HK J Paediatr (new s er ies) 2000;5:61- 64

Child Abuse and Neglect in Hong Kong

PLS I P

Abstract Heightened awareness of child abuse in Hong Kong dated back to a particularly serious case in 1978.
Since then a multidisciplinary approach to the problem is in place. Physical abuse is the most frequent
form of abuse detected but sexual abuse, rarely reported prior to 1990, had risen to 30% of all cases in
1998. Child neglect is not often established although deaths while children are left unattended continue
to occur. Psychological abuse has been difficult to identify because of its lack of concrete signs. Looking
forward, Hong Kong should seriously consider mandatory reporting by professionals. Training is required
in the recognition of uncommon forms of abuse. Conducting child death reviews is a means to identify
preventabl e causes of unnatural deaths. Focus sho uld not only be on remedial measures b ut also on
prevention. To truly prot ect children in Hong Kong, we need a Child Policy, a comprehensive Child
Ordinance and an independent Child Commission to ensure the policy's implementation.

Key words Child abuse; Neglect

Introduction measures in protecting children.

The awareness of child abuse it self and the different
Oppression of the weak and vulnerable existed probably fo rms of ab use hav e in creased p rog ressively amo ng
as long as manki nd. Henry Kempe1 brought child abuse professionals and the general publ ic. Table 1 sh ows the
to the fo refro nt in the west i n 1962 as "Battered Ch ild recent trend in reports of abuse. The incidence i n Hong
Syndrome". In Hong Kong child abuse was thought to be Kong of 0.6/1000 children 0-17 years4 is low by western
an isolated phenomenon till the Lai Shuk Mee incident in standard. United States in 1994 reported an incidence of
197 8.2 The p ubl ic o utcry l ead to a v olu ntary agency, 9 substantiated o r indicated reports per 1000 chil dren.5
Against C hild Abuse being formed the following year, Wi th out mand at ory rep ort in g and wi th o ur di fferent
1979, appropriately, the International Year of the Child. thresh olds for d iagnosing child abuse, compariso ns are
Since then, much work has been done in the government difficult to make. In any case, each society, because of its
and n on-govern ment sectors. Pro cedural g uidelines for cu lt ural, so cial, econ omi c, geog rap hi c and po lit ical
professionals h andling child abuse cases, l ast revised in backg round, has its own charact eristic p roblems. Some
1 99 8, 3 hav e b een wo rk ed o u t, i ncl ud i n g referral , of those facing Hong Kong are discussed below.
investigations, and mul tidiscipl inary case conferences.
Different serv ices, bot h preventi ve and th erapeutic, are
p ro v i d ed b y g o v e rn men t an d n o n -g o v er n men t Physical Abuse and Corporal Punishment
organizations. Some legislative changes in relation to child
abuse have also been made over the years.Yet much awaits Despite an increase in the proportion of reports of sexual
to be don e as we learn more about the problem in Hong abu se o ver the p ast few years, th e ab solut e nu mber of
Ko ng an d h ow effect iv e o r o therwise are o ur cu rrent children reported as physically abused is still on the rise
(Table 1). With in hospital practice, physical abuse is by
far the most common cause for child abuse admissions. In
a recent analysis,6 physical abuse alone or in combination
Department of Paediatrics, United Christian Hospital, Hong
with other forms of abuse accounted for 87% of suspected
Kong, China
cases admitted to public hospitals.
PLS IP FHKCPaed, FHKAM(Paediatrics)
Although corporal punishment in the penal system was
Correspondence to: Dr PLS IP abolished in 1990 and in schools in 1992, it is still widely
Received November 18, 1999 used at home. Even back in 1983, Lieh-Mak, et al7 studying
Ip 62

