This document discusses child maltreatment in Malaysia. It provides definitions of different types of child abuse according to WHO, including physical abuse, sexual abuse, emotional abuse, neglect, and exploitation. It then summarizes prevalence rates of different types of abuse in several Southeast Asian countries based on various studies. The document also discusses risk factors for child abuse, signs that should raise suspicion of maltreatment, diagnostic approaches, and features that indicate abusive head trauma versus accidental head injuries in children.

1. Azilah Sulaiman

2. “
”
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
DEFINITION BASED ON WHO’S WORLD REPORT ON VIOLENCE AND HEALTH (2002)

3. 2012

4. 1. Prevalence and incidence of physical abuse – range from 10% (from study of parent in China) to 20.2% (from study
of grade 6 students in Thailand)
2. Prevalence of child sexual abuse ranged from 1.7% in Hong Kong to 11/6% in Pacific Island. For convenience sample
it ranges from 1.2% in Cambodia to 17.1% in Thailand rising to 47% among prostituted women and girls in Thailand
3. Forced sexual intercourse prevalence were higher in girls than boys and especially pronounced in Cambodia –
51.2% girls compared with 1.9% boys reported having been forced to sexual intercourse
4. Prevalence of emotional abuse increased from 61.2% to 78.3% in China suggesting widespread emotional abuse
5. Prevalence of witnessing parental violence overall across all studies noted number of adults who said they had
witnessed physical violence between parents as a child ranged from 6% in adults China to 53% young adult males in
Philippines
6. Child labor prevalence range from 6.5% in Vietnam to 56% in a fishing area in Cambodia. MICS provides data on
percentage of children working in several countries range from 5.4% in Indonesia to 32.4% in Lao People’s
Democratic republic

5. DEFINITIONS:
• Physical Abuse “… 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” (Krug et al., 2002)
• Corporal Punishment : “… any punishment in which physical force is used and intended to cause some
degree of pain or discomfort, however light. Most involves hitting (‘smacking’, ‘slapping’, ‘spanking’)
children, with the hand or with an implement – whip, stick, belt, shoe, wooden spoon, etc. But it can also
involve, for example, kicking, shaking or throwing children, scratching, pinching, burning, scalding or forced
ingestion (for example, washing children’s mouths out with soap or forcing them to swallow hot spices)

6. • 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 to gratify or satisfy the needs of the other person.”
• Emotional Abuse involves “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”
(Krug et al., 2002)

7. • 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” (Krug et al., 2002). Child exploitation also includes the recruitment and
use of children in armed conflict, child trafficking and the sale of children
• Neglect can be defined as “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” (Krug et al., 2002)

8. 2013

9. • The objective of the assessment is to evaluate the level of understanding and adherence to child protection principles defined in
international and national law and policy; the functioning of government agencies at all levels; the operationalization of the policy
framework; and the relevance of the currently established system to the Malaysian context
• Although Malaysia enacted the Child Act in 2001, these new principles and practices have yet to be incorporated. Differential
classification and treatment of child victims of sexual exploitation and undocumented children remain problematic, as well as the lack
of a uniform national adoption law.
• Lack of investment in the child protection system has resulted in insufficient allocation of resources to realize the system envisaged
under the Child Act. The limited number of trained Child Protectors and broader coordination issues also impede the optimal
development of a child protection system
• The number of cases brought to the attention of the authorities remains very low and is almost certainly not representative of the
actual prevalence of abuse and neglect. A number of factors for this were cited by respondents during the interviews including
stigma/shame, the culture of silence within communities, reluctance of extended families to inform authorities, financial reliance on
perpetrators and lack of confidence in the authorities
• In general, the study revealed a sense of commitment of Child Protectors to their important role within the protection system.
However, the findings across all states reviewed showed that they are significantly compromised in their function due to lack of
training and relative inexperience. The majority of police (apart from D11 officers) have not received specific training to recognize the
symptoms of abuse, violence, and neglect, nor do they have special criteria for making a rapid assessment of the risk to a child.
Targeted, skills based training is required to strengthen capacity of staff and officers to implement their obligations under the Child
Act and the CRC

