Child Abuse & Neglect 50 (2015) 33–41
A systems approach to addressing child maltreatment in China Jin Peng Nationwide Children’s Hospital and The Ohio State University
Huiping Zhu ∗∗ Capital Medical University
Jianbo Shao, Wenyan Yao Wuhan Children’s Hospital
Chuanhua Yu Wuhan University
Hongyan Yao Chinese Center for Disease Control and Prevention
Junxin Shi, Huiyun Xiang ∗ Nationwide Children’s Hospital
China needs a formalized child protection system a r t i c l e
i n f o
Article history: Available online 26 September 2015
DOI of the original article:http://dx.doi.org/10.1016/j.chiabu.2015.05.015. ∗ Correspondence concerning this article should be addressed to Huiyun Xiang, Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. Electronic mail may be sent to [email protected]. ∗∗ Correspondence concerning this article should be addressed to Huiping Zhu, School of Public Health at Capital Medical University, Beijing, The People’s Republic of China. Electronic mail may be sent to [email protected].
http://dx.doi.org/10.1016/j.chiabu.2015.08.008 0145-2134/© 2015 Elsevier Ltd. All rights reserved.
Child Abuse & Neglect 50 (2015) 33–41
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lthough child maltreatment may have a long history in Chinese society, only as recently as the early 1990s has it received societal recognition. Despite the lack of national data, an increasing number of child abuse cases have been reported in Chinese media and in professional journals in recent years. According to the China National Radio, the number of abused children treated at a child protection center in Xi’an City increased steadily from 18 in 2006 to 361 in 2010. There is an urgent need to address this issue. The question is: what child protection strategies can effectively address child maltreatment in China? Our research suggests that a systems approach has the greatest potential to address child maltreatment in China.
A Systems Approach to Child Maltreatment Child protection efforts have historically focused on single issues such as violence, neglect, child trafficking, street children, and child labor. In the absence of an understanding of how each single issue relates to the overall system, this diffused approach often results in fragmented child protection response and ineffective programs. This approach is neither sustainable nor capable of reaching all children who are in need of protection. To be more effective in addressing child maltreatment, a systems approach is recommended by many child protection organizations such as the United Nations Children’s Fund, the United Nations High Commissioner for Refugees, and Save the Children. In a child protection system, children, families, communities, and formal and informal organizations are brought together through a set of common goals. Each child protection system has its unique structures, functions, and capacities, based on the sociocultural context in which it operates. In some countries, formal system structures are not appropriate because parents, family members, and community members protect children through informal mechanisms. In other contexts, formal system structures are necessary to coordinate a variety of stakeholders within the system. Common functions of a child protection system include governance, management, and enforcement. Specific functions usually fit with the overarching system goals. Finally, capacity refers to human resources, funding, and infrastructure. A well-functioning system is able to optimize the use of resources to achieve its goals. 34
In addition to structures, functions, and capacities, a child protection system often has an accountability mechanism that incorporates data collection, research, and communication with stakeholders (e.g., social workers, the general public). Without accountability, it is hard to know how well the system operates, how the context has changed, and how to improve its structures, functions, and capacities. Within a given context, the boundary between a child protection system and other formal systems (e.g., education, health) is an important indicator of how that specific child protection system defines its functions, capacities, and accountability.
The Nature of Child Maltreatment in China In this Directions article, we discuss key contributing factors to child maltreatment in China. These factors were derived from feedback received on a survey and in focus groups conducted with emergency department physicians and nurses in 2013. In addition to providing a better understanding of the knowledge base and the types of experiences doctors and nurses have regarding child maltreatment, the study provided insight into the role of culture in how child maltreatment is addressed in China. Indeed, this study pointed to major challenges that China must address to effectively reduce child maltreatment. Following a discussion of contributing factors, we provide some preliminary recommendations of strategies for addressing child maltreatment in China. We realize that child maltreatment is an important but controversial social issue, and we do not portend to offer a panacea. Rather, we hope that this article will help raise public awareness of child maltreatment and improve the understanding of child protection in the Chinese context.
Contributing Factors to Child Maltreatment in China Factor No. 1: Confucianism Understanding child maltreatment in China requires an awareness of cultural values such as filial piety (Xiao) and Familism. Derived from Confucianism, filial piety and familism emphasize hierarchical social structures, family reputation, patriarchal authority, obedience, and loyalty. Influenced by such values for thousands of years, childrearing practices in Chinese society have developed
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certain features that can be different from those of Western societies. For example, Chinese culture emphasizes parental authority, children’s obedience toward their parents, and high expectations for children’s academic performance. Physical punishment has been historically used among Chinese parents as a means to punish disobedient children and reinforce filial piety. In 2008, Phil Leung and colleagues surveyed 6,592 students in southern China about their experiences of child maltreatment. They found that children’s disobedience toward their parents was the most common reason for child maltreatment, followed by poor academic performance and parents quarreling. They further noted that children who were perceived as disobedient and had poor academic performance were at the highest risk of being physically punished by their parents. Because the intent of inflicting physical punishment is to enhance children’s moral development or academic success, Chinese people consider physical punishment a means of displaying parental love and care to their children rather than child maltreatment. For this reason, Chinese parents often believe that physical punishment should be tolerated or even appreciated by children. Such deep-rooted cultural and social norms may prohibit children from complaining or acting in opposition to their parents. As a consequence, Chinese children are likely not aware of being maltreated and therefore do not seek help.
Factor No. 2: Socioeconomic Changes Left-behind Children. Since the late 1970s, when China began economic reforms, many farmers have migrated from rural areas to large cities to increase family income and pursue better life opportunities. By filling the demands for labor in the industrial and service sectors in large cities, this rural-to-urban migration has served as a critical driving force for China’s soaring economic growth. However, it has also caused many social problems, including left-behind children. In 2005, Chengrong Duan and his colleagues evaluated the impact of this rural-to-urban migration. They found that 22 million children were living with grandparents or other relatives while their parents left to work in large cities. In 2006, Fangbiao Tao and his colleagues conducted a survey among 5,141 school-aged children, and found that left-behind children were more likely to be physically
or emotionally abused than their peers who lived with parents. Changes in Family Structure. Family structure in China has changed dramatically since China began its economic reforms. Indeed, family structures that were rarely observed in traditional Chinese society have become more common. China is experiencing a steadily increasing divorce rate and has more singleparent households. These changes in family structure can result in many social problems, including child maltreatment. In 2010, Cuixia Liu and his colleagues conducted a survey among 1,154 children in Wuhan City and found that children from single-parent families were at higher risk of being neglected than children from two-parent families. In 2004, Tao and his colleagues surveyed maltreatment experiences among school-aged children in Anhui Province and found that Children whose single parent remarried were significantly more likely to be maltreated by their stepparents.
