Table of Contents

HK J Paediatr (New Series)
Vol 5. No. 1, 2000

HK J Paediatr (New Series) 2000;5:61-64

Occasional Survey

Child Abuse and Neglect in Hong Kong

PLS Ip


Abstract

Heightened awareness of child abuse in Hong Kong dated back to a particularly serious case in 1978. Since then a multidisciplinary approach to the problem is in place. Physical abuse is the most frequent form of abuse detected but sexual abuse, rarely reported prior to 1990, had risen to 30% of all cases in 1998. Child neglect is not often established although deaths while children are left unattended continue to occur. Psychological abuse has been difficult to identify because of its lack of concrete signs. Looking forward, Hong Kong should seriously consider mandatory reporting by professionals. Training is required in the recognition of uncommon forms of abuse. Conducting child death reviews is a means to identify preventable causes of unnatural deaths. Focus should not only be on remedial measures but also on prevention. To truly protect children in Hong Kong, we need a Child Policy, a comprehensive Child Ordinance and an independent Child Commission to ensure the policy's implementation.

Keyword : Child abuse; Neglect


Abstract in Chinese

Introduction

Oppression of the weak and vulnerable existed probably as long as mankind. Henry Kempe1 brought child abuse to the forefront in the west in 1962 as "Battered Child Syndrome". In Hong Kong child abuse was thought to be an isolated phenomenon till the Lai Shuk Mee incident in 1978.2 The public outcry lead to a voluntary agency, Against Child Abuse being formed the following year, 1979, appropriately, the International Year of the Child.

Since then, much work has been done in the government and non-government sectors. Procedural guidelines for professionals handling child abuse cases, last revised in 1998,3 have been worked out, including referral, investigations, and multidisciplinary case conferences. Different services, both preventive and therapeutic, are provided by government and non-government organizations. Some legislative changes in relation to child abuse have also been made over the years. Yet much awaits to be done as we learn more about the problem in Hong Kong and how effective or otherwise are our current measures in protecting children.

The awareness of child abuse itself and the different forms of abuse have increased progressively among professionals and the general public. Table 1 shows the recent trend in reports of abuse. The incidence in Hong Kong of 0.6/1000 children 0-17 years4 is low by western standard. United States in 1994 reported an incidence of 9 substantiated or indicated reports per 1000 children.5 Without mandatory reporting and with our different thresholds for diagnosing child abuse, comparisons are difficult to make. In any case, each society, because of its cultural, social, economic, geographic and political background, has its own characteristic problems. Some of those facing Hong Kong are discussed below.

Physical Abuse and Corporal Punishment

Despite an increase in the proportion of reports of sexual abuse over the past few years, the absolute number of children reported as physically abused is still on the rise (Table 1). Within hospital practice, physical abuse is by far the most common cause for child abuse admissions. In a recent analysis,6 physical abuse alone or in combination with other forms of abuse accounted for 87% of suspected cases admitted to public hospitals.

Table 1 Active Child Abuse Cases in Hong Kong, Child Protection Registry, Social Welfare Department
Type of Abuse 1994
No. (%)
1995
No. (%)
1996
No. (%)
1997
No. (%)
1998
No. (%)
Physical 293 (65) 365 (64) 361 (52) 424 (51) 440 (52)
Neglect 26 (6) 25 (4) 44 (6) 51 (6) 51 (6)
Sexual 77 (17) 116 (20) 191 (28) 242 (29) 260 (30)
Psychological 15 (3) 24 (4) 31 (5) 30 (4) 24 (3)
Multiple 39 (9) 46 (8) 63 (9) 86 (10) 80 (9)
Total 450 (100) 576 (100) 690 (100) 833 (100) 855 (100)

