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Within the past 30 years, it has become recognized that there are children who are harmed by the very people who are expected to protect them. During this time period there has been a great increase in interest and research in the problem in developed countries, particularly those of North America and Europe. On the other hand, in the developing countries much less attention has been given. There are quite understandable reasons for this discrepancy, to be discussed later. Nevertheless, child abuse and neglect in their various forms are now known to be of global importance, affecting the health of a very large number of children in developing as well as developed countries. This paper is written for those involved in planning for and assuring child health in developing countries, reviewing what is known about child abuse and neglect in those areas, which include most of the world's children. It is hoped that this information will help those people assess the scope and magnitude of the problem in their own countries, and to consider new ways of further enhancing the health of their children.
Few authors have reviewed child abuse and neglect as they occur outside the developed countries. Gelles and Cornell (1983) included Third-World nations in their review of family violence including child abuse, although at that time they were able to find only 10 relevant publications including 2 from India and 6 from Africa. They found that the definitions of abuse and neglect used by
researchers in the Third-World were generally broader than those used elsewhere, and that there was a higher level of concern over the role of social structures and institutions in abuse. Korbin's (1981a) book has provided the most comprehensive look at the topic, examining eight developing countries. With data collected largely from an anthropological viewpoint, the authors consider overall cultural attitudes toward children, accepted practices which are actually or potentially harmful to children, occurrence of harmful practices which are not culturally sanctioned. Consistent with the anthropological perspective, the emphasis is on traditional cultures and the meaning of abuse within them, rather on worldwide epidemiology.
A literature search was conducted for all articles and books dealing with the subjects of child abuse and neglect in developing countries, and indexed in Index Medicus, Sociological Abstracts, or Psychological Abstracts. Articles in English, Spanish, or French were accepted. Selected literature on the subjects of infanticide and abuse against females was also reviewed.
II. ANALYSIS OF LITERATURE
Tables 1 and 2 show the distribution of the articles by country and region. Over 25 individual countries are represented, located in all regions of the developing world.
Table 1. Articles on Abuse and Neglect by Country
Africa, general Asia, general Bangladesh/Pakistan Bolivia Brazil Chile China Costa Rica East Africa/Kenya Hong Kong India Indonesia Jordan Latin America, general Malaysia Mexico Morocco New Guinea New Zealand Nigeria Peru Philippines Polynesia Singapore South Africa Sri Lanka Taiwan Tunisia Turkey West Indies
Number of Articles
2 2 1 1 1 1 2 1 3
3 18 1 1 2 3 11 1
2 1 7 1 1 1 1 2 1 1 3 2 1
Table 2. Articles on Abuse and Neglect by Region Region
Africa North Africa/Middle East Asia Latin America Oceania International or general
Number of Articles
Types of article
The articles can be categorized in various ways. Table 3 shows their distribution according to categories similar to those used by Gelles and Cornell (1983). When examining these papers it is important to consider what type of information is being presented and how it has been obtained, and readers are encouraged to attempt to critically analyze studies which they will encounter in the future.
Table 3. Articles on Abuse and Neglect by Category
Number of Articles
Position Paper Case Report Surveys/Series Case-Control and Other Epidemiological Studies Reviews Anthropological Studies Other
11 6 11 13 3
This was the most common type of paper found. The primary focus of such a paper is the qualitative analysis of one or more aspects of child abuse and neglect based on general knowledge, the authors' experience and observations, and previous related research. Opinions are presented regarding the dynamics, definitions, treatment, and prevention of abuse, but are not closely based on formal experimental or observational data.
Case reports are papers which present one or a few cases of abused or neglected children, generally as they are diagnosed by a physician. Most of these
papers use the cases as a didactic method to introduce readers to the diagnosis and treatment of abuse and neglect. Often they are the first papers on the subject to be published in a given country, and should serve to raise the readers' level of consciousness toward the existence of the problem. On the other hand, since they represent only selected instances of abuse, and only a small number, they cannot be used to make any inferences about the extent or types of abuse in a given country.
Surveys and series are similar to case reports but include a larger number of cases. Usually the cases are found by retrospectively reviewing records at one or more medical centers, orphanages, or other agencies. By their inclusion of many cases, these studies are able to make some generalizations about the population which was studied. On the other hand, series cannot estimate the extent of the problem in the general population, or generalize to different groups of abused children than the ones studied. For example, Masrour et 81. (1980) looked at 10 cases of battered children diagnosed at a medical center in Morocco. They found that of the 7 cases with radiologic studies, 6 had fractures, and 4 had multiple fractures. Although based on this study we could expect to find fractures in most Moroccan children admitted to a medical center and diagnosed with abuse, we do not know anything about children who may be abused but are not admitted to the medical center. Nor can we compare the abused children with those who are not abused and thus are not included in the study.
Case-Control and other Epidemiological Studies
This small group of studies group of studies goes beyond series and case reports by making some attempt to estimate the frequency of abuse in the general
population, or to find risk factors by comparing abused with non-abused children. Singh et al. (1962) compared various groups of Punjabi villagers, including infants and females, with regard to (1) the medical care they received for illness, and (2) their death rates. The results indicated a relative neglect of those groups. Christoffel et ai. (1981) used WHO data on international death rates to compare rates of inflicted and non-inflicted deaths in developing and developed countries. They found that death rates due to inflicted injuries were comparable across groups of countries and suggested that there may be a type of family violence which is relatively independent of culture. Caution is required, however, in using such international data which is quite variable in reliability. It must also be remembered that deaths due to abuse are not necessarily reported as such. In a related study Fiala & LaFree (1988) looked at cross-national data on child homicide in conjunction with various social and economic indices, and concluded that it is more common in countries where many women are working but have low social status and where spending on welfare services is low. Goodall (1979) used a case-control design to compare children with and without kwashiorkor. She found that the malnourished children were more likely be living with someone besides the mother, to have parents who were separated, and to have been sent away from home at the time of weaning (the usual practice in some African communities). An informative study from Hong-Kong by Lieh-Mak et al. (1983) compared characteristics of abused children with those of matched controls who were pediatric inpatients without trauma. Families of abused children were found to have a higher prevalence of psychiatric problems, to be more socially isolated,
to report more worries, and to have more marital discord.
Finally, de Meer (1988) collected data on child mortality in a peasant community in Peru. The perinatal mortality rate was anomalously high and by its distribution suggested that infanticide was being practiced especially in families with 2 or more living children.
It can be seen that even these studies address only indirectly the issues
of child abuse and neglect. Clearly there is a need for further epidemiologic research before we can begin to estimate the importance of the problem in quantitative terms, or to compare rates among countries. Meanwhile we are left with qualitative studies, which though less than ideal do help to give an idea of the scope of abuse and neglect in certain locations.
These papers distill information from previous studies and present it in new ways or to new audiences. In some cases (e.g. Vicuna, 1981) the sources are mostly the abuse and neglect literature of the developed countries, with little that is specific to the developing country. Others, such as de Silva (1981), bring together existing data in such a way as to provide a coherent picture of the problem in a given country.
The anthropological studies considered here, most of which are found in Korbin (1981a), are based on intensive observation of participants in a given culture over a prolonged period of time. These are crucial importance because of the insights they provide from an insider's point of view. Thus while good epidemiologic studies could tell us the number of victims of infanticide, they could never address issues such as the value of the newborn to the mother or
to the village, or the meanings or types of infanticide.