Factor No. 3: Lack of Public Awareness China has a relatively low level of public awareness regarding child maltreatment. In a comparative review of data on child maltreatment collected in China and in Canada, Colin Ross and his colleagues found that the general public in China had significantly lower awareness of child maltreatment compared to the general public of Canada. In 2006, Cheng-Chao Zhou and his colleagues conducted a survey about public attitudes toward child maltreatment among 11,621 residents of Weihai City. They found that 30.7% of the respondents considered child abuse to be legal. Cultural values such as filial piety may hamper Chinese people’s ability to reason about what child maltreatment is, why it happens, and what effects it has. Chinese people are often sympathetic to parents who use physical punishment to teach their children the importance of respecting and honoring parents. Social norms, such as “family issues should be confined and resolved within the family,” may also contribute to the lack of public awareness regarding child maltreatment in China. In traditional Chinese society, childrearing practices are considered private family matters that should not be judged or interfered with by outsiders or government authorities. Influenced by such social norms, the general 35
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public is often reluctant to report or intervene in child maltreatment that occurs within the family.
Factor No. 4: Lack of Workable Legislations/Laws The constitution of the People’s Republic of China states that children and youth are protected by law, and thus child maltreatment is prohibited (Article 49). However, the constitution neither defines what constitutes child maltreatment nor does it specify penalties for committing offenses. The Protection of Minors of the People’s Republic of China states that parents or caregivers ought to educate their children with proper means (Article 10). The law does not explicitly forbid parents from practicing physical punishment. The law does declare that a court may withdraw the guardianship of the parents if they refuse to change their abusive behavior toward their child or are not capable of ensuring their child’s safety and well-being (Article 12). The withdrawal of parents’ guardianship rarely happens in China because few people are willing to file petitions. Concerned adults (e.g., friends; neighbors) are unlikely to file a petition for two reasons. First, they are often sympathetic to parents who use physical punishment to reinforce filial piety. Second, they often consider physical punishment to be a private family issue that should not be judged or interfered with by outsiders or government authorities. Physicians and nurses also play an important role in the detection and reporting of child maltreatment. Legislation that requires medical professionals and other professionals who interact with children to report child abuse has been enacted in many Western countries. To examine whether such mandatory reporting laws exist in China, we conducted a survey among 304 emergency department (ED) physicians and nurses from 15 large children’s hospitals in December of 2013. All participants completed the survey questionnaire. About 40% of ED physicians and nurses reported that they had treated injured children whom they suspected were victims of physical abuse (see Table 1). Among those who had encountered suspected child abuse, only 17% diagnosed and reported child abuse to a government agency. Most ED physicians and nurses (73%) reported a lack of knowledge regarding physical child abuse and that they did not know how to diagnose physical child abuse. The majority of ED physicians and nurses (96%) said that they had never received training on how to identify, diag36
nose, and report physical child abuse. “Hiding/refusing to report the circumstances of the injury by parents,” “lack of training,” and “lack of guidelines/laws” were reported by ED physicians and nurses as the top three obstacles to reporting physical child abuse (see Table 2). These findings showed that China lacks effective mandatory reporting laws regarding child abuse and Chinese medical professionals lack knowledge and training on the identification and reporting of physical child abuse. This study suggests that many Chinese maltreated children remain in danger because they are not identified or reported.
Factor No. 5: Lack of Social and Support Services China has no formalized social services and limited social supports to address child maltreatment. In other countries, formalized social services include family preservation services, housing and financial assistance, child removal, and foster care. In the absence of these social services, maltreated children do not have a place to stay if the guardianship of their parents is withdrawn by a court. Other countries also have indirect social supports which can help reduce the risk of child maltreatment. These include services such as community programs advocating appropriate parenting practices, neighborhood centers offering child care services to stressed parents, substance abuse treatment centers providing services to parents who are addicted to drugs, and school-based programs offering mentoring and counseling services to maltreated children. These programs, in conjunction with formalized social services, can result in the reduction of risk factors that contribute to child maltreatment.
Recommendations Based on our review of the literature and our own research findings, some preliminary recommendations are made here for establishing a child protection system to improve the lives of children in the People’s Republic of China. These recommendations include establishing child protection agencies, enacting child protection legislation, and implementing prevention and intervention programs.
