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Contents lists available at ScienceDirect
Child Abuse & Neglect
Child and adolescent abuse and neglect in the city of Curitiba, Brazil夽 Lucimara Cheles da Silva Franzin a,∗ , Márcia Olandovski b , Maria Lúcia Tozetto Vettorazzi c , Renata Iani Werneck b , Samuel Jorge Moysés b , Solena Ziemer Kusma b , Simone Tetu Moysés b a b c
Faculdade Ingá – UNINGÀ, Araras, 36, Jardim das Flores, Arapongas, Paraná, CEP – 86701140, Brazil Pontifícia Universidade do Paraná, Imaculada Conceic¸ão 1155, Prado Velho – Curitiba, Paraná, Brazil Instituto Federal do Paraná, João Negrão, 1285, Rebouc¸as – Curitiba, Paraná, Brazil
a r t i c l e
i n f o
Article history: Received 12 December 2012 Received in revised form 5 February 2014 Accepted 13 February 2014 Available online xxx
Keywords: Child abuse Neglect Domestic violence Maltreatment
a b s t r a c t Identify and analyze cases of child and adolescent abuse and neglect in Curitiba, Brazil. This is an exploratory descriptive study that takes a quantitative approach. Secondary data from the reporting registry of the Network for the Protection of Children and Adolescents at Risk for Violence in Curitiba, Brazil, dating from 2004 to 2009, were analyzed. Variables included the victims’ sociodemographic profile, place of notification, type, nature and severity of abuse, information about the author of the aggression or abuse, and physical lesions. The frequency distribution and associations between the variables were analyzed using the Chi-square test at a 5% significance level. The analysis of 19,316 records showed that domestic violence, abuse and neglect directed against children and adolescents were the most frequently recorded situation, with 17,082 cases (88.4%) distributed in the following manner: neglect, with 9742 reports (57.0%); physical violence, with 1341 reports (7.9%); sexual violence, with 796 reports (4.7%); psychological violence, with 574 reports (3.4%); and abandonment, with 190 reports (1.1%). Of the total, 43.9% were considered severe cases. The most affected age group was between 5 and 14 years of age, with balance between genders. In the majority of cases, the mother was registered as the author of the abuse or neglect. Physical sequelae (20.2%) mostly affected the head and upper and lower limbs, with consequent lesions manifesting as bruises, cuts, and fractures. An increase in the visibility of domestic violence and children and adolescents abuse and neglect has been observed in the city during the last few years, suggesting the effectiveness of the reporting strategies proposed by the protection network. It is important to increase social security and public welfare policies to prevent child and adolescent abuse and neglect, focusing on family support. © 2014 Elsevier Ltd. All rights reserved.
Introduction Violence is globally recognized as a social and public health issue (Minayo, 2009) that is present in all social classes, countries, and communities (Cavalcanti, 2001).
夽 Funding: Fundac¸ão Araucária. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.02.003 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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2
ARTICLE IN PRESS L.C. da Silva Franzin et al. / Child Abuse & Neglect xxx (2014) xxx–xxx
The World Report on Violence and Health, published by the World Health Organization in 2002, gave visibility to a type of violence, including abuse and neglect, that often does not result in serious sequelae or death, but rather generates physical injury, oppression, and psychological and social damage in victims, usually children, women, and the elderly. Victims of this type of abuse are submitted to physical, sexual, psychological abuse, deprivation and neglect in a chronic manner (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Norman et al., 2012). Scaling the magnitude of this phenomenon has been a challenge for researchers in the area (Moura & Reichenheim, 2005). Global statistics show that injuries related to abuse and neglect are responsible for the deaths of 950,000 children and adolescents under the age of 18 worldwide, while 10 million children require hospitalization due to non-fatal injuries (WHO, 2008). In the United States, for example, registries confirm a high incidence of child abuse and neglect (Finklhor & Jones, 2006; USA, 2008). In 2006, approximately 3.6 million children were investigated by Child Protective Services; of these, 905,000 (25%) had been abused or neglected (Shipman & Taussig, 2009). There are also reports of over 900,000 annual victims of child abuse, with more than 1400 deaths (Finklhor & Jones, 2006; USA, 2008). Although it is difficult to estimate the costs resulting from the inflicted injuries, it has been estimated that the United States spends nine billion dollars annually on the consequences of child maltreatment (USA, 2008). In Brazil, external causes (accidents and violence), including child abuse and neglect, are considered the leading cause of death in children between 1 and 19 years of age (Brasil, 2008). From 2009 to 2010, 44.6% of the total cases of domestic violence, sexual and other forms of abuse and neglect registered by the National Surveillance System involved children and adolescents in this age group (Brasil, 2013). This has been a reason for concern for governmental and non-governmental institutions as it promotes high morbidity and mortality population rates and high costs for the Brazilian Health System (SUS). In 2004, 90 billion reais were spent – 5% of GDP, according to the Institute of Applied Economic Research of the Ministry of Planning, Budget and Management (IPEA/MOP) – on the treatment of sequelae of accidents and violence (Brasil, 2010). Less visible but more widely known are the effects of suffering individual abuse and neglect on children and adolescents (Brasil, 2008). According to the Brazilian Constitution, the family, society, and the state have a duty to ensure children and adolescents enjoy the right to life, health, food, education, leisure, professional training, culture, dignity, respect, freedom, and family and community life, in addition to keeping them safe from all forms of negligence, discrimination, exploitation, violence, cruelty and oppression (Caput art. 277 of the Federal Constitution) (Brasil, 1988). This was ratified in the 4th article of the Law 8.069 of 1990, known as the Statute of Children and Adolescents (Brasil, 2001a, 2001b), which, based on the full protection doctrine, determines that any violation or omission of their fundamental rights constitutes a transgression of adult caregivers’ (or the state, society, and institutions) power/duty to protect, and must be punishable by law. Thus, domestic abuse and