Southern Philippines Medical Center

Women and Children Protection Unit

RECOGNIZING and
REPORTING CHILD ABUSE
Imelda M. Mallorca
Clinical Psychologist
Women and Children Protection Unit 
Government’s call to
Action against Domestic
Violence
Department of Health
A.O. 1-B 1997

Women and Children

Protection Units
WCPU (39)
DMC Women and Children
Protection Unit
• 1999
• Support from DOH,
PGH CPU-Advisory
Board Foundation,
Alakbay Foundation,
Development of
Peole’s Foundation
and ……..concerned
citizens
WCPU
Principles of Care

Caring for the family

Protection of the abused from the
perpetrator
Reporting of the abuse incident to proper
authorities
Provision of adequate medical treatment,
psycho-social support
Referral to other agencies for
comprehensive care and support
WCPU

Six programs
1.Health services
2.Networking
3.Training and education
4.Information and advocacy
5.Program management
6.Research
 WOMEN AND CHILDREN
PROTECTION UNIT

OPD E.R. Walk-In

Outpatient Dept. If medically unstable Referral from
managed at E.R. first Inpatient/private

WCPU
What happens when a client comes to
WCPU?

Step 1: Consent
Complete examination
Photographs
Disclose physicians
duty by law to report
cases of abuse or
neglect to DSWD
(children)
 HOW SHOULD A CLIENT BE
PREPARED?

 Tell client what will happen in a language she/he can

understand
 Reassure client the exam is not painful
 Interviewers are friendly people who just want to help
 No wrong answers
 Remind to tell the truth
 Do not promise what you can not give
 2. Provision of care to Clients

2000 – 2009 7937 cases seen

Incest
6 boys, 662 girls, 70 women
Non-Incest
67 boys, 1630 girls, 584 women
Physical/Emotional
571 boys, 547 girls, 3333 women
Patients served: Breakdown of
cases by type of abuse
4500

4000

3500

3000 Sexual
2500 Physical/Emo.
PA/SA
2000 Emo/Psyc.
Neglect
1500
UVA
1000

500

0
2000-2009
Breakdown of cases by
SEX of victim

8000
7000
6000
5000
4000 Female
Male
3000
2000
1000
0
2000-2009
Profile of perpetrators
7621 perpetrators
 Sexual 3072 Physical and Emotional 4549
Multipleperpetrators 324
Unknown perpetrators 628
The rest were known to victim
parent/guardian 783
relative 708
neighbor 1018
spouse/partner 3231
friend/acquaintance 516
others 413
WHAT TO BRING?

Copy of police/NBI statement or Social

Worker’s report copy
Clothing/bedding with blood stains
Favorite toy or game (child)
Step 2 INTAKE INTERVIEW

Information gathering by Social Worker

STEP 3 INTERVIEW

• Interview
regarding
abuse or
neglect
UNICEF donated recording equipment
STEP 4 PHYSICAL EXAM

 ACUTE – within 72 hours

should be seen ASAP
CHRONIC – beyond 72 hours
 Complete P.E.
 Colposcopic exam
 Laboratory:Gram stain,
spermatocytes determination
 STEP 5 SAFETY PLAN

Discuss result of examination

Case plan
Need to file a complaint > issuance of
medical certificate
STEP 6 Mental Health
Screening

Seenby Psychiatrist/Psychologist
How the victim is coping
Need for therapy
 STEP 7 HOME VISITS

Within 10 days, Social Worker visit

home of patient
Schedule for follow-up
DMC-WCPU
Playroom area
 Definition
A CHILD is….

 a person who has not attained

the age of 18, or
 those over but unable to fully
take care of themselves or Source: UNICEF 2007

protect themselves from

abuse, neglect, cruelty,
exploitation or discrimination
because of a physical or
mental disability or condition
CHILDHOOD ABUSE is...
 a repeated pattern of damaging
interactions between parent (or
presumably other significant adults) and
child that becomes typical of the
relationship.