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Table 1 Surveyed emergency department physicians’ and nurses’ knowledge and experiences of reporting physical child abuse in China. Physician n
(%)
Nurse n
Total (%)
n
(%)
Total 154 150 304 Knowledge of physical child abuse 20 (13.0) 18 (12.0) 38 (12.5) No knowledge Know little but do not know how to diagnose 89 (57.8) 96 (64.0) 185 (60.9) 34 (22.1) 27 (18.0) 61 (20.1) Know how to diagnose but do not know how to report to government agency Know how to diagnose and how to report to government agency 9 (5.8) 8 (5.3) 17 (5.6) 2 (1.3) 1 (0.7) 3 (1.0) Unknown Ever treated children whom you suspected were victims of physical abuse Yes 60 (39.0) 64 (42.7) 124 (40.8) 94 (61.0) 86 (57.3) 180 (59.2) No In your practice, if you have ever treated patients whom you suspected were victims of physical child abuse, what have you typically done? 18 (30.0) 29 (45.3) 47 (37.9) Asked caregiver about injury but did not write notes on medical records Asked caregiver injury and wrote notes on medical records (28.3) 12 (18.8) 29 17 (23.4) (20.0) 9 (14.1) 12 21 (16.9) Asked caregiver, diagnosed child abuse and reported to government agency 13 (21.7) 14 (21.9) 27 (21.8) Suspected but did not ask caregiver about the injury Knowledge of head injuries caused by physical child abuse 21 (13.6) 19 (12.7) 40 (13.2) No knowledge 81 (52.6) 86 (57.3) 167 (54.9) Know little but do not know how to diagnose Know how to diagnose but do not know how to report to government agency 30 (19.5) 25 (16.7) 55 (18.1) 10 (6.5) 8 (5.3) 18 (5.9) Know how to diagnose and how to report to government agency 12 (7.8) 12 (8.0) 24 (7.9) Unknown Ever treated head injuries that you suspected were caused by physical child abuse 50 (32.5) 43 (28.7) 93 (30.6) Yes No 104 (67.5) 107 (71.3) 211 (69.4) In your practice, if you have ever treated head injuries that you suspected were caused by physical child abuse, what have you done? 18 (37.5) 21 (50.0) 39 (43.3) Asked caregiver about injury but did not write notes on medical records 13 (27.1) 9 (21.4) 22 (24.4) Asked caregiver about injury and wrote notes on medical records Asked caregiver, diagnosed child abuse and reported to government agency 11 (22.9) 5 (11.9) 16 (17.8) 6 (12.5) 7 (16.7) 13 (14.4) Suspected but did not ask caregiver about the injury Based on your knowledge and experience, which of the following groups of children is at the highest risk of head injury caused by physical child abuse? 113 (73.4) 118 (78.7) 231 (76.0) Less than 6 years old 6–9 years old 31 (20.1) 26 (17.3) 57 (18.8) 9 (5.8) 4 (2.7) 13 (4.3) 10–14 years old Unknown 1 (0.6) 2 (1.3) 3 (1.0)
Recommendation 1: Establish Child Protection Agencies A central child protection agency should be established within the government to serve as a focal point for national efforts to address child maltreatment. Its missions may include improving the safety and wellbeing of children, supporting essential child protection services, and maintaining productive partnerships with local child protection agencies. To fulfill these missions, the central child protection agency should provide funds to support local child protection services, offer training and technical support to improve service delivery, award
grants to stimulate innovative research, and disseminate research findings to help child protection agencies and other providers improve their services. In addition, local child protective services (CPS) should be established to handle reports of suspicious child maltreatment from medical professionals or the general public. As the central child protection agency, CPS can assume a variety of responsibilities. Generally, it is accountable for receiving reports of child maltreatment, conducting initial and family assessment, providing direct services to maltreated children and at-risk families, and coordinating services provided by other professionals or providers. CPS 37
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Table 2 Perceived barriers for identifying, diagnosing and reporting physical child abuse among surveyed emergency department physicians and nurses in China. Physician n
(%)
Nurse n
Total (%)
Total 154 150 Are you aware of any standardized protocol of identifying and diagnosing physical child abuse in China? Yes 21 (13.6) 21 (14.0) 133 (86.4) 129 (86.0) No Are you aware of any standardized protocol of reporting physical child abuse cases to the government agencies in China? 20 (13.0) 22 (14.7) Yes 134 (87.0) 128 (85.3) No Have you received any training on how to identify and diagnose physical child abuse? 8 (5.2) 3 (2.0) Yes No 145 (94.2) 147 (98.0) 1 (0.6) 0 (0.0) Unknown Would you like to receive formal training in the next 12 months regarding how to diagnose and report physical child abuse? (96.1) 144 (96.0) Yes 148 4 (2.6) 4 (2.7) No, my knowledge and skills are sufficient No, I feel it is not relevant to my practice 1 (0.6) 2 (1.3) 1 (0.6) 0 (0.0) Unknown Barriers for reporting physical child abuse Hiding/refusing to report the circumstances of the injury by parents 101 (65.6) 84 (56.0) 66 (42.9) 69 (46.0) Physicians/nurses lack motive, experience, knowledge and training 58 (37.7) 53 (35.3) There’re no guideline/law, don’t know how to report Children cannot report because of young age 19 (12.3) 24 (16.0) 15 (9.7) 10 (6.7) Lack of attention or support from government, society and law enforcement Child has mental problems 2 (1.3) 1 (0.7) 0 (0.0) 2 (1.3) Injury is too severe to report 1 (0.6) 1 (0.7) Guardians/parents have mental problems 1 (0.6) 0 (0.0) Physicians/nurses have too much work-load
plays the leading role in coordinating communication and collaboration among the various professionals responsible for addressing child maltreatment. Such professionals may include child care providers, teachers, physicians, nurses, mental health professionals, substance abuse treatment providers, law enforcement personnel, judicial system personnel, and social workers.
Recommendation 2: Improve Child Protection Laws Constitutional laws should be established to protect children’s rights, prohibit child abuse and neglect, and explicitly define what constitutes child maltreatment. Domestic laws should set out entitlements in sufficient detail to enable effective remedies for families. Criminal laws should specify penalties for those who commit child maltreatment. Municipal laws should emphasize local child protection agencies’ duty and power to act on behalf of a child when parents are unable or unwilling 38
n
(%)
304 42 262
(13.8) (86.2)
42 262
(13.8) (86.2)
11 292 1
(3.6) (96.1) (0.3)
292 8 3 1
(96.1) (2.6) (1.0) (0.3)
185 135 111 43 25 3 2 2 1
(60.9) (44.4) (36.5) (14.1) (8.2) (1.0) (0.7) (0.7) (0.3)
to provide sufficient care to their children. Furthermore, professionals whose work involves children (e.g., teachers; physicians) should be mandated by law to report suspected cases. The mandatory reporting law should identify agencies accountable for responding to reports of child maltreatment, specify mandatory reporters, provide guidelines for both mandatory reporters and voluntary reporters, protect reporters’ legal rights, and specify penalties for failure to report or false reporting.
