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CHILD ABUSE
the
Hidden Menace
Merle P. Tan, MD, FPPS,
MHPEd

Road Map
Dierent forms of child abuse
New forms of child abuse
2015 NaIonal baseline study on violence
against children

What Is Child
Maltreatment?

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DeniIon of Child Abuse

(according to R.A. 7610)
ABUSE OR MALTREATMENT
whether habitual or not
regardless of intenIon
regardless of cooperaIon by child

Forms of Child Abuse

PHYSICAL ABUSE

SEXUAL ABUSE

PSYCHOLOGICAL ABUSE

NEGLECT

Forms of Child Abuse

PHYSICAL ABUSE

SEXUAL ABUSE

PSYCHOLOGICAL ABUSE

NEGLECT

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PHYSICAL ABUSE
DeniIon (WHO, 2000)
results from an act of commission
which produces actual physical
harm (or holds potenIal for
harm) which is reasonably within
the control of a parent or person
in a posiIon of responsibility,
power or trust. May be single or
repeated incident.

What is physical
abuse?
According to Philippine Law:

Physical injury that includes

but is not limited to lacerations,
fractured bones, burns, internal
injury or serious bodily harm
suffered by the child (R.A.
7610)

Accident or
Abuse?
Accident: an event occurring
randomly, unexpectedly, or by
chance

Intentional: an event
occurring voluntarily,
assuming conscious or
unconscious control, reflecting
underlying conflict or impulse

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Detecting Physical
Abuse

Presenti
History ng Biomecha
given injuries nics

Growth &
Developme
nt
Non-
Accidental ? or accidental
(Inflicted) ?

BRUISING PATTERNS
ACCIDENTAL ABUSIVE

S Maguire. Arch Dis Child Educ Pract

Ed 2010;95:170-177

Does the bruise show a paXern?

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AGING OF BRUISES

Color changes occur as bruises age.

Colors vary widely with age of bruises.
Variability in color dependent upon:
Depth of bruise
LocaIon
Vascularity of underlying Issue
Age and complexion of child
Source: Maguire (2010)

RED FLAGS

u There is a discrepancy between history given and

injuries sustained

u The history of how injury was sustained is

incompatible with childs development

u The story changes or varies

u There was an unreasonable delay in seeking care

u The parent or caretaker denies that there is an

injury

u The parent or caretaker seems hostile towards the

child

CHILDREN MORE
LIKELY TO SUSTAIN
PHYSICAL ABUSE
Youngest children (<3 years)
most likely to be physically
abused
With disability, behavioural or
learning difficulty
Consider socio-economic
status
S Maguire. Arch Dis Child Educ Pract
Ed 2010;95:170-177

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Forms of Child Abuse

PHYSICAL ABUSE

SEXUAL ABUSE

PSYCHOLOGICAL ABUSE

NEGLECT

SEXUAL ABUSE
DeniGon (WHO, 2000)
involves acts in which an
adult uses a child for
sexual graIcaIon. These
acts include inappropriate
exposure to adult
sexuality, direct sexual
contact, or making a child
available to others either
directly or indirectly for
immoral and illegal acts,
such as through
pornography.

Sexual Abuse
Signs
1. Says that he/she has been
abused most common
presentaIon!

2. Sexually TransmiXed
InfecIons

3. Pregnancy

4. PsychosomaIc Illness
frequent headache, stomach
ache with no cause

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Sexual Abuse
Physical Signs
1. Diculty Walking
2. Torn, Stained or Bloody
Underclothing
3. AbnormaliIes in Genital/
Anal Areas
4. itching, pain, swelling
and soreness of the
genitalia
5. stomachache

Sexual Abuse
Physical Signs
6. injuries such as
laceraIons, bruises,
bleeding
7. frequent urinary or yeast
infecIons (U.T.I.)
8. pain on urinaIon
9. vaginal /penile discharge
10. poor sphincter control or
they pass urine or stools
without them knowing

Limits of InterpretaIon of Physical Findings

in Child Sexual Abuse
DistribuIon of abnormal ndings in sexually abused girls:

5%

abnormal
normal

95% Even if sexually abused children do

disclose that they have been
abused, it is possible for them to
have normal physical examinaIon
ndings 95% of the Ime.