12. Child maltreatment prevention readiness assessment in Malaysia
Country Report 2011
IRENE CHEAH GUAT SIM PAEDIATRIC INSTITUTE, HOSPITAL KUALA
LUMPUR CHOO WAN YUEN UNIVERSITY OF MALAYA

13. Child maltreatment prevention readiness assessment in Malaysia,Country Report 2011
IRENE CHEAH GUAT SIM PAEDIATRIC INSTITUTE, HOSPITAL KUALA LUMPUR CHOO WAN
YUEN UNIVERSITY OF MALAYA

14. WHEN TO SUSPECT MALTREATMENT

15. STEP BY STEP DIAGNOSTIC APPROACH
•Universal screening has yet to show
significant impact on identification of
abused child
•High index of suspicion
•Detailed history followed by meticulous
physical examination

16. Abuse
Somatic
Unreported

18. RISK FACTORS
STRONG:
• Domestic violence
• Reported concurrent child abuse with domestic violence ranges from 22% to 67%
• Substance abuse/mental health disorder in parent/ carer
• Excessive crying and/or frequent tantrums in infancy
• Lack of maturity/poor coping skills in parents/ carer
• Parent/ carer abused as a child

19. WEAK:
• Poor socioeconomic status
• Poverty, economic crisis within family, poor family income, inadequate childcare arrangements, and poor
parental education may contribute towards child physical abuse
• Also a strong significant risk factor for neglect and failure to thrive
• Demanding parent role
• Child with physical disability or mental health problem (especially with challenging behavior) may be at
greater risk
• Low birth weight, twins/multiples associated with greater risks

20. HISTORY SUGGESTIVE OF NAI
• May be challenging
• History – should include the “mechanism” of each injury present
• Suspect NAI if:
a) History of trauma inconsistent with injuries, changing or inconsistent history
b)Present of other unexplained co-existent injuries or previous history of injuries
c) Injuries that DO NOT FIT the developmental age of the child
d)Children known to social services/ from family with high risk factors
e)Faltering growth
f) Poor parent-child bonding
g) Parental attempt at excusing or justifying the injury inappropriately or blaming younger siblings or pet

21. HEAD INJURIES:
• Abusive head trauma (AHT) most
common cause of fatal physical abuse
• Mortality ranged from 11% to 33%
• Proposed as results of:
a) Shaking alone
b)Shaking with impact
c) Impact alone
• Distinguishing AHT from accidental head
trauma need careful interpretation of
history associated with presenting signs
and symptoms

22. •Features to alert AHT includes:
a)Subdural hemorrhage in children <1 year old
(typically small and multiple)
b)Significant head injury with no explanation of trauma,
or with explanation involving low fall or trivial injury
c)Co-existing apnea
d)Co- existing bruising to the head or neck, retinal
hemorrhages and ribs or long bones fracture

23. •Retinal hemorrhage:
a)Involve multiple retinal layers and extending to periphery is highly specific for AHT
(85% of cases)
b)Few retinal hemorrhage confined to posterior pole is non-specific
c)Must exclude other medical causes of retinal hemorrhage
d)May present following accidental high-impact trauma (usually evident on history)
e)Infant <6 weeks of age, may have minor retinal hemorrnage during delivery
especially after assisted delivery

24. SPINAL INJURIES:
•Uncommon
•Should be considered in any child with severe abusive injuries
•Spinal lesion may occur in cervical spine commonly associated with
abusive head injury in younger infants (mean age 5 months) or in the
thoraco-lumbar spine in older toddler (mean age 14months)

25. ABDOMINAL INJURIES:
•Rare- but has high morbidity and mortality
•Predominant in children <5 years old
•Frequently there is delay in seeking treatment
•Most specific blunt injuries to the abdomen due to abuse – hollow viscus injury which
are often associated with other abdominal injury (small bowel and splenic injury) or with
bruising, fractures, torn frenulum, head injury, bites and burns
•Solid organ injury common in both accidental and inflicted injury e.g. MVA

26. FRACTURES:
•1/3 of children <2 years with physical abuse sustained fractures
•Fractures sustained after accident – frequently involved school-age children
•If NO underlying bone disorder – abuse should be excluded
•Abusive fractures have been recorded in every bone or group of bones in body
•DDX includes:
a)Accidental trauma
b)Osteogenesis imperfecta
c)Ostopenia of prematurity
d)Rarer metabolic condition that cause bone fragility

