1

WHO/HSC/PVI/99.1
Distr: Limited
Original: English

© World Health Organization, 1999

This document is not issued to the general public, and all rights are
reserved by the World Health Organization (WHO). The document may
not be reviewed, abstracted, quoted, reproduced or translated, in part
or in whole, without the prior written permission of WHO. No part of this
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prior written permissions of WHO.

The views expressed in documents by named authors are solely the

responsibility of those authors.

Copies of this document are available from:

Violence and Injury Prevention Team

Disability/Injury Prevention and Rehabilitation
Cluster on Social Change and Mental Health
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Fax: 0041.22.791.4332
E-mail: pvi@who.ch

2
Acknowledgements .............................................. 4

Introduction .......................................................... 5

Opening Session ................................................... 7

Definition ............................................................. 13

Health Burden ...................................................... 17

Contributing Factors ............................................ 21

Prevention ........................................................... 25

Good Practice ..................................................... 27

Data collection methods ..................................... 31

Annex 1: List of Participants ................................. 39

Annex 2: List of Presentations ............................... 42

Annex 3: WHO’s Plan of Action on Violence

Prevention ........................................................... 43

Annex 4: Agenda ................................................. 47

Annex 5: Selected Bibliography ........................... 49

3
 cknowledgements

W
HO would like to thank the Global Forum for Health
Research for their kind joint sponsorship of this consultation
and also the Japanese government for their continued
support. Special thanks go to the participants who
worked very hard before the consultation, during the pre-consultation
e-mail discussions and during the three days here in Geneva. We are
grateful to Dr Helen Agathonos-Georgopoulou for her valuable input as
Chair of this consultation. Acknowledgements also go to the Violence
and Injury Prevention Team, specifically to those who contributed to
the development of this report, Dr Carol Djeddah, Dr Mary Ruth Fox, Ms
Nadine France, Dr Etienne Krug and Ms Iris Tetford.

“I believe that the only way to attain genuine development is through our
investment in the quality of life we can provide our children. This task is now
the challenge of the new millenium- it cannot be accomplished by one country
alone.” Dr Zelided Alma de Ruiz

4
 Introduction

WHO Child Abuse

Prevention Electronic
Network

C
hild abuse1 is a major unrecognised problem,
impairing the health and welfare of children and The WHO Child Abuse
adolescents. Consequences are often immediate, Prevention Electronic Network
was set up to support the
impinging on the formative years, and long lasting,
WHO Consultation on Child
following victims throughout their lives. To address this
Abuse Prevention. Two
problem, the Initiative on Child Abuse Prevention was launched months before the
jointly by the World Health Organization and the Global Forum for consultation, participants and
Health Research. The initiative aims to ensure adequate other experts who could not
implementation of The Plan of Action on Violence and Health attend began exchanging ideas
endorsed by the World Health Assembly in 1998 and to secure an through the email network.
operational framework for public health involvement in the This innovative strategy
prevention and control of violence. enabled participants to get to
know each other and initiate
Given the many forms, circumstances and consequences of work well in advance of their
violence, measurement of the magnitude of child abuse has until first actual meeting. The
now been very unsatisfactory. Analyses of cause- and discussions raised many
age-specific mortality statistics has been the most widely used important issues, facilitating
approach, but deaths from violence are only the tip of the the start of in-depth
discussions which continued in
iceberg, merely hinting at the massive scale of the problem.
Geneva weeks later. In
Data on morbidity and other consequences, such as disabilities
keeping with the objectives of
and socio-economic implications, are scarce and often the meeting, discussions began
unreliable and existing surveillance systems do not always with the essential components
capture child abuse. There is inadequate data for solid policy of a working definition of child
development. abuse. Following this,
participants shared their
A group of experts met in Geneva from 29 - 31 March 1999 to experiences about risk factors
discuss these issues and to reach consensus on practical steps and health consequences.
and concrete actions to be taken. The consultation, jointly Subsequently, methods for
organized by the World Health Organization and The Global data collection and research
Forum for Health Research, was attended by 27 experts from from the different regions were
around the world (See Annex 1). The WHO consultation focused discussed. Participants then
on the most appropriate and needed actions to raise awareness presented examples of good
and decrease the public health burden caused by child abuse practices on many aspects of
child abuse from their
and on the development of effective prevention policies. This is
countries. These discussions
the report from that meeting and from the e-mail network
provided a rich source of
discussions which preceded it. It reflects essential ideas and experiences from experts in
recommendations from papers presented at the conference, the field of child abuse
follow-up discussions and workshop outcomes. At times, prevention.
information from publications by the participants have been
incorporated, to explain more fully ideas that were discussed in
the consultation.

1The term “child abuse” in this report is used to mean child abuse and
neglect (CAN) and child maltreatment (see also WHO definition).

5
6
 Opening Session

T
he consultation opened with presentations from WHO
programmes closely related to the prevention of child abuse.
Attention was drawn to the paucity of data available on child
abuse, the need to measure the problem and formulate health
policy and programming. The United Nations Convention on the Rights
of the Child (CRC) was highlighted as a primary tool in guarding the
human rights of the child. The mental health consequences of child
abuse, such as depression and suicide, were highlighted showing the
importance of involving the mental health community. Furthermore,
the issue of substance abuse and its association with family violence
was stressed. In all these areas, WHO is committed to a concerted
effort to support child abuse prevention.

Welcome remarks

Dr. Claude Romer, Coordinator, Violence and Injury Prevention Team,

WHO, welcomed participants and thanked them for taking the time to
assist WHO in the initial stage of its work on child abuse and neglect. He
underlined the importance of a science-based public health approach
towards the prevention of violence. WHO has already embarked on
work in several related areas, including domestic violence against
women. He described the consultation as an important step, as WHO
takes up the issue of children's security and protection on a global
scale. Research is now required to understand how the pieces fit
together and how to generate reliable and valid data. Crucial issues
such as risk factor analyses, policy development and resource
mobilization need to be addressed. WHO will tackle the issue using a
multi-sectoral approach to define a framework for action. Dr Romer
concluded by thanking the Global Forum for Health Research for
enabling the consultation to take place.

Mr. Louis Currat, Executive Secretary, Global Forum for Health

Research, echoed the need for more research and a public health
approach to address child abuse and neglect. He noted that the
Consultation was a first step in a global initiative on child abuse
prevention which should complement efforts to address violence
against women.

The Global Forum is an international foundation established to address

the 10-90 dis-equilibrium in research funding. Of the health research
resources spent globally, 90% go to industrialised countries, while the
remaining 10% are used in developing nations. The organization seeks
to remedy the imbalance by ensuring adequate funds are shifted to
countries in most need. The Global Forum is pleased to be able to work
together with WHO on child abuse prevention and violence in general.

7

Kenya -
Multidisciplinary
campaign against
child abuse and
neglect
Following a survey of public
attitudes on child abuse and
neglect and of existing child
abuse programmes in Kenya,
ANPPCAN together with other
partners, mounted a
multidisciplinary campaign in
October 1998. The objectives
of this project are to raise
public awareness, establish
protection and counselling
services and empower victims
and potential victims to
identify potential abusers.
More broadly, this project
hopes to enable government
departments and NGOs to
work together against child
abuse and neglect and to
successfully implement the
National Programme of Action
for Children. To achieve this,
the project has used the mass
and print media, folk media,
posters, pamphlets targeted at
school-going children,
conducted awareness
workshops for care providers
at provincial and district
levels, developed a training
manual on child abuse and
neglect and hosted a national
conference. Some of the major
lessons learned from this
project are:
Awareness raising alone is not
enough
Interventions should include
service provision from the
outset
Child protection must be
community based
Criminalising child abuse is
not an effective strategy in
countries like Kenya
It is vital that youth are
involved in this type of project
Mass media campaigns must
be well planned to counteract
media-directed hype
Opening statements
Dr. Björn Thylefors, Director, Department of Disability/Injury
Prevention and Rehabilitation, spoke on behalf of Dr Yasuhiro
Suzuki, Executive Director, Cluster of Social Change and Mental
Health. He noted that WHO has initiated work in a complex area
where there are no simple answers or interventions. Child abuse
affects not only children, but also women and other family
members and can ruin or contaminate communities, damaging
complex social and familial relations and interactions. The
repercussions of child abuse are felt through increased violence in
the home and at school, decreased school performance, a
subsequent loss of work productivity and increased mental health
disorders. The trail of disaster continues as the abused child shows
an increased chance of becoming an abusing parent. Thus, while
not communicable in the same sense as infectious diseases, child
abuse nevertheless shows transmissibility from one generation to
the next and increased outbreaks under certain conditions, such
as poverty and social and economic stress.
The United Nations Convention on the Rights of the Child (CRC) has
spearheaded increased awareness of the problem. Article 19 of
the CRC protects all children from “all forms of physical or mental
violence, injury or abuse, neglect or negligent treatment,
maltreatment or exploitation, including sexual abuse”. The CRC
provides a basis for WHO to address conditions and practices in life
which have a major influence, not only on disease outcomes, but
also on the physical, mental and social well being of children. This
consultation provides the opportunity for WHO and the Global
Forum for Health Research to begin a strong partnership with the
international health community at large, and to share good
practices and lessons learned. Global solutions require local
collaboration to design and implement culturally acceptable ways
to alleviate the burden on families and children. WHO is committed
to maintaining links around the world and complementing local
efforts with international support as it represents a challenge for the
next millenium.
In his remarks to the Consultation, Dr. Alan Lopez, Coordinator,
Epidemiology and Burden of Disease Team, Cluster of Evidence
and Information for Policy, outlined the health burden attributable
to child maltreatment. The attributable burden is "… for a specific
risk factor, population and time, … the difference between burden
currently observed and the burden that would have been
observed under an alternative population distribution of exposure".
More simply stated, the health burden is the difference between
health outcomes where there is an indicated level of maltreatment
and those where there is not. While attempts at measuring the
health burden of child maltreatment do exist, there is general
agreement that more epidemiological data is needed to validate
current estimates. Dr. Lopez presented the classification of child
abuse from the International Classification of Diseases (ICD) 10 and
an overview of data available on mortality from child abuse based
on the ICD. He was pleased to report that WHO will continue to
develop its activities to measure the health burden of child abuse.
8
In his message to participants, Dr. James Tulloch, Director, Child and
Adolescent Health, presented a human rights perspective on child
health. The primary tool, the CRC defines the totality of children's
human rights including non-discrimination and the right to life. The CRC
is the most widely ratified of all UN conventions. As it is a binding
agreement, countries must report to the Convention and are obliged
to implement its standards. WHO has contributed to the CRC process
by providing child health and health services information and will assist
countries with technical support in implementing recommendations. Dr.
Tulloch indicated that through WHO's role in this monitoring process in
health areas, more emphasis can be directed to the area of child
abuse and neglect involving risk factors and health consequences. In
addition, WHO has drawn upon the CRC to develop health
professionals’ training materials which support a holistic approach to
child health.