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ELASTICITY OF HYMEN
AND ANAL SPHINCTER
Normal Genital Anatomy
Hymen Tissue is ELASTIC
vIt can stretch to allow penetration, even
in the pre-pubertal child.
vfull penetrationparticularly in an
older child, may cause no visible
trauma

(Bays & Chadwick, 1993; Huffman, Dewhurst &

Capraro, 1981; Mahran & Saleh, 1964; Pokorny, 1987;
Teixeira, 1981)

Genital Anatomy of Pregnant

Adolescents

Normal does not mean Nothing

Happened
Research by Kellog et al Pediatrics (2004)
113: e67-e69
Only 2 of the 36 pregnant teens had
definitive findings of penetration.
www.pediatrics.org

Fig 1. Normal examinaGon in a 13-year-old adolescent pregnant with her second child

Kellogg, N. D. et al. Pediatrics 2004;113:e67-e69

Copyright 2004 American Academy of Pediatrics

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New Research
Reports of Repetitive Penile-Genital
Penetration often Have No Definitive
Evidence of Penetration
Jim Anderst, Nancy Kellog & Inkyung Jung
Pediatrics 2009;124;e403-e409

Terms that are not used

anymore and procedures that
should not be done:

Intact hymen
Virgin state
Can accommodate 2 fingers, etc.
Nipples when pressed had no milk.

CYBERCRIME:
CYBERSEX,
CYBERPORNOGRAPHY,
CYBERBULLYING ,
CYBERSTALKING &
SEXTING

New Forms of Abuse

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Signs to
Watch Out For
1. Prevents others from
viewing the computer
screen

2. Has disks / thumbdrive that

he or she will not allow
others to see

3. Uses les that ends

with .gif or .jpg

4. Exhibits furIve or secret

behavior when using the
internet

Children who are

being abused
immediately tell their
parents.

True FALSE

The truth is:

EsImates suggest that only 3% of all cases of
CSA* and only 12% of rape* are ever reported
to the police.

**Finkelhor et al (1994). Children as Victims of Violence. Pediatrics,

94(4, :413-420) and Hanson et al (1999). Factors related to the reporting
of childhood rape. CAN, 23, 559-69

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The truth is:

Among Filipino sexually abused children aged 4 17 years who
underwent medico-legal evaluation, initial disclosures were more
commonly elicited (47.1%) than voluntary (34.9%).
Disclosures within 72 hours of the first/only incident were less
frequent (37.2%).
The odds of delayed disclosure was increased 4 times with an
intrafamilial perpetrator (p=0.001, CI 1.69-9.00).
Delayed disclosures were also 3 times more likely with an
intrafamilial confidant (p=0.046, CI 2.46-17.72), and 6.6 times more
likely for children who were threatened verbally (p<0.001, CI
1.02-8.93

Hernandez SS, Madrid BJ, Castillo MS, 2012

Children who are

being sexually abused
will have physical
findings to show
evidence of abuse.
True FALSE

The truth is:

Even with a history of severe abuse such as
vaginal or anal penetraIon, the rate of
abnormal medical ndings are only 5.5%.*

*Heger, et al (2002). Children referred For possible sexual abuse: medical

Findings in 2384 children. Child Abuse & Neglect, 26, 645-59.

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The truth is:

In a case review of 36 pregnant teens who were
sexually abused, only 2 of the 36 (5.5%) showed
deniIve evidence of penetraIon.*

*Kellog, et al. (2004). Genital Anatomyin pregnant adolescents:

Normaldoesnot mean nothing happened..Pediatrics, 113
(1 pt 1), 67-9.

The truth is:

In the Philippines, a review of 153 cases of
sexually abused pregnant adolescents seen in a
child protecIon unit of a terIary hospital from
2005-2010 showed that hymen was normal in
half (52.3%) of cases of pregnant adolescents.

Makalinaw, SR, 2011

However, Child Sexual Abuse is harmful:

q CSA is associated with posttraumatic
stress disorder, delinquency, academic
difficulties, conduct disorders, substance
abuse, depression, anxiety, suicidal
ideation, personality disorders.
Physical health problems such as HIV,
pain syndromes, gynecologic conditions,
neurobiological disorders, and
gastrointestinal problems.

Berkowitz, 1998; Johnson, 2004; Putnam;

Ullman & Brecklin, 2003, Dallam et al, 2001

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Forms of Child Abuse

PHYSICAL ABUSE

SEXUAL ABUSE

PSYCHOLOGICAL ABUSE

NEGLECT

PYSCHOLOGICA
L ABUSE

DeniGon (WHO, 2000)

Involves intenIonal acts
which lead to a failure to
provide a
developmentally
appropriate/ supporIve
environment including
the availability of a
primary aXachment
gure, or acts which
themselves have an
adverse eect on the
emoIonal health and
development of a child.
hXp://www.novabucks.org/images/
ChildAbuseImageWithHand1.jpg

Categories of
Psychological
Abuse
Spurning

Beli`ling, denigraGng or
rejecGng

Ridiculing

Singling out

HumiliaGng in public
hXp://www.novabucks.org/images/
ChildAbuseImageWithHand1.jpg

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Categories of
Psychological
Abuse
Terrorizing
IsolaGng
ExploiGng/
corrupGng
Denying
emoGonal
responsiveness
hXp://www.novabucks.org/images/
ChildAbuseImageWithHand1.jpg

Forms of Child Abuse

PHYSICAL ABUSE

SEXUAL ABUSE

PSYCHOLOGICAL ABUSE

NEGLECT

WILL YOU NOW BE ABLE TO

RECOGNIZE NEGLECT?

