KATHMANDU, OCTOBER 10

"Abuse may be defined as the following to treat (a person or animal) in a harsh or harmful way or to use or treat (something) in a way that causes damage or to use (something) wrongly".

According to the World Health Organization (WHO), the well-being of an individual is encompassed in the realization of their abilities, coping with normal stresses of life, productive work and contribution to their community. Cultural differences, subjective assessments, and competing professional theories all affect how one defines "mental health".

Types of Abuse

1. Physical abuse- Physical injury resulting from practices such as punching, beating, kicking, biting, or burning. Physical injuries may occur in single or repeated episodes. It can range in severity from minor bruising to death.
2. Neglect- Harm or endangerment as a result of failing to provide for the child's basic needs, by providing inadequate nutrition, clothing, hygiene or supervision. Unlike other forms of abuse, it is an act of omission by the caregiver, which jeopardizes or impairs the child’s physical, intellectual or emotional development.
3. Sexual abuse- When an adult or older person uses his or her power over a child to involve the child in sexual activity. The abuser may trick, threaten, or force a child to take part in sexual activity. Child sexual abuse may include suggestive behaviour or comments, exposure or exhibition of the genitals, fondling genitals, masturbation, oral sex and penetration.
4. Emotional abuse- A behavioural pattern in which a parent or caregiver repeatedly attacks a child’s self-esteem and social competence over time. The child may be constantly told that they are worthless, rejected and shown no affection, subjected to repeated verbal threats and severe punishments and restricted from contact with others. This is sometimes called psychological abuse.
5. Domestic Violence– A situation where a child is a witness to or involved in violent family disputes, including physical, verbal or sexual abuse toward any member of the family. Exposure to domestic violence is considered a reason for notification of child abuse under legislation in NSW. Other states may recognise it within the category of psychological abuse.
6. Multi-type maltreatment- The interaction of different types of abuse may be more predictive of the child’s outcome than only looking at one type of abuse. Generally when one form of child abuse exists, then the child will also be either exposed to, or at risk of, other forms of abuse. If abuse occurs frequently and severely, then the child is likely to have poorer outcomes in regard to his or her health and wellbeing.

Risk Factors for Child Abuse

There are some factors or circumstances that are known to increase the risk of child abuse, although not all families who have these risk factors will go on to abuse their children. There is a higher risk of abuse and violence in some disadvantaged families that have experienced multiple social and financial problems.

However it is important not to stereotype families or make assumptions about their relationships on this basis. It is also important to realise that abuse can occur in families that do not appear to fit this profile. Risk factors for child abuse include:

• Lack of parenting skills and knowledge in the parent or caregiver
• Poor interpersonal skills, coping skills, self-esteem or self-control in the parent or caregiver
• Teenage or early pregnancy and lack of support
• Low socio-economic status including unemployment, homelessness, poverty
• Family problems such as domestic violence, substance use, family breakdown, criminal activity
• Health problems in the parent or caregiver, such as chronic ill health, physical or mental illness
• Health or behaviour problems in the child, such as chronic ill health, difficult behaviour, low birth weight, disability, developmental delay or impairment
• History of intergenerational abuse.

Warning Signs of Abuse

There are warning signs that suggest the possibility of abuse. However it is important to remember that the presence of these signs does not necessarily mean that abuse has occurred. Some of these can also represent behaviour or mental health problems which have arisen for reasons other than abuse.

• Telling people about the abuse, directly or indirectly (eg in a poem or drawing)
• Physical signs of being beaten or abused, such as bruising, broken bones
• Sexual behaviour inappropriate or too precocious for the child's age
• Teenage pregnancy, promiscuity or sexually-transmitted diseases
• Self-destructive behaviour, substance use or risk taking behaviour
• Externalising problems such as disruptive or aggressive behaviour, bullying
• Internalising problems such as withdrawal, anxiety, depression, guilt, distrust
• Mental illness such as depression, anxiety disorders or eating disorders
• Self-harm or suicidal behaviour, threats of suicide

Child Abuse and Mental Health

Experiencing abuse in childhood or adolescence has been identified as a significant risk factor for poor mental health, poor attachment and connection to parents and family, and general adjustment problems. Certain children may be less vulnerable to such problems following abuse or neglect, if there are other factors that offset these effects. Such protective factors include connectedness to other members of the family or peers, minimal other life stress, level of development and resilience prior to abuse, and the availability of resources, intervention and support programs.

Effects on General Mental Health

Adjustment in later life varies and will be affected by factors such as age of child when abused, severity, frequency and duration of abuse. Children or adolescents who have been abused may be more likely to show some of the following characteristics:

• Be withdrawn, have trouble showing affection or be less popular with peers
• Be aggressive, have low impulse control or be involved in conflict with others
• Have a higher incidence of overall behaviour problems (varies with age)
• Lack an understanding of consequences of actions and moral reasoning
• Lack a sense of safety or belonging, may not value these
• Have difficulty trusting other people or relating to them emotionally or sexually
• Have problems with identity, self-perception, self-esteem, confidence
• Have difficulty managing or integrating new events or stresses into their life
• Be unable to manage strong emotions, seem sad or anxious much of the time
• Report more health problems and accidents ∑Be more prone to drug and alcohol use, misuse, or abuse

Risk of Mental Illness and Disorders

Child abuse is a risk factor for a number of mental illnesses that may be diagnosed in childhood, adolescence or adulthood. Not all children who have suffered abuse will develop a diagnosable mental illness, but in general there is a higher risk of developing:

• A depressive illness, such as major depression or clinical depression
• Anxiety disorders, including panic disorder, social phobia, generalised anxiety disorder and post-traumatic stress disorder
• Disruptive behaviour disorders and risk-taking behaviour, including conduct disorder or oppositional defiant disorder and anti-social behaviour disorder
• Substance abuse disorders, with dependence on alcohol or other drugs
• Eating disorders such as anorexia or bulimia
• Personality disorders in adulthood- One study has suggested that victims of childhood physical abuse have a 40% chance of being diagnosed with major depressive disorder at some stage in their life and a 30% chance of being diagnosed with a disruptive behaviour disorder. In other research, more than a third of childhood victims of physical and sexual abuse developed post-traumatic stress disorder (PTSD) during their lifetime.

Risk of Suicide and Self Harm

There is an association between childhood abuse and the risk of suicidal behaviour. One study found that a history of physical abuse increases the odds of attempting suicide by almost 5 times, while a history of emotional abuse may increase the odds of a suicide attempt by more than 12 times.

Management of Abuse.

• Awareness about abuse and its impacts on children, adolescents, teachers, parents and caregivers.
• Educate children and adolescent about the types of abuses and its way to cope.
• Anti -bullying spaces at home, school and community
• Strict rules/regulations/ law about abuse from children to adults.
• Concept of good touch and bad touch from home, school and community.
• Avoid passing critical comments/remarks
• Say no to physical punishment
• Be available for your children when needed
• Allow open space to enquire or discuss about child’s question/queries
• Be genuine and respect your child
• Have ground rules at home
• Keep boundaries and limitation according to need and age
• Decrease use of electronic gadgets
• Use play for better bonding and relationship
• Consult to nearest clinician if there is change in sleep. Appetite or daily routine of any children and adolescent.

Rampukar Sah is a Clinical Psychologist and is trained in child and adolescent psychiatry. He is currently a consultant at Kanti Childrens Hospital.