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Understand that one person can do something about violence but many people can stop violence.
No violence against children is justifiable; all violence against children is preventable.
In November 2006 the UN issued the Secretary-General’s Report1 on violence against children. In a joint initiative, the Office of the High Commissioner on Human Rights (OHCHR), the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) have led the first global attempt to describe the scale and impact of all forms of violence against children. It follows the previous study2 by Graca Machel (wife of Nelson Mandela) on violence against children in armed conflict. It is therefore relevant to the UK and to the work of paediatricians who see the results of this violence in children’s lives, and is essential reading both in its wealth of statistics and its global overview of how to prevent violence. We review the report to bring out its implications for UK paediatricians, who are much concerned with the impact of violence and have a central role to play in its prevention. Paediatricians are key players in the management of child abuse and in protecting children from harm. Can they also take a high profile role in the prevention of violence and the promotion of non-violent policies?
The independent expert appointed to lead the study is Dr Paulo Pinheiro and his concept for the study outlines the objectives and methodology.3 The research covered the magnitude of violence, the causes both locally and nationally, and strategies for prevention. The methods used included information obtained from international and national organisations, regional consultations, field visits and wide discussion with children and young people. The last was a strong feature of the study and adds to its value; children’s comments are provided below. New research was not carried out, but existing literature was appraised. The definitions of violence come from Article 19 of the UN Convention on the Rights of the Child: “all forms of physical or mental violence, injury and abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse”, and the World report on violence and health4: “the intentional use of physical force or power, threatened or actual, against a child, by an individual or group, that either results in or has a high likelihood of resulting in actual or potential harm to the child’s health, survival, development or dignity”.
The study confirms and adds depth to what we already know about child abuse in the Western world. The overall picture is gloomy and optimism comes only from seeing fresh insights into how to stop the violence. The report covers violence in the following sectors: home and family, school, care and justice systems, work settings and the community. Selected findings from the comprehensive report are presented.
GENERAL ISSUES
Societal acceptance of violence is universal and an important factor in its continuation: both children and perpetrators accept and justify physical, sexual and psychological violence as inevitable and normal, particularly when no “visible” or lasting physical injury results. Paediatricians and other health professionals across the world can do much more to expose the hidden face of violence.
The lack of an explicit legal prohibition of corporal punishment reflects societal tolerance. At least 106 countries do not prohibit the use of corporal punishment in schools, 147 countries do not prohibit it within alternative care settings, and as yet only 16 countries have prohibited its use in the home.5 Nevertheless, there is evidence that such a ban forms a key part of a preventive strategy.6
RISK FACTORS
The low status of certain groups of children is highlighted. Many of these groups are common in the UK: children in poverty, disabled children, children not in parental care and those from ethnic minorities, especially asylum seekers. Parental loss or separation heightens vulnerability. Socioeconomic status is a contributory factor: the rate of homicide of children in 2002 was twice as high in low-income countries than high-income countries (2.58 vs 1.21/100 000 population).7
SETTINGS
The extent of violence in several settings was examined, some of which are highlighted below.
Violence in the home and family
I hate being a child. I hate being hit and I hate being taken for granted. I have feelings and emotions. I need love, care, protection and attention. (girl, 13, South Asia, 2005)
Studies from many countries in all regions of the world suggest that between 80% and 98% of children suffer physical punishment in their homes, with a third or more experiencing severe physical punishment resulting from the use of implements.
Between 133 and 275 million children witness domestic violence annually.8 The frequent exposure of children to violence in their homes, usually through fights between parents or between a mother and her partner, can severely affect a child’s well-being, personal development and social interaction in childhood and adulthood.9 Intimate partner violence is also known to increase the risk of violence against children in the family.10 11
Harmful traditional practices continue. Globally, 100–140 million girls and women have undergone some form of female genital mutilation/cutting. In Africa, 3 million girls and women are subjected to genital mutilation/cutting every year.12
Violence in educational settings
In developing countries, 20–65% of school-aged children reported having been verbally or physically bullied in the past 30 days.13 Cyber-bullying, fighting, physical assault, gangs and weapons are reported with increasing frequency in industrialised countries.14–17 The serious health impacts of bullying are highlighted, but only 42% of the world’s children are legally protected from violence at school. Figure 1 illustrates rates of bullying reported by children across Europe and these are disturbingly high.
Sometimes we were beaten for having dirty collars on our shirts or long nails. The punishment is very severe. It is impossible for the shirt of an active standard 4, 5, 6 student to be sparkling white at 4 pm unless the boy/girl is sick. My maths teacher in class eight made us kneel on a Saturday for 2 hours for failing a sum. We could be told to kneel on pebbles. (Simon’s story, middle primary school; unpublished UNICEF report, 2005)
Violence in places of work
Recent estimates indicate that 218 million children were involved in child labour, of whom 126 million were in hazardous work,18 with 5.7 million in forced or bonded labour and 1.8 million in prostitution and pornography, while 1.2 million were victims of trafficking.19 Although the incidence of child labour has diminished by 11%, with 25% fewer children working in hazardous occupations,20 violence is neglected in debates on child labour. Young workers need to see their contribution to family survival as positive but instead reported denigration by employers.
