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IntroductionIt gives me a great pleasure to release the Fourth “Child Maltreatment Registry” annual report for the period 19 Safar 1434 to 28 Safar 1435 H corresponding to January 1st to December 31st2013. This distinctive national registry provides a centralized data collection mechanism of all reported cases of child maltreatments from 41 Child Protection Centers (CPC) distributed in major hospitals in the kingdom. With these data we will be able to determine the incidence, types, risk factors, epidemiological characteristics, and consequences of child maltreatment. Such data will enable professionals and policy makers to implement evidence- based child maltreatment prevention programs. The report is in Arabic and English and highlights the important information that will be useful to the public health officials, concerned governmental agencies, and to all professionals working with children in the field of medicine, social services, education, psychology , and others. Finally, I would like to extend my thanks and appreciation to all team members of CPC’s for their enthusiasm and dedication, the devoted members of the national committee for their constant advice and support, the Council of Health Services administration and staff for all the logistic support provided, the registry members in King Faisal Specialist Hospital and Research Center for their technical support and data management. Last but not least, this report would not have been possible without the hard work and efforts devoted by the registry task force Dr. Majid Aleissa, chairman of registry task force, Dr. Abdulhameed Al Habib, MOH representative, and Mr. Saad Alsayyari, the team leader of information technology in the National Family Safety Program for gathering all the data in this report.

Chairman of the National Health Committee For Violence and Abuse Maha Almuneef , MD, FAAP

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National Health Committee for Prevention of Violence and Maltreatment

List of Members

Chairperson: Dr. Maha Al Muneef

The National Family Safety Program

Members:Dr. Majid Al Eissa National Guard Health Affairs Dr. AbdulHamid Al Habib Ministry of Health Dr. Salih Al Salhi Ministry of HealthMr. Turki Al Malki Ministry of HealthDr. Ghada Al Sulai Ministry of HealthDr. Anbar Khan Ministry of HealthDr. Sulaiman Al Mohaimeed Armed Forced Medical Services Dr. Maher Al Meshari Armed Forced Medical ServicesDr. Hasan Al Khuraisi Medical Services- Ministry of InteriorDr. Aqeel Al Anazi Medical Services- Ministry of InteriorDr. Husain Al Shamrani King Faisal Hospital and Research Center Dr. AbdulAziz Al Harthi King Faisal Hospital and Research Center Dr. Mohammed Al Othman Ministry of Higher Education Mr. Mansour Al Dohaiman Ministry of Higher EducationDr. Khalid Bazaid Ministry of Higher EducationDr. Mahdi Abumadini Ministry of Higher EducationDr. Amr Al Habshi Ministry of Higher Education Mr. Abdullah Al Mohsen Ministry of Social Affairs

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Executive Summary In 1434-2013, Eighteen child protection teams around the country reported 212 child maltreatment events (172 children).

The majority of the victims are Saudis 87%. Most of the reports were from Riyadh, and Eastern provinces. Parents were the vast majority of identified offenders (72%). The majority of cases were Neglect (46.2%) or physical maltreatment (34.9%). The remaining were Sexual (13.2%) or Emotional maltreatment (5.7%). In total both gender were almost equally affected. However, females were more subjected to physical maltreatment & neglect more than males. Infants less than 1 year (18.8%) are the highest risk age group. Other risk factors include large family size (> 6 members) (13.1%), parental divorce (11.2%), father’s unemployment (11.7%). Almost 1/3 of the cases had unreported maltreatment event in the past. During the past year (107) of children maltreatment events (62.2%) required hospital admissions for treatment or protection and (39.3%) of the admissions were to intensive care units. Twelve children (7%) died due to maltreatment and (10.1%) left hospitals with a chronic illness and (7.6%) left with new disability.

Only 18 of the 41 (44%) child protection teams registered child maltreatment cases in their center last year in only 6 regions of the 13 regions of the kingdom of Saudi Arabia. This indicates that many of the healthcare professionals’ lack of case recognition skills, awareness of referral and substantiation capabilities, or incompliance with the mandatory registry case reporting guidelines.