Despite the variety of approaches and purposes found in the literature, several important areas of agreement are found. (1) The definition of abuse across cultures is both important and difficult. (2) There is not enough information at present to determine the epidemiologic importance of abuse and neglect in any developing country. (3) Workers in developing countries are concerned with a wider range of phenomena under the label of "abuse and neglect", some of which are undoubtedly of greater public health significance in those countries than are the classic phenomena such as the battered child. (4) Child abuse and neglect of some kind occurs in most if not all cultures. (5) While the occurrence of CAN is widespread, the specific forms tend to more specific to a culture. (6) There are valid reasons for assigning CAN varying priority in different countries. (7) Certain factors such as urbanization are generally agreed to contribute to an increase in CAN.
Definitions: what constitutes child abuse and neglect?
One of the most problematic questions in the area of cross cultural child abuse and neglect is how to define it. In its earliest formulations, such as "battered child syndrome," it was limited to severe physical injury inflicted by a parent or caretaker. Over time the definition has become broader, to include such entities as sexual and emotional abuse. At the same time the definition is more vague and less concensual. Even within a single society such as North America there are disagreements over what does or does not constitute abuse or neglect (Taylor & Newberger, 1983). Furthermore, while some workers in developing countries use a relatively narrow definition (e.g. Masrour et a1., 1980; Animashuan, 1977), there has been a tendency to widen it still further. Bhattacharyya (1983) suggests that
" .•. child abuse should be defined in a wider sense, as impaired development of a child for a considerable period or death resulting from any adverse environmental factor that could otherwise be prevented to operate on the basis of scientific knowledge and adequate health services. " thus implicating all levels of society from parent to government, and including all sorts of injury. Consistent with this approach, Bhattacharyya cites malnutrition and associated infections as India's "most alarming" forms of abuse. Apart from the issue of which levels of actors to include, the main definitional problem stems from a paradox. On the one hand, any definition of abuse in a given culture must take into account that culture's values, standards of child rearing, and adult roles for which the child is being prepared. Thus normative child rearing practices naturally differ among India, where group orientation and loyalty are stressed (Poffenberger, 1981), Taiwan and China where the main social tie is loyalty and obedience to parents (Wu, 1981), and a New Guinea tribe which values physical endurance and prowess in war (Langness, 1981). On the other hand, an uncritical acceptance of cultural norms would deny the existence of any transcendent values such as the child's right to a healthy life or to life itself. While we need to understand the cultural values and forces which lead to practices such as child sacrifice, wife burning, and dangerous child labor, probably none of us would consider them acceptable. Furthermore, progress in raising the status of women, children, and other groups has often begun with the efforts of a few directed against cultural norms which they consider transcendentally wrong. With this background, we will consider several elements which appear important in the definition of abuse.
The most fundamental aspect of child abuse and neglect is that they are harmful to the child, that is, detrimental in some way to his well-being. While severe physical injury, severe malnutrition, and death are recognized universally as harmful, many other circumstances are not. As cultural values (what is good) vary, so will the concept of harm (what is not good). Likewise even from an outsiders point of view what may be good for a child in one setting may be harmful in another. For example, female circumcision and genital mutilation is practiced in much of Africa. This is unquestionably harmful in terms of immediate pain, risk of infection, and risk of serious obstetric complications including maternal and child death (Tevoedjre, 1981). At the same time, a woman who has not had the procedure performed may not be accepted as a member of her tribe, and be unmarriageable (LeVine & LeVine, 1981). Thus even educated women may support the practice as necessary given the cultural context (Lowenstein, 1978; LeVine & LeVine, 1981).
Many workers' definitions of abuse include some aspect of intent to cause harm (e.g. Animashuan, 1977; Masrour 1980; Langness, 1981). One reason for this is that the there seems to be an important difference between intentional and unintentional harm, not only from the caretaker's point of view but from the child's. It has often been observed that what is so destructive about child abuse and neglect (as opposed to other forms of injury) is that the betrayal of the child's trust leads to defective socialization (e.g. inability to form close relationships, defective parenting behavior). Other workers, perhaps the majority of those in the developing countries, do not include intent as a criterion of abuse. Thus Johnson (1981) defines abuse
as "any child-rearing technique that results in physical harm or death or emotionally deprives the child of self-esteem and a sense of competence." However, if one defines as abusive behaviors or circumstances when there is no intention of harm, one is saying little else than that they are harmful. Also, without intent as a criterion one needs to be even more careful to include only clearly harmful practices, otherwise perhaps nearly all parental behavior could be classed as abusive from someone's point of view.
Culturally acceptable versus idiosyncratic practices
Korbin (1981a) explores the difference between (1) practices which though perhaps abusive from an external viewpoint are culturally accepted and (2) those which are rejected by the culture but occur at the hands of certain caretakers (who would thus be classed as "deviant"). She points out that it is more clearly appropriate to consider the deviant behaviors as abusive than those which are culturally accepted.
Level of control
While early definitions focused in the caretaker's behavior, broader definitions such as that of Bhattacharyya [above] consider any institution or society as a whole to be capable of abuse. The problems here are similar to those of intention. It is certainly true that harm may come to children as a result of parents, school systems, economic policies, lack of health facilities, international trade problems, warfare, and a host of other factors. Therefore when considering the welfare of children from a global standpoint it is essential to consider all these factors. However to lump all these widely-different problems together under the label of child abuse and neglect seems to accomplish little beyond calling attention to them. Clearly the different problems have different bases, different effects on children, and call for interventions which are not only different in nature but
addressed to distinct levels. Thus there seems to be some value to separating harm caused by parents and other caretakers of individual children from other types of harm.
At one level the question of what constitutes child abuse and neglect is a semantic question which depends on our purposes. For those working at the national or international level, broad definitions serve to draw attention to the ways children suffer because of national and international policies as well as at lower levels. For others working at a local or regional level, it might be more important to focus on local customs and idiosyncratic parental practices which are harmful. It is obvious that deciding to label or not to label a practice as abusive does not in any way change the practice or the effect it has on the child.
Lack of data is a general problem
Little is known of the epidemiology of child abuse and neglect in any developing country, and there are often conflicting claims. The lack of data should not be surprising since obtaining accurate epidemiologic information is problematic even in developing countries with great resources to study the issue (cf. Straus & Gelles, 1986; Stocks 1988). I was unable to find a single study from which the incidence of any given form of abuse could be semi-accurately estimated in any developing country.1 There are several reasons for the absence of information. First, in many countries there is still little interest in or awareness of the problem. De la Torre
1 The exception might be the work done in the area of neglect of females in India, where a considerable amount of research has been done over a long period of time. See Miller, 1981.
(1975) attributes this partly to the fundamentally "organic" or biologic focus of pediatric hospitals in developing countries, with little interest in psychological and sociological factors. In informal discussions with pediatricians from several developing countries I have found that none of their training programs dealt with abuse and neglect. Even where there is interest, gathering information is difficult. There are usually problems of communications and travel which impede data collection. In addition there are generally fewer resources available for large studies. As a result of these problems, even such gross measures as total mortality rates are known to be unreliable in many developing countries.