neglect refers to all actions and omissions that affect the welfare, physical or psychological integrity, freedom, and/or the right to well-rounded development of a family member (Brasil, 2001a, 2001b). It is usually related to family conflicts that turn into intolerance, abuse, oppression, and neglect (Curitiba, 2008; Minayo, 2009). Domestic abuse and neglect perpetrated against a child and/or adolescent consists of intentional acts of physical force or power in the family home, or omission committed by parents, relative or guardian, resulting in physical, sexual, or psychological injuries, and in neglect or deprivation, with abandonment being the extreme case. This can turn an environment that should be safe into a place devoid of any type of respect and protection (Curitiba, 2008). It promotes damage to physical, emotional, social and intellectual development (Guerra, 2008; Norman et al., 2012). The abuse and neglect of children and adolescents in the family environment makes them vulnerable to multiple health problems, in addition to psychological implications for the victims and their relatives, such as mental health problems, depression, post-traumatic stress, low self-esteem, social problems, suicidal behavior, aggression, attention deficit and hyperactivity, and behavioral problems, such as delinquency, risky sexual behavior, and the use of chemical substances. Sequelae, such as behavioral problems and mental disorders, sometimes are associated with physical injuries (Kayris & Johnson, 2002; Norman et al., 2012). Nonetheless, in many societies, only a small portion of these children receive adequate care (Shipman & Taussig, 2009). This phenomenon can only be identified by health, education and welfare professionals who are familiar with the warning signs through a close and holistic analysis of the children, adolescents, and their families, expanding their opportunities to observe risk situations and reducing their consequences (Curitiba, 2008; Moura & Reichenheim, 2005). The decrease, loss or absence of bonds between parents and children has been identified as a warning sign of a situation that may lead to family violence, child abuse and neglect, reinforcing the need for monitoring the family. This risk may be linked to socioeconomic and cultural contexts that restrict family social relationships, enabling them to meet their basic needs. In addition, family behavior may suffer influence of extreme poverty and lacking of basic social support (Bringiotti, 2005; Curitiba, 2008; Sousa et al., 2011). Although reporting is mandatory when there is a suspicion or confirmation of domestic child abuse or neglect in Brazil (Brasil, 2010), it has been underreported, and there is a lack of consistent data (Brito, Zanetta, Mendonc¸a, Barison, & Andrade, 2005). In recent decades, health care programs have sought to develop integrated actions with multidisciplinary teams, aiming to promote the health of individuals and their home environment by identifying risk and protection factors. Care for children and adolescents and their families involves the emotional and material support they need for adequate development. The Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Network for the Protection of Children and Adolescents at Risk for Violence in the city of Curitiba, Brazil (RPCAV) is one of these programs (Curitiba, 2008). The RPCAV, which is organized by the municipal government, was established in 2000 and is driven by the magnitude of child and adolescent abuse and neglect in the city (Curitiba, 2008). The aims of the network include bringing visibility to child and adolescent abuse and neglect; improving the capacity of professionals for integrated and intersectoral work; offering help to victims, their families, and the author of the aggression and neglect through an educational, not punitive, approach to neutralize the conditions that generate maltreatment; controlling relapses; and developing preventive actions with community participation. The network is based on a mandatory reporting system for all forms of abuse and neglect, suspected or confirmed, with legal basis in the Federal Constitution (Article 227) (Brasil, 1988), and the Statute of Children and Adolescents (Articles 13 and 245) (Brasil, 2001a, 2001b). It involves more than 200 municipal public institutions that work with children and adolescents, as well as non-governmental institutions, including Guardian Councils, Public Ministry, hospitals, organized civil society institutions, military and civil police, and the Court of Childhood and Youth. It encourages the reporting of cases of child and adolescent abuse and neglect through an integrated and intersectoral work. Reporting is mandatory for all professionals working in schools, health services, and other institutions working with children in the city, by using a standard form. Community and family members, neighbors, or children themselves can report through a call center at the Municipal Social Action Foundation/Victimized Attention Service, or can go directly to the Local Guardian Council. The institutional notifications follow a protocol that defines the criteria used to recognize the nature of such maltreatment acts as physical, psychological or sexual abuse, neglect and abandonment (Brasil, 2008; Curitiba, 2008). According to the protocol, physical abuse is the use of force with the intent to produce injury to the child or adolescent and may leave evident (or not) body marks that cause pain or even death (Curitiba, 2008; Guerra, 2008; Minayo, 2002). Although the Brazilian Criminal Code and Civil Code have articles that punish this type of maltreatment, some social groups and families still perpetuate this practice (Guerra, 2008), as it can be not perceived as violence, but is considered to have an educational intent (Donoso & Ricas, 2009). Psychological abuse is usually associated with other forms of abuse (Brito et al., 2005; Paluci & Fisher, 2011). It endangers or causes risk to the child’s or adolescent’s development, self-esteem and identity (Brasil, 2010). It is manifested by acts of rejection, depreciation, disrespect, discrimination, humiliating punishments, exaggerated self-charging (Brasil, 2004; Curitiba, 2008), and verbal or gestural aggression (Moore & Pepler, 2006). When the victim is a child or adolescent, this type of abuse has a devastating effect on his/her self-esteem and can lead to vengeful and depressive personalities or even suicide (Minayo, 2009; Moore & Pepler, 2006). Sexual abuse includes the act or game that occurs in heterosexual and homosexual relationships, in which a person in a position of power forces the other to carry out sexual practices through direct contact or exploitation of adults with the aim of exciting