Although corporal punishment in the penal system was abolished in 1990 and in schools in 1992, it is still widely used at home. Even back in 1983, Lieh-Mak, et al7 studying cases from Against Child Abuse and a teaching hospital, found 81% of perpetrators spanked their children more than once a week and 51% considered spanking the most effective mode of punishment while none of the controls thought so. Significantly more perpetrators received physical punishment during their childhood as well. Among 100 university students in Hong Kong surveyed by Samuda8 in 1988, 95% said corporal punishment was used in their homes. Of concern was that one third of the students approved of spanking children less than 3 years old. In a public opinion survey in 1996, Lau, et al9 reported 79% of adults believed parents had the right to use corporal punishment on their children and 45% that it was an effective means of discipline. Parents do not realize the negative effect of corporal punishment on their children. A study done by Mok, et al10 in 1999 amongst primary 5 students showed that the 40% of children who experienced corporal punishment in the previous month often thought they deserved to be punished. This seemingly justified the act, but the same children suffered significantly more low self esteem, were more anxious and depressed, resorted to more self-inflicted harm and had more somatic symptoms. Nowadays, physical abuse can be established in case conferences with less external bruises than a decade ago, but it is still not uncommon to see professionals argue physical abuse as "inappropriate, harsh and excessive physical punishment" (Ip11). Sweden had already prohibited corporal punishment not only in institutions but at home in 1979. Since then Finland and a number of other countries have followed Sweden's lead.12 Hong Kong should take up the challenge of demonstrating to our children that conflict resolution without violence is both preferable and feasible.

Neglect and Unattended Children

Neglect does not feature very high among our cases of child abuse, being constantly around 6% (Table 1). This reflects more what is viewed as neglect rather than the actual situation. An example is the problem of children left unattended. Earlier surveys13,14 in the late 1980's showed between 7% and 42% of parents left their young children at home to go to work, to shopping or for other leisure activities at a time when some 30 children a year were dying while unattended. A government consultation paper to the public in 199113 concluded that more parental education and support rather than legislation was the answer. Parents' right to work or freedom to have leisure activities overshadowed the child's right to protection and survival. The punitive aspects of legislation was emphasized while legislation could have been seen as a means of stating clearly the minimum standard of care expected of caretakers. Another general household survey in 199715 showed the practice had changed little with children as young as 5 years or below being left unattended. Although the number of children 9 years or below, who died while unattended came down to 5 in 1997, the number had increased again to 14 in 1998.16 How many children are injured is unknown. Hong Kong needs a multi-pronged approach to this problem. No doubt public education and support are important. The government should ensure underused occasional child care centres are user friendly, practical assistance is given to mutual help groups and incentives offered for work-based child care centres. Land developers could also be required to include child care facilities in their housing developments, but legislation is still an important part of the package so parents know the consequences of their failure to protect their children. It is too late to say parents are already penalized after children are injured or lost their lives.

Sexual Abuse

Sexual abuse was rarely reported prior to 1990 accounting for less that 2% of around 450 active cases at any one time. Since then, the numbers have increased markedly. In 1998 162 or 40% of new cases involved sexual abuse.4 Ninety-eight percent were girls with 47% of the perpetrators being known to the victim, 41% unrelated and 12% unknown.

Much resources have been devoted to the investigation of child sexual abuse in response to legislative changes in 1995. Since then, videotaped interviews could be used as evidence in court and children's evidence could be accepted without corroboration. They could also be cross-examined in court using video-link monitors. Unfortunately, disclosure is often a process rather than a point event. The difficulties have been managing the very young who is unable to give a history, like a toddler with sexually transmitted disease, or an older child who elects not to disclose. Some children and families felt devastated when not enough evidence for prosecution was treated as child sexual abuse not having occurred. Others had to wait inordinately long for therapy when therapy is critical at the time of disclosure, not weeks or months later. Whether the cases were established or otherwise, children and families may be transferred from social worker to social worker and clinical psychologist to clinical psychologist as each confines his/her role to investigation, assessment or treatment. The frustration families experience is understandable.