Dr. Benedetto Saraceno, Director, Division of Mental Health, began by

emphasizing the universality of child abuse and pointed out that it has
been only in the past years that child abuse and neglect has become
recognized as serious problem. A strong correlation exists between
experiencing child abuse and the later commission of crime, abuse of
drugs and poor social adjustment. Prevention strategies, such as public
education, education for young parents and community support, are
an imperative. The mental health community has an essential role to
play in providing support and training. WHO’s Department of Mental
Health is committed to taking action in this area.

In her opening message, Dr. Mary Jansen, Director, Department of

Substance Abuse, stressed the importance of considering the issue of
child abuse and neglect with the broader issues of family dysfunction
and violence in the community. There is a strong association between
psychoactive substance use - most prominently alcohol - and family
violence. Although the relationship between substance abuse and
violence is not a direct causal one, many links exist. For example,
criminality is associated with illicit drug use; and substance abusers are
marginalized by society. In the UK alcohol use is associated with 50% of
assaults in the home. The consequences of substance abuse for
families and children are often overlooked in national public health
programme responses. Evidence suggests that in developing countries
the principal alcohol related problem for women is the drinking and
related behaviour of men. These women are, in turn, at an increased
risk of attempted suicide, substance abuse and depression, which may
compromise their parenting abilities and has important consequences
for the physical and mental health of their children. The Substance
Abuse Department looks forward to collaborating in future WHO work
in this area.

In her presentation, Dr. Viviana Mangiaterra, Regional Advisor on Child

Health and Development, Regional Office for Europe, summarized the
conclusions and recommendations of the first WHO European Meeting
on Strategies on Child Protection, which was held in October 1998 and
where more that 30 countries were present. At the meeting, there was
consensus on the fact that child abuse and neglect is a public health
issue requiring deeper understanding of the underlying process. The
experts also agreed that the health sector has a key role to play in
recognizing, referring, treating and preventing child abuse. It was

9
 emphasized that health professionals need to work in collaboration
with the other sectors in multidisciplinary teams. Regarding the issue of
definitions, it was stressed that a common definition is needed to serve
as the basis for developing a model and methodology for collecting
comparable data, and producing guidelines for health professionals
which can be widely used by all Member States. Other key messages
of the meeting were the need to refocus awareness, resources and
training in order to offer better family support and create a strong and
safe environment for children and families. Dr Mangiaterra also
presented WHO’s follow-up activities on child abuse and neglect in the
European region.

Dr. Carol Djeddah, Medical Officer responsible for the child abuse
prevention initiative in the Violence and Injury Prevention Team,
welcomed the valued participation of experts from around the globe
and presented the outline of the public health approach to violence
prevention, as endorsed by the World Health Assembly in 1998 (see
Annex 3). The four steps are to:

1. Define the problem - this includes gathering information on the

dimensions of the problem as well as associated statistics detailing
morbidity, mortality and contributing factors.

2. Understand the problem - conduct risk-factor identification and

research.

3. Identify and evaluate interventions.

4. Implement interventions and disseminate information.

The objectives of the consultation

Agree on a definition of child abuse.

Highlight contributing factors, health consequences and related costs of
child abuse.

Review data collection methods for increased accuracy at national and
local levels.

Review good practices for prevention of child abuse and suggest research
orientation.

Reach consensus on practical steps and concrete actions to be taken

10
 WHO – Street children
and substance abuse
Growing support and interest in the prevention of child abuse
and neglect enables the international community to define the The WHO Street Children
public health dimensions of child abuse and to develop Project is of particular
relevant norms and standards. Clear strategies to support relevance to child abuse and
countries in the prevention and management of child abuse neglect. Many children who
must be developed. Child abuse is a highly complex and end up on the street are
multifaceted phenomenon. Dr. Djeddah presented the escaping abuse and neglect at
objectives of the meeting and closed by assuring the group home. Once on the street,
children may be sexually and
that the Violence and Injury Prevention Team will work together
physically exploited in a
with all WHO programmes, both at headquarters and in the
number of ways, including
regions, concerned with child abuse. WHO will continue to work trading sex for drugs or food
with its partners, collaborating centers, community-based for themselves or for their
organizations, governmental and non governmental families. Children may use
organizations and other UN Agencies to combat child abuse. drugs to ease the pain of street
life and subsequently become
more vulnerable from regular
intoxication. The WHO
Project is designed to enable
communities to undertake their
own assessments with ^rapid
assessment and response”
methods and guides.
Community planning includes
representation from various
sectors (e.g. health, welfare,
education, criminal justice),
levels (e.g. family, community
and national) and settings
(e.g. streets, schools, and
workplace). Targeting multiple
risk situations and behaviours,
the Street Children Project,
goes far beyond the health
sector, as community
organization and participation
is an essential ingredient.
Youth and community advisory
groups actually become the
“community gate keepers”.

Research is a tool for action,

to inform, monitoring and
evaluate interventions. Within-
country capacity building is an
essential component and
various guides and training
packages have been developed
to meet this need. There is a
diverse range of model
programmes (best practices)
some of which are non-
governmental, that facilitate
the transfer of technology at
all levels.

11
12
 Working Definition

C
hild abuse can justifiably be viewed as a public health
problem with immediate and long-term health
consequences. Current methods of collecting statistics on
child health and mortality are not adequate measures of
the burden of disease and ill-health resulting from child maltreatment
and abuse. The emotional impact and developmental effects,
although initially unrecognized or unacknowledged, have become
areas of major concern. Emphasis has shifted in many regions of the
world from mortality and easily observable physical trauma to the often
silent, yet inexorable, damage to the optimum development of the
whole child. Harm occurs in all spheres, emotional, physical, social and
sexual, with the subsequent costs and losses to society. Considering the
emerging recognition of child abuse and the lack of valid data to
complement future efforts, definitions are needed to support:

Recognition and diagnosis of the problem

Measurement of risk factors, prevalence and consequences

Design, implementation and evaluation of interventions

Mobilization of resources

A working group was convened on the first day of the consultation and
continued throughout the session to refine the definition. The core
elements of a definition should refer to the child, the abusing agent
and direct and indirect harm caused by the abuse.

The context

A considerable amount of child maltreatment is perpetrated by those

in closest proximity to the child. While it is accepted that maltreatment
can occur because of wider societal systems, organisations and
processes, it is also agreed that a major step in developing prevention
strategies is to recognise those dangers which are in the control of
individuals closest to the child. These individuals are most frequently
family and community members and in some cases strangers whom
the child encounters within their day to day environment. For this
purpose, the family is defined as parents and siblings, or where
applicable, members of the extended family or community as
provided for by local custom and legal guardians or other persons
legally responsible for the child. Members of the community can
include those in occupational relationships with the child (such as
education and health professionals, child caregivers, and employers)
and other persons in a proximal relationship (such as friends of the
family).

The focus of the consultation was initially child abuse in the family
context, yet the pronounced overlap between child abuse in the
family and in the broader society necessitates a broadening of the field
of view. It was also recognized that one definition of child abuse

13
 cannot serve all purposes; for example a definition that would serve to
increase awareness differs from that for service provision, and a
definition for legal purposes differs from that for research. For that
reason a diagnosis must be adaptable and include descriptions of
different types or classifications which can be adapted and/or
expanded on as is appropriate for the setting.

A child is defined in the CRC as ‘Every human being below the age of
18 years unless under the law applicable to the child majority is
attained earlier’. Throughout the consultation the importance of the
CRC in the area of child abuse was emphasised. While Article 19 of the
Convention specifically addresses child abuse and
recommends a broad outline for its identification,
reporting, investigation, treatment, follow-up and
WHO defines health as “a state prevention. Other Articles in the Convention emphasize
of complete physical, mental, and the important role of the health-care community in
social well-being, not merely the monitoring and reporting child abuse, as a channel for
absence of disease…”. advocacy and direct technical support to countries. In its
review of country reports for CRC, WHO highlights these
important issues and suggests practical interventions.
Related areas concerning disabled children, parental responsibilities,
child exploitation, children in armed conflict, child rehabilitation and
others are highlighted by the Articles concerning survival and
development and the right to health care. The Convention, in
discussing multiple rights and responsibilities, emphasises that “rights”
refers to the child’s “ … social, spiritual and moral well being and
physical and mental health and to achievement of fullest possible
individual development in all areas”.

Preamble to the definition

Child abuse has serious physical and psychosocial consequences

which adversely affect health. It refers to any act or failure to act that
violates the rights of the child, that endangers his or her optimum
health, survival or development.

Awareness of cultural factors must remain high as they influence all

aspects of the problem from the occurrence and definition of abuse
through its treatment and to its successful prevention. Any intervention,
to be successful whether for data gathering, prevention or even
increasing public awareness, must take into consideration the cultural
environment in which it is to occur. Background or baseline conditions
beyond the control of families or caretakers, such as poverty,
inaccessible health care, inadequate nutrition, unavailability of
education can be contributing factors to child abuse. Social upheaval
and instability, conflict and war may also contribute to increases in
child abuse and neglect.

14
General definition and proposed classifications

Child abuse or maltreatment constitutes all forms of physical and/or

emotional ill-treatment, sexual abuse, neglect or negligent treatment or
commercial or other exploitation, resulting in actual or potential harm
to the child’s health, survival, development or dignity in the context of a
relationship of responsibility, trust or power.

Physical abuse

Physical abuse of a child is that which results in actual or potential

physical harm from an interaction or lack of an interaction, which is
reasonably within the control of a parent or person in a position of
responsibility, power or trust. There may be a single or repeated
incidents.

Emotional abuse

Emotional abuse includes the failure to provide a developmentally

appropriate, supportive environment, including the availability of a
primary attachment figure, so that the child can develop a stable and
full range of emotional and social competencies commensurate with
her or his personal potentials and in the context of the society in which
the child dwells. There may also be acts towards the child that cause or
have a high probability of causing harm to the child’s health or
physical, mental, spiritual, moral or social development. These acts
must be reasonably within the control of the parent or person in a
relationship of responsibility, trust or power. Acts include restriction of
movement, patterns of belittling, denigrating, scapegoating,
threatening, scaring, discriminating, ridiculing or other non-physical
forms of hostile or rejecting treatment.