the victim or using the victim to obtain sexual excitement using physical force or psychological influence (Curitiba, 2008; Minayo, 2009; Moore & Pepler, 2006; da Silva, Coelho, & Caponi, 2007). Most injuries resulting from this type of abuse are emotional, although some children have physical lesions or contract sexually transmitted diseases (Adams et al., 2007). Sexual abuse does not occur only in the home and is predominant in this environment. It victimizes both genders, but girls are frequently the victim (Ayala et al., 2009; Baptista, Franc¸a, Costa, & Brito, 2008; Carvalho, Barros, Alves, & Gurgel, 2009; Guerra, 2008). Neglect, one of the most frequent forms of maltreatment (Costa et al., 2007), is associated with high morbidity and mortality rates of victimized children and adolescents. It represents an omission of familial and societal duty to provide for the child or adolescent’s physical, social, and emotional needs (Curitiba, 2008; Minayo, 2002). To understand it, it is necessary to assess its social, cultural, regional, and contextual aspects, which interfere in what may be considered as neglect or not, as it can be associated with poverty and social exclusion. It is important to evaluate parental responsibility in the context of family life, the family’s access to social services offered by the community, its economic situation, safe living environment, depression, domestic violence and levels of supervision (Costa et al., 2007; Dubowitz, Papas, Black, & Starr, 2002). Thus, it is not always easy to differentiate what is inability or impossibility from intentional acts of the parent or guardian to provide their children and adolescents with the minimum acceptable requirements. Even facing the diagnosis of the social impossibility of good care, it is considered necessary to establish all social and legal safeguards, including mandatory case reporting. The RPCAV protocol (Curitiba, 2008) defines four modalities of neglect against children and adolescents: protection neglect (actions and/or omissions which expose them to risks, damaging their integrity and development, and violating their rights); health neglect (when they live in conditions under which health cannot be maintained and their basic needs, such as hygiene and nutrition, are ignored); education neglect (failing to assure registration, monitoring and development at school); and structural neglect (structural, economic, and social conditions beyond the family’s control that jeopardize their growth and development) (Curitiba, 2008; Minayo, 2002). The literature also quotes lack of food, clothes, and shelter as a subtype of physical neglect (Liu et al., 2003). The abandonment and deprivation of care considered as extreme neglect is characterized by the absence, refusal or desertion of the care needed by someone vulnerable who should receive the attention and care of their families (Minayo, 2009). Considering the epidemiological and biopsychosocial importance of child and adolescent abuse and neglect, it is critical to recognize the profile of cases to reinforce the assurance of protection. This study sought to identify and analyze cases of child and adolescent abuse and neglect registered at RPCAV in Curitiba, Brazil, from 2004 to 2009.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Number of noficaons/ 100.000 inhabitants
300
258.69 241.49
250 200
181.54
186.25
2006
2007
146.56 150
120.92
100 50 0 2004
2005
2008
2009
Year Fig. 1. Historical series of the number of reports of child and adolescent abuse and neglect, by 100,000 inhabitants, of residents from 0 to 18 years of age in Curitiba, Brazil. Source: CE/SMS – RPCAV database.
Methods This is an exploratory and descriptive study that takes a quantitative approach. Data were collected from the registry of RPCAV, Curitiba, Brazil, considering all records entered in the database between January 2004 and December 2009. The database includes information provided by trained professionals working at schools, clinics, and other institutions that work with children and adolescents who were able to identify confirmed or suspected individual maltreatment situations according to the network protocol and complete a standard notification form. This form is sent to the municipal, regional, or local reference institutions that are responsible for confirming the case, if suspected, and forwarding the case file to the database manager at the Municipal Secretariat of Health. Data are entered, checking for double counting if the same children were reported by different institutions, and the information is systematized. Information provided by the community through the call center directed to the local Guardian Council or to the Victimazed Attention Service is investigated and, if confirmed, a notification form is completed and the data entered in the database. The study included all institutional notifications of individual situations of abuse or neglect against children and adolescents between 0 and 18 years old, living in Curitiba, and in contact with services with reporting responsibilities for the period of time under study. In total, 19,316 records were analyzed. Although the network covers the majority of city institutions with which children and adolescents have contact, some population groups, such as very young children that are not at school or infant education centers, and older adolescents, could be excluded. The analyzed variables included information about the spatial distribution of the notifications of children and adolescents abuse or neglect by regions of Curitiba; occurrence of maltreatment (suspected or confirmed case); unit of notification; type and nature of maltreatment; frequency of maltreatment (eventual or recurring); severity of the case (classified as mild, moderate and severe according to the general condition of the victim, family constitution, type and characteristics of aggression, and profile of the author of the maltreatment); victims’ sociodemographic profiles (age group, sex, education); presence and type of detectable body injury; and information about the author of the maltreatment (bond with the victim, illegal alcohol/drug dependence). The data were stored in EPI-INFO Program, where variables coding adjustments were made, and analyzed using SPSS 17.0. The results were expressed in tables of frequency distributions and contingencies tables, using the Chi-square test and a 5% significance level. This study was approved by the Ethics Committee for Research of the Pontifical Catholic University of Paraná (PUC-PR) on 04/28/2010 – Protocol no. 5528, and by the Ethics Committee of the Health Department of Curitiba (07/26/2010 – Protocol no. 54/2010), in agreement with Resolution 196/96 of the National Ethics in Research Council.
