Any definition of child abuse and neglect assumes a definition of the child. According to the Convention on the Rights of the Child a child is "every human being below the age of 18 years unless under the law applicable to the child majority is attained earlier".
Child abuse and neglect, sometimes also referred to as child maltreatment, is defined in the World Report on Violence and Health as:
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 (WHO, 1999; forthcoming ).
Within the broad definition of child maltreatment, five subtypes are distinguished – these are physical abuse; sexual abuse; neglect and negligent treatment; emotional abuse and exploitation. These sub-categories of child maltreatment, and their definitions as given below, were arrived at following an extensive review of different countries' definitions of child maltreatment and a 1999 WHO Consultation on Child Abuse Prevention .
Physical abuse of a child is that which results in actual or potential physical harm from an interaction or lack of interaction, which is reasonably within the control of a parent or person in a position of responsibility, power, or trust. There may be single or repeated incidents (WHO, 1999).
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 an 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. This may included but not is limited to the inducement or coercion of a child to engage in any unlawful sexual activity; the exploitative use of a child in prostitution or other unlawful sexual practices; the exploitative use of children in pornographic performances and materials (WHO, 1999).
Neglect and negligent treatment is the inattention or omission on the part of the caregiver 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 (WHO, 1999).
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 potential, and in the context of the society in which the child dwells. There may also be acts toward 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, scape-goating, threatening, scaring, discriminating, ridiculing, or other non-physical forms of hostile or rejecting treatment (WHO, 1999).
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, moral or social-emotional development (WHO, 1999).
Burden of Disease
The burden of disease due to child abuse and neglect is made up of deaths, disabilities and illness arising immediately from acts of child maltreatment, plus a much larger burden of disease associated with psychiatric and physical disorders that appear to be causally related to the abuse but which onset often many years after the abuse occurred. However, owing to the taboos which exist in most societies around recognising, disclosing, reporting and recording child maltreatment, both these immediate and delayed health effects are particularly difficult to measure accurately.
According to the World Report on Violence and Health , in the year 2000 an estimated 57,000 children under 15 years of age died by homicide. The homicide rates for children aged 0-4 years were over twice as high as rates among children aged 5-14 years. Head injuries are the most frequent cause of death, followed by abdominal injuries and suffocation.
Many more children are subjected to non-fatal abuse and neglect. For instance, a risk assessment conducted for the 2002 World Report on Violence and Health showed that 8% of male and 25% of female children up to age 18 experience sexual abuse of some kind. Compared to non-abused individuals, adult victims of non-contact sexual abuse are four times more likely to suffer post traumatic stress disorder. Victims of contact sexual abuse are twice as likely to suffer depression, panic disorder and drug abuse. Sexual abuse involving intercourse doubles the chances of becoming depressed, triples the likelihood of developing panic disorder and leaves victims four times more likely to attempt suicide.
Risk factors for child maltreatment, as for all other forms of violence, occur on multiple levels ranging from biological and individual-level factors (such as sex, age and pre-maturity on the part of victims, and a history of being abused and of substance abuse on the part of perpetrators), to societal level risks such as socio-economic inequalities, the strength of the social welfare system and the impact of larger social conflicts and war. As for other forms of violence no single risk factor is by itself sufficient to predict being abused or becoming an abuser, and therefore prevention is most likely to be effective if it targets multiple levels of risk simultaneously.
Owing to the cultural sensitivities that surround child maltreatment, working to identify, understand and prevent it carries particularly high risks in respect of labelling and stigmatization. The 1999 WHO Consultation on Child Abuse Prevention therefore advised the following caution in respect of working with a risk-based approach.
Compiling lists of general or culturally relative risks is a necessary first step toward assessing the interaction of risk and protective circumstances in each family, community and culture. However, theories that propose single factors or combinations of risk factors as invariably leading directly to child abuse will stigmatize families which fall within the profile and lead to missed cases of child abuse, which do not fit the profile. In families where child abuse does exist, they may be more likely to hide the abuse as it now carries a public condemnation. In families where it is not present, stigmatization may translate into marginalization of the family, including the children
Although ratification of the Convention on the Rights of the Child by nearly every country in the world means that there is nearly universal support for the concept of the primary prevention of child abuse and neglect, most interventions focus on tertiary prevention by working with perpetrators and victims after abuse has already occurred. While these tertiary prevention programmes are undoubtedly important in minimizing trauma and reducing future risk for revictimization and re-offending, a great deal more attention is required to build up primary prevention programmes. More specifically, efforts must be made to test whether home visitation and other family support programmes, which in developed country settings have been shown to be effective in reducing both child maltreatment and subsequent risk of youth violence, are equally effective in low- to middle-income developing countries.
Preventing the abuse of children in settings other than the family (such as schools, hospitals, psychiatric institutions and prisons), and by persons other than caregivers (such as members of the clergy, the police and teachers) is also an important area of work, but one which is likely to require very different strategies to those which have proven effective in preventing intra-familial child maltreatment.
Global Level Prevention
At a global level, WHO has two main activities in the area of preventing child maltreatment. First, the preparation of guidelines for an Integrated Multisectoral Approach to Child Abuse Prevention , and second participation in the steering group of the United Nations Global Study of Violence Against Children.
Integrated Multisectoral Approach to Child Abuse Prevention . As noted in the section on risk factors, effective prevention requires multi-level interventions that simultaneously address risk factors at different levels. Furthermore, because the opportunities for prevention are widely spread throughout the different areas that make up social life (such as school, work, the home and recreational settings) effective prevention requires bringing together the different disciplines and sectors that can influence the exposure of people to risk factors and connect them to primary prevention programmes. To help meet this need WHO is collaborating with the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) to prepare a set of guidelines for an Integrated Multisectoral Approach to Child Abuse Prevention . Efforts to prevent child maltreatment have grown with the recognition of interpersonal violence as a global public health priority; scientific evidence that child abuse and neglect can be prevented, and the emergence of human rights conventions specifically concerned with the child. These guidelines for preventing child maltreatment combine the strengths of these different streams. They draw upon the Convention on the Rights of the Child and other human rights documents; they are informed by the best available scientific evidence on the causes, consequences and prevention of child maltreatment, and they are shaped by the principles and practices of public health.
United Nations Global Study of Violence Against Children. At one of its two days of general discussion of the theme of violence against children in 2001, The Committee on the Rights of the Child recommended that the UN secretary-general be requested, through the General Assembly, to conduct an in-depth international study on violence against children (see United Nations General Assembly, A/56/488 ). WHO is working together with UNHCHR and UNICEF in a core partners group that will take primary responsibility within the UN system for supporting the proposed UN Global Study on Violence against Children. It is anticipated that this study will make a major contribution to the prevention of all forms of child maltreatment by highlighting the problem for policy and decision makers and drawing attention to what works in preventing child maltreatment of different types and across different settings.
Regional Level Prevention
WHO regional activities for the prevention of child maltreatment are strongest in three regions, the Africa region (AFRO), the European region (EURO) and the region of the Americas (AMRO).
In AFRO the prevention of child sexual abuse, sexual trafficking and female genital mutilation have been identified as priorities within the reproductive health division.
EURO is developing and piloting in ex-Soviet and transition countries a training package for the prevention of child maltreatment through home visitation, parent training and parent support.
PAHO has published a bibliography on child abuse and maltreatment ("Bibliografía sobre abuso o maltrato infantil"- HCT/AIEPI-44E). The table of contents and introduction are in Spanish while the titles and abstracts included in the bibliography are mainly in English. AMRO is also developing a system to incorporate child maltreatment prevention into programmes for the Integrated Management of Childhood Illness (IMCI) .