Neglect and negligent treatment

Neglect is the failure to provide for the development of the child in all
spheres: health, education, emotional development, nutrition, shelter,
and safe living conditions, in the context of resources reasonably
available to the family or caretakers and causes or has a high
probability of causing harm to the child’s health or physical, mental,
spiritual, moral or social development. This includes the failure to
properly supervise and protect children from harm as much as is
feasible.

Sexual abuse

Child sexual abuse is the involvement of a child in sexual activity that

he or she does not fully comprehend, is unable to give informed
consent to, or for which the child is not developmentally prepared and
cannot give consent, or that violate the laws or social taboos of
society. Child sexual abuse is evidenced by this activity between a
child and an adult or another child who by age or development is in a
relationship of responsibility, trust or power, the activity being intended

15
to gratify or satisfy the needs of the other person. This may include but
is not limited to:

The inducement or coercion of a child to engage in any unlawful

sexual activity.

The exploitative use of child in prostitution or other unlawful sexual
practices.

The exploitative use of children in pornographic performances and
materials.

Exploitation

Commercial or other exploitation of a child refers to use of the child in

work or other activities for the benefit of others. This includes, but is not
limited to, child labour and child prostitution. These activities are to the
detriment of the child’s physical or mental health, education, or
spiritual, moral or social-emotional development.

16
 Health Burden

C
hild abuse has been endemic for generations. It is present in
most societies but often goes unrecognised. Information
about the extent of this form of violence from scientifically
sound studies is still relatively insufficient.

The burden

Injuries, intentional and unintentional, are a large and neglected health

problem in all regions, accounting for 16% of the
global burden of disease in 1998 as measured in
DALYs2. Violence and self-inflicted injuries A recent estimate from WHO
(including suicide) are a major public health shows that 40 million children
concern because of their increasing significance aged 0-14 around the world
within the global disease burden. The burden of ill suffer from abuse and neglect
health caused by child abuse forms a significant and require health and social
portion of the total burden. care.

Health consequences

Increasing knowledge of normal child development and the negative

health consequences of abuse to the individual, family and society,
draws attention to the need to address the problem. The physical,
behavioural and emotional manifestations will vary between children,
depending on the developmental stage at which the abuse occurs
and its severity.

The immeasurable damage in family disruption and individual trauma

to family members and other affected people compounds with its
effects on each of their lives. Because health is more than the absence
of disease, the suffering and decreased quality of life, resulting from
child abuse, is significant.

Health systems

The health care system is well placed to identify and refer victims of
child abuse. An understanding of child abuse as a problem with many
facets suggests that no one person or discipline can effectively
manage cases. All disciplines dealing with children must work together,
to play an active role in the recognition and treatment of abuse. A
multidisciplinary protection team should include representatives from
the medical, mental health, education, social service and legal
professions working with government agencies, NGOs and other key
members of the community to ensure a comprehensive approach to
child abuse prevention, intervention and treatment. Child protection
teams should be active at all levels.

2 The Disability Adjusted Life Year quantify, not only the number of deaths but also the
impact of premature death and disability on a population.

17
 Figure 1: Health consequences of child abuse*

Physical
Physical

Bruises

Bruises and
and welts
welts

Burns/scalds

Burns/scalds Emotional/
Emotional/

Ocular

Ocular damage
damage Sexual
Sexual behavioural
behavioural

Lacerations

Lacerations and
and
abrasions
abrasions
Unwanted

Unwanted
Poor

Poor self-esteem
self-esteem

Fractures

Fractures pregnancy
pregnancy Hyperactivity

Hyperactivity



Abdominal/thoracic

Abdominal/thoracic
STDs

STDs
Self-inflicted

Self-inflicted injuries
injuries
injuries
injuries
HIV/AIDS
HIV/AIDS
Poor
Poor peer
peer relationships


relationships

Poisoning

Poisoning
Morbidity

Morbidity
Feelings

Feelings of
of shame
shame

Asphyxia

Asphyxia due
due to
to /guilt
/guilt

Central

Central nervous
nervous adverse
adverse
Somatic

Somaticdisorders
disorders
system
systeminjuries
injuries reproductive
reproductive
Deterioration

Deterioration in
in school
school

Munchausen

Munchausen health
health performance
performance
syndrome
syndrome bybyproxy
proxy outcomes
outcomes
Eating

Eating disorder
disorder

Depression,

Depression, anxiety
anxiety

Drug/alcohol

Drug/alcohol abuse
abuse

Long-term
Long-term

Developmental

Developmental effects
effects

Disability

Disability

Eating

Eating disorders
disorders

Sleep

Sleep disorders
disorders

Alcohol/drug

Alcohol/drug abuse
abuse
Fatal
Fatal

Depression,

Depression, anxiety
anxiety

Delinquency,

Delinquency, violent
violent
Homicide

Homicide
behaviour
behaviour
Suicide

Suicide

Self

Self destructiveness
destructiveness
Infanticide

Infanticide

Risk

Risk taking
takingbehaviour
behaviour
HIV/AIDS

HIV/AIDS

Increased probability of

Increased probability of
Sex

Sexselective
selectiveabortion
abortion
becoming
becomingan an abusing
abusingparent
parent
Mortality

Mortality due
dueto
to adverse
adverse

Long

Long term
termreproductive
reproductive reproductive
reproductive health
healthoutcomes
outcomes
health
health outcomes
outcomes

Sexual

Sexual dysfunction
dysfunction
Infertility

Infertility

* This is not a comprehensive list, but merely an attempt to highlight some of the most common consequences.

18
 One example of the
inappropriate
medical care for
Financial costs unrecognised cases of
child abuse
While the obvious financial costs for both the short and long term
The story of Rachel, a 24 year
care of victims of child abuse are high, it is the hidden costs along
old woman who had suffered
with the societal costs which are staggering. Some examples are:
from child abuse was presented
to illustrate inappropriate

Medical care and complications medical care and the multiple

Mental health and substance abuse care for victims, missed opportunities for
perpetrators and families treatment and protection. In

Inappropriate medical care for unrecognized abuse (see addition to having been
Rachel’s story) neglected and beaten by both of

Criminal justice systems expenditure her parents, she was sexually

Legal costs abused by her father since the

Social welfare organizations costs age of six, with a resultant

Costs to the educational system caused by poor school pregnancy and unsafe abortion
performance in her teens.

Years of life lost because of death, disability and long-term costs
Because of her apparent
This list is not exhaustive, but reflects some of the components that unhappiness and lack of
friends, she saw a psychiatrist
should be taken into account when calculating costs. This does not
starting at age nine.
take into account all social and economic multiplier effects (i.e. the
Subsequently, she was
impact on productivity and impact on the quality of life). An diagnosed successively as
example is given in Table 1. Additional research, studies and data having depression,
are urgently needed in this area. schizophrenia and borderline
personality disorder and
It is clear that preventive costs are many times less than the received treatments including
combination of treatment and long term costs to the individual, the electroconvulsive therapy and
family and society. antipsychotic drugs. She almost
died from a severe overdosage
Table 1: An example of costs of child abuse and neglect in of drugs.
the United States in 1996 (1997 dollars)
Her profound failure to
Sexual Physical Emotional/ Total
develop a sense of herself as a
neglect worthy and whole human being
Medical spending 140,000,000 430,000,000 5,000,000 570,000,000 as a result of the severe abuse
Mental health 1,570,000,000 1,390,000,000 2,140,000,000 5,110,000,000 and neglect resulted in a life of
Future 540,000,000 2,880,000,000 250,000,000 3,670,000,000
earnings/school misery which she nearly ended.
Public programmes 300,000,000 1,000,000,000 1,750,000,000 3,050,000,000 With the help of several
Property damage - 10,000,000 - 10,000,000 modalities of
Total economic 2,540,000,000 5,720,000,000 4,150,000,000 12,410,000,000
#Cases 223,000 411,000 1,505,700 2,140,122
psychotherapeutic intervention
in her adult life, she appeared
Source: Children’s Safety Network Economics and Insurance Resource Center, at the National to have saved herself and the
Public Services Institute, Landover, MD, 1998. Cost per case from Miller, Cohen and Wiersema promise of a better future.
(1996). All costs were inflated to 1997 US Dollars. Costs were calculated based on incidents
reported in Child Maltreatment 1996, NCANDS, and adjusted for under-reporting using methods
described in Miller, Cohen and Wiersema (1996). The number of professionals
(teachers, health care
providers and mental health
specialists) involved with her
during this abused childhood
represents the number of
missed opportunities for
protecting her and ending the
nightmare existence she lived is
disturbing. If even one of these
child-oriented professionals or
some other individual had been
able to detect the secret abuse
she was subject to, and offer
her protection from her abusive
family, the life of this one child
would have been vastly
19 different.
20
 Contributing Factors

T
he primary goal of a public health approach is to prevent
abuse. The approach combines prevention activities with
interventions designed to promote early identification and care
for victims, as well as preventing the reoccurrence of abuse and
its intergenerational transfer. A multidisciplinary approach, which
promotes responsibility for health at all levels of society, encourages
communication between the sectors and makes use of the strengths of
all disciplines, while avoiding overlap of efforts. The most successful
interventions are based on a thorough understanding of the factors
underlying abuse in any given culture or society.

Child abuse is the result of many factors coming together in a complex

interplay. These contributing elements called risk
factors, increase the likelihood of abuse. Protective Social capital represents the
factors, in contrast, appear to diminish the likelihood degree of social cohesion which
of abuse or its negative consequences. Social capital exists in communities. It refers to
may provide a potent resource, able to ameliorate the processes between people
risk factors either by supporting children or their which establish networks, norms,
families directly or at social or cultural levels. and social trust, and facilitate co-
Resilience refers to the ability of certain children, ordination and co-operation for
unlike others who have also been victimized, to mutual benefit.
recover from those negative experiences. These Health Promotion glossary,
children are able to thrive and progress WHO/HPR/HEP/98.1, WHO, Geneva
developmentally despite their abuse histories.
Interventions need to both decrease risk factors and
promote protective factors.

There is no single factor that can adequately account for the high
levels of child abuse worldwide. Child abuse results from a complex
combination of personal, cultural and social factors. In considering the
many interrelated factors that contribute to child abuse, figure 2
illustrates some of the more important factors operating at four levels.
These levels are individual, the family, the community and broader
societal and cultural values.