27. SITES REMARKS
RIBS  Strongest predictor of abuse in infant in the absence of pathological cause or
major trauma
 Commonly due to: squeezing of chest or direct blow
 Characteristically multiple and can occur at any points of ribs, most suspicious if
involve posterior part
LONG BONES  Spiral fractures in pre-mobile child very worrying for abuse
 If there is adequate history of trauma in ambulatory children – usually
accidental
METAPHYSEAL  A.k.a corner fracture/ bucket handle fracture/classic metaphyseal lesion
 Highly specific for abuse in children <1 year old
SUPRACONDYLAR  Far more common in accidental injury
SKULL  Simple linear fracture – equally prevalent in abusive and non-abusive trauma
 If diastatic/complex/associated with other injury more common in inflicted
injury

28. • Fractures in different stages of healing
- present in 70% of physically abused child < 1year old, and in 50% of all children

32. ORAL INJURIES:
• Mouth should be fully examined, any missing or abnormal teeth should be recorded
• Commonest  bruise or laceration to lips
• Other possible injuries:
a)Torn frenulum
⁻ Frequently associated with severe or fatal injury (head trauma)
⁻ Suspect abuse if noted bruises over cheek, ears, neck or trunk
⁻ May occur in forced feeding of infant
⁻ Isolated lesion  may occur accidentally from direct blow e.g. swing hitting mouth, fall onto face or sporting injury
b)Dental injuries
⁻ Advisable to seek pediatric dental
⁻ Abusive – forced intrusion or extrusion, microfractures
⁻ Dental neglect (parents/care taker may not aware of it)

33. BRUISES:
•Present in 90% of physically abused child
•Distinguishing between accidental and non-accidental bruise is important
•Accidental:
a)Typically in independently moving child
b)Location – on the front or bony prominence
c)Predominantly on shin and legs
d)Over the head  forehead, nose, upper lip or chin

34. The medical assessment of bruising in suspected child maltreatment cases: A clinical perspective Michelle GK et. al; Canadian Paediatric Society Child and Youth Maltreatment Section Paediatr Child Health 2013;18(8):433-7

35. • Non-accidental:
a) Head and face most common then buttock and over soft tissues
⁻ Slap mark on cheeks and neck extending to scalps  may see mark of hand or fingers
⁻ Bruise to ear unusual in accident
⁻ Injury to mastoid, lower jaw, eyes and mouth is strongly associated with abuse
⁻ Bruise around neck suggest strangulation
b)May reflect the object used, may interspersed with abrasion
c) Tend to be larger and more numerous
d)A pair of small crescent shaped bruise facing each other – pinch mark
e)Over the lower back, buttocks or outer thigh are related often to punishment
f) Over genitalia and inner thigh  sexual abuse or punishment for problem of “toileting”

40. BURNS:
• Scalds:
a) Most common in childhood both accidental and abusive
b)Accidental:
⁻ Usually involve face, head, neck, upper trunk and one limb
⁻ Pattern: mixed depth – deeper at site of contact then became more superficial as it goes down body
⁻ Extent: varies on amount of fluid involved
c) Abuse:
⁻ Typically immersion injury
⁻ In all children <2 years old – full skeletal survey MUST be done
⁻ Distribution: usually lower extremities with or without perineum or buttock involvement, may be sparing of flexures area
⁻ Glove-stocking appearance, absent of splash marks (restraint of child)
⁻ Pattern: usually uniform with clear margin, symmetrical involvement not uncommon/ pour or thrown pattern at unusual
site e.g. back of hand, face, genitals

41. • Contact and caustic burns:
a) Most common non scald burn in abused children
b)Most frequently noted at the back, shoulders, buttocks and usually clearly demarcated
c) Caustic burn- alkali or acid placed in mouth, eye or skin

43. INVESTIGATIONS:
• Children < 2 years old are at particular risk of severe forms of abuse. A more comprehensive
investigation is therefore required in these age group
INITIAL INVESTIGATIONS IN ALL PATIENTS:
• Full blood counts and clotting factor
• LFT and serum amylase to screen for occult intra-abdominal injury
• Photo documentation of any possible injuries
BMJ best practice- child abuse guideline – last updated8th Dec 2014