Recommendation 3: Implement Three Levels of Prevention (Primary, Secondary, and Tertiary) Primary Prevention. Primary prevention programs target the general public with the goal of preventing child maltreatment before it occurs. As previously mentioned, China has a relatively low level of public awareness regarding child abuse. Legislation is likely to have little effect in addressing child
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maltreatment without a raised public awareness of the problem. Two primary prevention strategies are often used to raise public awareness of child maltreatment: public awareness campaigns and open discussions. Public awareness campaigns target the general public. The primary goal of public awareness campaigns is to enhance the general public’s knowledge about what constitutes child maltreatment, why it happens, and what effects it has. Public awareness campaigns also seek to encourage the general public to report child maltreatment and to inform concerned citizens about where and how to report suspected cases. Open discussions (on the radio or television) target parents and caregivers. The goal is to help parents and caregivers recognize the negative effects of physical punishment on children’s physical and mental development and to encourage them to use proper means of child discipline. It can be very challenging for parents to accept new parenting styles that directly contradict their existing values and beliefs. To effectively change Chinese parents’ childrearing practices, open discussions ought to recognize the influence of cultural values in shaping Chinese parents’ beliefs and behaviors. For example, open discussions may incorporate teachings from Eastern philosophies that are treasured among the Chinese, such as Buddhism and Confucianism. Both Buddhism and Confucianism emphasize the end of violence and development of harmony. By using such Eastern principles, open discussions could be more effective in convincing Chinese parents to avoid violent means of child discipline.
maltreatment has already occurred. The goal of tertiary prevention is to minimize negative consequences of maltreatment and prevent future maltreatment. Tertiary prevention provides a continuum of child protective services, from identifying child maltreatment to reunifying maltreated children and their families. Typical child protective services include receiving reports of suspected cases, initial assessment, family assessment, service provision, and evaluation of child protection progress. Effective delivery of child protective services requires seamless coordination and collaboration among a variety of responsible professionals, such as physicians, teachers, child protective services caseworkers, social workers, and law enforcement personnel. CPS should be the agency to lead and coordinate these services. The role of each stakeholder involved needs to be discussed and agreed upon before a formal protocol is established. Funding and other resources from national and local government are essential for operating an effective and sustainable program.
Recommendation 4: Identify, Report, and Assess
Secondary Prevention. Secondary prevention focuses efforts and resources on helping children who are at risk of maltreatment. Research has recognized a number of risk factors commonly associated with child maltreatment such as substance abuse, young maternal age, child disabilities, and poverty. Children living in families where these factors exist are at higher risk of experiencing maltreatment. The goal of secondary prevention is to reduce these risk factors to prevent child maltreatment before it occurs. Examples of secondary prevention strategies include substance abuse treatment programs, parent education classes, respite care centers, home visitations, family preservation services, and school-based programs.
Identification and Reporting. Identification and reporting of child maltreatment are initial steps in the process of delivering child protective services. CPS should be held accountable for responding to the reports of child maltreatment. A central reporting network should be established within CPS to simplify the reporting process of child maltreatment. Concerned citizens (e.g., friends, neighbors) should be encouraged to report suspected child maltreatment, and, as previously mentioned, professionals (e.g., physicians; teachers) whose work involves direct and ongoing contact with children should be mandatory reporters of child maltreatment. Mandatory reporting laws, however, cannot be effective if these professionals do not know how to carry out their roles. Two strategies can be particularly helpful to enhance mandatory reporters’ ability to identify and report child maltreatment. First, continued education programs should be provided to improve mandatory reporters’ knowledge and skills in identifying and reporting child maltreatment. Second, reporting protocols and guidelines should be developed and implemented to promote standardized identification and reporting of child maltreatment.
Tertiary Prevention. Tertiary prevention focuses efforts and resources on families in which child
Assessment. Once CPS receives reports of child maltreatment, CPS caseworkers should conduct an initial 39
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assessment to identify the occurrence of child maltreatment and investigate family conditions. This assessment should be followed by a family assessment, should the initial assessment suggest that ongoing services are needed. Whereas the aim of the initial assessment is to identify problems, family assessment gains a greater understanding of needs and resources. To be effective, family assessment must acknowledge the diversity of families and respect each family’s values and beliefs. Upon the completion of family assessment, CPS caseworkers should have identified critical factors contributing to the maltreatment and services needed to reduce the risk of future maltreatment. These results can then be translated into the best possible intervention plans. Once individualized intervention plans are established, CPS caseworkers should provide or request services suggested in the plans to help strengthen families’ capacity to provide sufficient care for their children. Depending on the target of specific services, intervention services provided by CPS can be classified into three categories: services provided to the entire family (e.g., financial aid, housing assistance), services provided to parents or caregivers (e.g., parent education, substance abuse treatment, psychological treatment), and services provided to maltreated children (e.g., medical treatment, counseling services, life skills education). In addition, intervention services may be provided according to the family’s level of risk for child maltreatment. For families at low risk for child maltreatment, general support services (e.g., parent education) can be provided to prevent child maltreatment before it occurs. For families at moderate risk for maltreatment, individualized remedial services (e.g., counseling services) should be provided to reduce the risk for future maltreatment. For families whose children are at great risk for future maltreatment, adoption or foster care services may be required to ensure the child’s safety and well-being. Finally, the family’s progress should be evaluated to ensure the effectiveness of the services provided and to decide whether additional intervention services are needed or ongoing interventions can be terminated. Evaluation of family progress should begin as soon as interventions are implemented and continue at regular intervals until expected outcomes have been achieved. The evaluation of family progress should address the following issues: What changes have occurred to the family’s level of risk for child maltreatment?, Has the risk of maltreatment been reduced to a level that the 40
parents or caregivers are capable of providing sufficient care to their children, allowing the interventions to be terminated?, If not, what adjustments need to be made to further reduce risk factors of maltreatment?, and If the maltreated child was removed from home, is family unification possible or is an alternative plan needed?
Conclusions and Implications for Future Research Addressing child maltreatment is a difficult task in any society. A systems approach has proven to be the most effective in preventing child maltreatment worldwide. To effectively address child maltreatment in China, a formalized child protection system needs to be established. To be most effective and sustainable, this child protection system should be tailored to reflect China’s unique cultural and socioeconomic characteristics. Upon the establishment of an effective child protection system, the Chinese government should implement evaluation programs to monitor the progress of child protection services with the goal of determining whether a particular child prevention or intervention service is effective, what improvements should be made to the service, and what adjustments need to be made to improve the delivery of the service. All evaluation programs should seek to identify the positive and negative effects that child protection services may have on children’s safety and well-being. To better understand the potential for improved wellbeing of Chinese children, more research will be needed. The government should offer more funding opportunities to promote research about child maltreatment and the child protection system in China. Future research efforts should be directed toward generating more innovative intervention programs. In particular, efforts should be focused on developing culturally responsive programs that take into consideration China’s unique cultural and socioeconomic characteristics. Research projects are unlikely to be successful without the availability of systematic baseline data. Thus, the government should develop national databases to allow the estimation of the prevalence, patterns, and trends of child maltreatment in China. These data could be obtained by conducting national surveys or collecting reports from local child protection agencies.