 American Academy of Pediatrics

 Definition

R.A 7610 defined Child abuse and

neglect as:

1.    Psychological and physical abuse,

neglect, cruelty, sexual abuse and
emotional maltreatment;
2.   Any act by deeds or words which debases,
degrades, or demeans the intrinsic worth
and dignity of a child as a human being;
 Definition

R.A 7610 defined Child abuse and neglect

as:

3.   Unreasonable deprivation of his basic

needs for survival, such as food and
shelter;
4. Failure to immediately give medical
treatment to an injured child resulting in
serious impairment of his growth and
development or in his permanent incapacity
or death.
RA 9775: Anti-Child Pornography Act of
2009
Refers to any representation, whether
visual, audio, or written combination
thereof by electronic, mechanical, digital,
optical, magnetic or any other means, of a
child engaged or involved in real or
simulated explicit sexual activities.
RA 3815: Acts of Lasciviousness
The act of having physical contact with
the body of another person for the
purpose of obtaining sexual gratification
other than, or without intention of sexual
intercourse.

 Punishable by Prision Correccional

Old Rape Law RA 8353

 Rape as a crime against  Rape as a crime against

chastity. persons.

 Only “chaste women “ Rape violates a woman’s well

could have a successful being and not just her
prosecution for rape. virginity or purity.

RA 8353: Anti-Rape Law

Penile or traditional rape Sexual Assault

Committed by a man who  Insertion of the penis into

shall have sexual the mouth or anal orifice.
intercourse through force,
 Insertion of any object or
threat or intimidation.
instrument into the genital
or anal orifice.
Penalty: Life Imprisonment
 Penalty: 6 yrs & 1 day

Two Kinds of RAPE

Who can be raped?
 Anyone can be a rape
victim but the incidence of
rape is more rampant in
woman and girls
Who can commit rape?
 MAN or WOMAN
 It is also possible that a
man can rape his own wife.
(marital rape)
 What Constitutes CHILD ABUSE?

When a mother has a child because she

feels life is emotionally incomplete and
wants someone to make it whole.... Her
child is BOUND to be abused..
What Constitutes Child Abuse
When a mother takes psychiatric
medication or drinks alcohol or smokes
for whatever reason, she becomes less
emotionally available to her child, and
this is abuse.
What Constitutes..
When parents fight in front of their child
and use their child as a pawn in the
marriage, even in the mildest and subtlest
of ways.

When parents have not healed from any

of their own traumas of their own
childhood...
they have no choice but to act out these
traumas unconsciously on their child.
What Constitutes..
When parents do not devote 100% of the
best of their life’s energies toward guiding
and nurturing their children, their children
suffer abuse
RECOGNITION
 Red Flags

Physical Injuries:

Central injuries, specifically face,

neck,or throat

Injuries to chest, breast,

abdomen, or genitals
(“ bathing suit” pattern)

Source: Faller,1993.
 Red Flags
Physical Injuries:
 Bilateral injuries or injury to multiple areas
 Contusions, lacerations, abrasions, ecchymoses
 Stab wounds, burns, human bites,
 Fractures (particularly of the nose and
orbits), spiral wrist fractures

Source: Faller,1993.
 Red Flags

Physical Injuries
Substantial delay between time of injury
and presentation for treatment

Multiple injuries in various stages of

healing

Extent or type of injury inconsistent with

patient’s explanation

Source: Faller,1993.
Data Collection

 Interview the parents separately.

 Interview with empathy, patience, and

in a totally non-accusatory manner.
What should you ask?
What happened?
Where?
When?
How?
Who did it?
Are there any witnesses?
What did you do?
Data Collection for health professionals
 Complete Physical Examination
 Bruises, intra-oral lesions, hidden head
lesions under the hair
 Neck, ears
 Abdominal examination
 Genitalia, buttocks, posterior aspects
 Abuse vs. Discipline
Corporal punishment is widely accepted
as a form of child punishment.
Anything harsher than spanking with the
palm of the hand is “crossing the line”
Non violent means like withdrawing
privileges is better.
SHAKEN BABY SYNDROME
Shaken Baby Syndrome (SBS)
 Violent shaking or shaking plus
head impact against a hard or even
soft surface
SBS/SIS
Crying is the usual trigger to shaking
Infant held by chest, upper arms or
neck
Variable duration – 4-20 seconds
2-4 shakes per second
Head rotates in many directions on the
axis of the neck
 The Shaking