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Table of Content

Introduction 3 National Health Committee for Prevention of Violence and Maltreatment: List of Members

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Executive Summary 5

Table of Content 6

Registry Functionality 7

Definitions of Child Maltreatment 10

Patterns of Child Maltreatment Cases 12

Demographics of Child Maltreatment Cases 18

• Perpetrators Demographics

• Victims Demographics

• Risk Factors

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25 Responding to Child Maltreatment Cases 26

Complications of Child Maltreatment 32

Distribution of Child Maltreatment Cases

Appendix: Electronic case Registration Form

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Registry Functionality

Case Ascertainment The registry collects data from all Child Protection Teams within the Kingdom of Saudi Arabia. Data Set Data is collected on a three-part registration web-form approved by the National Committee for Prevention of Violence and Maltreatment in Health Sector. The registrar is responsible for the data collection, data entry and validation. Software DesignThe registry is a web-based online registration system with SQL 2005 database as a back end and internet-enable design as a front end. The Web Server used for the design of the Registry is the Microsoft Internet Information Server (IIS) with a DOT NET framework. Forms and software functionalities are designed using Visual Studio.NET application. The database including all the tables, indexes, rules, stored procedures, views and triggers is upgraded and maintained with Microsoft SQL Server 2005 in addition to several security checks, the system is designed as such that there are five kinds of users that can have access to the registry software with defined set of privileges. These users can be categorized as:

• National Registrar: with administrative rights like creating new users, data validation, data deletion and modifying static table information in addition to full control on data entry and update modules.

• Sector Registrar: with access to individual sectors only.

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• Common Registrar: with administrative privileges and access to individual centre’s only.

• Common users: with limited data entry and data modification privileges.

• Browse only users: For browsing the general statistics only without any deletion or data export privileges.

Eُncryption techniques are used for password protection which ensures the secure access to the registry application and thereby protecting patient data and its confidentiality. The facility to change a password for users as well as a facility to recover a forgotten password is also provided within the application. Validation

All data entry forms have validation checks and warning messages that restrict users from making any data entry mistakes. Validation rules are designed as a quality check of data entered in the database. The diagnosis validation rules that are integrated are run routinely to confirm accuracy. Privacy and Confidentiality Issues

Technology now allows personally identifiable health information to be easily collected, correlated and widely transmitted, renewing concerns over privacy and confidentiality. Since the registry is collecting personally identifiable health data, one of the major responsibilities of the registrar is to ensure attention to privacy as a fundamental consideration in collection and maintenance of the information obtained. It is also realized by the registry staff that mistakes in handling or protecting health data might result in revealing the intimate details of innocent people’s lives. The Registries Core Facility ensures that only authorized individuals should handle the raw data and information managed by the registry database, and is accessible to the right people through assigned passwords. Registry data is released to the researcher after proper approval from the registry committee, which makes sure that privacy of individual’s does not supersede other rights or societal goals while carrying out the research.

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In addition to personal effort in safeguarding the privacy and confidentiality, the web-application is also equipped with functionalities to monitor the registry access through the log access report. Also, an “Oath of Confidentiality” is required to be signed by all users of the registry thereby, leaving each user responsible for data security while handling patient’s information.

A common user and a registrar for each child protection team were trained on data entry and management, as well as a sector registrar. Each was given a secured access to the registry after signing the confidentiality oath form.

Registry Technical Team

• Mr. Saad Al Sayyari – Team Leader of Information Technology, NFSP – NGHA. • Mr. Saleh Al Aqeel – Senior Technical Specialist, Head – Technical Databases

Core Facility, BESC, KFSHRC. • Mr. Mansour Baig – Technical Specialist - Technical Databases Core Facility,

BESC, KFSHRC • Ms. Samia Al Hashim – Programmer / Analyst - Department of Biostatistics,

Epidemiology, and Scientific Computing, KFSHRC.

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Case Definition 1- The Child:

Any person who is less than 18 years of age.

2- Violence against the Child:

All forms of physical, sexual, emotional maltreatment, as well as neglect or exploitation of the child by his/her parents or caregivers, which might affect the health, the development, or the dignity of the child.

3- Physical maltreatment:

Infliction of an injury on a child (by beating, shaking, kicking, beating, burning, biting, suffocating, or poisoning) regardless of the perpetrator’s intention. It also includes Munchausen syndrome by proxy, in which the perpetrator fabricates or falsify signs and symptoms of a disease or actually cause it. It also includes Shaken Baby Syndrome in which the infants’ brains (and other organs) are injured secondary to violent shaking resulting in long term deficits.

4- Sexual maltreatment:

Exposing a child to any adult sexual activity or behavior, including oral sexual contact, touching, caressing, or penetration of the child by genitals or any body part or instrument, as well as verbal sexual harassment. It also includes exploitation of the child in prostitution, pornography, and exploitation through communication tools for sexual purposes.

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5- Emotional/psychological maltreatment:

All forms of psychologically destructive behavior by an adult to a child, including: rejecting, isolating, terrorizing, ignoring or corrupting the child, and might result into emotional, psychological and behavioral complications.