Results The investigated records included 19,316 reports of child and adolescent abuse and neglect occurring from January 2004 to December 2009 in Curitiba (Fig. 1). The average age of the victims was 7.8 years. There is a proportional increase in the number of records of maltreatment in the studied population from 2004 to 2008, with a slight decrease in 2009. Of the total, 5764 cases (29.8%) were reported by Basic Health Units, 5488 (28.4%) by Schools/Educational Centers, 4387 (22.7%) by the Victimized Attention Service of the Social Assistance Foundation, and 3452 of the cases (17.9%) were reported by hospitals. Considering the spatial distribution of child and adolescent abuse and neglect notifications in Curitiba, the largest number of reports originated in the western and south eastern regions of the city, with 3286 cases (17.0%) and 3167 cases (16,4%), Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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5
3000 2500 Neglect 2000
Phisical Sexual
1500
Psychological Abandonment
1000
Neglect + Associaons 500
Other Associaons
0 2004
2005
2006
2007
2008
2009
Fig. 2. Number of cases by year of notification, according to the nature of the abuse and neglect registered by RPCAV – Curitiba – PR, 2004/2009. Source: CE/SMS – RPCAV database.
respectively. Lower number of notifications came from the northern and central regions of the city, with 1064 (5.5%) and 729 cases (3.8%), respectively. Of all the cases of reported child and adolescent abuse and neglect during the study period, the majority (70%) were confirmed by the responsible institutions of the network (Guardian Council and the Municipal Social Action Foundation). Child and adolescent domestic abuse and neglect accounted for 88.4% of notified cases (17,082), and the others were distributed as extra familial (8.1%), fetal and self-harm abuse (2.9%). In 104 of the registered cases, there was no record reporting the type of abuse and neglect. The results presented below are related to the data analysis from child and adolescent domestic abuse and neglect only (n = 17,082). The data in Fig. 2 show the highest prevalence of cases of children and adolescents’ neglect in Curitiba, comprising 9742 (57%) notifications. Physical abuse was reported in 1341 cases (7.9%), sexual abuse in 796 cases (4.7%), psychological abuse in 574 cases (3.4%), and abandonment was reported in 190 cases (1.1%). The findings also showed that neglect can be associated with other types of maltreatment, mainly with physical and psychological violence. This situation was reported in 3312 notified cases (19.4%). The association of other forms of maltreatment, mainly a combination of physical, psychological, and sexual abuse, occurred in 1127 cases (6.6%). Considering the type of neglect registered, of the total number of reported cases (n = 9102), neglect of protection was the most frequent with 2261 cases (24.8%), followed by neglect of education in 931 cases (10.2%), and neglect of health in 723 cases (7.9%). Structural neglect was reported in 123 cases (1.4%). However, the combination of these different types of neglect was the most prevalent occurrence reported in the study, with 5053 cases (55.5%). Other types of neglect were reported in 11 cases (0.1%). In 27.2% of the cases (4649), child and adolescent abuse and neglect was considered chronic, that is, recurrent over the observed period of time, showing repeated episodes of maltreatment. Maltreatment occurring for the first time was reported in 3410 cases (20.0%), while in 478 cases, they were considered eventual (2.8%). The assessment of the severity of the case was based on information about the victim’s features, type of abuse, and the identified author of the abuse or neglect. Of the total reported cases, 43.9% were considered severe, 43.3% moderate, and
Severity of Cases 2000 1800 1600 1400 1200
Severe
1000
Moderate
800
Light Mild
600 400 200 0 2004
2005
2006
2007
2008
2009
Fig. 3. Number of notifications of child and adolescent abuse and neglect by 100,000 inhabitants, according to severity, registered by RPCAV – Curitiba – PR, 2004/2009. Source: CE/SMS – RPCAV database.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Table 1 Bivariate analysis of notifications of maltreatment according to age, nature of maltreatment, and sex, recorded by RPCAV – Curitiba – PR, 2004/2009. Age group
ARTICLE IN PRESS Child Abuse & Neglect xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Child Abuse & Neglect
Child and adolescent abuse and neglect in the city of Curitiba, Brazil夽 Lucimara Cheles da Silva Franzin a,∗ , Márcia Olandovski b , Maria Lúcia Tozetto Vettorazzi c , Renata Iani Werneck b , Samuel Jorge Moysés b , Solena Ziemer Kusma b , Simone Tetu Moysés b a b c
Faculdade Ingá – UNINGÀ, Araras, 36, Jardim das Flores, Arapongas, Paraná, CEP – 86701140, Brazil Pontifícia Universidade do Paraná, Imaculada Conceic¸ão 1155, Prado Velho – Curitiba, Paraná, Brazil Instituto Federal do Paraná, João Negrão, 1285, Rebouc¸as – Curitiba, Paraná, Brazil
a r t i c l e
i n f o
Article history: Received 12 December 2012 Received in revised form 5 February 2014 Accepted 13 February 2014 Available online xxx
Keywords: Child abuse Neglect Domestic violence Maltreatment