44. •SKELETAL SURVEY:
a)20 film skeletal survey (including oblique views of ribs) SHOULD be performed in any children <2
years old (AP/LAT skull, AP/LAT axial skeleton and trunk, AP bilateral arms, forearms, hands,
thighs, legs, feet)
b)Full skeletal survey should be done in children with abdominal injury if they are clinically stable
c)If the initial skeletal survey is negative – should repeat (without pelvic and skull) between 10 to 14
days to give further information of ambiguous findings, or identify further fractures and add
information about age of fractures
d)Babygram- not sufficient as it does not provide necessary details to identify fracture

45. SUSPECTED HEAD AND/OR SPINAL INJURY
• Initial investigations
• CT brain:
a) in children < 1year of age, children with neurological signs, & all children with significant head injury
b)Should be considered in abusive abdominal injury
• Dilated fundoscopy
• MRI brain:
a) Should be performed within 3-5 days or soon after the child is stable if any abnormalities are found in
CT brain
b)Should include DWI, T1 & T2 weighted sequence and FLAIR (DWI may help with prognostication)
c) MRI spine should be considered if suspected spine injury as well

46. SUSPECTED SKELETAL INJURY
• Initial investigations
• Spinal x-ray
• Bone scan:
a) highly suspicious cases with negative skeletal survey
b)Good at picking up rib and vertebral fx’s
c) Repeat bone scan at 2 weeks can identify occult injuries
SUSPECTED ORAL INJURY
• Mouth x-ray may reveal dental or mandibular fracture – need pediatric dental team to evaluate

47. ABDOMINO-PELVIC INJURIES:
• Initial investigations
• Ultrasound abdomen – may have limited role in screening for abdominal injuries
• CT abdomen/pelvis – definitive test
BITES
• Forensic swab for DNA
• Microbiological swabs should be taken t identify certain transmissible disaease e.g hepatitis, syphilis, HIV
• ? Referral to forensic odontology

48. BRUISES:
• Initial investigations
• Platelet function studies, vWF platelet function to help rule out bleeding disorder
POISONING:
• Toxicology testing
• Include prescribed drugs for family members, salts, emetics, recreational drugs
• Frequent presentation with purposed accidental ingestion – suspicion of child neglect due to poor
supervision or lack of safety provision at home

49. STEP BY STEP TREATMENT
• Individuals injury should be managed as appropriate, irrespective of whether they are caused by abuse or
accident
• However, if abuse is suspected physician needs to ensure the appropriate search for additional or hidden
injuries
• Should be multidisciplinary approach

50. Published June 2009

54. IMPLICATIONS OF
ABUSE CLUSTERS OF SEVERAL DIMENSIONS (Shekar Sheshadri 2002):
• Role task performance: effects in the form of refusal to attend school or deterioration in
school performance
• Physiological effects: bedwetting, sleep and appetite disturbance
• Physical symptoms: aches and pains, not feeling well
• Emotional reactions: fear, anxiety, depression, suicidal thoughts
• Behavioral manifestations: withdrawal, avoidance, sexualized behavior or distinct
psychiatric syndromes
• Self-perceptions: like negative self-esteems, feeling dirty, different, damaged
• Interpersonal problems: like conflicts, lack of trust, being either people pleasing or
hostile and socially withdrawn

55. • References:
₋ BMJ best practice, child abuse, 2014
₋ Malaysian guideline for the hospital management of child abuse and neglect, June 2009
₋ Regional WHO handbook for medical officers in managing child abuse, 2004
₋ Child Protection System in Malaysia , An Analysis of the System for Prevention and Response to Abuse, Violence and
Exploitation against Children, 2013
₋ NICE clinical guideline; when to suspect child maltreatment, 2009
(short film 'Removed' where a little girl struggles to survive the US foster care system. This movie will open your eyes
about the many children living in this difficult reality by Nathaniel Mathanick)
₋ https://www.youtube.com/watch?v=lOeQUwdAjE0 (removed part 1)
₋ https://www.youtube.com/watch?v=I1fGmEa6WnY (removed part 2)