Universality of child abuse and neglect
Though their frequency is difficult to determine and depends on the definition used, child abuse and neglect can be found in most if not all cultures. In all cultures there are parents and caretakers who for one reason or another go beyond their cultures~ recognized child rearing practices in ways which harm their children. On the other hand, there seems to be a clear concensus, based on observations in many countries, that this sort of idiosyncratic abuse (e.g. the classical battered child, or corporal punishment beyond what is accepted in the culture) is less frequent in most traditional societies than in North America (Loening, 1981; Poffenberger, 1981; LeVine & LeVine, 1981). While it may be true that abuse is rare in these situations, there are two precautions to keep in mind. First is the fact that abuse and neglect always tend to be hidden (at least the idiosyncratic types do) so that the lack of identified cases does not imply that no cases exist. For example, Wu (1981) in 1977 could find no statistics or other records on child abuse in hospitals or other health agencies in Taiwan, and health workers denied that it could exist in that country.
Cases of abuse were, however, found in newspaper reports. Interestingly the perpetrating mothers in these cases were generally regarded as being temporarily insane, a common social explanation for deviant behavior. Second, even if abuse is rare in traditional societies, many of these societies are rapidly changing in ways that may make abuse more likely. Urbanization and the disappearance of the extended family are two of the changes most cited as contributing to an increase in abuse and neglect. These are discussed below.
Practices more specific to developing countries
Certain types of abuse and neglect seem to be more common in developing countries than in the developed ones, including child labor and slavery, exploiting children for begging, and large scale sexual exploitation in certain areas. These practices are characterized by the fact that, although the caretakers may have originally exposed the children to these situations, the actual abusers are seldom the parents. In addition, these practices tend to be more "public" and continuous than typical forms abuse by parents, and should be subject to control by the public sector (e.g. by laws regulating child labor). It is significant that similar types of societal child abuse were prevalent in the Western countries in the past and were greatly reduced largely through legal reforms. Abandonment and infanticide may also be more prevalent in certain developing countries. Both appear to be directed toward freeing the mother (or group) from a child who is seen as some sort of burden, rather than being punitive. Both would be expected to be more frequent in communities where poverty is common and social services are lacking.
Differences in prioritization of problems
In developed countries child abuse and neglect rank high in importance among problems of children. Many other causes of morbidity and mortality have been controlled or eliminated, and attention can thus be focused on the minority of children who are abused. This is not the case in developing countries, where tremendous numbers of children suffer from malnutrition, infectious diseases, chronic disabilities, and high rates of accidental injuries. It is not uncommon to find that over 20% of all children die before the age of five years. For the most part the problems are well-understood and easily-controlled given adequate resources. Therefore it is not only understandable but quite appropriate that a large portion of a country's resources be directed toward these problems. At the same time, it is clear that in many developing countries neglect and abuse of children are significant public health problems, and likely to become greater problems as urbanization continues. Those involved in research and planning for child health and welfare in those countries should become familiar with manifestations of abuse and neglect and incorporate prevention and treatment as much as possible in the fabric of primary health care and social planning.
Contributing problems in developing countries
There appears to be considerable agreement as to some of the factors which contribute to the occurrence of abuse and neglect in developing countries. Once again there is little epidemiologic information on which to base these associations. As already mentioned, the breakup of the extended family and of the support of closely knit traditional communities has been implicated by many workers. The process of urbanization has several consequences which are generally believed
to lead to increased abuse and neglect as well to other risks to children. Finally,
population pressure and poverty are often cited, though their relationship with abuse is less clear. Each of these factors will be considered separately below, after a discussion of some important forms of abuse and neglect.
IV. SPECIFIC AREAS OF ABUSE AND NEGLECT
In this section we will look in more depth at some of the forms of child abuse and neglect which are thought to be important in the developing world. Undoubtedly their relative importance varies among societies, and no attempt will be made to generalize in this regard. Planners and other health workers should be aware of all of these areas in order to be able to consider their importance in the local context.
Infants have been abandoned in a wide variety of cultures throughout history. In some the practice has been condoned or ignored. In Western tradition, infants both in ancient Greece and Rome could be abandoned as an alternative to infanticide, as exemplified in the story of Oedipus. Abandonment continues to be a widespread problem. A survey of public prosecutions in Turkey showed 3700 prosecutions for abandonment of newborns over a 6 year period (Gunce & Konanc-Onur, 1983). The same authors found that a large proportion of children in two institutions in Ankara had been abandoned. Bhattacharyya (1983) estimated that India has over one million orphans, many abandoned due to illegitimacy. There have been increasing reports of abandonment in Mexico and it has been estimated that 25% of these children die before being found (Retana, 1978). The problem also exists in east, west, and south Africa (Bwibo, 1972; Loening, 1981; Animashuan, 1977) and Bwibo says that in East Africa there are "many newborn babies dropped in pit latrines, dustbins, or left on the wayside."
Multiple factors lead to abandonment, but fundamentally all have in common that the child is unwanted. Abandonment and infanticide are both ways of "solving" the problem of the unwanted child by eliminating her/him from the family. Animashuan (1977) feels that the response of Nigerian parents to severe stresses may be to abandon their babies "in the hope of a miracle" while under similar circumstances parents in "sophisticated societies" may batter their children. It could also be argued that where abandonment and infanticide are less available as options, the unwanted child, though remaining physically in the family, becomes a target for battering and other abuse (cf. Feder, 1978). Who are the unwanted children? The answer varies among cultures. In many, the illegitimate child is at great risk. While the extended family and traditional community may provide considerable protection against abuse for those considered as members, certain classes of children such as those born outside culturallyapproved marriage bonds are not recognized as valid members of society and thus are not subject to protection. Furthermore, tremendous pressure may be placed on the mother to somehow "correct" the problem, leading to the abandonment of death of a child she might otherwise desire (Gunce & Konanc-Onur, 1983; Haditono, 1981). Marzouki et a1. (1987) say that the illegitimate child in Tunisia is, "almost a social non-being ... subject to all sorts of violence without posing any problem of conscience". They note that even some members of the Tunisian Human Rights League refused to include the rights of these children in their charter. Similar observations regarding the illegitimate child's risk of abandonment, death, and abuse have been made across cultures (Bhattacharyya, 1983; Retana,
1978; Dave et a1., 1982; de Silva, 1981; Lokeshwar et a1., 1979; LeVine & LeVine, 1981).
Children with physical or mental defects are also frequently unwanted. Even deformities which may have little or no functional importance, such as an extra digit or albinism, may lead to abandonment or infanticide. Parents or the community may act out of superstition, fearing that the deformed child is a manifestation of an evil power. The community may reject the child simply due to his "differentness". In other cases parents may feel they lack the ability and resources to care for a special child. Especially where life is often a struggle for survival, the addition of a permanently dependent family member may seem intolerable. The problem of children with defects may be especially important in developing countries for at least two reasons. First, many disabilities are relatively frequent in those areas due to lack of health care. Among them would be deafness (from prenatal or infant infections), blindness (from trachoma, vitamin A deficiency, trauma), lameness (from poliomyelitis, trauma, birth defects). In Animashuan's series in Nigeria, 4 of 24 abandoned children had physical defects, while only 3 of 175 abandoned newborns in India had congenital anomalies (Lokeshwar et al., 1979). Second, there are far fewer resources for helping such children and their families. Gunce & Konanc-Onur (1983) state that many of these disabled children are abandoned due to lack of institutions, and cite the case of a father who kept his retarded child in a room with windows protected with barbed wire, due to lack of available institutional care. Another very important group of unwanted children in some areas are
females. The same series of Lokeshwar
and colleagues found that 59% of the
subjects were females. Abuse and neglect of girls is considered separately later.