a b s t r a c t Identify and analyze cases of child and adolescent abuse and neglect in Curitiba, Brazil. This is an exploratory descriptive study that takes a quantitative approach. Secondary data from the reporting registry of the Network for the Protection of Children and Adolescents at Risk for Violence in Curitiba, Brazil, dating from 2004 to 2009, were analyzed. Variables included the victims’ sociodemographic profile, place of notification, type, nature and severity of abuse, information about the author of the aggression or abuse, and physical lesions. The frequency distribution and associations between the variables were analyzed using the Chi-square test at a 5% significance level. The analysis of 19,316 records showed that domestic violence, abuse and neglect directed against children and adolescents were the most frequently recorded situation, with 17,082 cases (88.4%) distributed in the following manner: neglect, with 9742 reports (57.0%); physical violence, with 1341 reports (7.9%); sexual violence, with 796 reports (4.7%); psychological violence, with 574 reports (3.4%); and abandonment, with 190 reports (1.1%). Of the total, 43.9% were considered severe cases. The most affected age group was between 5 and 14 years of age, with balance between genders. In the majority of cases, the mother was registered as the author of the abuse or neglect. Physical sequelae (20.2%) mostly affected the head and upper and lower limbs, with consequent lesions manifesting as bruises, cuts, and fractures. An increase in the visibility of domestic violence and children and adolescents abuse and neglect has been observed in the city during the last few years, suggesting the effectiveness of the reporting strategies proposed by the protection network. It is important to increase social security and public welfare policies to prevent child and adolescent abuse and neglect, focusing on family support. © 2014 Elsevier Ltd. All rights reserved.
Introduction Violence is globally recognized as a social and public health issue (Minayo, 2009) that is present in all social classes, countries, and communities (Cavalcanti, 2001).
夽 Funding: Fundac¸ão Araucária. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.02.003 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
G Model CHIABU-2731; No. of Pages 9
2
ARTICLE IN PRESS L.C. da Silva Franzin et al. / Child Abuse & Neglect xxx (2014) xxx–xxx
The World Report on Violence and Health, published by the World Health Organization in 2002, gave visibility to a type of violence, including abuse and neglect, that often does not result in serious sequelae or death, but rather generates physical injury, oppression, and psychological and social damage in victims, usually children, women, and the elderly. Victims of this type of abuse are submitted to physical, sexual, psychological abuse, deprivation and neglect in a chronic manner (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; Norman et al., 2012). Scaling the magnitude of this phenomenon has been a challenge for researchers in the area (Moura & Reichenheim, 2005). Global statistics show that injuries related to abuse and neglect are responsible for the deaths of 950,000 children and adolescents under the age of 18 worldwide, while 10 million children require hospitalization due to non-fatal injuries (WHO, 2008). In the United States, for example, registries confirm a high incidence of child abuse and neglect (Finklhor & Jones, 2006; USA, 2008). In 2006, approximately 3.6 million children were investigated by Child Protective Services; of these, 905,000 (25%) had been abused or neglected (Shipman & Taussig, 2009). There are also reports of over 900,000 annual victims of child abuse, with more than 1400 deaths (Finklhor & Jones, 2006; USA, 2008). Although it is difficult to estimate the costs resulting from the inflicted injuries, it has been estimated that the United States spends nine billion dollars annually on the consequences of child maltreatment (USA, 2008). In Brazil, external causes (accidents and violence), including child abuse and neglect, are considered the leading cause of death in children between 1 and 19 years of age (Brasil, 2008). From 2009 to 2010, 44.6% of the total cases of domestic violence, sexual and other forms of abuse and neglect registered by the National Surveillance System involved children and adolescents in this age group (Brasil, 2013). This has been a reason for concern for governmental and non-governmental institutions as it promotes high morbidity and mortality population rates and high costs for the Brazilian Health System (SUS). In 2004, 90 billion reais were spent – 5% of GDP, according to the Institute of Applied Economic Research of the Ministry of Planning, Budget and Management (IPEA/MOP) – on the treatment of sequelae of accidents and violence (Brasil, 2010). Less visible but more widely known are the effects of suffering individual abuse and neglect on children and adolescents (Brasil, 2008). According to the Brazilian Constitution, the family, society, and the state have a duty to ensure children and adolescents enjoy the right to life, health, food, education, leisure, professional training, culture, dignity, respect, freedom, and family and community life, in addition to keeping them safe from all forms of negligence, discrimination, exploitation, violence, cruelty and oppression (Caput art. 277 of the Federal Constitution) (Brasil, 1988). This was ratified in the 4th article of the Law 8.069 of 1990, known as the Statute of Children and Adolescents (Brasil, 2001a, 2001b), which, based on the full protection doctrine, determines that any violation or omission of their fundamental rights constitutes a transgression of adult caregivers’ (or the state, society, and institutions) power/duty to protect, and must be punishable by law. Thus, domestic abuse and neglect refers to all actions and omissions that affect the welfare, physical or psychological integrity, freedom, and/or the right to well-rounded development of a family member (Brasil, 2001a, 2001b). It is usually related to family conflicts that turn into intolerance, abuse, oppression, and neglect (Curitiba, 2008; Minayo, 2009). Domestic abuse and neglect perpetrated against a child and/or adolescent consists of intentional acts of physical force or power in the family home, or omission committed by parents, relative or guardian, resulting in physical, sexual, or psychological injuries, and in neglect or deprivation, with abandonment being the extreme case. This can turn an environment that should be safe into a place devoid of any type of respect and protection (Curitiba, 2008). It promotes damage to physical, emotional, social and intellectual development (Guerra, 2008; Norman et al., 2012). The abuse and neglect of children and adolescents in the family environment makes them vulnerable to multiple health problems, in addition to psychological implications for the victims and their relatives, such as mental health problems, depression, post-traumatic stress, low self-esteem, social