that are unsuitable for their age, or not fed enough and may be severely punished if they do not perform well.

International studies indicate that child abuse and neglect, including sexual abuse, is most often carried out by family members, neighbours and teachers². Girls, orphans and disabled children are particularly vulnerable.

Consequences

Abuse and neglect can lead to:

• Death, disability and disease including AIDS/HIV.
• Physical and mental trauma, poor cognitive and social development (e.g. lack of concentration), fear.
• Malnutrition, stunted growth, loss of appetite, and mental and other illness.
• Lack of schooling including coming late to school or misbehaving in class.
• Early marriages and early teenage pregnancy, criminal abortion.

• Difficult childbirth due to genital mutilation
• Employers exploiting children

Abuse and neglect are the biggest causes of 'streetism', i.e. children running away from the 'home' to the more unsafe streets. There children, especially girls, often become sex workers (with increasing risks of HIV, unwanted pregnancy, etc.). Almost all the street girls and boys in Juba are involved in crime and so often suffer police harassment and imprisonment. Many abused children adopt violence as a way to survive; they attack anyone instinctively without warning even when they cannot defend themselves - which can result in serious physical trauma.

Vulnerable girls in Juba (Credit: CCC)

What can we do about child abuse and neglect?

Internationally child abuse is often given low priority – and the same is true in South Sudan. Reasons may be:

• Other health and social problems are so enormous that it has a low priority.
• Lack of funds and training and political will to deal with it.
• Attitudes of health workers. Even female doctors may condemn a little girl after rape accusing her of putting herself in danger.
• Low public awareness of what child abuse means – and its extent.
• Reluctance to acknowledge that parents and other carers do harm children.

The only place presently able to deal with sexual violence is Juba Teaching Hospital. Although staff in units in four Juba police stations, and several healthcare workers, have been trained to deal with gender-based violence few cases reach the courts or hospital. There are as yet few social workers trained to deal with sexual or other abuse or the budget to support them.

How we, as healthcare workers, can protect children

The advice and information of healthcare professionals is often taken seriously by both the authorities (e.g. police) and by families. We have a special responsibility to do what we can to treat abused children and prevent child abuse and neglect. So:

• Look out for signs and indications of abuse and neglect when you see children in OPD/clinics etc (e.g. unexplained bruising, broken bones or parents known to have problems related to poor health, substance abuse).
• Interview children you suspect to having been abused. Most children report physical abuse when you asked them in a non-threatening way. You can use dolls to represent, for example, a father, mother and child. The girl (or boy) can point to the doll showing where the abuse took place.
• Try to find, and if possible deal with, the underlying causes of abuse. This should include counselling the family. Counselling should always be part of the treatment of child abuse. 
• Report cases of severe abuse to the Social Welfare and police - who should monitor and record all these cases.

To prevent child abuse we can discuss with parents, carers and teachers:

• The consequences of physical and verbal abuse at home or at school. Most families want their children to become useful members of the family. So they need to know that abused and neglected children develop less well and do less well at school. Many young offenders have been abused in the past.
• The dangers of sexual abuse and how it can result in unwanted pregnancies even in very young girls – leading to the child dying or becoming disabled, malnourished or HIV+, dropping-out from school, leaving home or becoming a sex worker.
• The importance of good food, immunisation, cleanliness and prompt health care to prevent malnutrition and infections.
• The right of every child to a secure home, protection from violence, sex abuse and exploitation, to good nutrition, medical care, education, the right to express themselves and dignity.