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Acknowledgement This study was funded by the Ohio State University International Affairs Gateway Research Seed (Grant PI: Dr. Huiyun Xiang). Dr. Huiping Zhu was supported by the National Natural Science Foundation of China (Grant #: 81402688). The views expressed here are solely the responsibility of the authors and do not necessarily reflect the official views of the funding agencies.
Keywords: child maltreatment; physical child abuse; child protection system; culturally responsive interventions
Suggestions for Further Reading Duan, C., & Zhou, F. (2005). Wo guo liu shou er tong zhuang kuang yan jiu [Research on the left-behind children in China]. Population Research, 29, 29–36. Goldman, J., Salus, M. K., Wolcott, D., & Kennedy, K. Y. (2003). A coordinated response to child abuse and neglect: The foundation for practice. Child abuse and neglect user manual series. Washington, DC: United States of America: Office on Child Abuse and Neglect, U.S. Department of Health and Human Services. Leung, P. W. S., Wong, W. C. W., Chen, W. Q., & Tang, C. S. K. (2008). Prevalence and determinants of child maltreatment among high school students in Southern China: A large-scale school based survey. Child and Adolescent Psychiatry and Mental Health, 2, 27–48. Liao, M., Lee, A. S., Roberts-Lewis, A. C., Hong, J. S., & Jiao, K. (2011). Child maltreatment in China: An ecological review of the literature. Children and Youth Services Review, 33, 1709–1719. Liu, C., Jiang, Q., Luo, X., Chen, G., Zhang, D., & Xiang, G. (2010). Wu han shi cheng qu xue ling qian er tong hu shi xiang zhuang ji qi ying xiang yin su fen xi [Analysis on the influencing factors of child neglect among preschool children in Urban Wuhan]. Chinese Journal School Health, 31, 307–308. Qiao, D. P., & Chan, Y. C. (2005). Child abuse in China: a yet-to-be-acknowledged ‘social problem’ in the Chinese Mainland. Child & Family Social Work, 10, 21–27. Ross, C. A., Keyes, B. B., Xiao, Z., Yan, H., Wang, Z., & Zou, Z. (2005). Childhood physical and sexual abuse in China. Journal of Child Sexual Abuse, 14, 115–126. Tao, F., Xie, Q., Kim, S., Huang, K., Sun, Y., & Zhang, Ch. (2006). Qin shao nian tongnian qi fan fu shen ti he qing gan nue dai jing li ji qi xiang guang yin su yan jiu [A study of childhood physical and emotional abuse among Chinese adolescents]. Chinese Journal School Health, 27, 310–314. Tao, F., Zhang, H., Wang, D., Yang, Sh., Su, P., & Feng, E. (2004). She hui wen hua yin su dui An Hui sheng nong cun er tong ti fa xing wei de ying xiang [The influences of socio-cultural factors on the prevalence of physical punishment among children from rural areas in An Hui province]. Chinese General Practice, 7, 172–174. Wulczyn, F., Daro, D., Fluke, J., Feldman, S., Glodek, C., & Lifanda, K. (2010). Adapting a systems approach to child protection: Key concepts and considerations. New York, NY: United Nations Children’s Fund. Zhou, C., Song, X., Wang, J., Sun, H., Wang, X., & Zhang, X. (2006). Wei hai shi ju min er tong nue dai tai du ji qi ying xiang yin su fen xi [A study on attitude of child abuse and influencing factors among residents in Weihai City]. Chinese Journal of Child Health Care, 14, 276–278.
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A systems approach to addressing child maltreatment in China Jin Peng Nationwide Children’s Hospital and The Ohio State University
Huiping Zhu ∗∗ Capital Medical University
Jianbo Shao, Wenyan Yao Wuhan Children’s Hospital
Chuanhua Yu Wuhan University
Hongyan Yao Chinese Center for Disease Control and Prevention
Junxin Shi, Huiyun Xiang ∗ Nationwide Children’s Hospital
China needs a formalized child protection system a r t i c l e
i n f o
Article history: Available online 26 September 2015
DOI of the original article:http://dx.doi.org/10.1016/j.chiabu.2015.05.015. ∗ Correspondence concerning this article should be addressed to Huiyun Xiang, Center for Pediatric Trauma Research, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205, USA. Electronic mail may be sent to [email protected]. ∗∗ Correspondence concerning this article should be addressed to Huiping Zhu, School of Public Health at Capital Medical University, Beijing, The People’s Republic of China. Electronic mail may be sent to [email protected].
http://dx.doi.org/10.1016/j.chiabu.2015.08.008 0145-2134/© 2015 Elsevier Ltd. All rights reserved.
Child Abuse & Neglect 50 (2015) 33–41
A
lthough child maltreatment may have a long history in Chinese society, only as recently as the early 1990s has it received societal recognition. Despite the lack of national data, an increasing number of child abuse cases have been reported in Chinese media and in professional journals in recent years. According to the China National Radio, the number of abused children treated at a child protection center in Xi’an City increased steadily from 18 in 2006 to 361 in 2010. There is an urgent need to address this issue. The question is: what child protection strategies can effectively address child maltreatment in China? Our research suggests that a systems approach has the greatest potential to address child maltreatment in China.
A Systems Approach to Child Maltreatment Child protection efforts have historically focused on single issues such as violence, neglect, child trafficking, street children, and child labor. In the absence of an understanding of how each single issue relates to the overall system, this diffused approach often results in fragmented child protection response and ineffective programs. This approach is neither sustainable nor capable of reaching all children who are in need of protection. To be more effective in addressing child maltreatment, a systems approach is recommended by many child protection organizations such as the United Nations Children’s Fund, the United Nations High Commissioner for Refugees, and Save the Children. In a child protection system, children, families, communities, and formal and informal organizations are brought together through a set of common goals. Each child protection system has its unique structures, functions, and capacities, based on the sociocultural context in which it operates. In some countries, formal system structures are not appropriate because parents, family members, and community members protect children through informal mechanisms. In other contexts, formal system structures are necessary to coordinate a variety of stakeholders within the system. Common functions of a child protection system include governance, management, and enforcement. Specific functions usually fit with the overarching system goals. Finally, capacity refers to human resources, funding, and infrastructure. A well-functioning system is able to optimize the use of resources to achieve its goals. 34
In addition to structures, functions, and capacities, a child protection system often has an accountability mechanism that incorporates data collection, research, and communication with stakeholders (e.g., social workers, the general public). Without accountability, it is hard to know how well the system operates, how the context has changed, and how to improve its structures, functions, and capacities. Within a given context, the boundary between a child protection system and other formal systems (e.g., education, health) is an important indicator of how that specific child protection system defines its functions, capacities, and accountability.