problems, suicidal behavior, aggression, attention deficit and hyperactivity, and behavioral problems, such as delinquency, risky sexual behavior, and the use of chemical substances. Sequelae, such as behavioral problems and mental disorders, sometimes are associated with physical injuries (Kayris & Johnson, 2002; Norman et al., 2012). Nonetheless, in many societies, only a small portion of these children receive adequate care (Shipman & Taussig, 2009). This phenomenon can only be identified by health, education and welfare professionals who are familiar with the warning signs through a close and holistic analysis of the children, adolescents, and their families, expanding their opportunities to observe risk situations and reducing their consequences (Curitiba, 2008; Moura & Reichenheim, 2005). The decrease, loss or absence of bonds between parents and children has been identified as a warning sign of a situation that may lead to family violence, child abuse and neglect, reinforcing the need for monitoring the family. This risk may be linked to socioeconomic and cultural contexts that restrict family social relationships, enabling them to meet their basic needs. In addition, family behavior may suffer influence of extreme poverty and lacking of basic social support (Bringiotti, 2005; Curitiba, 2008; Sousa et al., 2011). Although reporting is mandatory when there is a suspicion or confirmation of domestic child abuse or neglect in Brazil (Brasil, 2010), it has been underreported, and there is a lack of consistent data (Brito, Zanetta, Mendonc¸a, Barison, & Andrade, 2005). In recent decades, health care programs have sought to develop integrated actions with multidisciplinary teams, aiming to promote the health of individuals and their home environment by identifying risk and protection factors. Care for children and adolescents and their families involves the emotional and material support they need for adequate development. The Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Network for the Protection of Children and Adolescents at Risk for Violence in the city of Curitiba, Brazil (RPCAV) is one of these programs (Curitiba, 2008). The RPCAV, which is organized by the municipal government, was established in 2000 and is driven by the magnitude of child and adolescent abuse and neglect in the city (Curitiba, 2008). The aims of the network include bringing visibility to child and adolescent abuse and neglect; improving the capacity of professionals for integrated and intersectoral work; offering help to victims, their families, and the author of the aggression and neglect through an educational, not punitive, approach to neutralize the conditions that generate maltreatment; controlling relapses; and developing preventive actions with community participation. The network is based on a mandatory reporting system for all forms of abuse and neglect, suspected or confirmed, with legal basis in the Federal Constitution (Article 227) (Brasil, 1988), and the Statute of Children and Adolescents (Articles 13 and 245) (Brasil, 2001a, 2001b). It involves more than 200 municipal public institutions that work with children and adolescents, as well as non-governmental institutions, including Guardian Councils, Public Ministry, hospitals, organized civil society institutions, military and civil police, and the Court of Childhood and Youth. It encourages the reporting of cases of child and adolescent abuse and neglect through an integrated and intersectoral work. Reporting is mandatory for all professionals working in schools, health services, and other institutions working with children in the city, by using a standard form. Community and family members, neighbors, or children themselves can report through a call center at the Municipal Social Action Foundation/Victimized Attention Service, or can go directly to the Local Guardian Council. The institutional notifications follow a protocol that defines the criteria used to recognize the nature of such maltreatment acts as physical, psychological or sexual abuse, neglect and abandonment (Brasil, 2008; Curitiba, 2008). According to the protocol, physical abuse is the use of force with the intent to produce injury to the child or adolescent and may leave evident (or not) body marks that cause pain or even death (Curitiba, 2008; Guerra, 2008; Minayo, 2002). Although the Brazilian Criminal Code and Civil Code have articles that punish this type of maltreatment, some social groups and families still perpetuate this practice (Guerra, 2008), as it can be not perceived as violence, but is considered to have an educational intent (Donoso & Ricas, 2009). Psychological abuse is usually associated with other forms of abuse (Brito et al., 2005; Paluci & Fisher, 2011). It endangers or causes risk to the child’s or adolescent’s development, self-esteem and identity (Brasil, 2010). It is manifested by acts of rejection, depreciation, disrespect, discrimination, humiliating punishments, exaggerated self-charging (Brasil, 2004; Curitiba, 2008), and verbal or gestural aggression (Moore & Pepler, 2006). When the victim is a child or adolescent, this type of abuse has a devastating effect on his/her self-esteem and can lead to vengeful and depressive personalities or even suicide (Minayo, 2009; Moore & Pepler, 2006). Sexual abuse includes the act or game that occurs in heterosexual and homosexual relationships, in which a person in a position of power forces the other to carry out sexual practices through direct contact or exploitation of adults with the aim of exciting the victim or using the victim to obtain sexual excitement using physical force or psychological influence (Curitiba, 2008; Minayo, 2009; Moore & Pepler, 2006; da Silva, Coelho, & Caponi, 2007). Most injuries resulting from this type of abuse are emotional, although some children have physical lesions or contract sexually transmitted diseases (Adams et al., 2007). Sexual abuse does not occur only in the home and is predominant in this environment. It victimizes both genders, but girls are frequently the victim (Ayala et al., 2009; Baptista, Franc¸a, Costa, & Brito, 2008; Carvalho, Barros, Alves, & Gurgel, 