Stage 3.

2 Paediatrics Child at risk Mary J Marret

Learning Objectives
1. Recognition of violence as a public health problem
2. Recognition of child victimization within the spectrum of community violence
3. Knowledge of basic concepts of child rights
4. Awareness of documents and legal instruments to promote implementation of
child rights
5. Knowledge of different categories of child maltreatment
6. Recognition of modes of presentation of physical and sexual abuse

Recognition of violence as a public health problem1

Violence is a preventable cause of mortality and ill-health.
The World Health Organization (WHO) defines violence as the intentional use of physical force
or power, threatened or actual, against oneself, another person or against a group or
community, which either results in or has a high likelihood of resulting in injury, death,
psychological harm, mal-development or deprivation.
All forms of violence across the lifespan have been recognized to have an adverse impact on
community health. They place a significant burden on health care services as well as the
criminal justice system. Violence is also detrimental to the cohesion of communities.
Table 1: Forms of violence across the lifespan (source: WHO)

 Youth violence
 Child maltreatment
 Intimate partner violence
 Elder abuse
 Sexual violence

Recognition of child victimization within the spectrum of community violence

The United Nations Secretary-General’s study on Violence against Children2 found that children
all around the world experience violence in different settings: homes, schools, streets, places of
work and entertainment, in care and detention centres. Most acts of violence against children
are carried out by people that they know and trust such as parents, boyfriends or girlfriends,
spouses or partners, teaches, schoolmates and employers.
Much of the violence against children remains hidden. Children are at great risk in communities
where violence is regarded as acceptable and a social norm. Violence against children is
harmful to their physical, sexual and psychological health.

1
World Health Organization http://www.who.int/topics/violence/en/ accessed 31 Oct 2017
2
World Report on Violence against Children 2006 https://www.unicef.org/violencestudy/reports.html accessed 31
Oct 2017

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Table 2: Groups vulnerable to specific forms of violence (Source: UN Secretary-General’s

report on Violence against children 2006)
Vulnerable groups Type of violence
Adolescent boys 15-17 Homicide
Young children

Young children Physical violence

Girls Sexual violence
Neglect
Forced prostitution
Children with disabilities All types
Ethnic minorities
Marginalized groups
Children in conflict with the law
Street children
Refugees
Other displaced children

Children who experience violence often have co-existing family problems. The Adverse
Childhood Experiences (ACE) study3 has reported that children who experience adversity in
childhood have poorer long-term health outcomes leading to disability and early death.

Early
death

Disease, disability & social

problems

Adoption of health risk behaviours

Social, emotional and cognitive impairment

Adverse childhood experiences

Figure 1: Potential influences throughout lifespan of adverse childhood experiences (Source: Felliti
et al 1998. American Journal of Preventive Medicine 14(4): 245-248)

3
Felliti, Anda, et al. 1998. American Journal of Preventive Medicine 14 (4): 245-248

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Stage 3.2 Paediatrics Child at risk Mary J Marret

The ACE study reported a dose-response relationship between the cumulative number of
adversities experienced in childhood and the risk of a number of adverse health outcomes listed
in Table 3.
Table 3: Association between exposure to childhood adversity & adverse health
outcomes (Source: Felliti et al 1998 Am J Prev Med 14(4): 245-248 & Anda et al 2006
European Archives of Psychiatry & Clinical Neuroscience 256(3): 174-186)

Types of childhood adversity Adverse health outcome

Childhood maltreatment Health risk behaviour/ psychological

 Physical abuse impairment
 Sexual abuse  Smoking
 Psychological abuse  Obesity
 Depressed mood
 Suicide attempt
 Alcohol abuse
 Illegal drug use
 Had a sexually transmitted disease

Family dysfunction Medical problems

 Parental substance abuse  Ischaemic heart disease
 Parental mental illness  Cancer
 Domestic violence  COPD
 Parent in jail  Hepatitis or jaundice
 Skeletal fractures
 Poor self-rated health

Psychological & behavioural problems

 Panic reactions
 Depression
 Anxiety
 Hallucinations
 Perceived stress
 Difficulty controlling anger
 Risk of violence towards intimate partner

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Child Rights
There was an old woman who lived in a shoe
She had so many children she didn’t know what to do
She gave them some broth without any bread
Then whipped them all soundly
And sent them to bed4