Twins are also unwanted in some societies (see next section).
Finally, a child may be unwanted simply because the parent(s) are unable to care for another child (or even for one). In the urban setting where child care is lacking and the extended family does not exist, where employment is hard to find and social services nonexistent, a new child may be unwelcome (d. Retana, 1978).
The practice of killing infants is very similar in many ways to that of abandonment. Both aim at permanent removal of the unwanted child from the family. Abandonment of an infant is actually a form of infanticide unless the child is left where she is sure to be rescued rapidly. In general the risk factors for abandonment discussed above are also those for infanticide. The term infanticide often implies killing with some degree of social acceptance, rather than the idiosyncratic murder of a baby. It has been practiced since ancient times in all or nearly all societies including the Western ones. Ritual sacrifice of children was recorded in Biblical times (e.g. 2 Kings 16:3) at least
as early as the second millennium Be and was a capital offense in the Jewish law (Leviticus 20:1-5). Even in European societies infanticide continued to be practiced at least through the 19th century, with an estimated 80% of illegitimate infants in England falling victims (Montag & Montag, 1979). Infanticide has also been an accepted and widespread practice in the past century in China (Korbin, 1981b), Japan (Wagatsuma, 1981), Africa (LeVine & LeVine, 1981), India (Miller, 1981; Ghosh, 1986). Illegitimacy is still a major reason for infanticide in areas where illegitimate children are socially rejected (Dave et al., 1982; Haditono, 1981).
In the past infanticide was also used as a means of population control both at the family and community level (Langness, 1981; Wagatsuma, 1981; Hunton, 1977). Although this reason is now less important due to increased availability
of contraception and to decreased approval of infanticide, some children are still killed because of being "excess." In some aboriginal groups the practice is still accepted or even mandatory (Johnson, 1981; Jenkins, 1988). In the rest of the world the killing of excess infants is generally not condoned but still occurs in some situations (e.g. in a rural Peruvian community, [de Meer, 1988], and of female children in India and China [see below]). The other factors mentioned above as leading to abandonment, such as defects and economic pressures, are also important in child homicide and infanticide. Even religious sacrifice of children still occurs in uncommon instances (Dave et a1., 1982; Bhattacharyya, 1983). When infanticide is accepted (or quietly ignored) in a culture, there is often some cultural definition of the victims as not-yet-persons, so not subject to protection, just as many Western cultures define the fetus as a non-person and accept abortion. In very adverse conditions where infant and child mortality rates are extremely high the child might not be fully accepted until the age of several years (e.g. Langness, 1981). In other cases infanticide is acceptable until the baby cries (indicating the entry of the spirit) (Wagatsuma, 1981) or nurses (Johnson, 1981).
VBattering and severe corporal punishment
Different cultures have different standards for how children may be punished or disciplined. In some corporal punishment is almost nonexistent, at least for smaller children (e.g. Polynesia). In others children may be severely beaten or suffer other physical harm in the course of punishment. In part the extent of punishment depends on the culture's concepts of the child. In the traditional Turkish culture the child is considered to "a very limited human being who will grow up at his own pace" (Olson, 1981) and parents do not expect to have complete control over their children any more than they do over the rest of the natural
environment. When corporal punishment is used it is used "pragmatically" rather than punitively or to establish the parent as the authority. At the opposite end of the spectrum is the traditional Chinese view that even very young children should show devotion and respect to their parents and place their parents' welfare before their own. The child is expected to obediently endure even the most severe and unreasonable punishment without complaint (Wu, 1981). Beating and whipping seem to be the most universal types of corporal punishments used and accepted. A survey of parents in Tunisia found that 80% had been beaten at least once in their own childhoods; these parents generally felt that the punishment had been necessary for their upbringing (Marzouki et
al., 1987). In a survey in Hong Kong over half the respondents had observed
children under 3 years old being beaten and nearly 80% had seen such young children with marks, bruises, or injuries; 7% had seen children under 3 years old, and 20% had seen those from 5-10 years old, being hit in the head with an object (Samuda, 1988). Similar frequencies were found in a survey in Taiwan (Wu,
1981). Four of 30 respondents in that study approved of kicking and beating
5-10 year-olds as punishment, and 3 approved of hitting them in the head. Despite the close cultural similarity with Taiwan and Hong Kong, physical punishment is reportedly uncommon in the People's Republic of China, where officially it is strongly disapproved of in general and strictly prohibited in schools (Korbin,
Many other methods of corporal punishment are used around the world, with varying potential for physical and psychological injury. In some areas of Africa parents may apply pepper to the child's eyes, anus, or genitals or to cuts resulting from a beating (LeVine, 1963). In some South American tribes and in Sri Lanka the child may be whipped with nettles, and in the case of South America
more severe punishments include hallucinogenic drugs and placing the child in the smoke of a fire, burning hot peppers, until he becomes unconscious (Johnson, 1981; de Silva, 1981). Children in parts of India may be hung by their hands from a hook on the ceiling as a particularly severe (and terrifying) punishment (Poffenberger, 1981).
It is difficult to determine where the boundary should be drawn between
acceptable and unacceptable forms of discipline. Clearly the cultural context is very important. Being caned or whipped in a culture where such punishment is common and expected carries a different psychological meaning to parents and child than it does where, for example, spanking is the only approved corporal punishment. Several authors are careful to point out that even in the cultures where corporal punishment is relatively frequent and severe, it occurs within limits rather than out of rage, and i;f does not necessarily reflect a lack of warmth in the parent-child relationship (Marzouki et 8.1., 1987; LeVine, 1963; Wu, 1981). Parents in many cases believe that the punishments are essential for the proper socialization of their children and would consider the failure to punish to be a true form of abuse in the long run (Nathan & Hwang, 1981). On the other hand, the potential for unintended harm clearly increases with the severity of the punishment. Social toleration of corporal punishment probably also increases the risk of serious injury, permanent disability, or death when the parent does become hostile or loses his control. In the case of the young child who is beaten, his life depends on the parents "proper technique", so to speak, since a single blow which is too forceful or in the wrong location can be fatal. Therefore it seems reasonable for the child advocate to press for the reduction or elimination of at least the more severe forms of corporal punishment
in all cultures. Parents may not conceive of any ways of discipline than those they already use, so the first task may be to introduce alternatives (Nathan & Hwang, 1981; Arnold, 1982).
Neglect may be thought of as failure to provide whatever care is necessary for the child's well-being. Furthermore, we need to differentiate situations where the caretaker is capable of providing the care but fails to do so from those where she simply does not have the ability or resources to provide proper care. Thus while it might be neglectful for a middle class mother to leave her infant at home in the care of a 5 year-old, we would not say the same if the mother lived alone with her children in an urban slum and had no other resources. Just as cultures differ as to standards of discipline, so they sometimes disagree about the standard of care due to children of different ages. American culture is highly protective and emphasizes personal independence and
achievement, and emotional warmth between parent and child. Neglect in that context could include failure to provide maximal protection against physical injury, or to provide a warm and consistent emotional relationship. Among many tribes in New Guinea personal autonomy is highly valued and warfare and violence are (or were) nearly continuous, placing the societ.y under pressure to produce ferociousness, endurance, and independence in its children. Even quite young children are left to play unsupervised in hazardous situations in the expectation that this is what is needed for their proper development (Langness, 1981). When judging the neglectfulness of a behavior we need to consider the cultural "risks" (that the child's development will be inappropriate for her culture) as well as physical risks.