Individual level

Studies have shown that parents’ own adverse life experiences and
mental health problems correlate with their abilities to respond to their
children’s needs. Factors that consistently appear as risk factors at the
individual level include substance abuse and a history of abuse as a
child or witnessing the abuse of one's mother.

21
 Figure 2: Multilevel risk factors
Family
Society
Size/density
Parent

Poor

Young age Community socioeconomic

Single parent Family status

Unwanted pregnancy
Social isolation

Poor parenting skills Individual
High levels of

Early exposure to stress
violence
Family

Substance abuse abuse/domestic

Inadequate prenatal care violence history

Physical or mental illness

Relationship problems
Community/society

Non-existent, un-enforced child protection laws
Child
Decreased value of children (minority, disabled, gender)

Sex
Social inequalities

Prematurity
Organized violence (wars, small arms, high crime rates)

Unwanted
High social acceptability of violence

Disabled
Media violence

Cultural norms

Family level

Many elements of family interactions have been shown to correlate

with child abuse. Conflicts and tensions between parents have a
correlation with poor quality parenting, as does domestic violence
against women.

Community/societal level

Abuse occurs as a result of a
combination of risk and protective
factors. In evaluating families, it is
important to consider the
equilibrium between the two.
Many prevention programmes
focus efforts on reinforcing the
child and family protective factors
such as enabling families to deal
with the social stress, promotion of
positive interactions between
children and parents.
The social network or lack thereof, is an important factor
in parents' ability to provide a healthy, non-violent
atmosphere for their children. In the case of teenage
mothers, research has shown that a strong support
network can ameliorate stress from social and personal
circumstances and enhance their coping skills.
Societies in times of conflicts or that have emerged from
wars are particularly vulnerable to outbreaks of
violence. The availability of arms, together with the
negative role of the media and the high level of poverty
and inequity, can exacerbate social and family
violence.

Children, who are mentally or physically ill, disabled or emotionally

dysfunctional may be placed out of the sight of society in institutions.
Numerous qualitative data exists to show that such institutions may be
the site of physical and sexual abuse, as well as neglect. This abuse
may continue for a lifetime.

22
 Cultural values Thailand – Asia works
together to prevent
While there seem to be some very common factors such as the
age of the parent, poor socio-economic status, the presence of
child abuse and
violence in the home, parent exposure to violence and neglect
substance abuse, which increase the chances that child abuse
will occur, some of the most powerful factors are those specific to The Centre for the Protection
of Children's Rights (CPCR)
the culture and society in which the family lives. Therefore, as in
was founded in 1981,
defining and measuring the problem, the assessment of risk
originally to eradicate child
factors and the weight they carry in each cultural situation is of labour exploitation in
prime importance. Thailand. From 1986
onwards, it expanded into
Another way of viewing child abuse and neglect is as a working against all forms of
continuum of culturally-defined and accepted child-rearing child abuse and neglect.
practices. Severe corporal punishment, for example, in some CPCR works in a
cases may be at the extreme end of normal child-rearing multidisciplinary fashion with
customs. a large network of
governmental and non-
Gender inequalities governmental organisations in
Cambodia, China, Laos,
Thailand, Myanmar and
In cultures with a strong son preference, girls may suffer in a
Vietnam in six key areas.
number of ways. High technology sex-determination procedures
enable parents to selectively abort females, thus allowing a
Monitoring the situation
second chance to conceive a male child. For the poorest of child abuse and neglect
families, parents may remove girls from school in order to work at in Thailand and other
home or for money to finance their brothers' education. If there countries in the Mekong
is not enough food to go around, the boy may be the one who sub-region. This includes
receives what little there is, to the detriment of his sisters. The identifying children at risk
same situation may arise for medical care. of abuse and neglect in
most settings such as
Negative valuing of girls also results in harsh consequences. In family, schools, etc.
cultures where dowry is practised, girls may be an economic
Investigation when child
burden to their families. Parents may chose to marry them off at abuse is suspected and/or
a young age, reducing the possibility of unmanageable dowry reported.
demands.
General and legal
protection for the child
victims so they will be
A need for more research secured from re-abuse or
neglect.
Country- and culturally-based studies are needed to provide
Treatment in
information on the relative weight of combinations of factors collaboration with health
resulting in child maltreatment. Research should indicate which service agencies to
factors are proximate or precipitating when superimposed on a provide medical care and
background level of risk combinations. Results will indicate the psycho-social
direction for appropriate preventive activities. Current rehabilitation to the child
knowledge is strongest in the area of physical abuse and victims.
neglect, while there is less information available on risk for sexual
Social re-integration of
and emotional abuse. abused children.

Prevention to build a safe
and caring society for all
A caution:
children. This programme
Compiling lists of general or culturally-specific risks is a necessary first step toward assessing
the interaction of risk and protective circumstances in each family, community and culture. covers various activities
However, theories that propose single factors or combinations of risk factors as invariably such as parental advice
leading directly to child abuse will stigmatise families which fall within the profile and lead to giving, enabling children
missed cases of child abuse, which do not fit the profile. In families where child abuse does with self-protective skills
exist, they may be more likely to hide the abuse as it now carries a public condemnation. In against sexual abuse and
families where it is not present, stigmatisation may translate into marginalization of the family, so on.
including the children.

23
24
 Prevention

Child abuse can be prevented. Interventions can be at the primary,

secondary or tertiary level. Primary prevention attempts to stop the
occurrence of abuse in the population by addressing issues which
affect whole populations, for example education about good
parenting. At secondary level, prevention efforts include interventions
with those at risk, for example, providing special parenting education
to new parents who themselves were abused as children and making
information available about community resources and safety planning.
Finally, tertiary prevention takes place after a problem has occurred to
remediate the effects so that it will not occur again, for example
offering therapeutic care to parents who abuse their children.

In general data shows that the earlier the intervention, the more likely it
is that it will be successful although there is only a little science on the
relative 'benefits' of each intervention. However, it seems that benefits
are most apparent when primary and secondary efforts succeed so
that children are not harmed in the first place.

Interventions must be sustainable and multi-sectoral. The Convention

on the Rights of the Child (CRC) represents a powerful instrument and
forms the basis for the primary prevention. Examples of each type of
prevention activity are described below. Primary, secondary and
tertiary prevention services are necessary for any community to provide
a full continuum of services. Prevention programmes have to be
adapted at country/community level and cost-effectiveness must be
considered when designing interventions.

Table 2: Prevention activities

Primary Secondary Tertiary

 Pre-natal, perinatal
 Perinatal and ongoing
 Early diagnosis

and early childhood identification of at risk
 Proper inter-disciplinary
health care that children and families services to ensure:
improves pregnancy
 Family support such as
 medical treatment, care,
outcomes and home visiting counselling,
strengthen early
 Clearly established referral management and
attachment system of support services support of

 Promoting good
 Substance abuse victims/families
parenting practices treatment programmes
 Reintegration in a child-

 Public awareness
 Community-based, family- friendly
activities ( i.e. through centred support, community/schools
media and assistance and networks
 Adequate child
campaigns)
 Information available protection laws and

 Community education about community child-friendly courts
programmes on CRC resources and safety

 Availability and planning
accessibility of social
 Schools based social
services, supports and services for high stress
networks environment

 School-based activities
towards non violence

25
Singapore – Issues on prevention
Experience from the Child Abuse and Neglect Prevention Standing Committee, Singapore
Children's Society.

A variety of ways are used for prevention in Singapore. These include the development of
parenting skills by “preparation for parenthood” classes, teaching high-school students about
child care and child development, giving adolescents experience in appropriate ways of
managing infants at pre-school and child-care centres and providing parents with information
about normal child development and behaviour.

Families at risk of childrearing difficulties are identified in the perinatal period. By providing
increased amounts of resources to these families identified, it may be possible to reduce the
incidence of abuse, although the potential problems of labelling a group of families as being at
risk for child abuse should be recognised.

Once child abuse is detected, management is aimed at preventing further episodes. This may be
done by relieving the parents of some of the stresses of child rearing by using pre-school and
other child-care services and by linking parents with appropriate community supports.

Currently, there is considerable emphasis on teaching young children about protection

behaviours and concepts such as "good touching and bad touching", "my body is my own" and
"kids can say no". While these concepts are important, all emphasis on prevention should not be
put on the child alone. Programmes need to be coupled with increased public education about
different forms of child abuse, increased education of the medical and legal professions and a
very firm stand by society that child abuse is unacceptable.

In primary prevention, the community's attitude towards child discipline needs to be changed,
and we have completed research on the public attitude towards child abuse. A lot of effort has
also been put into better social planning in the development of new towns - adequate social
services available to needy families, attempts to maintain and preserve the nuclear family
structures, etc.

Although there is a long way to go, the collection of accurate data should be a priority to learn
about the extent of the problems, the characteristics of the families, and the long-term effects on
the children. This information will form the basis for developing further research programmes;
to develop and evaluate treatment and plan preventive measures.

To break the cycle of abuse, treatment services must focus on the child as well as the parent.
They must help children develop feelings of self-worth and learn interpersonal skills and coping
mechanisms which will enable them to provide a more effective level of parenting for their own
children than they may have received in their own childhood.