Weak Neck Muscles

Normal Large Head
to Body ratio
Violent, sustained
shaking
Infant Brain vs.
Adult Brain
 Infant brain has approximately 25%
more water than the adult brain
 Infant brain has little or no myelin

Result: infant brain is much softer, more

gelatinous than adult and thus more
fragile
Orbital Hemorrhage
not shown
in this diagram
Signs and Symptoms of SBS/SIS
 Variable, depending on duration and
number of shakes, presence of impact
 Continuum from decreased responsiveness,
irritability, lethargy, limpness to:
◦ Seizures, tachypnea, bradycardia,
hypothermia
◦ Coma, death
Multiple Rib Fractures
 Neck Injuries

 Cervical spine injuries reported in

1% – 2%
 Hadley found sub- and epidural bleeding
in 6 fatal cases.
 Serious HT from
Short Falls

 Large literature shows short falls do not

produce serious head trauma except in
cases of epidural hematoma.
 EDH is usually easily distinguishable
from SDH/SAG by CT head scans.
Present Illness
 3 most common triggering events:

Inability to control infant crying

Feeding difficulties
Toileting issues
 Child Sexual Abuse
Definition:
Involvement of children and
adolescents in sexual activities that they
do not understand, that violate social
taboos, and/or to which they cannot give
informed consent.
Any act by a more powerful
person on a more vulnerable
person for the sexual
gratification of the more
powerful person.
CHILD SEXUAL ABUSE-
includes the employment, persuasion,
inducement, enticement or coercion of a
child to engage in, or assist another person
to engage in, sexual intercourse or
lascivious conduct, or the molestation,
prostitution of or incest with children
Characteristics of
Child Sexual Abuse
 Basic characteristics
of sexual abuse
 Children, in general do not like the
sexual contact.
 Sexual gratification of the abuser is the
usual aim of the abuse
 The power/age differential effectively
removes meaningful consent.
 The activity is usually secretive,
collusive and perpetuated by the more
powerful person
Patterns of Sexual Abuse

INTRAFAMILIAL
EXTRAFAMILIAL
INSTITUTIONAL
EXTERNAL
 Patterns of Sexual Abuse
INTRAFAMILIAL
 This includes abuse within the nuclear
and extended family as well as abuse
within adoptive or foster-families.
 2/3 of CSA victims are abused by the
family member. This includes not only
natural parents but also stepparents,
uncles, aunts, cousins, brothers and
sisters.
 Intrafamilial abuse is likely to be
chronic.
EXTRAFAMILIAL

 Includes abuse with adults frequently

known to the child from a a variety of
sources including neighbors and
family friends.
INSTITUTIONAL

 Includes abuse occurring within

schools, residential children’s
establishments, and organizations
both secular and religious.
EXTERNAL

 Includes assaults on children by

strangers in public places, child
abduction.
 Accommodation Syndrome
 The accommodation syndrome is often considered
as a progression of five stages:
Secrecy
Helplessness
Accommodation

Delayed Disclosure
Retraction
Secrecy
 Threats of physical violence
 Withdrawal of love and affection
 Child fears disapproval or
punishment.
 Older children understand the
implications for the family of a police
investigation:
 Imprisonment of family member
 Loss of income

 Shame and the possibility that they may be

held responsible
Helplessness
 Children are unable to stop the
abuse in most cases
 May resist at least initially but they
find that it is less trouble to lie still,
pretend to be sleep and “switch off”.
 Will not cry out or struggle to protect
themselves and is often
misinterpreted as willing compliance,
both by the abuser and society at
large.
 Accommodation
 The child who is able to
accommodate effectively to the
abuse will cover up the reality in
order to protect the parent, but also
to allow herself space for survival.
 Delayed Disclosure
It is likely children never disclose their sexual
abuse or often delayed. Disclosure is
favored by:
 Overwhelmingly impossible situation at home
 Presence of a sensitive friend, teacher or
counselor
 Absences, temporary or permanent, of the
abuser
 Educational initiatives, telephone “hotlines”
 Retraction
 Whatever children, adults and even
professional witnesses may say about
sexual abuse, there is a strong likelihood
that they will reverse it under pressure.
This pattern is most clearly seen when the
abuser is a trusted caregiver, a parent or
parent figure.
FACTS:
1. Children do not tell a lie/lies about the
abuse.
2. It is normal to be normal.
3. Children rarely disclose sexual abuse
immediately after the event.
Annular Hymen