In general neglect has not received much emphasis in the international literature on child abuse and neglect. Obviously poverty, the breakdown of the extended family (and even the nuclear family), and the urban situation of many families around the world make it very difficult for parents to provide for their children's needs, and hard choices are often made, as in the case of the mother who leaves her children unsupervised in order to work to provide food for survival. Given the prevalence of abandonment in some areas, it is logical to believe that many children are also neglected. LeVine & LeVine (1981) mention maternal alcoholism as one particular risk factor for disastrous neglect in East Africa. Malnutrition is one of the greatest problems of children in developing
countries. In part this is due to simple food shortages, poverty, and maldistribution. However, there is also evidence that even in areas of poverty much malnutrition is also associated with parental neglect (e.g. Jinadu, 1980). The neglect may be as obvious as the failure to feed the child adequate quantities of food, or as subtle as the withdrawal of the emotional relationship leading to apathy and depression in the child (Goodall, 1979; Bhattacharyya, 1981, 1983). Therefore it is important for the health worker to investigate cases of malnutrition for possible neglect (or unavoidable lack of care) and to include preventive measures in planning for community health care. For example, adequate day care facilities and creches can play an important part in avoiding malnutrition (Williams et al., 1985, p. 229). In some cases neglect appears to be selective or even intentional. Females, children with disabilities, and ill children may be given less care than other children in the same family. Johnson (1981) gives the example of the South American Indian mother of a sickly infant with chronic diarrhea, who persistently
ignored its crying and kept pushing it from her breast, and interprets this as
an example of "benign neglect" which may be a form of population control. As noted below, there clearly is selective neglect of girls in parts of India. On the other hand, we must be extremely careful when we attribute the mother's failure to provide proper care to her being neglectful, lest we blame her for circumstances over which she has no control. In extensive fieldwork in Brazil, Nations & Rebhun (1988) looked at parents in slums who at first might have appeared to be fatalistic and neglectful toward their sick children. They found that parents were fatalistic as a rationalizing mechanism after a child's death, but did not let their children die without doing all in their power to prevent the death, even at great cost. Rather than the parents being neglectful, "it was only upper class individuals such as physicians, nurses and government officials who spoke of neglect leading to death and who used the idea to justify their own tragic neglect of the impoverished population."
v Sexual abuse and exploitation
Sexual abuse of children is in most countries one of the last forms of abuse to be "discovered," due to incest taboos, the secrecy of the abuse, and the feeling that it "could not happen." In the past 10 years there have been several reports that sexual abuse does occur in developing countries, although there is no good way to estimate its prevalence. In a series of 1000 abused children in India, 93 were victims of sexual abuse. Two-thirds of these were adolescent females, 8 were pre-adolescent females, and 21 were males (Dave et al., 1982). In Malaysia 3 in a series of 19 abused children had been sexually abused, all were
females and had genital trauma or gonorrhea (Nathan & Hwang, 1981).2 Gunce & Konanc-Onur (1983) report that in Turkey 31,908 people were tried between and 1980 for raping children under 15 years of age. Information about perpetrators is available from two series. In a study of 183 victims of sexual abuse in Hong Kong, 5% of the perpetrators were relatives (including 5 fathers), 56% were acquaintances or friends, and 40% were strangers. Ninety percent of the victims were females (Law, 1979). In India, a study of 130 cases found that perpetrators included 2 fathers, 8 uncles, and 80 neighbors and friends (Mehta et al., 1979b). Twenty percent of the victims were less than 13 years old.
While sexual abuse is harmful in itself, the harm is compounded in countries where the victim is considered disgraced. To some extent this problem of blaming the victim may be universal. In India, and perhaps in other societies with strict sexual mores, the disgrace is so strong that the girl is often not accepted back into her family, becomes a social outcast, and often commits suicide. In Turkey girls are frequently kidnapped and raped with the perpetrators' intention of marrying them. After being raped the girl has essentially no one else she may marry, and Turkish law suspends punishment if the perpetrator marries the girl. Because of her disgrace, however, she is often subject to later abuse by her husband or in-laws and lacks the protection of her family. Besides marrying the perpetrator, prostitution may be the only alternative open to such a girl (Gunce
& Konanc-Onur, 1983; Olson, 1981).
2 Since physical findings are relatively uncommon in sexual abuse in the Western experience, one suspects that for each of these three cases of sexual abuse there would be many more undiscovered cases of abuse without physical evidence.
Sexual exploitation of children for profit occurs in many areas around the world. Children may be lured by "employment agents" to the city where they subsequently become essentially enslaved as prostitutes, even to the point of being kept locked up. Other adolescents and children may become involved more voluntarily. Child prostitution is said to be significant problem in Thailand and the Philippines. The customers in those areas are largely from the developed countries. Peru also has considerable child prostitution in areas where there is a large population of men developing the Amazon basin. Young boys are also used for homosexual prostitution, as in the Philippines and Sri Lanka (de Silva, 1981; Perpinan, 1985; Anti-slavery Society for the Protection of Human Rights, 1985). Kidnapping girls to use as prostitutes has been described in India (Bhattacharyya, 1983; Mehta et 81., 1979a) and doubtless occurs elsewhere. Sexual exploitation may also occur on a smaller scale when children are hired out as servants as occurs in many areas, as their masters may use them sexually (Okeahialam, 1984). Health workers should be aware of the likelihood of sexual exploitation of children in urban areas and should advocate necessary legal and social reforms to eliminate it.
The exploitation of children for the purposes of begging has been mentioned or described at least in Egypt, Niger (Williams et 81., 1985), India (Bhattacharyya, 1983; Mehta et 81., 1979a), Sri Lanka (de Silva, 1981), and Nigeria (Obikeze, 1984; Jinadu, 1986). In Sri Lanka children or families displaced from the land become part of a professional beggar group and are taught the "trade" of begging, not necessarily being exploited. In many other situations however, children are at the mercy of employers who use their begging as a source of income. The disabled ones are the most vulnerable. De Silva describes daily auctions where the "deformed, diseased or malnourished child" can be hired from private "owners"
or a beggar syndicate. The money collected goes to the entrepreneur while the child is lucky to receive a small meal. Parents and foster parents sometimes also use their children in this way. Even worse than the mere exploitation or enslavement of children for begging, the "owners" or parents may deliberately disfigure, maim, or starve the children to make them more pitiable. If the needed resources to care for destitute children can be mobilized, progress can be made in eliminating these practices, but it is doubtful that laws alone will be able to do so.
Related to begging is the entire subject of child labor. As in other areas, there is no clear line between what constitutes child abuse and what does not. India alone is estimated to have over 16 million child laborers and worldwide estimates of over 50 million are cited (Mehta et 8.1., 1985). In the context of poverty and developing countries, child labor in itself should not be considered abuse, as it can provide income which may be quite necessary for the survival of the child and his family. There are serious problems often related to child labor, however. (1) The child is vulnerable and dependent, therefore easily exploited. The "employment" may become slavery with no benefit to the child. Parents may be glad to find even an unpaid job for the child, so as to have one less mouth to feed, or may use their children simply as a source of income (Mehra, 1985; Gunce
& Konanc-Onur, 1983; Obiako, 1987). To the extent that the child suffers for the
benefit of others, this constitutes abuse.