cases from Against Child Abuse and a teaching hospital, showed between 7% and 42% of parents left their young
found 81% of p erpetrat ors spank ed their children more children at home to go to wo rk, to shopping or for other
than once a week and 51% considered spanking the most leisure activities at a time when some 30 children a year
effective mode of punishment while none of the controls were dying while unattended. A government consultation
th oug ht so . Sign ifi can tly more perpetrators receiv ed paper to the public in 1991 13 concluded that more parental
ph ysi cal pu nish men t d uri ng their chi ldho od as wel l. edu cati on and suppo rt rather th an l egislati on was t he
Among 100 university students in Hong Kong surveyed answer. Parents' right to work or freedom t o have leisure
by Samuda8 in 1988, 95% said corporal punishment was activities overshadowed the child's right to protection and
used in their homes. Of concern was that one third of the surv i val . The p un i ti v e aspect s o f l eg i slat io n was
students approved of spanking children less than 3 years emphasized whi le legislation could have been seen as a
old. In a public opinion survey in 1996, Lau, et al9 reported means of statin g clearly th e min imum standard of care
79% of adults believed parents had the right to use corporal expected of caretakers. Another general household survey
pu nish men t o n th eir ch ildren and 45% th at it was an in 1 997 15 sh owed the practice had changed litt le with
effectiv e means of discipline. Paren ts do not real ize the chi l d ren as yo u n g as 5 years o r b elo w b ei ng l eft
negative effect of corporal punishment on their children. unattended. Al though the number of child ren 9 years or
A study done by Mok, et al10 in 1999 amongst primary 5 below, who died while unattended came down to 5 in 1997,
students showed that the 40% of children who experienced the number had increased again to 14 in 1998.16 How many
corporal punishment in the previous month often thought children are injured is unknown. Hong Kong needs a multi-
they deserved to be punished. This seemingly justified the pron ged approach to th is probl em. No dou bt pu bl ic
act, but the same children suffered significantly more low edu cation and support are important. The g overnment
self esteem, were more anxious and depressed, resorted should ensure underused occasional child care centres are
t o more sel f-i n fl ict ed harm and h ad more somati c user friendly, practical assistance is given to mutual help
symptoms. Nowadays, physical abuse can be established groups and incentives offered for work-based child care
in case conferences with less external bruises than a decade centres. Land developers could also be required to include
ago, but it is still not uncommon to see professionals argue child care facilities i n their ho using dev elopments, but
phy sical ab use as "i napp ropri ate, harsh an d ex cessive leg islation is st ill an import ant p art of th e package so
p hy si cal p u ni sh men t" (Ip 11 ). Swed en h ad al read y parents know the consequences of their failure to protect
prohibited corporal punishment not only i n institutions th eir chil dren . It is too lat e t o say paren ts are already
but at home in 1979. Since then Finland and a number of penalized after children are injured or lost their lives.
other countries have followed Sweden's lead.12 Hong Kong
sh ould tak e up the challen ge o f demonstrat ing to o ur
children that conflict resolution without violence is both Sexual Abuse
preferable and feasible.
Sex u al ab use was rarely repo rted p rio r t o 1 99 0
accounting for less that 2% of around 450 active cases at
Neglect and Unattended Children any one time. Sin ce t hen, the n umbers have in creased
marked ly. In 1 998 162 or 40% of n ew cases involv ed
Neglect does not feature very high among our cases of sexual abuse.4 Ninety-eight percent were girls with 47%
child abuse, being constantly around 6% (Table 1). This of t he perp et rat ors bei ng k nown to th e vi cti m, 4 1%
refl ects more wh at is viewed as neglect rather than the unrelated and 12% unknown.
actual situation. An example is the problem of ch ildren Much resources have been devoted to the investigation
left unat ten ded . Earl ier survey s13, 14 i n t he lat e 1 980 's of child sexual abuse in response to legislative changes in

Table 1 Active Child Abuse Cases in Hong Kong, Child P rotection Registry, Social Welfare Department
1994 1995 1996 1997 1998
Type of Abuse No. (%) No. (%) No. (%) No. (%) No. (%)
Phys ical 293 (65) 365 (64) 361 (52) 424 (51) 440 (52)
Neglect 26 (6) 25 (4) 44 (6) 51 (6) 51 (6)
Sexual 77 (17) 116 (20) 191 (28) 242 (29) 260 (30)
Psychological 15 (3) 24 (4) 31 (5) 30 (4) 24 (3)
Multiple 39 (9) 46 (8) 63 (9) 86 (10) 80 (9)
Total 450 (100) 576 (100) 690 (100) 833 (100) 855 (100)
63 Child Abuse and Neglect in Hong Kong