Supine Prone
Crescentic Hymen
Imperforate Hymen
Hymenal tear and edema
 Partial tear of the hymen

2 weeks post injury 12 weeks 18 weeks

Perianal Trauma
Manifold effects of Sexual Abuse
 It is widely believed that sexual abuse is
harmful. Even children,physically mature enough
to experience pleasurable sexual sensations, are
hurt by and suffer from its effects.

 Effects may be short-term or long lasting.

Short-term effects upon the child

 Emotional
Disturbed behavior, soiling, wetting,
self-injury or abnormal emotional states
such as anxiety, depression and withdrawal
Short-term effects upon the child

 Educational and learning

Difficulty with learning, requirement for
special educational provisions or assistance
Short-term effects upon the child

 Social Relationships
Distortion of relationships with adult and
other children; may only be able to relate to
adults of one sex and have no class friends,
or alienate themselves by involving other
children in sexual activities.
 Long-term effects lasting into
adulthood
 Mental Health Problems
Depression, suicide, self-injury, low
self-esteem, alcohol/drug abuse
 Long-term effects lasting into
adulthood
 Sexual Adjustment
Prostitution, marital difficulties,
aversion to sexual contact, strict fertility
control.
 Long-term effects lasting into
adulthood
 Child-rearing difficulties
Reception of cycle of abuse, over
protectiveness, fear of intimacy or
displaying affection
 Long-term effects lasting into
adulthood
 Social Dysfunction
Delinquency, criminal behavior/offenses,
acts of violence, acceptance of “victim role”
 Traumatogenic effects of
child sexual abuse
Traumatic May include:
sexualization Aversive feelings about sex,
Overvaluing sex,
Sexual identity problems.
Behavioral manifestations could range from
hypersexual behaviors to avoidance of negative
sexual encounters

Stigmatization Common manifestations include:

“Damaged goods syndrome”
Feelings of guilt and responsibility for the abuse
Self-destructive behaviors such as substance
abuse, risk-taking acts, self-mutilation, suicidal
gestures and acts, and provocative behavior
designed to elicit punishment

Source: Faller,1993.
 Betrayal Lost of trust in his/her “protectors and nurturers”.
Manifestations:
Anger
Manipulating others
Re-enacting the trauma through subsequent
Involvement in exploitive and damaging relationships
Engaging in angry and acting-out behaviors.
Powerlessness
Behavioral manifestations could be as follows:
Aggression and exploitation of others
Avoidant responses, such as running away
Anxiety, including phobias
Sleep problems
Elimination problems
Eating problems
Revictimization.

Source: Faller,1993.
Common Behavioral Warning Signs in
Sexually Abused Children
Six to Twelve Years Old
Marked change in academic
performance
Loss of concentration
Premature focus on stereotyped roles of
sexuality
Inappropriate display of sexuality or
focus on opposite sex peers.

Increased masturbation, and

masturbation involving the use of objects,
rubbing up against objects such as
furniture, or the insertion of objects in the
vagina.
Inappropriate sex play with other
children.

Increased display of aggression towards

others.
Destructiveness with toys and personal
property
Withdrawal, Isolation, and periods of
listlessness.
 Loss of interest in previously enjoyed
activities.
 Change in sleeping or eating habits.
Noticeable weight loss or gain.
 Wetting or soiling pants in the day or
night.
 Poor self-esteem evidenced in
statements such as “I hate myself” or, “I
wish I were dead”
Adolescence:
◦ Failing grades
◦ Sudden onset of behavioral problems. Such as
drug use, lying, stealing, truancy, or running
away
◦ Suicidal ideation
◦ Self-mutilation, such as excessive body
piercing, tattoos, cutting one’s body
 Drastic change in appearance manifested
in type of clothes worn, hairstyle, etc.
 Withdrawal from family and/or friends
 Dressing in sexually provocative clothes
 Sexual promiscuity
 Increased sleeping
Change in appetite
Marked change in body weight
Marked change in routines and daily
behaviors
Loss of interest in previously enjoyed
activities
 Increased anger and irritability
 Persistence of fears or avoidance or
certain foods, people or situations
 Avoidance of opposite sex relations
 Sense of hopelessness.
 Behavioral Indicators of Abused Children