(2) Child labor often involves separation of even young children from their parents and homes. They are deprived of the normal social and emotional relationships necessary for development. (3) Employed children may be in the care of people who have no interest in their well-being. They are thus very prone to physical and sexual abuse. Because of medical and nutritional neglect by their employers, and because of harsh working conditions and long hours, they often have serious health problems and malnutrition. (Nathan & Hwang, 1981; Mehra 1982; Obiako, 1987; Obikeze, 1984; Nwako, 1974). On the other hand, for some children even moderately harsh conditions may be preferable to the alternatives. A survey of working children in India (Mehta et a1., 1985) found that those who received all their meals from their employers (2/3 of the total) were all fed adequately. Few illnesses or job-related health problems were encountered.
(4) Child labor frequently prevents the child from being educated. This is a serious problem since education is crucial both for the child's own sake and for the well-being of the entire society. The subject of child labor must thus be considered carefully in each local context. In many cases the its outright abolition would not be favorable to the child. At the same time it poses many risks to the child, which need to be controlled. The best approach will often be to investigate the conditions under which children are working locally, what their problems are, then to design appropriate intervention programs and interventions based on the findings. For example, employers could be required to provide regular health care and education for all employed children, the number of hours worked could be controlled, and working conditions could be inspected and regulated by a government agency. Children below a certain age could be forbidden to work.
Slavery could be considered as a type of employment. The distinctive nature of slavery is that the child is completely under the control of the owner for a prolonged period of time, the parents having lost or given up their rights to the child. In India the practice of "jeetha" consists of children being indentured to the landlord as repayment of the parents' debt. The children are used for any kind of labor or service desired by the landlord, and often live in very oppressive conditions. Sathyavathi (1975) found that 3 children in a series of 45 cases of child suicide were in this situation. A similar practice ("pawning") exists in Nigeria (Obikeze, 1984) where girls are usually the ones involved, and often become concubines or wives of their masters. In the Turkish institution of "besleme" orphan girls or those from poor families are taken by more well-to-do families, who maintain them in return for their labor. Some forms of employment border on slavery, as when parents send their children away to live with an employer for an extended period of time, with the parents receiving the wages (de Silva, 1981). All the disadvantages of child labor also apply to slavery. As with other forms of child labor, there may also be advantages to the child in some CIrcumstances, as when his survival is at stake. On the other hand, the degree of
control over the child also offers more opportunities for exploitation and abuse. As with child labor, the situation in each country must be considered on its own merits, but remembering the goal of promoting the child's emotional, physical, social, spiritual, and educational welfare.
Under the heading of cultural abuse we will consider a range of practices which exist in various areas which might be considered to be abusive or detrimental
to the child. These practices are characterized by the fact that they are, at least on the surface, intended to promote the child's welfare. They are not punitive nor designed (as infanticide) to benefit the community at the expense of the child. Therefore we can label them as "abuse" only with reservations.
It has been suggested (McKee, 1984) that certain acts become embedded in
the traditions of a culture for the express purpose of reducing the survival of its children, in order to curtail population growth or to adjust the sex ratio. Examples of this "progenicide" might include umbilical cord ceremonies such as application of dirt or dung, initiation rites, differential weaning with males being breast-fed longer than females, and counterproductive nutritional taboos. It is characteristic of all these behaviors that they are justified in terms of being necessary for the survival or well-being of the infant, while actually compromising that survival. The justification, however, removes the psychological barrier against harming one's children.
In various traditional societies around the world there are initiation rites which involve pain, shame, and sometimes injuries. Generally the males in a group are subjected to more severe treatment then females. In New Guinea, for example, practices in various tribes include holding the boys over the fire, forcing them to drink contaminated water or slaked lime, shooting tiny arrows into the tongue or up the urethra, and forcing them to have homosexual intercourse with older males (Langness, 1981). Similar ordeals and a wide variety of others are practiced in Africa (LeVine & LeVine, 1981) and elsewhere. Although some of these rites may have the potential for physical and psychological harm or even death, they
are considered to be essential to the development of the child (or new adult). Although boys may anticipate the experiences with some dread, they also take pride in the deeper significance of passing into a higher status. On the other hand, Langness also wonders whether at some level the initiation practices represent institutionalized expression of hostility against the young men, and whether certain behaviors "may be considered as 'abusive' irrespective of context." Once again then, the entire cultural context needs to be looked at before a single element can be isolated as abusive and needing to be changed. The risks and benefits of the various practices should be considered, and in some cases alternatives may be sought.
Ordeals and harmful treatments
Every society has a "health care" system designed to maintain the health of its members and to cure them when they fall ill. Many of the methods used are helpful or at least harmless, but some are harmful, causing pain with no benefit, or putting the child at risk for serious injury or death. A Latin American folk treatment for an ill infant includes holding him upside down with the top of his head in hot water, then shaking him vigorously three times while slapping the soles of his feet. While this might usually be innocuous, it can be fatal due to the "shaken baby syndrome" of subdural hemorrhage (bleeding around the brain) (Guarnaschelli et al., 1972). The Machiguenga Indians of South America dip their babies in river water to stop their crying, and give them scalding baths and scrape their skin with dogfish teeth to make them fat and able to endure pain with dignity (Johnson, 1981). In some areas of India newborns are ritually branded on the abdomen to ensure proper digestion of food and to prevent or treat respiratory infections; many become ill or die because of complications of
the burns (Dave et aJ., 1982). Dietary restrictions on ill children, such as giving a child with measles or diarrhea nothing to eat or drink are frequent and naturally are the cause of many deaths. We should not neglect that fact that harmful treatments are also used in the developed countries and that health care providers in all parts of the world are sometimes responsible. Some harmful practices such as bottle-feeding were introduced from the West. Practices such as giving unneeded injections or performing unnecessary surgery fall into this category of harmful care (except that the professionals should know better!) (Torrelio & Vargas, 1979). There are, then, an endless variety of potentially harmful "cures." Obviously the parents and practitioners should be praised for their attempts to help the children rather than blamed for the harmful effects we might see, and the focus of change should be on the provision and demonstration of more efficacious treatments. We cannot expect changes to occur if we cannot offer better methods which are accessible, and even then we must remember that change may be slow.
Removal of child from home
In many parts of Africa the young child is removed from his mother and his home at some point, often at weaning, or the start of the mother's next pregnancy (LeVine, 1963). He may be sent to live with a grandparent or with someone in the mother's clan. There are doubtless many attributed reasons for this. In the Baganda tribe the explanation is that the child is in danger of being infected by his mother's abdominal swelling (Goodall, 1979). Whatever the reason, this practice is generally harmful to the child. The combination of perceived rejection and withdrawal of mother's affection, the elimination of a clean nutritious food source, and the loss of other relationships and familiar surroundings can
cause serious depression and, as Goodall showed, makes him prone to malnutrition. This is another example of a practice which, though perhaps intended for the child's good, is actually harmful.
,.../ Abuse against females
Discrimination against females occurs in various forms in many areas of the world, developed and developing alike, and is a large area of study in its own right. In this paper we have room only to mention some of the most severe types of discrimination resulting in death, and the subject of female circumcision. We have already noted that in some areas girls are in the group of children classed as "unwanted" or "less wanted", thus they are subject to all sorts of abuse and neglect. The causes of the discrimination are beyond the scope of this paper but include may economic factors (females being valued more where they are more important labor sources), marriage practices such as dowries and hypergamy (a woman marrying into a higher social class), the valuation of males as warriors, and many other sociological factors. Most of the research I encountered on severe abuse and neglect against females is from India, where in some areas there are far fewer surviving females than males, but to a lesser degree females are selectively abused and neglected in other parts of the world as well.
