Definition

Child physical abuse, also known as non-accidental injury or battering, is when any child receives any physical injury as a result of acts (or omissions) on the part of his/her parents, guardians or others placed in a position of trust and responsibility for the child.

Under Malaysian law, as stated in the Child Act 2001, a child is deemed to be physically injured ‘if there is substantial and observable injury to any part of the child’s body as a result of non-accidental application of force or an agent to the child’s body that is evidenced amongst other things, a laceration, a contusion, an abrasion, a scar, a fracture or other bone injury, a dislocation, a sprain, haemorrhaging, the rupture of a viscus, a burn, a scald, the loss or alteration of consciousness or physiological functioning or the loss of hair and teeth’ (Child Act 2001 Section 17(2)(a) )

Within these definitions, hitting a child does not make it physical abuse unless it results in injury. However, using physical means to discipline children without clear and consistent guidelines of behaviour for the child may result in increased hyperactivity or aggressiveness. As such, several countries in Europe have passed laws against the hitting of children by parents. In Malaysia , corporal punishment in schools is still permitted.

Corporal punishment

Many parents feel that children should be beaten or receive pain for the purposes of discipline. ‘Spare the rod and spoil the child’ is the often quoted phrase by parents and other caregivers. Research continues to show that hitting children is widely practiced by parents of all social classes, involving children of all ages (Newson & Newson 1986 , SCAN Data). Most children receive mild punishment in the course of physical discipline which includes smacking or pulling of ears. However, most smacking or hitting were due to the parent or guardian being irritated or angry rather than in control. Although there is a difference between corporal punishment and physical abuse, many parents who end up hitting their children severely, start up by physically disciplining them. The injuries resulted when things got out of control.

Epidemiology

In UK, 1-2% of children experience physical abuse at some point in their childhood. More than 3 million adults (1 in 12 adults) said that they had frequently or occasionally suffered bruising or marking following physical punishment as a child and 9% of these felt that they had suffered long-term effects.

The number of cases seen by agencies depends on the number of reports seen. Reporting of physical abuse depends on a person’s perception of whether its considered disciplining or abuse, awareness of potential danger to child or due to lack of apathy.

Recognition of Physical Abuse

Direct report

A report of child abuse may be made by a child, a parent or a concerned third party

Presentation of an injury

Following an injury, the parents will usually bring the child for treatment at a hospital, health clinic or general practitioner.

Incidental discovery of injury

The injury (injuries) such as bruises, may be found by the school teachers, childminders at nurseries and it is not unusual for parents to deny knowledge of the injury and for there to be an unsatisfactory or vague explanation. Teachers are encouraged and nursery workers are mandated to report any suspicion of abuse to Jabatan Kebajikan Masyarakat. When a child is examined for injuries incurred, it is not always obvious that it is physical abuse, especially in a younger child who is not verbal yet or the child is too scared to say much.

Consider the possibility of physical abuse when the child:

• Has unexplained burns, bites, bruises, broken bones, or black eyes
• Has fading bruises or other marks noticeable especially after an absence from school
• Seems frightened of the parents and protests or cries when it is time to go home
• Shrinks at the approach of adults
• Reports injury by a parent or another adult caregiver

Consider the possibility of physical abuse when the parent or other adult caregiver :

• Offers conflicting, unconvincing, or no explanation for the child’s injury.
• Describes the child as ‘bad’, ‘difficult’ or in some other very negative way.
• Uses harsh physical discipline with the child.
• Has a history of drug abuse, alcoholism, domestic violence
• Many visits to hospital or health clinics
• Lack of response to child’s emotional needs

Injuries in Physical Abuse

Bruises

Bruises are often seen in physically abused children. The pattern typical of abuse is bruising in different parts of the child’s body, usually of different ages as well as size and shape. Falls down stairs do not cause such bruising. Physical abuse should be considered with bruising in young children who are not yet mobile.

Bruises on the sides of face, ears, outer thighs, buttocks and lower back are more often related to physical abuse. In a child with frequent bruising after insignificant knocks, the doctor will usually check for a bleeding problem if the child gives no history of physical abuse. Sometimes the bruising follows the shape of the instrument used, such as belts, cane in which case non-accidental injury is evidently the cause.

Broken bones (fractures)

Fractures from abuse usually result from the more extreme form of violence and are serious injuries. Fractures may occur in any bone, there may be only one or there may be many fractures of different ages. There may be no bruising over the fracture and the fracture may be only picked up on an X-ray if it is an old fracture.

In abused children, the majority of fractures are in children below the age of three . In non-abused children, a study found that 85% of fractures occur after the age of 5.

Common sites of fractures in physical abuse are ribs, collar bone, long bones in children below two years of age.

Accidental fractures of the head (skull) in young children usually follow falls but it is an uncommon occurrence and the child is usually not ill, as compared to the skull fractures occurring in abuse cases where there is associated bleeding in the brain, the child is usually very ill and may die. This is because of the greater force involved in child abuse as compared to accidental cases.

Burn and scalds

Burns and scald injuries to children are common and the majority involve various degrees of lack of supervision, including cases of neglect. (Link to accidents – scald/burn). If an adult has deliberately inflicted a burn on a child, there is usually premeditation as in a iron-shaped burn mark. Children who have been abused in this way are often terrified and may have difficulty telling what has happened to them.

Burns should be attended to quickly to avoid infection and scarring. The child with inflicted burns also needs protection and the family may need help. Types of burns seen include contact burns (as with clothes iron), cigarette burns, splash or immersion burns (as in forcing the child to sit in hot water) and flame burns (as from cigarette lighter).

‘Shaken Baby Syndrome’

Abdominal injury

Some children can be punched hard in the abdomen ( ‘stomach’ area). This can lead to injury of the vital organs such as liver, pacreas and intestines. There is usually no bruising on the abdomen and the child may have vomiting with a distended abdomen, looking generally unwell. The child should be brought to hospital as soon as possible as early treatment can save his/her life.

Outcome

Possible consequences of physical abuse and emotional abuse

• Hyperactive, aggressive, easily provoked to violent behaviour
• Lacking of empathy
• Emotional vulnerability expressed as bullying or delinquency
• Problems seen as being fault of others
• Interpersonal, academic and vocational difficulties

Management Committee and recovery

The aims of management are ;

• to secure a safe environment for the child
• to provide for his/her future needs
• prevent further abuse