Children who have been physically abused

TEND to display certain behavioral patterns.
The abused child may display inconsistent
behaviors in an attempt to adapt to an uncertain
environment.
 The behavioral patterns typically fall into 4
categories:
 1. Overly compliant, passive,
undemanding behaviors.

These behaviors are frequently seen in severely

abused children and are often adaptive in helping
the child maintain a “low profile”. Specific
behaviors may include:
Inhibited crying or verbal responses
Overall sad demeanor
Excessive self-control
Overt fear of parents
 2. Extremely aggressive, demanding and
rageful behaviors

These behaviors are more often seen in mildly or

inconsistently abused children whose behavior is
met with inconsistent responses form the
parent(s). Specific behaviors may include:
Hyperactivity
Temper tantrums
Aggressive behaviors
Indiscriminate seeking of affection
 3. Overly adaptive behaviors

These behaviors may be in the form of role reversal in

the parent-child relationship. These patterns are
frequently found in children whose parents
demonstrate unmet emotional needs and look
inappropriately to their child to fulfill these needs.
Specific behaviors may include:
 Inappropriate maturity
 Excessive concern for the parent’s needs
 Overly dependent behaviors
 Poor peer relationships
 4. Lags in development

Many abused children will demonstrate

developmental delays that can not be explained
by organic or congenital causes. These may
include:
Delays in toilet training
Speech and language delays
Learning disabilities
Delays in motor skill development
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases
Who should Report?
 Attending Physician
 Attending Nurse
 Head or Administrator of Health Care
Unit or Institution
IMPORTANT
 Reporter is granted immunity from any liability
arising from reporting
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases

What to Report?
 Suspicion of Child Abuse
 Examinationor treatment of child who
appears to have suffered abuse
 Medical diagnosis of child abuse
 Anyabuse, whether habitual or not,
and regardless of intention
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases
Why Report?
 Toprotect the child from high risk of further
abuse
 To protect siblings or other children at risk
 To notify authorities of suspicion of abuse
 To update national registry of child maltreatment
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases

How to Report?
 Either orally or in writing,
written report preferred
 When absolutely necessary, oral
report suffices
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases
Where to Report?
 To any of the following authorized agencies
 Departmentof Social Welfare and
Development (DSWD)
 Local Government Unit (LGU) social worker
 Child Rights Center (CRC)
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases

Where to Report (2)

 Anti-ChildAbuse Discrimination and
Exploitation Division (ACADED) National
Bureau of Investigation (NBI)
 Women and Children’s Desk, Philippine
National Police
 Rules and Regulations on the
Reporting and Investigation of
Child Abuse Cases

Failure to Report
Sanctions stipulated:

fine of no more than P2,000

Places child at risk for re-injury
Possible referral
agencies/groups/individuals
 Officeand hospital personnel with special training
(e.g. Women and Children Protection Unit of tertiary
government hospitals)
 Law enforcement (police, lawyers, advocates)
 Local hotlines (e.g., Women’s Crisis Center, Gabriela)
Possible referral
agencies/groups/individuals
 Mental health services
 Trained clergy
 Victim advocates
 Legal services
(examples: Women’s Legal Bureau,
WomenLead)
 Social workers
Collaborative Response
Religious Advocates Police
Leaders

Health
Professionals
Employers Friends

Policy Makers Judges & Legal Educators

Professionals
Early childhood trauma are rather like
GHOSTS in the MIND...
 Their presence is felt, influencing our
thoughts, beliefs and actions but they
are rarely seen with clarity.

 ANONYMOUS