26
 Good Practices: Hungary – An animation
film on child abuse for
children
In Hungary, the Family, Child, and
Youth Association primarily aims at

A
the prevention of sexual abuse of
children. One of its activities
s a prerequisite to specific child abuse and
includes the use of an animation
neglect interventions, basic needs of families and
film together with discussion. The
communities must be met. These include absence programme uses a film titled
of territorial conflict (war), safe and sufficient water “Chicoca’s Tree” (originally made
supply, effective sanitation, affordable education, in Mexico). With the help of the
affordable quality health services, and sufficient animal story, set in the jungle, the
employment. The foundation for healthy development is a film deals with most of the typical
good start for all babies, from conception, throughout elements of sexual abuse of
childhood. Any actions designed to promote healthy children. It is fairy tale-like, uses
beginnings should also discourage child abuse and neglect. funny language and has a happy
Abuse interventions often began on a small scale, as ending. However, it aims to make
community-based programmes or through health care this tragic subject easier to digest
facilities. Many professionals at health-care facilities have for children. The 30- minute
attempted to actively identify and manage cases of abuse, animation film prepares children for
often despite lack of training or support. the subsequent discussion and
picture drawing as well as helps
them to talk about their experiences.
Finally, appreciation is given to those non-governmental
organizations at local, national and international levels that Professionals projecting the film
have led the way in raising public attention concerning child and steering the discussions learn
abuse, sometimes in spite of public resistance to dealing with how to use the method of co-
the issue. counselling, which involves the
children’s family and teachers to
Country experiences help children comprehend the
trauma they may have experienced.
Drawing upon the country experiences of Brazil, Canada, If the family of a child does not
China, Dominican Republic, France, Germany, Greece, desire such assistance, they can turn
Hungary, Israel, Italy, Japan, Jordan, Kenya, Malaysia, to local family support service,
Senegal, Singapore, Switzerland, Thailand, United Kingdom, family development specialists or
child psychiatrists who will be
United States of America and Zimbabwe good practices
recommended to the family by a
were developed into specific areas that are inter-related.
professional projecting the film.
Any sound practice must include some, if not all, of these
actions. Professionals must go through a
special training for the use of this
Clear policy, protocols and programmes film and are awarded a certificate
which entitles them to the exclusive
In the prevention and care of child abuse, thorough use of the film. Results obtained
knowledge of CRC and active participation by all sectors of during continuous supervision and
society is important. Relevant government ministries and contact are statistically analysed,
NGOs need to work together with communities in an used in studies and published.
interdisciplinary, co-ordinated manner. Governments can
facilitate co-ordinated approaches through liaison between This approach has proved effective
from both a professional and
relevant ministries. Their effectiveness depends on high
financial point of view. The
standards of policy, protocols and programmes for each
preventive significance is
agency. Protocols must be tailored to the child's needs and immeasurable, but it is generally felt
be culturally sensitive. Clear roles and leadership, lines of that those children participating in
communication and mechanisms for co-ordination must be the programme will become more
developed and articulated. Culturally-adapted guidelines, body-and self-confident, be able to
protocols and measurement standards need to be protect themselves from such types
developed in a multidisciplinary forum. of abuse and will develop healthy
and decisive personalities.

27
Jordan experience –
what works?
The Prevention of Child Abuse
Project in Jordan focuses on
three main areas: community
services and support, child
protection and the health
sector response. Project goals
are:
1. Rehabilitation and
reunification of families at risk
for child abuse, help to victims
through the provision of
services and support to
overcome the ordeal.
2. Establishment of the first
community centre at a refugee
camp where different
programmes are being
implemented in the area of
child abuse: directed to
children, parents, teachers,
counsellors, parent aides as
well as child to child sessions.
3. Establishment of a national
center for the rehabilitation
and protection of children, a
temporary half way house for
abused children and their
families who are at severe
risk, a child hotline, a child
protection team, case
investigation and
management, case
conferences, individual and
group therapy, and research
related to child abuse.
4. Initiation of a survey at the
community center aimed to
assess the demographic
factors concerning the families
living in the refugee camp and
to assess the risk factors that
could lead to children being
abused.
5. Advocate for amendments to
Jordan's penal law to ensure
compliance with the CRC in
terms of child protection and
gender disparities in current
laws.
6. Raise awareness to prevent
child abuse through a public
awareness campaign with
outreach through community
work.
7. Provide help and moral and
financial support to families,
to control conditions that
could lead to abuse."
Data collection, monitoring and evaluation
It is critical to provide accurate and consistent data on child abuse.
A clear and uniform working definition will also help the planning,
monitoring and evaluation of child abuse interventions. Interventions
need to be documented to ensure that lessons learned from the
successes and failures can be shared with others.
Comprehensive services and equity
Comprehensive services include, for child victims, prevention and
protection (see also Table 2), treatment and care and physical and
psychosocial rehabilitation.
Schools, police, hospitals, courts and prisons should have a child
friendly approach. Services for offenders and non-offending care
givers should be provided. Multidisciplinary team work, good
supervision and follow-up will improve management and care of
child abuse and neglect.
Police, community health and social workers, medical and
paramedical staff, teachers and justice personnel should develop a
coordinated comprehensive approach to provide better services in
prevention and care of child abuse and neglect. They should be
trained not only in the management and care of child abuse and
neglect, but also in the identification and prevention.
Capacity building for professionals involved in child-related issues is
essential for comprehensive service provision. Child abuse and
neglect material needs to be integrated into education systems
and the curricula of training facilities for all disciplines.
Working with children
Many prevention programmes focus on reinforcing the child and
family protective factors and the promotion of positive interactions
between children and parents. Child resiliency must be identified,
understood and strengthened.
Working with families, parents and caretakers
It is vital for children’s health, that family members, most specifically
immediate parent or caretaker, have access to reliable information
on the physical and emotional development needs of children. Work
with families and parents includes promoting good parenthood and
parental attachment. Parents need to be helped with their children
in developing feelings of self-worth. Reproductive and sexual health
services, including prenatal and postnatal care are structures,
already in place in many health systems. They can provide
information on child abuse prevention and care. Interventions need
to also target families in difficult situations, such as unemployment,
poverty, low economic status. Home visiting can be a way for
preventing and monitoring child abuse in these families and needs
to be implemented in a manner that avoids stigmatization.
28
Field experience from some countries indicates that selective home visiting for
high risk families, begun prenatally or immediately after birth is highly
effective in preventing subsequent child abuse when regular visits occur over
a long period of time. Based on community and cultural practices this
approach may require adaption and reassessment to guarantee acceptability,
effectivenes and financial feasibility. In some cultures where home visiting is
neither feasible nor acceptable, this may be accomplished through groups or
other community centers or services.

Community involvement

Community-based and women’s organizations, youth associations, and

community and church leaders should be part of abuse prevention
activities. Their partnership in programmes is critical for the sustainability
of child protection and the promotion of the CRC.

Interdisciplinary and multi-sectoral approaches

Police, community health and social services, medical and

paramedical services, education and justice systems should develop a
coordinated comprehensive approach to provide better services in
prevention and care of child abuse and neglect. All personnel and
agencies dealing with child-related issues should form a network for
rapid intervention and integrated services.

Involving policy-makers

Policy-makers can intervene to make a difference in raising the

awareness, facilitating research and studies on cost-effective
measures, providing resources for prevention and early intervention
services to support families, communities and health/social services.

International collaboration and partnership

It has been clear that effective child abuse intervention requires the
collaboration and the contribution of each and every one in society.
From the prevention and protection, through the management and
care of child abuse, various international agencies have been active in
one way or another. Hence, coordinated efforts and the sharing of
experiences and lessons learned will improve the prevention and care
of child abuse. Resources for child abuse interventions are scarce.
Partnerships can alleviate such a situation, whereby best practices and
cost-effective interventions can be made known to potential interested
parties.

29
WHO – Mental health
WHO is active in the areas of improving mother and child interaction, in promoting life skills
education for children and in promoting child-friendly schools. This excerpt briefly outlines these
initiatives and shows how they link closely with child abuse prevention.

The child-friendly schools initiative involves a checklist covering nine areas of the school
environment which affect the psychosocial development of children. The checklist contains
statements which teachers and school authorities may use and answer to examine their school or
schools. Statements cover areas such as:

Does the school promote tolerance and equality between children of different social groups?
Is the learning environment based on active involvement and cooperation?
No physical punishment of children.
Bullying is not tolerated.
Is there a supportive and nurturing environment?
Does the education correspond to the reality of the children's lives?
Does the school help to establish connections between school and family life?
Does the school support children's creativity as well as academic abilities?
Does the school promote the self-esteem and self-confidence of children?

The life-skills initiative deals with the curricula of schools to help children develop the
psychosocial skills and the adaptive positive behaviour, that enables them to deal effectively with
the demands and challenges of everyday life. Generic life skills that are promoted include problem
solving and decision making, critical and creative thinking, communication and interpersonal
skills, self-awareness and empathy, and coping with stress and emotions. Life-skills education can
encompass and combat many social issues such as child abuse, alcohol and substance abuse,
HIV/AIDS and adolescent pregnancy among others.

The project on improving mother-child interaction focuses on encouraging mothers or caregivers

to foster better psychosocial development of their children by communicating, responding and
bonding with them in early infancy. Mothers with difficulty in emotionally bonding with their child
learn how to do this under the guidance of nurses, health visitors and professional staff of maternal
and child health clinics and from other mothers. An emotionally secure infancy is a fundamental
requirement for a stable adulthood.

Psychosocial development of children is one of the priority areas of work of the mental health
promotion and policy team within WHO.

30
 Data collection methods

R
esource utilization assessment requires evaluations in which
epidemiological data play a basic role. Integral to a public
health perspective is the maximisation of resources to ensure
the best possible health for communities. In addition, effective
public health policies and programmes also rely on the availability of
epidemiological data.

Epidemiological data are gathered from studies with different

experimental designs, carried out in specific geographical areas. In
most places, there is little data on the prevalence of child abuse and
on the severity of short- and long-term health consequences.
Inconsistent study methods, combined with a paucity of data, restrict
the comparability of the limited amount of existing data. Because
resources are often allocated in proportion to the available data on
health impacts of specific problems, inappropriate resource allocations
are common. In many countries, the situation is further worsened by an
emphasis on legal aspects of abuse and by interpreting it as a juridical
and administrative problem.

Improving data collection

Improving data collection on child abuse and neglect involves several

difficulties and choices. Data can be collected by official statistics
sources or by ad hoc studies or surveillance. Each is considered for its
advantages, disadvantages and feasibility.

A decision to use surveillance should be based on answers to several

questions. The first query is which statistics to use. Health, judicial,
police, or administration record may all be choices. Recent analyses of
the 51 countries of the WHO European Region points to utilising data
collection from within health care systems. The study revealed that
countries with current health statistics on child abuse and neglect, as
compared to those with judiciary data, had more complete and
relevant professional training and invested greater resources on
prevention and treatment. These results were independent of
variations in economic levels, social organizations and demographic
conditions. Although judicial and police data are important, they
should be considered as complementary, and cannot replace health
data.