Female infanticide, homicide, and severe neglect
The selective killing of girls was relatively frequent in the past in various areas including East Africa (Bwibo, 1972), and India (Miller, 1981; Jeffery et al., 1984). Some feel that the practice still continues in the People's Republic of China where males are highly valued and women are under pressure to have only one child (Light, 1985). Young brides in India (including teenage ones) are often victims of homicide or are driven to suicide by their husband or his family, and a government report from Gujarat in 1966 found that "persistent and calculated
physical and mental torture was employed in some casts to deliberately do away with the daughter-in-law" (Poffenberger, 1981). The frequent suicides of sexually abused girls was mentioned above. More common than the outright killing of females, however, is neglect, which may be minor or so severe that it can only be intentionally designed to result in death. It is the more serious forms of neglect which are believed to be responsible for the overall high death rates in females in India. In the most severe form of neglect infants are simply abandoned, often dying as a result. In two series of abandoned children baby girls were abandoned twice as often as males (Lokeshwar et a1., 1979; Mehta, 1982). The next most physically damaging form of neglect is probably nutritional. The child before 3 years of age is nutritionally fragile in the sense that provision of an adequate amount and quality of food is essential for development. Inadequate nutrition puts the child at risk for physical and mental developmental delays and makes her less likely to survive common childhood infections such as measles. Because of the strong preference given to males, however, girls may not be given adequate or proper food when food is scarce. In a 10-month observation period in Northwest India (Punjab) Pettigrew (1986) found abundant examples of such selective neglect. The food supply was controlled by the mother-in-law who did not necessarily allocate any milk to pregnant and lactating mothers or to infant girls. Boys were given breastmilk or buffalo milk as well as other high quality foods, while girls were given what was left over. A nutritional survey in Punjab cited by Ghosh (1986) found severe malnutrition to be over twice as frequent in girls as in boys.
When girls become ill due to infection, malnutrition, or other causes, they are less likely than males to be treated (Singh et al., 1962; Ghosh, 1986; Miller, 1984). The lower level of medical attention given to girls is not due to less need on their part, since the same areas have higher morbidity and mortality rates in the girls. In one area the female mortality was 30% higher; for every 100 girls under 5 years old, 2 died who would not be expected to on the basis of the male mortality rates. One mother succinctly put the justification for this behavior: "A girl is like a stone and nothing can hurt her but a boy is like a flower and must be treated with care" (Poffenberger, 1981). The most recent form of lethal abuse to appear is the selective abortion of female fetuses after the use of amniocentesis to determine the sex (Jeffery et
al., 1984; Ghosh, 1986).3 While due to the high cost and limited availability it
seems unlikely that the practice will significantly affect the demographics of India, the demand for the service does illustrate the degree to which females are unwanted and therefore at risk from the time of birth.
Female circumcision is a practice with ancient roots, antedating the introduction of Christianity and Islam, which is still widespread in Africa (Tevoedjre, 1981), and is important from a world health standpoint because of the negative
Ghosh quotes an advertising flyer for such a service: Most prospective couples in quest of a male child, as the social set up in India demands[,] keep on giving birth to a number of female children, which in a way not only enhances the increasing population but also leads to a chain reaction of many social, economical and mental stresses on these families. Amniocentesis and Antenatal sex determination has come to our rescue and can help in keeping some check over the accelerating population as well as give relief to the couple requiring male child [sic] .... 9. Sex determination is done in those patients having one or more than two [sic] female children.
effects on the health of a very large number of females. "Circumcision" refers to clitoridectomy, the excision of the clitoris, or to infibulation, a much more radical procedure consisting of "cutting away all external female genitalia, and almost closing the vaginal opening" (Lowenstein, 1978). It is usually performed in children and adolescents. As with male initiation rites, while at deeper levels the practice may represent institutionalized hostility toward females and their sexuality, on the surface it is performed as an accepted tradition and a necessary part of passing into adult life. Some of the proposed reasons or justifications for the practice are (1) assurance of chastity before marriage; (2) family planning as intercourse will be less frequent due to pain or lack of enjoyment; (3) initiation rite; (4) to keep sexual interest at a minimum, thus discouraging the girl from promiscuity or prostitution (Lowenstein, 1978). It could also be a form of progenicide as described above, since it decreases the survival both of the one on whom it is performed and on her children (at birth). Problems caused by these procedures go beyond the obvious ones of immediate severe pain and the likely permanent decrease in sexual enjoyment. Short term complications include infections which could be fatal. In the long term menstrual and urinary problems, and sterility may result. Due to scarring there may be serious or fatal complications during childbirth (Tevoedjre, 1981). Despite these problems there continues to be much support for the practice in many areas. Lowenstein (1978) surveyed of Sudanese university students' attitudes on the subject. The women, all of whom had been infibulated, strongly supported it, the main re*asons being given that "it is our custom" and "a woman cannot get a husband without it." While the middle aged men tended to support it also, young men did not. Thus the circumcision of females is still another
example of a practice which, though harmful in itself, cannot be properly analyzed outside the context of the cultures in which it occurs. While it is detrimental to women's health, an individual woman who has not had the procedure may suffer more in the end as a result of that lack. Therefore changes must occur at a deeper level, at the level of the values represented. Until women can be assured that their children will be married and fully incorporated into society without it, it will continue to be practiced. 4
In the final section of this paper we will consider some of the factors which
seem to underlie the occurrence of child abuse and neglect in the developing world.
Poverty increases the risk of abuse in various ways. It puts pressure on one or both parents to leave home to work elsewhere, adding to the stress on the remaining parent; lack of resources to raise a child may lead to her being abandoned, placed outside the home, or even killed; poverty leads to rationing of scarce resources, resulting in the differential neglect of some children such as females; the need for money leads parents to use children as sources of production (begging; child labor; slavery or indentured apprenticeship). Unfortunately the problem of poverty itself is very difficult to solve and the health worker will be more involved in ameliorating its negative effects than in eliminating it.
According to Lowenstein, the practice has been illegal in the Sudan since 1945, yet all the students in the survey had it performed.
Urbanization, the move of the population from rural to urban areas, is the dominant demographic change in most developing countries. Men, women, and families go to the city in search of employment. Sometimes no jobs are to be found. Even when there is work, living conditions are often worse than they were in the home town or village. Housing is cramped, unsanitary, and unaffordable. Many are forced to live in makeshift squatter towns or slums. Urbanization leads to the disintegration of traditional family structures which are a defense against abuse and neglect. It places new stresses on parents and tends to convert children from an asset (on the family farm) to a liability (requiring more living space, more expensive food) which may lead to a lower valuation of children (Olson, 1981). Lack of suitable child care facilities results , in children being unsupervised at home, supervised by another child, or supervised by unrelated caretakers, often very young themselves, who have little at stake in the child and may abuse and neglect him (de Silva, 1981; Okeahialam, 1984; Jinadu, 1980; Wu, 1981). While urbanization itself cannot be reversed, some of the effects can be ameliorated. Perhaps the most practical and important intervention is the provision of good child care in appropriate locations, with trained (or at least reliable) staff and good standards of hygiene and nutrition.