The ill-treatment and exploitation of children has existed for a long time and is not a new
phenomenon. Stories in literature (e.g.Oliver Twist5), folklore (e.g.Cinderella) and ancient history
make references to this problem. However, these problems were often ignored or tolerated
because children were not seen as individuals with their own rights and were subject to the
authority of adults.
In 1962, a paediatrician named Henry Kempe published a landmark paper6 describing features
of physical abuse in children entitled The Battered Child Syndrome. This led to greater
awareness of this problem and advocacy for the protection of children.
The UN Convention on the Rights of the Child 1989 (UNCRC)7 was drawn up as an
international legal treaty recognizing the rights of children. The UNCRC recognizes children as
human beings entitled to rights. However due to their young age, immaturity, lack of authority
and power, children are unable to seek or exercise their rights by themselves. Hence it is the
duty of governments and society as a whole to advocate on behalf of children.
Under the UNCRC, a child is defined as an individual under the age of 18 years. The UNCRC
contains 54 articles which outlines the rights of children and the responsibilities of adults and
governments to work together to ensure that children are able to enjoy these rights.
Table 4: Important principles within the UNCRC (Source: Unicef)

Non-discrimination (Article 2) The Convention applies to every child without

discrimination, whatever their ethnicity, gender,
religion, language, abilities or any other status,
whatever they think or say, whatever their family
background

Best interests of the child (Article 3) The best interests of the child must be a top priority
in all decisions and actions that affect children

The UNRC outlines rights which related to all aspects of childhood. They include survival rights,
development rights, protection rights and participation rights. Countries which have signed the
UNCRC have made a commitment to implement laws and policies that will make these rights a
reality in their respective countries.

4
Old nursery rhyme
5
19th century novel by Charles Dickens
6
Kempe, Silverman & Steele 1962. JAMA 181(1): 17-24
7
https://www.unicef.org/crc/accessed 31 October 2017

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Stage 3.2 Paediatrics Child at risk Mary J Marret

In addition to the UNCRC, the are three Optional Protocols on the sale of children, child
prostitution and child pornography. Governments which have ratified the UNCRC can choose
whether or not to sign the Optional Protocols. Malaysia has ratified the UNCRC in 1995 but has
placed reservations on some articles8
Table 5: Some examples of child rights under the UNCRC (Source: Unicef)
Survival rights  Right to life
 Right to an identity (identity documents, nationality)
 Right to food, shelter & health care
 Right to remain with parents

Development rights  Right to education

 Right to leisure & play

Protection rights  Right to protection from abuse, harmful influences &

exploitation

Participation rights  Right to freedom of expression

 The freedom to have friends
 The right to have access to information
 Respect for the views of the child
 Right to leisure & play (also listed under
development rights)

Does recognizing children’s rights undermine parental authority?

The UNCRC recognizes that parents/families have the primary responsibility to bring up children
and protect their rights. This includes giving them proper guidance. It is also recognizes that
parents and families have an important role in providing care, emotional support and protecting
the rights of children to learn their own culture, customs and religion.
However, the Convention upholds the rights of children in circumstances where parents do not
act responsibly, endanger or injure their children.

Child Protection Laws in Malaysia

Current laws in Malaysia which specifically address child protection are:

 Child Act 2001 (Act 611)

 Child (Amendment) Act 2016 – this contains amendments to the Child 2001
 Sexual Offences Against Children Act 2017 (Act 792)

8
These reservations include Article 2 on non-discrimination, Article 7 on name and nationality, Article 14 on
freedom of thought, conscience and religion, Article 28(1) on free and compulsory education at primary level,
Article 27 on torture and deprivation of liberty (https://www.unicef.org/malaysia/childrights_crc-reservations-
malaysia.html accessed 4 November 2017)

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Roles and responsibilities of doctors under the Child Act 2001

Under the Child Act 2001, a police officer or social welfare officer (designated as a “Child
Protector”) may take any child in need of care and protection9 into temporary custody. They may
order such a child to be brought to hospital for medical examination and treatment.
This law allows authorities to intervene on behalf of children whose safety and welfare are at
risk. This enables the protection of children whose parents or caregivers deny the problem, try
to conceal the abuse of children or do not cooperate in allowing a child at risk to be taken to a
safe place.
When a child in need of care and protection is brought to hospital, doctors should conduct a
medical examination and institute appropriate treatment. They should alert the Child Protector
and obtain authorization for any major urgent treatment or surgery in case the parents cannot
be contacted, refuse to give permission or are suspected to have inflicted the injuries. Doctors
may also be required to provide reports to the police and welfare officers which may be used in
court proceedings.
Under the Child Act 2001, doctors have a legal requirement to report any cases of child abuse
to the Child Protector. The penalty10 for failure to comply with the law includes a fine and
possible imprisonment.