2009; Guerra, 2008). Neglect, one of the most frequent forms of maltreatment (Costa et al., 2007), is associated with high morbidity and mortality rates of victimized children and adolescents. It represents an omission of familial and societal duty to provide for the child or adolescent’s physical, social, and emotional needs (Curitiba, 2008; Minayo, 2002). To understand it, it is necessary to assess its social, cultural, regional, and contextual aspects, which interfere in what may be considered as neglect or not, as it can be associated with poverty and social exclusion. It is important to evaluate parental responsibility in the context of family life, the family’s access to social services offered by the community, its economic situation, safe living environment, depression, domestic violence and levels of supervision (Costa et al., 2007; Dubowitz, Papas, Black, & Starr, 2002). Thus, it is not always easy to differentiate what is inability or impossibility from intentional acts of the parent or guardian to provide their children and adolescents with the minimum acceptable requirements. Even facing the diagnosis of the social impossibility of good care, it is considered necessary to establish all social and legal safeguards, including mandatory case reporting. The RPCAV protocol (Curitiba, 2008) defines four modalities of neglect against children and adolescents: protection neglect (actions and/or omissions which expose them to risks, damaging their integrity and development, and violating their rights); health neglect (when they live in conditions under which health cannot be maintained and their basic needs, such as hygiene and nutrition, are ignored); education neglect (failing to assure registration, monitoring and development at school); and structural neglect (structural, economic, and social conditions beyond the family’s control that jeopardize their growth and development) (Curitiba, 2008; Minayo, 2002). The literature also quotes lack of food, clothes, and shelter as a subtype of physical neglect (Liu et al., 2003). The abandonment and deprivation of care considered as extreme neglect is characterized by the absence, refusal or desertion of the care needed by someone vulnerable who should receive the attention and care of their families (Minayo, 2009). Considering the epidemiological and biopsychosocial importance of child and adolescent abuse and neglect, it is critical to recognize the profile of cases to reinforce the assurance of protection. This study sought to identify and analyze cases of child and adolescent abuse and neglect registered at RPCAV in Curitiba, Brazil, from 2004 to 2009.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Number of noficaons/ 100.000 inhabitants
300
258.69 241.49
250 200
181.54
186.25
2006
2007
146.56 150
120.92
100 50 0 2004
2005
2008
2009
Year Fig. 1. Historical series of the number of reports of child and adolescent abuse and neglect, by 100,000 inhabitants, of residents from 0 to 18 years of age in Curitiba, Brazil. Source: CE/SMS – RPCAV database.
Methods This is an exploratory and descriptive study that takes a quantitative approach. Data were collected from the registry of RPCAV, Curitiba, Brazil, considering all records entered in the database between January 2004 and December 2009. The database includes information provided by trained professionals working at schools, clinics, and other institutions that work with children and adolescents who were able to identify confirmed or suspected individual maltreatment situations according to the network protocol and complete a standard notification form. This form is sent to the municipal, regional, or local reference institutions that are responsible for confirming the case, if suspected, and forwarding the case file to the database manager at the Municipal Secretariat of Health. Data are entered, checking for double counting if the same children were reported by different institutions, and the information is systematized. Information provided by the community through the call center directed to the local Guardian Council or to the Victimazed Attention Service is investigated and, if confirmed, a notification form is completed and the data entered in the database. The study included all institutional notifications of individual situations of abuse or neglect against children and adolescents between 0 and 18 years old, living in Curitiba, and in contact with services with reporting responsibilities for the period of time under study. In total, 19,316 records were analyzed. Although the network covers the majority of city institutions with which children and adolescents have contact, some population groups, such as very young children that are not at school or infant education centers, and older adolescents, could be excluded. The analyzed variables included information about the spatial distribution of the notifications of children and adolescents abuse or neglect by regions of Curitiba; occurrence of maltreatment (suspected or confirmed case); unit of notification; type and nature of maltreatment; frequency of maltreatment (eventual or recurring); severity of the case (classified as mild, moderate and severe according to the general condition of the victim, family constitution, type and characteristics of aggression, and profile of the author of the maltreatment); victims’ sociodemographic profiles (age group, sex, education); presence and type of detectable body injury; and information about the author of the maltreatment (bond with the victim, illegal alcohol/drug dependence). The data were stored in EPI-INFO Program, where variables coding adjustments were made, and analyzed using SPSS 17.0. The results were expressed in tables of frequency distributions and contingencies tables, using the Chi-square test and a 5% significance level. This study was approved by the Ethics Committee for Research of the Pontifical Catholic University of Paraná (PUC-PR) on 04/28/2010 – Protocol no. 5528, and by the Ethics Committee of the Health Department of Curitiba (07/26/2010 – Protocol no. 54/2010), in agreement with Resolution 196/96 of the National Ethics in Research Council.