The Nature of Child Maltreatment in China In this Directions article, we discuss key contributing factors to child maltreatment in China. These factors were derived from feedback received on a survey and in focus groups conducted with emergency department physicians and nurses in 2013. In addition to providing a better understanding of the knowledge base and the types of experiences doctors and nurses have regarding child maltreatment, the study provided insight into the role of culture in how child maltreatment is addressed in China. Indeed, this study pointed to major challenges that China must address to effectively reduce child maltreatment. Following a discussion of contributing factors, we provide some preliminary recommendations of strategies for addressing child maltreatment in China. We realize that child maltreatment is an important but controversial social issue, and we do not portend to offer a panacea. Rather, we hope that this article will help raise public awareness of child maltreatment and improve the understanding of child protection in the Chinese context.
Contributing Factors to Child Maltreatment in China Factor No. 1: Confucianism Understanding child maltreatment in China requires an awareness of cultural values such as filial piety (Xiao) and Familism. Derived from Confucianism, filial piety and familism emphasize hierarchical social structures, family reputation, patriarchal authority, obedience, and loyalty. Influenced by such values for thousands of years, childrearing practices in Chinese society have developed
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certain features that can be different from those of Western societies. For example, Chinese culture emphasizes parental authority, children’s obedience toward their parents, and high expectations for children’s academic performance. Physical punishment has been historically used among Chinese parents as a means to punish disobedient children and reinforce filial piety. In 2008, Phil Leung and colleagues surveyed 6,592 students in southern China about their experiences of child maltreatment. They found that children’s disobedience toward their parents was the most common reason for child maltreatment, followed by poor academic performance and parents quarreling. They further noted that children who were perceived as disobedient and had poor academic performance were at the highest risk of being physically punished by their parents. Because the intent of inflicting physical punishment is to enhance children’s moral development or academic success, Chinese people consider physical punishment a means of displaying parental love and care to their children rather than child maltreatment. For this reason, Chinese parents often believe that physical punishment should be tolerated or even appreciated by children. Such deep-rooted cultural and social norms may prohibit children from complaining or acting in opposition to their parents. As a consequence, Chinese children are likely not aware of being maltreated and therefore do not seek help.
Factor No. 2: Socioeconomic Changes Left-behind Children. Since the late 1970s, when China began economic reforms, many farmers have migrated from rural areas to large cities to increase family income and pursue better life opportunities. By filling the demands for labor in the industrial and service sectors in large cities, this rural-to-urban migration has served as a critical driving force for China’s soaring economic growth. However, it has also caused many social problems, including left-behind children. In 2005, Chengrong Duan and his colleagues evaluated the impact of this rural-to-urban migration. They found that 22 million children were living with grandparents or other relatives while their parents left to work in large cities. In 2006, Fangbiao Tao and his colleagues conducted a survey among 5,141 school-aged children, and found that left-behind children were more likely to be physically
or emotionally abused than their peers who lived with parents. Changes in Family Structure. Family structure in China has changed dramatically since China began its economic reforms. Indeed, family structures that were rarely observed in traditional Chinese society have become more common. China is experiencing a steadily increasing divorce rate and has more singleparent households. These changes in family structure can result in many social problems, including child maltreatment. In 2010, Cuixia Liu and his colleagues conducted a survey among 1,154 children in Wuhan City and found that children from single-parent families were at higher risk of being neglected than children from two-parent families. In 2004, Tao and his colleagues surveyed maltreatment experiences among school-aged children in Anhui Province and found that Children whose single parent remarried were significantly more likely to be maltreated by their stepparents.
Factor No. 3: Lack of Public Awareness China has a relatively low level of public awareness regarding child maltreatment. In a comparative review of data on child maltreatment collected in China and in Canada, Colin Ross and his colleagues found that the general public in China had significantly lower awareness of child maltreatment compared to the general public of Canada. In 2006, Cheng-Chao Zhou and his colleagues conducted a survey about public attitudes toward child maltreatment among 11,621 residents of Weihai City. They found that 30.7% of the respondents considered child abuse to be legal. Cultural values such as filial piety may hamper Chinese people’s ability to reason about what child maltreatment is, why it happens, and what effects it has. Chinese people are often sympathetic to parents who use physical punishment to teach their children the importance of respecting and honoring parents. Social norms, such as “family issues should be confined and resolved within the family,” may also contribute to the lack of public awareness regarding child maltreatment in China. In traditional Chinese society, childrearing practices are considered private family matters that should not be judged or interfered with by outsiders or government authorities. Influenced by such social norms, the general 35
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public is often reluctant to report or intervene in child maltreatment that occurs within the family.
Factor No. 4: Lack of Workable Legislations/Laws The constitution of the People’s Republic of China states that children and youth are protected by law, and thus child maltreatment is prohibited (Article 49). However, the constitution neither defines what constitutes child maltreatment nor does it specify penalties for committing offenses. The Protection of Minors of the People’s Republic of China states that parents or caregivers ought to educate their children with proper means (Article 10). The law does not explicitly forbid parents from practicing physical punishment. The law does declare that a court may withdraw the guardianship of the parents if they refuse to change their abusive behavior toward their child or are not capable of ensuring their child’s safety and well-being (Article 12). The withdrawal of parents’ guardianship rarely happens in China because few people are willing to file petitions. Concerned adults (e.g., friends; neighbors) are unlikely to file a petition for two reasons. First, they are often sympathetic to parents who use physical punishment to reinforce filial piety. Second, they often consider physical punishment to be a private family issue that should not be judged or interfered with by outsiders or government authorities. Physicians and nurses also play an important role in the detection and reporting of child maltreatment. Legislation that requires medical professionals and other professionals who interact with children to report child abuse has been enacted in many Western countries. To examine whether such mandatory reporting laws exist in China, we conducted a survey among 304 emergency department (ED) physicians and nurses from 15 large children’s hospitals in December of 2013. All participants completed the survey questionnaire. About 40% of ED physicians and nurses reported that they had treated injured children whom they suspected were victims of physical abuse (see Table 1). Among those who had encountered suspected child abuse, only 17% diagnosed and reported child abuse to a government agency. Most ED physicians and nurses (73%) reported a lack of knowledge regarding physical child abuse and that they did not know how to diagnose physical child abuse. The majority of ED physicians and nurses (96%) said that they had never received training on how to identify, diag36
nose, and report physical child abuse. “Hiding/refusing to report the circumstances of the injury by parents,” “lack of training,” and “lack of guidelines/laws” were reported by ED physicians and nurses as the top three obstacles to reporting physical child abuse (see Table 2). These findings showed that China lacks effective mandatory reporting laws regarding child abuse and Chinese medical professionals lack knowledge and training on the identification and reporting of physical child abuse. This study suggests that many Chinese maltreated children remain in danger because they are not identified or reported.