Psychological Abuse and Neglect

The identification of psychological abuse and neglect has always been difficult because of the lack of concrete signs like bruises. Hence the incidence remains low (Table 1). Yet even before demonstrable harm, persistently placing children in an environment at risk of harm can also be defined as abuse.3 In fact, for the frequently reported physical abuse, external bruises often disappear rapidly but the psychological trauma remains.10 The psychological status of our children is demonstrated by the number of deaths from suicides amongst 10-19 year olds which have been around 20 a year for the last 5 years.16 In a study of adolescent health from a regional hospital,17 it was found that 20% of all discharges were from "complications of pregnancy, childbirth, and the puerperium", "symptoms, signs and ill-defined conditions" and "suicide and self-inflicted injuries". Hong Kong prides herself for having one of the lowest infant mortality in the world.18 We need to pay attention to our morbidities.

Looking Forward

Despite a rising number of reports of child abuse, under-reporting is probably still prevalent as other countries that started mandatory reporting have found. Hong Kong should seriously consider whether mandatory reporting should be introduced for professionals. Child Death Review is an useful tool to learn about the most serious outcome of abuse so that we can target our preventive efforts. Currently the Child Protection Registry4 of the Social Welfare Department does not even record deaths from abuse. Uncommon forms of child abuse like shaken baby syndrome and Munchausen by Proxy are surfacing in Hong Kong and attention has recently been drawn towards child pornography and paedophiles with the proposed Prevention of Child Pornography Bill and Crimes (Amendment) Bill 1999. Training in the recognition of these problems is required for all disciplines.

That a complex problem like child abuse requires multidisciplinary cooperation in its management is well recognized. Hong Kong has started a good basis for such an approach.3 In order to make this a success, we need to identify people with the aptitude and interest to manage psycho-social problems involving children and families; people who could work with different disciplines. Such skills and working relationships are not easy to develop. The requirement of rotation every couple of years in some disciplines in the name of broadening the staff's experience and avoiding burnout wastes staff training and expertise. Child abuse work is no doubt stressful, but there are ways to tackle this like staff recognition, staff development and flexible working conditions.

Since the formation of specialized units in some disciplines, like the Child Abuse Investigation Units of the police, the contrast between working with officers in or outside the units is great. Outside these special units, violence within the family has not been accorded the same priority as violence outside the family. The identification of Medical Coordinators on Child Abuse among Paediatric units of public hospitals has also been a step forward, but if their labour intensive work is not recognized, few people would want to continue in the post. We have to accept that to manage child abuse properly, we need an investment of time and energy.

The system of multidisciplinary case conference has been in place for many years. It is very helpful when used properly. If it is used to fulfill procedural requirement, or to shift responsibility, then it is a waste of valuable professional time. Family participation in conferences started around 1996. It has a very empowering effect on the families. We need to put in much more effort before parents and child could effectively participate in the whole process of the conference rather than the discussion or explanation of the welfare plan. Voting in case conferences needs review. The practice originated when a decision has to be made as to what degree of physical punishment is considered abuse. To use voting on medical diagnoses like shaken baby syndrome or sexual abuse of a young child with sexually transmitted disease is unwarranted.

We are still a long way from providing adequate treatment for children who suffered abuse and their family members, not to mention the offenders. Encouraging reporting, especially of sexual abuse, without the accompanying timely therapy and support to deal with the emotional turmoil and threat to the child and non-offending family members, is doing these families a disservice.

Outcome studies of decisions made at case conferences are very deficient. The Privacy Ordinance being used as a reason for not informing original conference participants of the progress of the cases needs to be overcomed. There is no apparent audit mechanism to see whether recommendations of conferences are being carried out and to what extent; whether children and families received services recommended and when. Without these important information, it is not easy to improve on our decision-making skills.

Resources for prevention always pale in comparison with that for crisis intervention. Still there has been various efforts made over the years. Government advertisements of public interest periodically appear on television but they have to compete with many other government publicity priorities. Family life education programmes by government and non-government agencies cover parent child relationships but many other areas as well. District Committees on Child Abuse started in 1993 have done good work in the local level to increase awareness and improve inter-agency working relationships. These committees were dissolved in 1999 and now becomes subcommittees of District Coordinating Committees on Family and Child Welfare Service. Whether this means a lowering of the attention for child abuse or an improved focus on the family and the child awaits to be seen.