6- Neglect:

Failure to provide for affordable child’s basic needs (including food, clothes, vaccination, healthcare, education, and safety) by his/her parents or any other caregiver.

7- Child Protection Team:

A multidisciplinary team composes of a pediatrician or pediatric surgeon, a psychiatrist or psychologist, and a social worker determines the type of violence after thorough evaluation and documents the nature of violence, subtype, and immediate injuries and complications. Currently there are 42 child protection teams in different hospitals across the country.

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Patterns of Child Maltreatment

In 2013 there were 172 maltreated children registered in major hospitals across Saudi Arabia with 212 maltreatment events. It is common that a maltreated child is exposed to more than one type of violence at the same time; hence the difference. Neglect and physical maltreatment were the most common forms with 98 neglect cases (46.2%), and 74 cases of physical maltreatment were reported (34.9%). Sexual maltreatment cases were 28 (13.2%), and emotional maltreatment was the less with 12 cases (5.7%). (Fig.1-1)

Fig. 1-1: Distribution of child maltreatment forms.

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Physical maltreatment and neglect were slightly more common among girls, (54%) and (52%) respectively (Fig.1-2). On the other hand, sexual maltreatment and emotional maltreatment was distributed equally between both genders.

Fig.1-2: Gender distribution of child maltreatment forms.

The distribution of registered cases was expected in a hospital-based registry. Physically maltreated or neglected children are expected to have physical injuries that require medical attention and hospital treatment. Therefore, those cases are more frequently detected and reported to child protection teams. In contrast, physical injuries in sexual maltreatment cases are uncommon which explains the lesser presentation to hospitals and subsequent reporting. Emotional maltreatment cases usually present late to hospitals mostly with mental health complications. Those cases are harder to recognize . Although emotional maltreatment is the most common type of abuse it is often undiagnosed and sometimes overlooked if there is another maltreatment form.

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Fig. 1-3: Physical injuries reported in child maltreatment cases.

Violence-related injuries reported were either internal or external. External injuries included: bruises (37.8%), abrasions (28.4%), burns (27.2%), fractures (9.5%), and lacerations (13.5%). Thoraco-abdominal trauma was the most common reported internal organs injury (20.3%), followed by abusive head trauma (13.5%). (Fig. 1-3).

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Fig. 1-4: Distribution of child neglect subtypes.

The reported neglect subtypes included child’s health neglect (23.1%), nutritional neglect (6.7%), and neglect of child’s education (2.9%). On the other hand, general neglect cases (when more than one form of neglect at least was identified) represented (61.5%) of cases. (5.8%) of reported cases involved abandoned infants (Fig. 1-4). There were no significant gender differences among the subtypes of neglect cases.

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Fig. 1-6: Distribution of child sexual maltreatment subtypes.

Fig. 1-7: Distribution of child sexual maltreatment subtypes.

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The registered sexual maltreatment cases included assault (46.4%) or harassment of the child (53.6%) (Fig. 1-6). There was no significant difference between both gender in the sexual maltreatment subtypes too (Fig. 1-7).

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Demographics of Child Maltreatment Cases

1- Demographics of the Perpetrators:

Fig. 2.1: Distribution of perpetrators in child maltreatment cases by identification.

In (66.5%) of all child maltreatment cases reported the perpetrators were identified or suspected. Yet, in (33.5%) of cases the perpetrators remained unknown (Fig 2.1). Parents represented most of the perpetrators in child maltreatment cases (72.3%), followed by other caregivers (e.g. teachers, drivers, housemaids, domestic workers, and family friends) in (15.6%) of cases, then other relatives (e.g. cousins, uncles, aunties, grandparents) were the perpetrators in (6.4%) of cases. Step-parents and siblings (5.7%) were the least common perpetrators. (Fig. 2.2).

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Fig. 2.2: Distribution of perpetrators in maltreatment cases.

Fig. 2.3: Distribution of perpetrators in physical maltreatment cases.

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Fig. 2.4: Distribution of perpetrators in sexual maltreatment cases.

Children’s parents were the most common perpetrators in all forms of child maltreatment reported except for sexual maltreatment where they were preceded by other caregivers (Fig 2.4). While In neglect cases Children’s parents represented the largest percentage of the abusive.

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2- Demographics of the Victims:

Fig. 2-3: Nationalities of maltreated children.

Fig. 2-4: Gender distribution of all child maltreatment cases.

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The majority of the reported maltreated children in the registry were Saudis (86%) (Fig. 2-3). The is because most of the protection teams follow the government & military hospitals, and the majority of the non-Saudis children, resort to treatment in the private hospitals.