Child maltreatment or Child Abuse

The abuse or maltreatment of children may occur in different forms:

 Physical abuse
 Sexual abuse
 Emotional abuse
 Neglect
Does this problem exist in Malaysia?
Every year, an increasing number of cases of child maltreatment are reported to the Department
of Social Welfare (Table 6). However, a much larger proportion of child maltreatment remains
hidden and unreported.
Prevalence data from population-based studies provide a better reflection of the true magnitude
of the problem. Anonymous surveys conducted among primary and secondary school children
in peninsular Malaysia reveal that a significant proportion have experienced child maltreatment
and other forms of victimization (Table 7). At least 20% have experienced multiple types of
maltreatment.

9
Examples include any child suspected to have been abused or neglected, children with suspicious injuries,
children found in suspicious or dangerous circumstances & any children who are living under the same roof as
these children
10
Fine of RM 5000, imprisonment of < 2 years or both

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Table 6: Cases of child abuse and neglect reported to the Department of Social Welfare,
Malaysia from 2000-2010 (Source: Department of Social Welfare, 2012)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Abandoned 71 70 121 98 26 68 53 63 58 62 115
Neglect 183 303 357 389 563 601 682 761 952 981 1250
Physical 362 287 354 410 445 431 495 586 863 895 846
Sexual 258 251 324 430 559 623 728 775 805 728 937
Emotional 24 56 32 32 63 77 50 45 90 98 71
Others 36 69 54 31 0 0 0 49 12 25 38
Total 934 1036 1242 1390 1656 1800 1999 2279 2780 2789 3257

Table 7: Prevalence studies in Malaysia on child victimization (Source: Choo, Dunne, Marret,
Fleming, Wong, 2011. Journal of Adolescent Health 49(6): 627-634, Ahmed, Choo, Marret, Cheah,
Othman, Chinna 2015. PLoS ONE 10(3): e0119449, Marret, Choo 2017. BMJ Open 7: e014959)

Choo, Dunne, Marret, Ahmed, Choo, Marret, Marret & Choo 2017
Fleming, Wong 2011 Cheah, Othman, Chinna n= 1487
n = 1870 2015
adolescents in Selangor n = 3509 adolescents in N.
children in Selangor Sembilan
Physical (%) 19.0 52.7 (parents) 50.2
29.2 (teachers)
Emotional (%) 20.4 20.5 26.3
Sexual (%) 22.2 not available 17.0
Neglect (%) 21.3 38.9 not available
Multiple (%) 22 43 not available
Online harassment (%) 52.2
Online unwanted sexual 17.2
solicitation (%)

Risk factors for child maltreatment11

A child lives within the ecosystem of the community as individual who depends on adults for
care and attention. Factors which increase a child’s vulnerability to maltreatment include: (a)
requirement for higher levels of care due to infancy or special needs (b) diminished capacity of
parents and families to provide for the child’s needs (c) lack of community resources and
infrastructure to support families with children.

parent/family
communityparent child
Society community

Figure 2. An ecological model of child maltreatment. Adapted from Garbarino 1977. Journal
of Marriage & the Family 39(4): 721-735

11
Child Maltreatment Fact sheet, WHO (www.who.int/mediacentre/factsheet/fs150/en accessed 4 Nov 2017)

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Child Factors
Some children may be at increased risk of maltreatment through no fault of their own

 Children under 4 years & adolescents

 Children who are not wanted or do not fulfil parental expectations
 Children with special needs, who cry persistently or look different
Parent or caregiver factors

 Difficulty bonding with a newborn child

 Not nurturing the child
 Previously abused in childhood
 Lacking awareness of child development, unrealistic expectations
 Misuse of alcohol & drugs
 Involvement in criminal activity
 Financial difficulty
Relationship factors

 Physical, developmental or mental problems in a family member

 Family conflict or violence
 Social isolation from the community, lack of a support network
 No support from the extended family
Community & societal factors

 Gender & social inequality

 Lack of proper housing & support services
 High unemployment & poverty
 Easy availability of drugs & alcohol
 Lack of policies and programmes to prevent child maltreatment & exploitation of children
 Society or culture that accepts or promotes the use of violence
 Policies that result in poor living standards, social inequalities & instability