Results The investigated records included 19,316 reports of child and adolescent abuse and neglect occurring from January 2004 to December 2009 in Curitiba (Fig. 1). The average age of the victims was 7.8 years. There is a proportional increase in the number of records of maltreatment in the studied population from 2004 to 2008, with a slight decrease in 2009. Of the total, 5764 cases (29.8%) were reported by Basic Health Units, 5488 (28.4%) by Schools/Educational Centers, 4387 (22.7%) by the Victimized Attention Service of the Social Assistance Foundation, and 3452 of the cases (17.9%) were reported by hospitals. Considering the spatial distribution of child and adolescent abuse and neglect notifications in Curitiba, the largest number of reports originated in the western and south eastern regions of the city, with 3286 cases (17.0%) and 3167 cases (16,4%), Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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3000 2500 Neglect 2000
Phisical Sexual
1500
Psychological Abandonment
1000
Neglect + Associaons 500
Other Associaons
0 2004
2005
2006
2007
2008
2009
Fig. 2. Number of cases by year of notification, according to the nature of the abuse and neglect registered by RPCAV – Curitiba – PR, 2004/2009. Source: CE/SMS – RPCAV database.
respectively. Lower number of notifications came from the northern and central regions of the city, with 1064 (5.5%) and 729 cases (3.8%), respectively. Of all the cases of reported child and adolescent abuse and neglect during the study period, the majority (70%) were confirmed by the responsible institutions of the network (Guardian Council and the Municipal Social Action Foundation). Child and adolescent domestic abuse and neglect accounted for 88.4% of notified cases (17,082), and the others were distributed as extra familial (8.1%), fetal and self-harm abuse (2.9%). In 104 of the registered cases, there was no record reporting the type of abuse and neglect. The results presented below are related to the data analysis from child and adolescent domestic abuse and neglect only (n = 17,082). The data in Fig. 2 show the highest prevalence of cases of children and adolescents’ neglect in Curitiba, comprising 9742 (57%) notifications. Physical abuse was reported in 1341 cases (7.9%), sexual abuse in 796 cases (4.7%), psychological abuse in 574 cases (3.4%), and abandonment was reported in 190 cases (1.1%). The findings also showed that neglect can be associated with other types of maltreatment, mainly with physical and psychological violence. This situation was reported in 3312 notified cases (19.4%). The association of other forms of maltreatment, mainly a combination of physical, psychological, and sexual abuse, occurred in 1127 cases (6.6%). Considering the type of neglect registered, of the total number of reported cases (n = 9102), neglect of protection was the most frequent with 2261 cases (24.8%), followed by neglect of education in 931 cases (10.2%), and neglect of health in 723 cases (7.9%). Structural neglect was reported in 123 cases (1.4%). However, the combination of these different types of neglect was the most prevalent occurrence reported in the study, with 5053 cases (55.5%). Other types of neglect were reported in 11 cases (0.1%). In 27.2% of the cases (4649), child and adolescent abuse and neglect was considered chronic, that is, recurrent over the observed period of time, showing repeated episodes of maltreatment. Maltreatment occurring for the first time was reported in 3410 cases (20.0%), while in 478 cases, they were considered eventual (2.8%). The assessment of the severity of the case was based on information about the victim’s features, type of abuse, and the identified author of the abuse or neglect. Of the total reported cases, 43.9% were considered severe, 43.3% moderate, and
Severity of Cases 2000 1800 1600 1400 1200
Severe
1000
Moderate
800
Light Mild
600 400 200 0 2004
2005
2006
2007
2008
2009
Fig. 3. Number of notifications of child and adolescent abuse and neglect by 100,000 inhabitants, according to severity, registered by RPCAV – Curitiba – PR, 2004/2009. Source: CE/SMS – RPCAV database.
Please cite this article in press as: da Silva Franzin, L. C., et al. Child and adolescent abuse and neglect in the city of Curitiba, Brazil. Child Abuse & Neglect (2014), http://dx.doi.org/10.1016/j.chiabu.2014.02.003
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Table 1 Bivariate analysis of notifications of maltreatment according to age, nature of maltreatment, and sex, recorded by RPCAV – Curitiba – PR, 2004/2009. Age group