Violence in care and justice institutions
Some of us are abused at home. We move into the child welfare system that is meant to protect us. The system abuses us. We try to make a complaint and nothing is done. We harbour all this anger and lash out at our peers, family, friends, social workers, foster parents, group home staff, teachers, etc, and the cycle continues. Somewhere this needs to stop. (young person, North America, 2004)
As many as 8 million children are in residential care,21 mostly because of disability, family disintegration, violence in the home, and social and economic conditions, including poverty.22 Violence by institutional staff, for the purpose of “disciplining” children, includes beatings, harassment, torture, isolation, restraint and rape.23 Some children with disabilities may be subject to violence under the guise of treatment, such as electro-convulsive treatment (ECT) without the use of muscle relaxants or anaesthesia.24 Electric shocks may also be used as “aversion treatment” to control children’s behaviour.
Neglect is an additional feature of many residential institutions where conditions are so poor that the health and lives of children are put at risk. There is no access to education, recreation, rehabilitation or other programmes. Children with disabilities are often left in their beds or cribs for long periods without human contact or stimulation. This can lead to severe physical, mental and psychological damage.
Children in detention may be subjected to humiliating treatment, such as being stripped naked and caned in front of other detainees. Girls in detention facilities are at particular risk of physical and sexual abuse, especially when supervised by male staff.25 A recent report in the UK described the painful restraints used on children held in secure units.26
Sometimes one day in prison felt like a year. But after 10 days you get used to it and you don’t cry as much. (boy in juvenile detention, Middle East, 2003)
Actions taken
States have enacted laws which address issues relating to violence against children and some have harmonised domestic legislation with the Convention, its Optional Protocols and other treaties. However, legal reforms have often focused on narrow, albeit important, issues rather than taking a comprehensive approach to violence against children. Few states have carried out a thorough review of the legal framework to address violence against children more effectively. Implementation of laws, including legal reforms, remains a challenge.
Recommendations
Some views of children in the European region are listed in table 1.
RECOMMENDATIONS OF THE REPORT
The study developed recommendations specific for each setting, and also presented 12 overarching recommendations, outlining broad actions which all states must take to prevent and respond to violence against children (table 2).
CONCLUSIONS
Despite states’ obligations, lack of political will and leadership mean that children’s lives continue to be blighted by violence. More than a third of member states of the Council of Europe now give children the same protection from assault as adults.5 In the UK, debate continues on whether chastisement of children by parents is justifiable. Section 58 of the Children Act (2004) allows the common assault of children to continue to be justified as “reasonable punishment”. Scotland is the only country in the UK to have passed legislation preventing the corporal punishment of children. The Criminal Justice (Scotland) Act was quietly introduced in 2003. Section 51 bans the use of implements to hit children, shaking and blows to the head. The act, which abandoned the proposed age prohibition of 3 years and instead introduced the concept of “justifiable assault” of children, has been criticised as conflicting with international and European human rights standards.
Governments cannot do the job alone– all sectors of society must share the responsibility to condemn and prevent violence against children, and to respond to the predicament of child victims. The clear message from children is that they want violence to stop. Public education should be part of the prevention strategy and schools should be encouraged to adopt and implement codes of conduct which involve children at an early age to promote effective social and communication skills to achieve non-violent conflict resolution. Teachers should use teaching and learning strategies which are not based on threats, fear, humiliation or physical punishment. Effective anti-bullying campaigns should tackle the increasing use of technology as a medium for bullying. Although the UK has come a long way with the introduction of personal safety campaigns, there is still a lack of multi-agency training.
It has been argued that equity in child health can only be achieved when children’s rights are fulfilled.27 The health services for child victims of assault, particularly sexual assault, continue to be a post-code lottery. Despite guidance from the Royal College of Paediatrics and Child Health and the Association of Forensic Physicians,28 many areas suffer from a lack of paediatricians and forensic medical examiners who are trained and willing to do this work. Children, whether abused or perpetrators of abuse, continue to wait too long for therapeutic and counselling services. A great deal more needs to be done to involve children and young people in the design and delivery of health and social services.
Professionals worry about reporting at too low a threshold and have doubts about the efficacy of the child protection procedures. As a result, many children and young people who have suffered abuse do so in silence. In the UK, around 4500 children call ChildLine daily, but lack of funds means that only 2500 of them will get through to the counsellors for comfort, advice and protection.
Some direct quotations from the report deliver powerful messages. Too often, we see that legislation is on the books but that many children remain on the margins of society– not registered at birth, not in school, too poor to see a doctor and, as a result, all the more vulnerable to violence and abuse (Rima Salah, Deputy Executive Director of UNICEF). Dr Pinheiro concludes that ending violence against children is a matter of urgency. There should be no more excuses or delays: the problem is out in the open, the obligations of governments are clear and the means to deal with it are known, affordable and available. Ways in which paediatricians in the UK can contribute are summarised in table 3.
Footnotes
Competing interests: None.