Physical abuse
Children who present with physical injuries should be carefully examined, bearing in mind the
possibility that the injury may have been inflicted or could be the result of inadequate care and
supervision.
Table 8: Terms used in reference to childhood injury

Accidental injury Injury that was unintentional, resulting from an unexpected event
Injury that is unavoidable

Inflicted injury Injury caused by another person

Physical abuse Injury inflicted by a carer
Physical assault Injury inflicted by a non carer

Suspicious injury Injury which may be the result of physical abuse

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Patterns of bruising suspicious of abuse

Bruising is the commonest injury seen in physical abuse12. A systematic review of literature has
identified the following patterns of bruising in children to be suspicious of abuse13

 Bruises in children who are not mobile

 Bruising in babies
 Bruises away from bony prominences
 Bruises to face, back, abdomen, arms, buttocks, ears and hands
 Multiple bruises in clusters
 Bruises that carry the imprint of an implement

Accidental bruising Abusive bruising patterns

Figure 3: Distribution of bruising in children (source: Maguire 2010. Archives of Disease

in Childhood – Education & Practice 95: 170-177)

12
Kemp, Maguire, Nuttal, Collins, Dunstan 2015. Archives of Disease in Childhood 99(2):108-113
13
Maguire, Mann, Sibert, Kemp 2005. Archives of Disease in Childhood 90: 182-186

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Stage 3.2 Paediatrics Child at risk Mary J Marret

Figure 4: Soft tissue bruising patterns from various instruments used in inflicted injuries
(Source: Nelson Textbook of Pediatrics, 18th edition)

Oral injuries

Force feeding using utensils such as spoons can result in oral injuries. These may include
lacerations to the lips, and tearing of the frenulum of the tongue or lips.

Burns

Burns in children can be the result of accidents as well as inflicted injury.

The following patterns as suspicious of abusive burns

 Immersion burns (with a “glove” or “stocking” distribution)

 Contact burns or branding (caused by application of hot objects)
 Burns over the genitalia

Figure 5: Common burn patterns from heated objects which reflect instruments used in
inflicted injuries (Source: Nelson Textbook of Pediatrics, 18th edition)

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Skeletal injuries

Unlike accidental fractures which typically present with a history of loss of function/mobility
immediately following a fall or trauma, fractures due to physical abuse may be discovered
incidentally or when a skeletal survey is done.
The following patterns are suspicious of abuse

 The presence of multiple fractures of different ages (different stages of healing)

 Multiple rib fractures
 Metaphyseal-epiphyseal injuries: “bucket-handle” fractures caused by shaking, pulling
and twisting
 Long bone fractures in a child who is not yet mobile

Severe injuries and fatal abuse

Infants and young children under the age of 3 years are most vulnerable to severe injuries that
may result in fatality or long-term disability. Abusive head trauma and abdominal injuries are the
most common type of injuries seen in fatal child physical abuse.
Abusive Head Trauma (AHT)14
This includes injuries from blunt force trauma, shaking or a combination of forces. The term
“abusive head trauma” is recommended instead of the older term of “Shaken Baby Syndrome”
as shaking is not the only form of trauma that may be inflicted on an infant with head injuries15.
Children under the age of 2 years are most vulnerable. The relatively large head size of infants
combined with weak neck muscles make young infants more susceptible.
The usual patterns of injury seen in AHT are subdural haemorrhage, subarachnoid
haemorrhage and hypoxic-ischaemic injury to the brain. There may sometimes be other
associated injuries such as skull fractures, retinal haemorrhages, bruises and other skeletal
injuries.
Infants who suffer AHT usually present with non-specific symptoms:

 seizure (most common)

 irritability
 vomiting
 poor feeding
 lethargy
 drowsiness
 apnoea
 big head
 pallor & difficulty breathing

14
Committee on Child Abuse and Neglect 2001. Pediatrics 108 (1): 206-210
15
Christian, Block et al 2009. Pediatrics 123(5):

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Stage 3.2 Paediatrics Child at risk Mary J Marret

AHT should be considered as a possible diagnosis when a previously healthy baby

presents with the abrupt onset of seizures and altered consciousness.
Look for additional signs such as retinal haemorrhages, a bulging fontanelle, pallor
and bruising that may be pointers to the diagnosis.
An urgent CT scan of the brain is indicated in young infants who present with sudden
alteration of consciousness.
Remember that external bruising may not always be present in infants with AHT
Infants found to have subdural haemorrhage should undergo detailed ophthalmologic
examination for retinal haemorrhages and skeletal survey for fractures. This should be
accompanied by a careful evaluation of the family/social circumstances with
involvement of social welfare services.