Fig. 2-5: Distribution of child maltreatment cases by children’s age groups.

Infants (less than one year of age) represented (18.8%) of cases. The percentages of maltreated children between 2-5 years of age represented (40.6%) ,and 6-12 years were (37.1%). Adolescents 13-18 years represented (3.5%) .There were no significant differences in gender in these two age groups. (Fig 2-5 and Fig. 2-6).

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Fig. 2-6: Gender distribution of all child maltreatment cases by children’s age groups.

Fig. 2-7: Distribution of children with previous unreported child maltreatment events.

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Fig. 2-8: Gender distribution of children with previous unreported child maltreatment events.

The registry had four cases of repeated maltreatment events after they have been reported in the past. However, the data assigned in the registry indicates that (35.5%) of the maltreated children has had previous unreported maltreatment events; the majority of them were males (59.1%) (Fig.2-7), (Fig. 2-8).

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3- Violence Risk Factors:

Table 2-1: Identified risk factors for child maltreatment.

Risk Factor Total %Large Family (>6 members) 27 13.1%

Father's unemployment 24 11.7%

Divorced Parent 23 11.2%

Chronic Illness/Disability of Child 17 8.3%

Chronic Illness/Disability of Parent 12 5.8%

Disclosed Drug or Alcohol Abuse 9 4.4%

Poverty 9 4.4%

Young Parent 8 3.9%

Others 77 37.4%

Total 206 100.0% Several risk factors for maltreatment have been identified including: large family size – more than 6 members- (13.1%), Father’s unemployment (11.7%), separation of the parents (11.2%), child disability or chronic illness (8.3%) , parents disability or chronic illness (5.8%), disclosed parental abuse of drug or alcohol (4.4%), poverty (4.4%) and young parental age –less than 20 years- (3.9%). In addition to the above, (37.4%) had risk factors other than the above mentioned (Fig 2-1)

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Responding to Child Maltreatment Cases

Treating physicians reported most of the registered child maltreatment cases by (47.9%) & family member (41.3%). Other sources included: Social Services (5.8%), educational facilities (2.5%), and others facilities (2.5%). Fig. 3-1: Distribution of child maltreatment cases by hospital admissions

Among all reported events 107 (62.2%) required hospital admissions, with no significant gender differences (Fig. 3-1 and Fig 3-2). This indicates the severity of the physical injuries that have been handled by the protection teams in the health sector.

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Fig. 3-2: Gender distribution of child maltreatment cases hospital admissions.

Fig 3-3: Distribution of child maltreatment cases by admission site.

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Fig 3-4: Gender distribution of child maltreatment cases by admission site.

The majority of the children were admitted to the wards (60.7%) and about (39.3%) were admitted to the intensive care unit (Fig 3-3).

Fig. 3-5: Distribution of child maltreatment cases by laboratory investigations results.

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Fig. 3-6: Distribution of child maltreatment cases by diagnostic radiology results.

Fig. 3-7: Distribution of cases of child sexual maltreatment by obtaining of sexually transmitted diseases investigations.

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Fig. 3-8: Distribution of child maltreatment cases by photographic documentation.

Diagnostic laboratory investigations were abnormal in (12.3%) of the investigated reported cases (Fig. 3-5). Diagnostic Radiology results were abnormal in (16.0%) of cases (Fig. 3-6). Diagnostic serology, PCR, or cultures for sexually transmitted infections were collected in (53.6%) of child sexual maltreatment cases reported (Fig. 3-7). Photographic documentation of injuries was performed in (6.6%) of cases (Fig. 3-8).

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Fig 3-9: Distribution of child maltreatment cases by other governmental agency notification.

Subsequently, Child Protection Teams notified different governmental agencies. Among all notifications (42.4%) were made to police, (49.4%) to the ministry of social affairs, regional principality (2.9%) (Fig. 3-9). The variances in the child protection teams subsequent notifications reflects their lack of awareness about the notification process, or the inefficient efforts made forcing child protection teams to notify several agencies to guarantee the protection of children.

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Complications of Child Maltreatment

Fig. 4-1: Distribution of child maltreatment cases by fatalities.

Fig. 4-2: Gender distribution of child maltreatment cases fatalities.

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Twelve of the registered children (7.0%) died secondary to violence complications ,with an increase in the maltreated female children deaths than males (Figure 4-2).

Fig. 4-3: Distribution of child maltreatment long term outcomes (total 113 living children with reported oucomes).

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Fig. 4-4: Gender distribution of child maltreatment long term outcomes (total 113 living children with reported outcomes).