Factor No. 5: Lack of Social and Support Services China has no formalized social services and limited social supports to address child maltreatment. In other countries, formalized social services include family preservation services, housing and financial assistance, child removal, and foster care. In the absence of these social services, maltreated children do not have a place to stay if the guardianship of their parents is withdrawn by a court. Other countries also have indirect social supports which can help reduce the risk of child maltreatment. These include services such as community programs advocating appropriate parenting practices, neighborhood centers offering child care services to stressed parents, substance abuse treatment centers providing services to parents who are addicted to drugs, and school-based programs offering mentoring and counseling services to maltreated children. These programs, in conjunction with formalized social services, can result in the reduction of risk factors that contribute to child maltreatment.
Recommendations Based on our review of the literature and our own research findings, some preliminary recommendations are made here for establishing a child protection system to improve the lives of children in the People’s Republic of China. These recommendations include establishing child protection agencies, enacting child protection legislation, and implementing prevention and intervention programs.
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Table 1 Surveyed emergency department physicians’ and nurses’ knowledge and experiences of reporting physical child abuse in China. Physician n
(%)
Nurse n
Total (%)
n
(%)
Total 154 150 304 Knowledge of physical child abuse 20 (13.0) 18 (12.0) 38 (12.5) No knowledge Know little but do not know how to diagnose 89 (57.8) 96 (64.0) 185 (60.9) 34 (22.1) 27 (18.0) 61 (20.1) Know how to diagnose but do not know how to report to government agency Know how to diagnose and how to report to government agency 9 (5.8) 8 (5.3) 17 (5.6) 2 (1.3) 1 (0.7) 3 (1.0) Unknown Ever treated children whom you suspected were victims of physical abuse Yes 60 (39.0) 64 (42.7) 124 (40.8) 94 (61.0) 86 (57.3) 180 (59.2) No In your practice, if you have ever treated patients whom you suspected were victims of physical child abuse, what have you typically done? 18 (30.0) 29 (45.3) 47 (37.9) Asked caregiver about injury but did not write notes on medical records Asked caregiver injury and wrote notes on medical records (28.3) 12 (18.8) 29 17 (23.4) (20.0) 9 (14.1) 12 21 (16.9) Asked caregiver, diagnosed child abuse and reported to government agency 13 (21.7) 14 (21.9) 27 (21.8) Suspected but did not ask caregiver about the injury Knowledge of head injuries caused by physical child abuse 21 (13.6) 19 (12.7) 40 (13.2) No knowledge 81 (52.6) 86 (57.3) 167 (54.9) Know little but do not know how to diagnose Know how to diagnose but do not know how to report to government agency 30 (19.5) 25 (16.7) 55 (18.1) 10 (6.5) 8 (5.3) 18 (5.9) Know how to diagnose and how to report to government agency 12 (7.8) 12 (8.0) 24 (7.9) Unknown Ever treated head injuries that you suspected were caused by physical child abuse 50 (32.5) 43 (28.7) 93 (30.6) Yes No 104 (67.5) 107 (71.3) 211 (69.4) In your practice, if you have ever treated head injuries that you suspected were caused by physical child abuse, what have you done? 18 (37.5) 21 (50.0) 39 (43.3) Asked caregiver about injury but did not write notes on medical records 13 (27.1) 9 (21.4) 22 (24.4) Asked caregiver about injury and wrote notes on medical records Asked caregiver, diagnosed child abuse and reported to government agency 11 (22.9) 5 (11.9) 16 (17.8) 6 (12.5) 7 (16.7) 13 (14.4) Suspected but did not ask caregiver about the injury Based on your knowledge and experience, which of the following groups of children is at the highest risk of head injury caused by physical child abuse? 113 (73.4) 118 (78.7) 231 (76.0) Less than 6 years old 6–9 years old 31 (20.1) 26 (17.3) 57 (18.8) 9 (5.8) 4 (2.7) 13 (4.3) 10–14 years old Unknown 1 (0.6) 2 (1.3) 3 (1.0)
Recommendation 1: Establish Child Protection Agencies A central child protection agency should be established within the government to serve as a focal point for national efforts to address child maltreatment. Its missions may include improving the safety and wellbeing of children, supporting essential child protection services, and maintaining productive partnerships with local child protection agencies. To fulfill these missions, the central child protection agency should provide funds to support local child protection services, offer training and technical support to improve service delivery, award
grants to stimulate innovative research, and disseminate research findings to help child protection agencies and other providers improve their services. In addition, local child protective services (CPS) should be established to handle reports of suspicious child maltreatment from medical professionals or the general public. As the central child protection agency, CPS can assume a variety of responsibilities. Generally, it is accountable for receiving reports of child maltreatment, conducting initial and family assessment, providing direct services to maltreated children and at-risk families, and coordinating services provided by other professionals or providers. CPS 37
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Table 2 Perceived barriers for identifying, diagnosing and reporting physical child abuse among surveyed emergency department physicians and nurses in China. Physician n
(%)
Nurse n
Total (%)
Total 154 150 Are you aware of any standardized protocol of identifying and diagnosing physical child abuse in China? Yes 21 (13.6) 21 (14.0) 133 (86.4) 129 (86.0) No Are you aware of any standardized protocol of reporting physical child abuse cases to the government agencies in China? 20 (13.0) 22 (14.7) Yes 134 (87.0) 128 (85.3) No Have you received any training on how to identify and diagnose physical child abuse? 8 (5.2) 3 (2.0) Yes No 145 (94.2) 147 (98.0) 1 (0.6) 0 (0.0) Unknown Would you like to receive formal training in the next 12 months regarding how to diagnose and report physical child abuse? (96.1) 144 (96.0) Yes 148 4 (2.6) 4 (2.7) No, my knowledge and skills are sufficient No, I feel it is not relevant to my practice 1 (0.6) 2 (1.3) 1 (0.6) 0 (0.0) Unknown Barriers for reporting physical child abuse Hiding/refusing to report the circumstances of the injury by parents 101 (65.6) 84 (56.0) 66 (42.9) 69 (46.0) Physicians/nurses lack motive, experience, knowledge and training 58 (37.7) 53 (35.3) There’re no guideline/law, don’t know how to report Children cannot report because of young age 19 (12.3) 24 (16.0) 15 (9.7) 10 (6.7) Lack of attention or support from government, society and law enforcement Child has mental problems 2 (1.3) 1 (0.7) 0 (0.0) 2 (1.3) Injury is too severe to report 1 (0.6) 1 (0.7) Guardians/parents have mental problems 1 (0.6) 0 (0.0) Physicians/nurses have too much work-load
plays the leading role in coordinating communication and collaboration among the various professionals responsible for addressing child maltreatment. Such professionals may include child care providers, teachers, physicians, nurses, mental health professionals, substance abuse treatment providers, law enforcement personnel, judicial system personnel, and social workers.