Abdominal trauma
Blunt abdominal trauma (eg by punching, kicking, stepping) can result in rupture of solid organs,
bowel perforation and tearing of mesentery. Death may result from hypovolaemic shock due to
haemorrhage or peritonitis and sepsis. The injury pattern as well as associated delays in
seeking treatment contributes to high mortality.

Presentations of physical abuse

 Pathognomonic injury pattern

 Injuries of different ages
 Significant injury inconsistent with the history of trivial trauma
 Significant injury with no history of trauma
 History & injury consistent with abuse
 Multiple fractures in different stages of healing

Other non-specific indicators that the child requires closer examination

Parental reaction & behaviour are inappropriate
 Delay in seeking treatment
 Lack of concern about child’s injury

Child
 Unkempt, malnourished
 “frozen watchfulness”: child who is alert, aware of surroundings but displays no
response or expression
 Abnormal interaction with parent
 Frequent absence from school

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Sexual abuse
Child sexual abuse (csa) is the involvement of dependent, developmentally immature children
and adolescents in sexual activities that they do not fully comprehend, are unable to give their
informed consent to and that violate the social taboos of family roles16.
This includes a spectrum of sexual activities:

 exposure
 touching or fondling
 penetration
 online exploitation: sexual solicitation, grooming & transmission of images
 using children in transactional sex or prostitution
Most children are sexually abused by people known to them, in places where they usually
spend time such as home, school, and the homes of relatives or friends. Their abusers include
family members, teachers, neighbours, drivers & babysitters.
Child sexual abuse is not uncommon and affects children of both genders. A systematic review
across 24 countries reported a prevalence of 8 to 31% for girls and 3 to 17% for boys17. In
contrast, prevalence data from some Asian countries including Malaysia report a similar
prevalence across genders.
The disparity between reported cases of child sexual abuse and prevalence data (refer Table 6
& 7) indicates that it is a largely hidden problem within the community. Cultural inhibitions and
taboos that limit discussions regarding sexual matters make it difficult for affected children to
talk about their problems. In Malaysia, more girls compared to boys are brought for medical
attention in relation to concerns surrounding sexual abuse. Many parents are protective of their
daughters and monitor their movements closely. Few parents are aware that their sons are also
vulnerable to child sexual abuse. It appears that boys may be more inhibited about disclosing
their experiences.
Table 9: Child sexual abuse in Asia (sources: Choo et al 2011. J of Adolescent Health 49(6); Ji,
Finkelhor, Dunne 2013. Child Abuse & Neglect 37(9): 613-22; Zhu et al 2015. Asia Pacific J of Public
Health 27(6): 643-51; Kacker 2007. Study on Child Abuse :India 2007, Ministry of Women & Child
Development, India; Nguyen et al 2009. Bull World Health Organ 87:22–30)

Study Country Contact csa (%) Penetrative csa (%)

Boys Girls Boys Girls
Choo et al 2011 Malaysia 14.8 13.8 3.0 3,1
Ji et al 2013 (meta-analysis) China 8.0 9.5 0-2.9 0.4-2.9
Zhu et al 2015 Taiwan 2.3 2.4 0.4 0.4
Kacker et al 2007 India 23.06* 18.58*
Nguyen et al 2009 Vietnam 21.0* 18.5*
*merged with data for penetrative csa

16
Schecter & Roberge 1976. In Child Abuse and Neglect: The family and Community. Helfer, Kempe (Eds).
Cambridge: Ballinger
17
Barth, Bermetz, Helm, Trelle, Tonia 2013. International Journal of Public Health 58(3):469-83