1995. Since then, videotaped interviews could be used as Social Welfare Department does no t even record deaths
evidence in court and children's evidence could be accepted from abuse. Uncommon forms of child abuse like shaken
without corroboration. They could also be cross-examined baby syndrome and Munchausen by Proxy are surfacing
i n co urt usin g vi d eo -l in k mo ni to rs. Unfortu nately , in Hon g Ko ng and attentio n has recen tly been drawn
disclosure is often a process rather than a point event. The to ward s child po rnog rap hy and paed oph iles wi th t he
difficu lties have been managing t he very young who is proposed Prevention of Child Pornography Bill and Crimes
un abl e to gi ve a hi sto ry, lik e a to ddler with sex ual ly (Amend ment) Bill 1999. Trai ning in th e recognit ion of
tran smitted disease, or an o lder chi ld who elects no t to these problems is required for all disciplines.
disclose. Some children and families felt devastated when Th at a comp lex probl em li ke chi ld abu se req uires
not enough evidence for prosecution was treated as child multidisciplinary cooperation in its management is well
sexual abu se n ot h avin g occurred. Others h ad t o wait recognized. Hong Kong has started a good basis for such
inordinately lo ng for therapy when therapy is critical at an approach.3 In order to make this a success, we need to
the time of disclosure, not weeks or months later. Whether identify people with the aptitude and interest to manage
th e cases were estab lished or oth erwi se, chi ldren and psycho-social problems involving children and families;
families may be transferred from so cial worker to social people wh o could work with different discipli nes. Such
worker and clinical psychologist to clinical psychologist skills and working relationships are not easy to develop.
as each confines his/her role to investigation, assessment The requirement of rotation every couple of years in some
o r treatmen t. The fru st rati on famil ies ex peri en ce i s disciplines in the name of broadening the staff's experience
understandable. and avoiding burnout wastes staff training and expertise.
Child abuse work is no doubt stressful, but there are ways
to tackle this like staff recognition, staff development and
Psychological Abuse and Neglect flexible working conditions.
Si nce th e fo rmati on o f sp eciali zed u ni ts i n so me
The identification of psychological abuse and neglect discip lines, like the Child Abuse Investigation Un its of
has always been difficult because of the lack of concrete the police, the contrast between working with officers in
signs like bruises. Hence the incidence remains low (Table or outside the units is great. Outside these special units,
1).Yet even before demonstrable harm, persistently placing violence within the family has not been accorded the same
chi ldren in an envi ronment at risk of harm can also be priority as violence outside the family. The identification
defined as abuse.3 In fact , for the frequ ent ly rep ort ed of Medical Coordinators on Child Abuse among Paediatric
physical abuse, external bru ises often disappear rapidly units of public hospitals has also been a step forward, but
but the psychological trauma remains.10 The psychological if their labour intensive work is not recognized, few people
status of our children is demonstrated by the nu mber of would want to continue in the post. We have to accept that
deaths from suicides amongst 10-19 year olds which have to manage child abuse properly, we need an inv estment
been around 20 a year for the last 5 years.16 In a study of of time an d energy.
adolescent health from a regional hospital,17 it was found The sy stem of mu ltidiscipl inary case conference has
that 20% of al l discharges were from "co mplicatio ns of been in place for many years. It is very helpful when used
pregnancy, childbirth, and the puerperium", "symptoms, properly. If it is used to fulfill procedural requirement, or
signs and ill-defined condit ions" and "suicide and self- to shift respo nsibi li ty, t hen i t i s a waste of v alu ab le
inflicted injuries". Hong Ko ng prides herself for having pro fessio nal ti me. Family p artici pation in co nferen ces
one of the lowest infant mortality in the world.18 We need started around 1996. It has a very empowering effect on
to pay attention to our morbidities. the families. We need to put in much more effort before
parents and child could effectively participate in the whole
process of the conference rather t han th e discussion or
Looking Forward explanation of the welfare plan. Voting in case conferences
needs review. The practice originated when a decision has
Despite a rising number of reports of child abuse, under- to be made as to what degree of ph ysical punish ment is
reporting is probably still prevalent as other countries that considered abuse. To use voting on medical diagnoses like
st art ed man dat ory reportin g h ave fo und . Hong Ko ng shaken baby syndrome or sexual abuse of a young child
should seriously consider whether mandatory reporting with sexually transmitted disease is unwarranted.
sh ou ld be in tro duced fo r p ro fessi onals. C hil d Death We are sti ll a l on g way fro m prov id in g ad eq uate
Review is an useful tool to learn about the mo st serious treatment for children who suffered abuse and their family
out come o f abuse so t hat we can target our p revent ive members, no t t o ment ion the offen ders. Encouragi ng
effo rts. Cu rrently the Ch ild Protectio n Registry 4 of the rep ort in g , esp ecial ly o f sexu al ab use, wi t ho u t th e
Ip 64

accomp anying timely therap y and supp ort to deal with over the last two decades but this should only drive us on
the emotio nal turmoil an d threat to t he chil d and non- to advance further in the area of child protection.
offendi ng famil y members, is do in g t hese famili es a
disservice.
Outcome studies of decisions made at case conferences References
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