Disintegration of family (nuclear and extended)
The extended family and close- knit community are commonly cited as protective factors against abuse and neglect in traditional societies. Because of the sharing of child rearing responsibilities the parents themselves are not faced with the continuous stress themselves; when the pressure builds there are alternatives such as sending the child to stay in another home for a while (Mehta, 1982;
Langness, 1981). At the same time, others besides the parents are concerned for the welfare of the child. If the parents begin to go beyond the cultural standards of care and discipline other relatives or friends may feel free to intervene. (Olson, 1981; Ritchie & Ritchie, 1981; Tevoedjre, 1981; Wu, 1981; Korbin, 1981b). As traditional societies become urbanized and face other pressures of social change, there tends to be disintegration of the wide network, and the responsibilities fall on the parents alone. The new pressures, lack of support, and lack of anyone to intervene combine to make abuse and neglect possible in families where they might not occur in other circumstances (Fraser & Kilbride, 1980; Okeahialam, 1984). Beyond the loss of the extended family, even the nuclear family is under new stresses. Both men and women are often separated from their spouses and children for long periods while working in the city or in another country. Men may have one wife and family in the city and another back home. The resulting marital discord and single parents are further factors in abuse. Prevention directed at these factors might be directed toward the
strengthening of a sense of community. For greatest success I suspect that this should be part of an integrated community development or primary health care project (not a vertical "child abuse prevention project"5). When designing and implementing such projects in urban areas the problems of family breakdown and its impact on children should be kept in mind so as to ameliorate them as far as possible.
5 Although one of the only child abuse prevention projects to be described in a developing country was just such a vertical one, involving community volunteers in a "Neighborhood Protective Strategy for Children", which proved to be fairly successful (del Castillo, 1985).
Absence of formal support systems
In most developing countries there is a lack of social support systems which could help prevent, detect, and treat child abuse. Development of these institutions is hampered by lack of money and personnel and probably also by the failure to see them as important. Some of the elements of a system to protect children have been mentioned already. Others would include:
Placements for unwanted/abused/neglected children. In most countries child
protective, adoption and foster care systems are underdeveloped. Many of the case histories in the literature the child was returned to the parents even after the diagnosis of abuse (e.g. Santhanakrishnan et al., 1973; Bhattacharyya, 1983; Hock & Hwang, 1975; Woon et al., 1974). It has even been claimed that with a "positive approach" "permanent removal of the abused child from the parental care may hardly be needed" (Santhanakrishnan et al., 1979). In view of the well-established experience in various countries (including India) that abused children are likely to suffer further abuse if returned home, such decisions should be made carefully, and every attempt should be made to establish safe and healthy homes where children may be kept at least temporarily. While the governments of developing countries may not be able to directly support dependent children, adoption can be encouraged and made simple and accessible. As a good example, Costa Rica recently reorganized its entire system of institutional care for abandoned children so as to integrate it, to provide rapid assessment of child and family, to promote family reunification when possible but also to seek adoption without delay when necessary (Lizano, 1982).
Support systems for parents. These could include assistance with training or
rehabilitation of disabled children; crisis intervention; and nutritional supplements to high risk women and children.
Primary health care including care available to working children. Services
should include good, culturally acceptable family planning services and prenatal care.
Trained workers. In many areas there are few if any trained social workers
or others who are familiar with or skilled in the issues involved in prevention and treatment of abuse and neglect (Oyemade, 1980). Governments should consider providing professional training for a reasonable number of workers. Meanwhile the shortage of trained social workers and medical personnel mandates the use of alternative strategies, such as the use of primary health care system for child protection. Therefore those involved in health care systems should also identify people who can become special resources in this area.
Children at special risk
We have already discussed many of the categories of children who in some societies may have little protection, including the illegitimate, the disabled or deformed, and females. Other risk factors in the child may include prematurity (Jinadu et al., 1982), and being in any way a "difficult" child, such as having sleep problems, excessive crying, or feeding problems (Fahaiel & Tabbane, 1974). Community and child health workers should be familiar with these risk factors and others which may be important locally. Careful thought should be given to classes of children who may not be fully integrated into the community (e.g. servants, certain racial or religious groups, working children) and may thus be at increased risk of abuse from parents or from others.
Needed changes in law
While legislation is limited in what it can accomplish, in that it cannot eliminate poverty, stop urbanization, keep families together, or make them love
their children, there are certain ways in which the law can be used to protect children. The ability of laws to effect changes will naturally depend on the resources available to implement and enforce them.
Regulation of child labor. Ways of protecting the working child have been discussed above.
Reporting laws. Laws governing the reporting of abuse and neglect need to be considered. Reporting may be made mandatory, so that defined classes of people (such as physicians and teachers) are legally obliged to report abuse or suspected abuse. One reason for this approach is that while sometimes the case may be handled well without the awareness of an agency or authorities, in other instances the child will be inadequately protected. Mandatory reporting makes sense when the agency receiving the reports is more capable of handling cases than are the reporters. Confidentiality concerns must also be addressed, as the duties of confidentiality and reporting may conflict, as in Morocco (Masrour et al., 1980). In any case, when making decisions about reporting, legislators must keep in mind that the well-being of the child is the paramount consideration. To avoid discouraging reporting, the administrative procedures required of the reporters should be as simple as possible (Nwako, 1974).
Regulation of child care facilities. In the absence of any regulation, some child care facilities neglect or abuse children, and some will be unhealthy for other reasons. Therefore it is reasonable to establish some basic standards and means of enforcement. For example, the ratio of children to caretakers could
be limited, and adequate sanitary facilities required. At the same excessive regulation could be burdensome and counterproductive by restricting the number of facilities in operation.
* Laws regarding perpetrators.
Another issue is the policy of the law toward
those who have abused or neglected children. Again the law should consider the best interests of the child. In many countries abusing parents are harshly punished. Factors to consider are the effects this has on the children, and whether it prevents conscientious workers from reporting abuse (e.g. Masrour
et al., 1980; Nazer, 1988).
Prohibitions on exploitative practices. It should go without saying that the
law should provide maximal protection against practices such as prostitution of minors and slavery. The mere existence of laws is not enough, however, without the political will to do whatever is necessary to end these practices.
Cultural values and standards
Even legal reforms may be of little effect in those aspects of abuse (or harm to children) where the entire cultural fabric is involved. We have seen how the customs and values of a culture, such as its views of whether children should become warriors or farmers, whether young children are capable of obedience, how to treat illnesses and ensure health, and what sorts of parental discipline are acceptable, all affect the way children are treated. In some cases a set of cultural beliefs and values lead to great suffering or death for some members, such as females in India, illegitimate children in many places, or Afro-Americans in America. Those whose goals are to promote equity and the well-being of all have the difficult task of balancing the acceptance of cultural differences with the need to change some aspects of any culture to more closely reflect those goals.
Many of these factors are also associated with other health problems, and many will be difficult to resolve without overall improvements in economic and social bases. At the same time, some progress can be made on the basis of increased public awareness and sensitivity. The process of reforms in the now-developed countries began when economic conditions were similar to those in many now-developing countries, and progress was effected not simply because of increased standard of living but because of changes in values. For this reason child advocates, health planners, and reformers in the developing countries should not conclude that the situation is unchangeable, but should press for changes which can be made in the context of the culture in which they operate.
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