Nine children (7.6%) had new disabilities, While 12 children left with chronic diseases as a result of violence abuse (10.1 %) Figure (4-3), Disabilities were more among maltreated female children compared to maltreated males (Figure 4-4).

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Distribution of Child Maltreatment Cases

Fig. 5-1: Distribution of child maltreatment reports by regions.

The reported cases were only from 6 regions: Riyadh (51.7%) Eastern Province (24.4%), Makkah (8.1%), Medina (8.1%), Jazan (5.8%), Qassim (1.7%). Lack of reported cases from Tabuk, Asir, Najran, Hail, Al-Jouf, , or Northern Boarders regions dose not necessary mean absence of child maltreatment cases presenting to hospitals in these region. Child maltreatment cases in these regions could have been undiagnosed, not referred to the hospitals’ child protection teams, or were not reported by the team to the registry (Fig. 5-1). Probably for the same reasons 56% of the child protection centers across country did not report any cases in 2013 (table 5-1). The latter indicate that there is a need for continuous training of health care professional and the members of child protection teams in all regions in view of the high professionals turn-over rates in order to improve cases detection, referral, and reporting mechanisms.

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Table 5-1: Distribution of child maltreatment cases by reporting centers

Institution Cases

Male Female Total %King Abdulaziz Medical City, National Guard Health Affairs - Riyadh 29 26 55 32.0%

Maternity & Children’s Hospital – Dammam 15 12 27 15.7%

King Saud Medical Complex - Riyadh 9 13 22 12.8%

Maternity & Children's Hospital – Madinah 7 7 14 8.1%

Maternity & Children’s Hospital - Al Ahsa 5 7 12 7.0%

Maternity & Children's Hospital - Jizan 3 7 10 5.8%

Maternity and Children Hospital of Misa’adiah - Jeddah 5 2 7 4.1%

Security Forces Hospital - Riyadh 3 3 6 3.5%

Maternity & Children's Hospital - Makkah 3 2 5 2.9%

Prince Salman Hospital - Riyadh 2 2 4 2.3%

Maternity & Children's Hospital - Buraidah 0 3 3 1.7%

Imam Abdulrahman Al Faisal Hospital - Dammam 1 0 1 0.6%

Wadi Al Dawasir General Hospital - Riyadh 0 1 1 0.6%

Royal Commission of Jubail and Yanbu Hospital - Jubail 1 0 1 0.6%

King Fahad Armed Forces Hospital - Jeddah 1 0 1 0.6%

King Faisal Specialist Hospital and Research Centre - Riyadh 1 0 1 0.6%

King Abdulaziz university hospital - Jeddah 0 1 1 0.6%

King Abdulaziz Medical City, National Guard Health Affairs - Ahsa 1 0 1 0.6%

King Fahd Military Medical Complex - Dahran 0 0 0 0.0%

King Khaled General Hospital - Hafar Al Batin 0 0 0 0.0%

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King Khaled Civil Hospital - Tabuk 0 0 0 0.0%

Saudi Aramco Hospital - Dahran 0 0 0 0.0%

Al Hada Armed Forces Hospital - Al Taif 0 0 0 0.0%

Southern Region Armed Forces Hospital 0 0 0 0.0%

Maternity & Children's Hospital - Khamis Mushait 0 0 0 0.0%

King Abdulaziz Medical City, National Guard Health Affairs - Jeddah 0 0 0 0.0%

Maternity & Children's Hospital - Najran 0 0 0 0.0%

King Faisal Specialist Hospital and Research Centre - Jeddah 0 0 0 0.0%

Al-Qunfudah General Hospital 0 0 0 0.0%

Prince Sultan Medial Military City- Riyadh 0 0 0 0.0%

Children’s hospital in King Fahad Medical City - Riyadh 0 0 0 0.0%

king Abdulaziz Specialist Hospital - Taif 0 0 0 0.0%

King Saud university hospital - Riyadh 0 0 0 0.0%

North west Armed Forces Hospital 0 0 0 0.0%

King Abdullah bin Abdulaziz Hospital - Bishah 0 0 0 0.0%

Arar Central Hospital 0 0 0 0.0%

Al Qurayyat General Hospital 0 0 0 0.0%

Royal Commission of Jubail and Yanbu Hospital - Yanbu 0 0 0 0.0%

Maternity & Children's Hospital - Al Jouf 0 0 0 0.0%

King Fahad Hospital - Al Baha 0 0 0 0.0%

King Khaled Hospital - Hail 0 0 0 0.0%

Total 86 86 172 100%

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Appendix: Electronic Case Registration Form

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