Against Child Abuse has piloted many preventive programmes targeted at children, parents - both mothers and fathers, professionals and the community at large. All types of abuse are covered including "Beyond the Rod" and self-protection from sexual abuse. Some particularly successful programmes recently have been "Let the Dolphin Lead" which empowers children to participate in affairs affecting themselves and the society and the "Healthy Start Home Visiting Programme" for families with expectant mothers.19 Community support is required to see these programmes move from pilot projects to territory-wide services.

Legislations in Hong Kong related to children are many. It is gratifying to see further amendments proposed to close loopholes like requiring children to state specific details of each sexual abuse incident, but it is about time we work towards a comprehensive set of Child Ordinance to reflect the needs of child protection in modern times and the spirit of the Convention on the Rights of the Child.

To truly protect children, we need not piecemeal effort but a Child Policy to guide all matters related to children and an independent Child Commission to see that the policy is put to practice. We have made significant progress over the last two decades but this should only drive us on to advance further in the area of child protection.


References

1. Kempe CH, Silverman FN, Droegemueller W, et al. The battered child syndrome JAMA 1962;181:105-12.

2. Thomas J. Against Child Abuse - the first ten years. In 10th Anniversary Commemorative Issue 1979-1989. Hong Kong: Against Child Abuse, 1989:8-9.

3. Social Welfare Department, Hong Kong. Procedures for handling child abuse cases. 1998. Printing Department, Hong Kong.

4. Child Protection Registry. Statistical Report 1998. Hong Kong: Social Welfare Department, 1998.

5. US Department of Health and Human Services, National Center on Child Abuse and Neglect, Child Maltreatment 1994: Reports from the States to the National Center on Child Abuse and Neglect. Washington, DC: US Government Printing Office, 1996.

6. Medical Co-ordinators on Child Abuse, Hospital Authority, Hong Kong. Suspected child abuse cases in public hospitals: an interim analysis of 494 cases. In: Proceedings of the ISPCAN 5th Asian Conference on Child Protection, Hong Kong, November 25-27, 1999.

7. Lieh-Mak F, Chung SY, Liu YW. Characteristics of child battering in Hong Kong: a controlled study. Br J Psychiatry 1983;142:89-94.

8. Samuda GM. Child discipline and abuse in Hong Kong. Child Abuse Negl 1988;12:283-7.

9. Lau JTF, Cheung JCK, Chan MW, et al. Survey of public opinion on child abuse. Report of the Public Education Sub-Committee on Child Abuse 1996. Working Group on Child Abuse, Social Welfare Department, Hong Kong

10. Mok JWS, Ip PLS, Cheung SL, et al. An empirical study of children's perception of corporal punishment and their psychological functioning in a Chinese community. In Proceedings of the ISPCAN 5th Asian Conference on Child Protection, November 25-27, 1999.

11. Ip P. Multidisciplinary decision-making. In: O'Brian C, Cheng CYL, Rhind N, editors. Responding to child abuse: Procedures and practice for child protection in Hong Kong: Hong Kong University Press, 1997:47-62.

12. Communication from EPOCH (End Physical Punishment of Children), 1996.

13. Social Welfare Department, Hong Kong. Measures to prevent children from being left unattended at home (consultation paper). Hong Kong: Social Welfare Department, 1991.

14. Against Child Abuse. Survey report in child-rearing in Tuen Mun. Hong Kong: Against Child Abuse, 1987.

15. Census and Statistics Department, Hong Kong SAR. Social data collected via the General Household Survey Special Topics Report No. 17 - Leaving children aged 12 and below unattended at home. Hong Kong: Printing Department, 1997:1-22.

16. Hong Kong Coroner's Reports. 1989-1998. Hong Kong Government Printer.

17. Cheung PCH, Ip PLS. Vital information on adolescent health from a hospital perspective. HK J Paediatr (new series) 1999;4:32-7.

18. Chan M. Annual Department Report 1996-1997. Hong Kong: Department of Health, 1997.

19. Against Child Abuse. Annual Report 1997-1998. Hong Kong: Against Child Abuse, 1998.

 
 

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