Better data for policy

Health data may be invaluable for policy and programme

development. However, exactly which pieces of information are
essential? The answer needs to give information on what is detected,
how is it defined, how is it assessed, and what instruments can be used.
These can be assembled into axes of description, for instance, the kind
of event and the circumstances that surround it, the victim and the

31

Brazil – Experience of
mandatory reporting
Reporting in Brazil is
mandatory for health
professionals and teachers.
Reporting is done to a Council
of Guardians, that has five
members elected by the
community for a two-year
term. Each municipality has at
least one council for every
200,000 inhabitants. The
Council of Guardians is in
charge of protecting the child
using all social means -
temporary shelter, hospitals
and specialized clinics. The
prosecution of the perpetrator
is done by a specialized
prosecutor and the Minors
Judge is only in charge of the
applicable measures like
stripping parental rights,
which is used as a last resort
or adoption, prioritizing in-
country adoption. The Council
of Guardians works on a 24-
hour basis. To be a counsellor
the pre-requisite is to live in
the town and be 18 years old
or older. This Council is in
touch with the various child
protection teams in hospitals,
schools and clinics. All the
protective agents are located
in one facility - police,
prosecutors and the judiciary.
perpetrator, the psychic and physical injuries, and the behavioural
and social harms. Surveys, which draw from official statistics, may be
limited in scope. Often in health statistics, protocols only require the
recording of events that determine physical or psychological injures,
or behavioural or social harm, and not the risk situation.
Classifications
Some epidemiological debate has focused on the axis intendedness
of injury. However, a good clinical diagnosis may be as crucial as
determining the intentions of actions. When a symptom profile fits a
working definition of a child abuse and neglect clinical picture, it
should be noted in the patient records. For example, a baby with
subdural haematomas and retinal haemorrhages can be classified
as shaken baby syndrome, independent of intentionality or
unintentionality of the event. In other words, in the absence of
confirmed intentionality, accurate classifications may be a strong
indicator of abuse.
Child abuse and neglect classifications may be most effective when
similar to those adopted for other health problems. Current standard
tools for disease classification are the International Classification of
Diseases (ICD) and the Diagnostic and Statistics Manual (DSM). The
International Classification of Impairments, Disabilities and Handicaps
(ICIDH) serves a similar purpose for impairments, disabilities and
handicaps. The most recent editions, the ICD (10) and the DSM (IV)
refer to child abuse and neglect, but are not comprehensive in
approach to collecting information on, for example, acute events
and medium and long-term consequences.
The International Classification for External Causes of Injuries (ICECI) is
intended to provide an in-depth tool for reporting cases of externally
caused injuries, including those resulting from child abuse and
neglect. WHO, in collaboration with the Consumer Safety Institute,
Netherlands, is co-ordinating the development and testing of ICECI.
This standardised data collection tool is designed to complement
the International Classification of Diseases (ICD). Although the ICECI
is based on the ICD, it contains a larger number of data elements,
promoting a more in-depth standard of data collection. Its release is
planned for early 2000.
Mortality rates
Another area where standardized recording tools are essential is the
recording of deaths caused by child abuse and neglect. Mortality
rates provide only a crude estimate of a population's health, and of
levels of child abuse and neglect. Mortality rates from child abuse
must be considered as the lowest baseline figure for abuse. Wide
variations in recording standards exist between regions, between
institutions and even between professionals within a single facility.
These variations apply to methods of recording, definitions and
health workers willingness and ability to recognize child abuse as the
cause of death. In many places, infant deaths may not be reported
to health providers in the first place.
32
Ad hoc studies and surveys

After reviewing the most salient issues with official surveillance statistics,
it is important to address the second approach to data collection, ad
hoc studies and surveys. These cannot replace agency-based data,
but are complementary by providing information otherwise not
available. Several methodologies, based on prospective or
retrospective approaches, exist. These may use a variety of monitoring
sources, such as hospitals, courts, child protection services, social
services and self-reported data. Each of these has biases and over- or
under-estimations of the phenomenon.

Ad hoc studies or monitoring demand a multi-sector approach with

simultaneous implementation of the different public and private
services involved at national and local levels. In order to obtain highest
quality data, information collection should reflect the social and
cultural situation. This means that local surveillance networks have to
produce information useful to treat cases and to integrate multi-
sectoral interventions. Local survey networks must parallel intervention
networks and produce information to orient and support concrete
activities. Information with an epidemiological value needs to support
planning and evaluation decisions.

Crucial areas of knowledge

Four crucial areas of knowledge are needed from data collection

systems. First, the level of long-term outcomes indicates the impact
that child abuse and neglect has on public health systems. Long-term
outcomes are also crucial defining factors determining the
effectiveness of interventions. Another important point is the
assessment, treatments and interventions implemented in relation to
resources invested. These can contribute to estimates of the resources
that communities invest in order to deal with child abuse, and are
therefore important for the computation of costs in economic analyses.
Third, because child abuse and neglect often takes place within a
family environment, an understanding of the conditions of those
families, in comparison to others, may be vital. Family background,
composition, social and health problems and available resources
represent elements to understand better the distribution of protective
and risk factors in the community, orienting prevention activities. Finally,
effectiveness in prevention and rehabilitation are the most telling
indicators of the success of interventions. Victim rehabilitation and
decreases in levels of child abuse reveal all about the success of
activities.

33
Zimbabwe – insights into a comprehensive and effective response
The Training and Research Support Centre (TARSC) of the Child and Law Project in Zimbabwe undertook
a participatory and multi-sectoral response to child sexual abuse. Recognition of child sexual abuse has
only evolved recently as a grave and self-perpetuating problem in Zimbabwe. No systematic national
research has been conducted to determine prevalence rates. Only small, local research has been
documented. Building on this information, TARSC embarked on participatory research among rural and
urban groups across the country. A reference group of individuals and professionals from the affected
communities first established the particular aspect of child abuse to be studied. It was decided that using a
new education philosophy, ‘education for social change’, areas of concern would be identified by the
communities, enabling reflection on causes and participatory strategies for action. Role play, drama,
pictures and conversations were used to draw out the communities’ views, experiences and perceptions
around child sexual abuse. The groups consulted during this process were youth in and out of school, adult
men and women, professionals, community leaders and government, and NGOs active in children’s issues.
A two-stage process collected views about children and their rights, the extent, nature, forms and causes of
sexual abuse of children as well as what can be done to prevent, detect, report and manage the problem.

During this research process, consultative meetings were held with the reference group to monitor progress
and a leaflet detailing stage one results was prepared in English and Shona, the local language. These
groups later developed and implemented action programmes. Professionals, having been involved from the
beginning of the study, became a part of the overall collective group working together at each stage of the
development process, instead of being brought in at the end to deliver a service. Following evaluation
findings, many activities were implemented to prevent child abuse and neglect. Two examples are the
school information programme and the legal programme. TARSC implemented the school information
programme with the Ministry of Health and Child Welfare, focusing on training, capacity building and
development of training materials for school psychologists, heads and teachers, administrative staff and
children.

Together with the Ministry of Justice, Legal and Parliamentary Affairs, TARSC initiatiated a legal
programme. Plans included the establishment of multisectoral training on child victim-friendly courts, a
national committee including defence council, public prosecutors, magistrates, doctors, psychologists,
nurses, police and NGOs, and courses for trainee lawyers and reporting protocols. For abusers, a
committee has been set up to investigate the possibility of pre-trial diversion for juvenile sexual offenders,
training of prison officers, police and public prosecutors on management of young sexual offenders,
training and a review of sentencing patterns.

Innovative initiatives have also been launched on the subject of public awareness, health professional
awareness and crisis intervention

34
Recommendations

C
hild abuse prevention is an issue in which health and related
professionals need to take on the full responsibility of their
role in identifying and treating victims and preventing its
occurrence. Policy makers should be involved at an early
stage to ensure commitment. Efforts to prevent child abuse must be
developed in partnership between governments, civil society, non-
governmental organizations, international organizations, universities,
community groups, and scientists. The following recommendations
should be implemented in a child-focused, family-centred,
community-based and culturally adapted way. The prevention of child
abuse should be integrated into existing efforts to prevent and combat
other forms of violence, including domestic violence against women.

The United Nations Convention on the Rights of the Child must form the
basis for actions against child abuse. The convention sets out the rights
of children and is the most widely ratified of all United Nations
conventions. This provides a common ground for countries to work
towards the elimination of child abuse.

Research

Research will contribute to a science-based approach to child abuse

prevention and provide ethically-acceptable guidance for effective,
efficient and sustainable strategies. Research on child abuse
prevention, has until recently, been scarce. Research should represent
an ongoing activity and improve the understanding on:

Health burden

Risk and protective factors

Health systems/costs

Monitoring and evaluation

Data Collection

Previous attempts to assess the magnitude and consequences of child

abuse worldwide have been inadequate. There is a need to provide
technical support for collecting evidence at both the national and
international level.

Standardized assessment instruments for prevalence,

consequences and cost assessment should be developed. Tools
should be adapted to country and community needs.

A worldwide data-bank for the collection of data on child abuse

should be developed and maintained.

35
Good practices

To strenghten ways of preventing child abuse there is a need to identify

public health policies and programmes aimed at prevention at
primary, secondary and tertiary levels.

Tools for monitoring and evaluating programmes should be

developed and adapted.

Guidelines on good practices should be developed for adaptation

worldwide.

Advocacy

International awareness and concern for child abuse as a public health

issue must be advocated at every level using all advocacy channels
with a special focus on networking. Child abuse must be linked to
existing networks and work on domestic violence against women.

A global electronic discussion network on child abuse should be

developed.

Policy

The WHO definition on child abuse should be adapted to country

situations.

Policy should have an interdisciplinary and collaborative approach

that permits the involvement of the medical, mental health,
education, police, social services and legal professions. Policies
should focus on prevention, rehabilitation and care.

Child abuse is a public health issue and activities for its prevention
should be incorporated at national level into existing public health
policy, programming and budgets.

Guidelines, protocols and measurement standards need to be

developed by consensus in a multidisciplinary form. Clear roles and
leadership, lines of communication and mechanisms for
coordination must be developed and articulated.

Appropriate legislation should be developed and introduced with

the various groups concerned and should be accompanied by
appropriate information, education, training and prevention
activities.

Training

Child abuse training material needs to be developed and integrated

into the education system and curricula of all relevant disciplines.

Training guidelines should be developed to enable professionals to

identify abuse and those at risk of abuse, to manage and refer
cases appropriately and to increase knowledge of existing
interventions available at family and community level.

36
Recommendations to WHO

WHO should continue to promote the issue of child abuse using a

public health approach, within the United Nations Convention on
the Rights of the Child.

WHO should continue to collaborate with United Nations agencies

and non-governmental organisations concerned with child abuse
and violence against women.

WHO should continue to develop norms and standards in the area

of child abuse and domestic violence against women. It should
submit the adopted definition and classifications for child abuse for
consideration in the next revision of International Classification of
Diseases (ICD) and the International Classification of External
Causes of Injuries (ICECI).

WHO should contribute to the development of standardised

assessment tool and methodologies for data collection and
estimation at local and national level.

WHO should ensure the inclusion of child abuse on its research

agenda.

WHO should promote the quantification of health burden, including

health consequences and costs of child abuse.

WHO should develop guidelines on good practices for adaptation

worldwide. This should include tools to evaluate interventions and
disseminate information on good practices.