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Stage 3.2 Paediatrics
Table 10: Presentations of child sexual abuse
Verbal
Physical
Behavioural
Many of these behaviours
are non-specific indicators
that a child or teenager is
emotionally distressed.
Child sexual abuse should be
considered as a possible
trigger for such distress.
Table 11: Dynamics of child sexual abuse
“No objection” does not
mean consent
Consent is not
“informed” or freely
given
The child may not reveal
the problem or tell
someone much later
Children may be selected
and groomed
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Child at risk Mary J Marret
 disclosure of sexual abuse by child
(most important indicator, but often ignored by adults)
 local genital symptoms of pain, irritation & bleeding
 enuresis (bed-wetting)
 sexually transmitted disease
 pregnancy
 recurrent UTI (less common)
 foreign body in vagina
 sexualized behaviour in young children
 depression
 self-harming, attempted suicide
 chronic runaway
 frequent psychosomatic complaints (eg headache,
abdominal pain) without an apparent medical cause
 drug or alcohol abuse
 avoidance of certain adults
 deteriorating school performance
A young child who experiences sexual abuse may not object
because
 he/she does not really understand what is happening
 he/she has been told to obey adults and figures of
authority
He/she may not realize that this is “sexual abuse”
He/she may have been silenced with threats or bribes
The child may have tried to tell someone but was not believed
or silenced
Any child can be a victim if perpetrators find an opportunity
Children who are timid, over-friendly or isolated may be easy
targets
Children may be lured through activities that interest them
Adults can manipulate circumstances to get a child alone in
their company
The abuse may begin with seemingly innocent touches and
progress over time to more invasive forms of abuse
Stage 3.2 Paediatrics Child at risk Mary J Marret

Normal examination findings in children who disclose sexual abuse

It is quite common to examine children who describe experiences of sexual abuse and not find
any signs of injury.
Normal examination findings are not “proof” that abuse did not occur.
Some types of abuse involving exposure & contact may not result in injuries.
Some signs may have disappeared or resolved if the child reveals the abuse much later.

Technology-facilitated sexual abuse18

The availability of digital and communication technologies has created new ways in which
sexual abuse of children can occur, both online and offline. This has unfortunately allowed
sexual exploitation to occur at remote locations (without necessarily being in direct physical
contact with the child) and across country borders.
Some of these include:

 Unwanted sexual solicitation online

 Exploitation through the creation & dissemination of sexualized images of children
known as child sexual exploitation material19
 Luring children & adolescents to offline meetings followed by sexual assault20

Neglect
Neglect occurs when a child’s basic needs are not met. It is the commonest form of child
maltreatment worldwide. Chronic neglect is detrimental to the health and well-being of children.
Some forms of neglect

 physical neglect (lack of provision of food, shelter, clothing, abandonment)

 inadequate supervision (this can sometimes lead to fatality such as drowning)
 educational neglect (not sending a child to school)
 medical neglect (not bringing a child for immunization, not seeking treatment for illness)
 emotional neglect (ignoring, not showing love & affection to a child)
A recent study found that supervisory neglect was the most common form of neglect reported by
primary school children in Selangor21.
Neglect is more difficult to recognize because of its non-specific presenting symptoms such as
growth failure, behavioural problems and developmental delay.

18
Henry & Powell 2016. Trauma, Violence & Abuse doi 10.1177/1524838016650189
19
The term “child sexual exploitation material” replaces what is commonly referred to as “child pornography”
20
Marret & Choo 2016. Journal of Interpersonal Violence doi: 10.1177/00886260515625502
21
Ahmed, Choo, Marret, Cheah, Othman, Chinna 2015. PLoS ONE 10(3): e0119449

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Emotional abuse
Emotional abuse is the most prevalent form of child abuse. It can occur by itself or in
combination with other forms of child maltreatment22.
Table 12: Some examples of emotional abuse23

Emotional unavailability & Mother who is depressed or has a substance

unresponsiveness abuse problem does not respond to a child’s
cries to be fed, changed, cuddled
Does not respond when the child smiles,
reaches out, wants to play

Hostility towards a child Rejection

Verbal abuse
Discriminatory treatment compared to other
siblings

Developmentally inappropriate Harsh punishment of a toddler for wetting his

interactions pants

Young child assuming adult responsibilities &

looking after parent (eg oldest child of an
alcoholic single mother)

Witnessing violent quarrels between parents

Disregarding child’s preferences & wishes Forcing a child to participate in an activity in

which he has no aptitude or interest

Child custody following parental divorce

Corrupting a child Grooming to be a pickpocket or sex worker

Isolating a child Not allowed to have friends

Reporting suspected child abuse

Local agencies & institutions that may be contacted / accessed if there are suspicions that a
child may have been abused

 The nearest welfare office (hotline Talian Nur 15999)

 The local police station
 The nearest hospital
The University of Malaya Medical Centre and some government hospitals have designated
SCAN teams (suspected child abuse and neglect teams) which handle referrals.

22
Claussen & Crittenden 1991. Child Abuse and Neglect. 15(1-2): 5-18
23
Glaser 2002. Child Abuse and Neglect 26 (6-7): 697-714

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