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Is this child neglect?

The answer is YES

because even though they
live in an urban poor area,
the other children and
people in this picture have
clothes on. There is no
excuse for allowing this child
to go around naked, when
his parents have clothes on
and capable of providing
clothes for themselves and
to their other children.
Parents who allow their
children to walk around
naked, and putting them at
risk for sexual abuse, can
be held liable for child
neglect.

Are these child neglect?

The correct answer is
YES.

Aside from being illegal,

begging on the streets can
put a child at risk of being hit
by vehicles or even being
sexually abused by
strangers. Children should
not be allowed to beg in
behalf of their parents. This
lack of supervision and
blatant disregard for the
safety of child can still be
considered as neglect even
in the background of
poverty.

NeglectActs of
Omission
Basic
q Failure to provide
Needs for reasons other
than poverty
Physical
EmoIonal
Health physical or mental
EducaIonal

q Failure to supervise
Inadequate supervision
Exposure to violent
environments

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NATIONAL BASELINE STUDY ON VIOLENCE AGAINST CHILDREN: PHILIPPINES 2015

NaIonal Baseline Study on Violence Against

Children (CWC Philippines, 2015)

VAC STUDY : Physical

violence
Prevalence of physical
violence during childhood
occurred mostly at home
(60.4%)
3 out of 5 respondents
experienced Physical
violence
Mother, father , brothers
and sister ( in this order)
are menIoned as
perpetrators.

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VAC STUDY : Sexual

Violence
17.1 % of children aged
13 to <18 experienced
sexual violence whole
growing up
More males claimed to
have sexual violence

The truth is:

There may be more boys who are sexually abused than girls!

National Baseline Study on Violence Against Children, Philippines, 2015

Reason why boys do not report sexual abuse:

They are unaware that it They blame themselves;

was sexual abuse accept responsibility for
especially if the abuser is what happened
female
Peer pressure
Stigmatization
Lack of societal
Homophobia encouragement to report
e.g. rape laws define rape
Beliefs about masculinity
as being committed only
on a female.

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:
1 in 2 Filipino children
experiences online abuse
VAC Study 2015

::
1 in every 5 Filipino children
who experience online abuse
is exposed to
sexually explicit content
VAC Study 2015

:
6 out of Ten
Filipino Children experience bullying

VAC Study 2015

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How is child sexual abuse discovered?

1. Disclosure of the Child

2. Physical Signs and Symptoms

3. Behavioral Changes

4. Other means of discovery

What are the

EFFECTS of
ABUSE?

Toxic Stress Changes the Brain

Mead H, Beauchaine T, Shannon K (2010)

Development Psychopathology (22) 1-22

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Toxic Stress Damages Brain Architecture

Healthy Abused
Brain Brain

The Eects of Neglect on the Architecture of

the Brain

Child TraumaGc Stress is Serious

Interferes with childrens ability

to concentrate and learn
Can delay development of their
brains/bodies
Leads to depression, substance
abuse, health problems, school
failure, delinquency, and future
employment problems

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Child TraumaGc Stress is

Serious
Changes how children view the
world and their own futures, their
behavior, interests, and
relaIonships with family and
friends

Takes a toll on families and

communiIes

Child TraumaGc Stress is

Serious
EducaIonal impact
Learning problems
Lower Grades
More absences
More negaIve comments in
permanent record

Child TraumaGc Stress and

Juvenile JusGce
Criminal/juvenile jusIce impact
Increases risk of arrest as
juveniles/adults
Increases risk of commisng
violent crime
Increases risk of perpetraIon of
domesIc violence
Increased risk of problem drug
use as an adult

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Consequences of Child
Maltreatment

Time does not heal all

wounds!

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PARENTING

SMX MALL OF ASIA

NOVEMBER 31 TO DECEMBER 1 , 2017

WEBSITE: www.childprotecIonnetwork.org
manilaconference@yahoo.com
Tel no: 4043954; fax 4043955

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