WHO, through its regional offices, should promote the collection

and dissemination of information.

WHO, through its regional offices and other partners should develop
and test training materials suitable for use at regional and country
level and promote their incorporation into training curricula for
health workers.

WHO should provide technical support for the development of

regional and national policies and programmes for the prevention
of child abuse.

WHO should raise additional funds to ensure that an Initiative on

child abuse prevention can be carried out.

WHO should establish a global electronic discussion network on

child abuse.

37
38
 Annex 1: List of Participants

Dr. Helen Agathonos-Georgopoulou, Dept. of Family Relations, Centre of Study

and Prevention of Child Abuse & Neglect, Institute of Child Health, 7 Fokidos Str.
Athens 11526, Greece. Tel/ Fax: 30 1 779 3648 e-mail: agatinst@otenet.gr

Dr. Paul Bouvier, Service de la Santé de la Jeunesse, Office de la Jeunesse,

Département de l’Instruction publique, 11 rue du Glacis de Rive, C. P. 3682,
1211 Geneva 3, Switzerland. Tel: 7876150 Fax: 787 6117 e-mail:
Paul.Bouvier@etat.ge.ch

Dr. Irene Cheah, Pediatric Institute, Kuala Lumpur Hospital, Jalan Pahang,
Kuala Lumpur, 50586 Malaysia. Tel: 603 290 6321 (direct) 603.2921044 ext. 6114
Fax: 603 2948187 e-mail: igscheah@ppp.nasionet.net

Dr. Tamar Cohen, Meital Israel Centre for Treatment of Child Sexual Abuse, 14,
Ibn Gvirol st. Jerusalem, Israel 92430. Tel: 972 2 5630428 Fax: 972 2 5639042
e-mail: alon@jerusalemexport.com

Dr. Zelided A. De Ruiz, Family Institute of Santo Domingo, Dominican Republic.

Tel: 809 685 7846 Fax: 809 6 885 897 e-mail: lic.zar@codetel.net.do

Dr. Felicity de Zulueta, Traumatic Stress Service, Clinical Treatment Center,

Maudsley Hospital, London SE58AZ, UK. Tel: 44.171.9192969 Fax: 44.171.9193573
e-mail: f.dezulueta@iop.bpmf.ac.uk

Dr. Anne Cohn Donnelly, Adjunct Professor, Nonprofit Management, Kellogg

School of Management, Northwestern University, 1427 Sheridan Road,
Wilmette, Illinois 60091, USA. Tel: 1.847.4673000 Fax: 1.847 491 8525 e-mail: a-
donnelly@nwu.edu

Dr. E Dufourcq, Inspecteur Général des Affaires Sociales, IGAS, 21 rue d’Astorg,
75008 Paris, France. Fax: 33.1.44563784

Dr. Paola Facchin, Epidemiology and Community Medicine Unit, Department

of Pediatrics, University of Padua, Via Giustiniani 3, 35128, Padua, Italy. Tel: 390
498 213 968 Fax: 39.049.8759475 e-mail: facchin@child.unipd.pedi.it

Dr. Franklin Farinati, Federal Foundation of Medical Science Academy, Brazil.

Tel: 55.513318737 Fax:55.51.3330899 e-mail: franklin@cpovo.net

Dr. Tilman Furniss, Chairman of the Dept., Professor of Child & Adolescent
Psychiatry, University Hospital, Münster, Schmeddingstrasse 50148149 Münster,
Germany. Tel: 49 251 8356608 Fax: 49251 8356249 e:mail:
furniss@uni-muenster.de

Professor Jiao Fu Yong, Head, Department of Paediatricts, The Shanxi Provincial

People’s Hospital, Xian, Republic of China. Tel: 86.29.525.1331 ext 2017 Fax:
86.29.523.6987 e-mail: jiaofy@yahoo.com or btsy2sein.sxgb.com.cn

Dr. David Gough, Social Science Research Unit, London University Institute of
Education, 18 Woburn Square, London WC1H 0NS, UK. Tel Direct: 44 171 612
6812
Office: 44 171 612 6397 Fax: 44 171 612 6400 e-mail: d.gough@ioe.ac.uk

39
Dr. Daniel Halpérin, Consultation Interdiscipinaire de Médicine et de Prévention
de la Violence, Hôpital Cantonal, rue Micheli-du-Crest 24, CH-1211 Geneva 14,
Switzerland. Tel:372 96 41 Fax: 372 9645 e-mail: daniel.halperin@hcuge.ch

Dr. Maria Herczog, National Institute of Family and Children, Tuzer Utca 33-35,
Budapest, Hungary. Tel: (area code 1134) 0036 1 4656020 Fax: 361 465 6027
Mobile: 0036 309 710923 e-mail: herczog@mail.datanet.hu

Dr. Lai Yun Ho, Vice Chairman, Child Abuse and Neglect Standing Committee,
Singapore Children’s Society, Yishun Family Service Centre, Block 107, Yishun
Ring Road, 01-233, Singapore 650122. Tel: 65.3259033 Fax: 65 3253036 e-mail:
gnehly@sgh.gov.sg

Ms Wanda M. Hunter, Research Associate Professor, Dept. of Social Medicine,

CB# 7240, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599,
USA. Tel: (919) 962-1136 Fax: (919) 966-7499 e-mail: whunter@med.unc.edu

Ms Naira Khan, Training & Research Support Centre, Coordinator: Child & Law
Project, Project on Sexual Harrassment, 47 Van Praagh Avenue, Milton Park,
Harare, Zimbabwe. Tel: 263 4 705108 Fax: 263 4737 220 e-mail:
nabeel@harare.iafrica.com

Dr. Sanphasit Koompraphant, Director, Centre for the Protection of Children’s

Rights, 185/16 Charansanitwong 12 RD, Bangkokyai, Bangkok 10600, Thailand.
Tel: 66 2 412 1196 or 412 0739 Fax:66 2 412 9833 e-mail: cpcr@internet.ksc.net.th

Dr. Seringne Mor Mbaye, Centre de Guidance Infantile et Familiale de Dakar,

BP 7221 Dakar, Sénégal. Tel: 00221.8233386 Fax: 00221.8245859

Dr. Marcellina Mian, SCAN Programme, Hospital for Sick Children, 555 University
Avenue, Toronto, Ontario, Canada M5S IX8. Tel: 1 416 8135794 Fax: 1 416 813
5846 e-mail: marcellina.mian@sickkids.on.ca

Mrs Hind Khuloqi Nasser, Jordan River Foundation, Director of Jordan River
Children Technical Project, P.O. Box 2943, Amman 11181, Jordan. Tel:
962.6.5933212 ext 404 Fax: 962.6.5933210 e-mail: OCF@nets.com.jo

Dr. Philista Onyango, Sociology Lecturer, ANPPCAN, Regional Lenana, Rose

Avenue off Lemona Road, P O Box 71420, Nairobi, Kenya Tel: 254 2 722496 Fax:
254 2 721999 e-mail: anppcan@arcc.or.ke

Dr. Gene Shelley, Division of Violence Prevention, National Center for Injury
Prevention and Control, Centers for Disease Control and Prevention, 4770
Buford Highway, NW MS K-60, Atlanta, Georgia, USA. Tel: 001 770 488 4284 Fax:
001.770 488 4349 e-mail: gzs5@cdc.gov

Prof. Catherine So-Kum Tang, Psychology Department, The Chinese University

of Hong Kong, Shatin, NT Hong Kong. Tel: 852 260 96503 Fax: 852 260 35019
e-mail: ctang@cuhk.edu.hk

Dr. Corinne Wattam, Lancaster University, United Kingdom. Tel Dir: 441772
893838 Tel Off: 44 1772 201201/894/352 or 00441772 893450/3454 e-mail:
c.wattam@uclan.ac.uk

40
Dr. Toshihiko Yanagawa, Cochrane Injuries Group, Institute of Child Health,
Great Ormond Street Hospital for Children, NHS Trust, 30 Guilford Street, London
WC1N 1EH, UK. Tel: 44.171.2429789 ext 2131 Fax: 44.171.2422723 e-mail:
tyanagawa@mail.wakayama-med.ac.jp

WHO Secretariat

Dr. A. Ball, Medical Officer, Substance Abuse (SAB)

Dr. R. Billington, Team Coordinator, Mental Health (MNH)
Dr. C. Dehlot, Medical Officer, Violence and Injury Prevention (PVI)
Dr. C. Djeddah, Medical Officer, Violence and Injury Prevention (PVI)
Dr. C. Garcia-Moreno, Project Coordinator, Global Programme for Evidence for
Health Policy (GPE)
Dr. M-R. Fox, Medical Officer, Violence and Injury Prevention (PVI)
Ms N. France, Technical Officer, Violence and Injury Prevention (PVI)
Dr. G. Hafez, Director, Health Protection and Promotion, Regional Office for the
Eastern Mediterranean (EMRO)
Dr. M. Jansen, Director, Substance Abuse (SAB)
Dr. E. Krug, Medical Officer, Violence and Injury Prevention (PVI)
Dr. M. Ladjali, Gender Specialist, Women’s Health (WMH)
Dr. R. Lozano, Medical Officer, Evidence and Information for Policy (EIP)
Ms D. Luciani, Associate Professional Officer, Child Health, Regional Office for
Europe (EURO)
Dr. V. Mangiaterra, Regional Advisor for Child Health, Regional Office for
Europe (EURO)
Dr. K. Mbaye, Regional Advisor for Child Health, Regional Office for Africa
(AFRO)
Dr. C. Murray, Director, Global Programme for Evidence for Health Policy (GPE)
Dr. C. Romer, Coordinator, Violence and Injury Prevention (PVI)
Dr. B. Saraceno, Director, Mental Health (MNH)
Mr M. Stahlhofer, Technical Officer, Child and Adolescent Health (CAH)
Dr. Y. Suzuki, Executive Director, Social Change and Mental Health (HSC)
Ms I. Tetford, Technical Officer, Violence and Injury Prevention (PVI)
Dr. B. Thylefors, Director, Disability/Injury Prevention and Rehabilitation (DPR)
Dr. J. Tulloch, Director, Child and Adolescent Health (CAH)
Dr. T. Ustun, Group Leader, Assessment, Classification and Epidemiology (ACE)

Global Forum for Health Research

Mr. L. Currat, Executive Secretary, Global Forum for Health Research

Dr. T. C. Nchinda, Senior Public Health Specialist, Global Forum for Health
Research

41
 Annex 2: List of Presentations
A participatory and multisectoral response to child sexual abuse in
Zimbabwe, Dr. N. Khan
Breaking the cycle, Dr. F. De Zulueta
Child abuse and health: a challenge for WHO, Dr. B. Thylefors
Child abuse and mental health, Dr. B. Saraceno
Child development, adolescent health and human rights, Dr. J. Tulloch
Child protection: strategies in the European region, Dr. V. Mangiaterra
Clinical costs, Dr. D. Halpérin
Current mental health programs towards the prevention of child abuse,
Dr. R. Billington
Data collection and exchange, Dr. R. Lozano
Experience from practice in Singapore, Dr. L-Y. Ho
Experiences in Kenya to protect children, Dr. P. Onyango
Family violence and substance abuse, Dr. M. Jansen
Health consequences, Dr. F. Farinati
Improving methodologies of data collection, Dr. P. Facchin
Lack of attention and action, Dr. M. Herczog
Lessons learned and future action, China, Dr. J. Fu Yong
Methodology and data collection in Japan, Dr. T. Yanagawa
Prediction of physical child maltreatment, Dr. H. Agathonos-
Georgopoulou
Preventing child abuse by focusing on new parent, Dr. A. Cohn
Donnelly
Purpose and objectives of the consultation, Dr. C. Djeddah
Social determinants and risk factors, Dr. T. Cohen
Socio-economic costs of child abuse, Ms W. Hunter
Substance use and vulnerable young people, Dr. A. Ball
The burden attributable to child abuse, Dr. C. Murray
The Jordan experience of child abuse, Dr. H. Nasser
World report on violence, Dr. E. Krug

42
 Annex 3: WHO’s Plan of Action on Violence
Prevention
The Forty-ninth World Health Assembly in resolution WHA49.25 declared
the prevention of violence a public health priority. The following year,
the Fiftieth World Health Assembly passed resolution WHA50.19 which
endorsed the WHO plan of action on violence prevention and health.

The following text is the WHO Plan of Action:

WHO integrated plan of action on violence and

health

This plan is the first step in consolidating the activities of several WHO
programmes concerning violence, and in building a coherent WHO
public health approach to violence and health. During the first three
years the first objective and the highest priority will be better to define
the problem.

Objective 1. To describe the problem (first priority)

WHO will seek to characterize different types of violence, define their

magnitude, and assess the public health consequences: it will establish
operational definitions for different types of violence, with data systems
and methodology, to quantify burden of violence in terms of its impact
on mortality, morbidity and quality of life of the population.

Activities:

to survey the capacities of current data collection systems to

obtain, analyse and use information about violence; and to
develop accurate, affordable and valid measures for collecting
information about non-fatal violence and its costs and
consequences;

to develop a typology and definitions of different types of violence,

related risk behaviour and consequences;

to collect data on deaths from all external causes in order to assess
the accuracy of classification, and to collect accurate
demographic data for calculation of rates;

in collaboration with other sectors concerned, to improve baseline

data on suicide and homicide, especially those coming to the
attention of the health sector, including information on sex, age,
relationship of victim/perpetrator, and circumstances;

to facilitate the development and adaptation of research

methodology to describe and measure violence better in its
different forms, with its determinants and physical, psychological
and social consequences;

to promote and provide technical support for the compilation of

local and national analyses of data on different types of violence,

43
 and for international comparisons (the analyses must be informed
by a gender and equity perspective);

to carry out district- or community-based surveys of violence in

order to determine the nature and extent of interpersonal violence,
especially in relation to women, children and adolescents;

to ensure that the information collected is disseminated and used

appropriately.

Objective 2. To understand the problem: conduct risk-factor

identification and research: to promote research and increase
information on determinants and consequences of violence through all
appropriate technical programmes of the Organization.

Activities:

to strengthen and support research related to violence in all

appropriate WHO programmes;

to advocate the development of research on violence through the

global ACHR and its regional committees;

to use available mechanisms and resources to promote research

"networking" among WHO collaborating centres, nongovernmental
organizations and other institutions as a priority, confirming the
need for a public health approach to violence and health;

to promote research on the costs of violence;

to create an inventory of research activities on health-related

violence in order to facilitate "networking" and the exchange of
data and information;

to organize and disseminate the results of such research so that

they can be effectively used for policy formulation and
programming.

Objective 3. Identification and evaluation of interventions: to

determine measures and programmes aimed at preventing violence
and mitigating its effects, and to assess their effectiveness.

Activities:

to identify and document existing activities for preventing different

forms of violence and for managing their consequences;

to foster the development and evaluation of demonstration

projects, promoting innovative, challenging and non-traditional
responses, in order to determine which methods are effective and
why, and what are the impediments to effective action, with
special attention to community-based interventions;

to assess curricula for conflict resolution and promote their inclusion
in the training of health workers and teachers dealing with children

44
 and adolescents, and to promote the adaptation of such materials
for health education of parents and children.

Objective 4. Programme implementation and dissemination: to

strengthen the capacity, primarily of the health system but also of all
concerned parties on the basis of the evaluation of existing activities, in
order to implement coherent programmes.

Activities:

to provide technical support and guidance to the health sector in

improving the quality, effectiveness, equity and efficiency of
services for those affected by violence, and in particular to devote
attention to the coordination and interfaces of the health sector
with other sectors, in order to ensure that secondary victimization
does not occur;

to promote, as part of the curriculum for training and the continuing
professional development of health professionals at all levels, the
incorporation of an understanding of violence and its health
consequences, as well as the requirements for the provision of
sensitive services;

to adapt and evaluate methods of preventing violence and

managing its health consequences that facilitate the involvement
of families, communities, women and young people, the health
sector and other appropriate sectors, in the analysis, formulation,
implementation and evaluation of locally suitable strategies;

to promote and support community-based approaches in the

prevention of violence, and the management of the
consequences, through coordinated regional and national
intersectoral policies, legislation and services that strengthen the
related capacity of communities;

to promote greater intersectoral involvement in the prevention and

management of violence;

to promote the integration of violence prevention into local

development programmes and efforts to empower communities; to
promote joint projects of developed and developing countries,
given the increased importance of violence as a public health issue
in both North and South, and considering the potential for each to
learn from the other;

to disseminate information and new knowledge generated by data

collection and the results of research as a basis for policy
development and action at all levels.

Resources and means of implementation

If WHO is to respond to the challenge of violence prevention as a

public health priority, complementary and more efficient use of its
resources will be necessary, maximizing its expertise and experience.
WHO will also have to strengthen the role and responsibilities of its
networks of collaborating centres, as well as to increase its cooperation

45
with competent national institutions and nongovernmental
organizations. Furthermore, WHO will have to mobilize additional
extrabudgetary resources, giving priority to the need for investment in
monitoring and surveillance as the foundation for appropriate policies
and cost-effective and efficient programmes. The Organization will
take a lead in mobilizing and coordinating action to prevent and
control violence. In this global endeavour the task force will continue
to monitor the whole process, working in close collaboration with all
interested parties. It will make every effort to develop this new initiative
for violence prevention and health in the framework of the renewed
health-for-all strategy.

Evaluation

At the end of the first three years of activity sufficient data and
experience should have been accumulated to allow for the
formulation of precise goals and quantifiable targets to evaluate the
programme in subsequent years. By that time it should also be possible
to establish operational targets based on the concept of "best
practices". Furthermore, it is likely that authorities will be better able to
determine the areas and circumstances amenable to public health
interventions, either to prevent violence or to mitigate its effects.
Indicators for such an evaluation should have been selected by then.

46
 Annex 4: Agenda

Monday, 29 March

OPENING SESSION
Welcome remarks Dr. C. Romer
Mr. L. Currat
Opening addresses
Child abuse and health: a challenge for WHO Dr. B. Thylefors
The burden attributable to child abuse Dr. C. Murray
Child development, adolescent health and human rights Dr. J. Tulloch
Child abuse and mental health Dr. B. Saraceno
Family violence and substance abuse Dr. M. Jansen
Child protection: strategies in the European region Dr. V. Mangiaterra

Purpose and objectives of the consultation Dr. C. Djeddah

Introduction of participants
Election of officers
Adoption of the agenda

Agenda item 1: Review and agreement on a working definition of child

abuse

Discussant: Dr. C. Wattam

Summary of the pre-consultation e-mail discussion
Definitions, classification and assessment Dr. T. B. Ustun
Defining abuse Dr. C. Wattam

Discussion

Agenda item 1 (continued)

Discussion
Adoption of proposed definition

Agenda item 2: Social determinants, risk factors, health consequences and

related costs

Discussant: Dr. T. Cohen

Summary of the pre-consultation e-mail discussion
Social determinants and risk factors
Health consequences
Dr. F. Farinati
Discussion

Prediction of physical child maltreatment Dr. H. Agathonos-

Georgopoulou
Clinical costs Dr. D. Halpérin
Socio-economic costs Dr. W. Hunter

Discussion

Tuesday, 30 March

Agenda item 3: Review different methodologies to improve data collection at

national/local level

Discussant: Dr. P Facchin

Summary of the pre-consultation e-mail discussion
Improving methodologies of data collection

47
Methodology and data collection in Japan Dr. T. Yanagawa
World report on violence Dr. E. Krug
Data collection and exchange Dr. R. Lozano

Discussion

Agenda item 4: Lessons learned from best practices across the regions

Discussant: Dr. M Mian

Summary of the pre-consultation e-mail discussion
Current mental health programs towards
the prevention of child abuse Dr. R. Billington
Substance use and vulnerable young people Dr. A. Ball

Discussion

A participatory and multisectoral response to

child sexual abuse in Zimbabwe Dr. N. Khan
Experiences in Kenya to protect children Dr. P. Onyango
The Jordan experience of child abuse Dr. H. Nasser

Discussion

Agenda item 4 (continued)

Lack of attention and action

Dr. M. Herczog
Breaking the cycle Dr. F. De Zulueta
Preventing child abuse by focusing on new parent Dr. A. Cohn Donnelly

Discussion

Experience from practice in Singapore Dr. L-Y. Ho

Lessons learned and future action, China Dr. J. Fu Yong

Discussion

Agenda item 5 : Concrete steps to be taken to reduce child abuse

Working groups
1. Working definition
2. Country programming
3. Good practice and lessons learned

Wednesday, 31 March

Agenda item 5 (continued)

Working groups

Agenda item 5 (continued in plenary)

Report back and discussions

Agenda item 6: Turning recommendations into action

Summary and perspectives Dr. M. Mian

Dr. F. de Zulueta
Dr. C. Wattam
Discussion

Closing

48
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