Recommendation 2: Improve Child Protection Laws Constitutional laws should be established to protect children’s rights, prohibit child abuse and neglect, and explicitly define what constitutes child maltreatment. Domestic laws should set out entitlements in sufficient detail to enable effective remedies for families. Criminal laws should specify penalties for those who commit child maltreatment. Municipal laws should emphasize local child protection agencies’ duty and power to act on behalf of a child when parents are unable or unwilling 38
n
(%)
304 42 262
(13.8) (86.2)
42 262
(13.8) (86.2)
11 292 1
(3.6) (96.1) (0.3)
292 8 3 1
(96.1) (2.6) (1.0) (0.3)
185 135 111 43 25 3 2 2 1
(60.9) (44.4) (36.5) (14.1) (8.2) (1.0) (0.7) (0.7) (0.3)
to provide sufficient care to their children. Furthermore, professionals whose work involves children (e.g., teachers; physicians) should be mandated by law to report suspected cases. The mandatory reporting law should identify agencies accountable for responding to reports of child maltreatment, specify mandatory reporters, provide guidelines for both mandatory reporters and voluntary reporters, protect reporters’ legal rights, and specify penalties for failure to report or false reporting.
Recommendation 3: Implement Three Levels of Prevention (Primary, Secondary, and Tertiary) Primary Prevention. Primary prevention programs target the general public with the goal of preventing child maltreatment before it occurs. As previously mentioned, China has a relatively low level of public awareness regarding child abuse. Legislation is likely to have little effect in addressing child
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maltreatment without a raised public awareness of the problem. Two primary prevention strategies are often used to raise public awareness of child maltreatment: public awareness campaigns and open discussions. Public awareness campaigns target the general public. The primary goal of public awareness campaigns is to enhance the general public’s knowledge about what constitutes child maltreatment, why it happens, and what effects it has. Public awareness campaigns also seek to encourage the general public to report child maltreatment and to inform concerned citizens about where and how to report suspected cases. Open discussions (on the radio or television) target parents and caregivers. The goal is to help parents and caregivers recognize the negative effects of physical punishment on children’s physical and mental development and to encourage them to use proper means of child discipline. It can be very challenging for parents to accept new parenting styles that directly contradict their existing values and beliefs. To effectively change Chinese parents’ childrearing practices, open discussions ought to recognize the influence of cultural values in shaping Chinese parents’ beliefs and behaviors. For example, open discussions may incorporate teachings from Eastern philosophies that are treasured among the Chinese, such as Buddhism and Confucianism. Both Buddhism and Confucianism emphasize the end of violence and development of harmony. By using such Eastern principles, open discussions could be more effective in convincing Chinese parents to avoid violent means of child discipline.
maltreatment has already occurred. The goal of tertiary prevention is to minimize negative consequences of maltreatment and prevent future maltreatment. Tertiary prevention provides a continuum of child protective services, from identifying child maltreatment to reunifying maltreated children and their families. Typical child protective services include receiving reports of suspected cases, initial assessment, family assessment, service provision, and evaluation of child protection progress. Effective delivery of child protective services requires seamless coordination and collaboration among a variety of responsible professionals, such as physicians, teachers, child protective services caseworkers, social workers, and law enforcement personnel. CPS should be the agency to lead and coordinate these services. The role of each stakeholder involved needs to be discussed and agreed upon before a formal protocol is established. Funding and other resources from national and local government are essential for operating an effective and sustainable program.
Recommendation 4: Identify, Report, and Assess
Secondary Prevention. Secondary prevention focuses efforts and resources on helping children who are at risk of maltreatment. Research has recognized a number of risk factors commonly associated with child maltreatment such as substance abuse, young maternal age, child disabilities, and poverty. Children living in families where these factors exist are at higher risk of experiencing maltreatment. The goal of secondary prevention is to reduce these risk factors to prevent child maltreatment before it occurs. Examples of secondary prevention strategies include substance abuse treatment programs, parent education classes, respite care centers, home visitations, family preservation services, and school-based programs.
Identification and Reporting. Identification and reporting of child maltreatment are initial steps in the process of delivering child protective services. CPS should be held accountable for responding to the reports of child maltreatment. A central reporting network should be established within CPS to simplify the reporting process of child maltreatment. Concerned citizens (e.g., friends, neighbors) should be encouraged to report suspected child maltreatment, and, as previously mentioned, professionals (e.g., physicians; teachers) whose work involves direct and ongoing contact with children should be mandatory reporters of child maltreatment. Mandatory reporting laws, however, cannot be effective if these professionals do not know how to carry out their roles. Two strategies can be particularly helpful to enhance mandatory reporters’ ability to identify and report child maltreatment. First, continued education programs should be provided to improve mandatory reporters’ knowledge and skills in identifying and reporting child maltreatment. Second, reporting protocols and guidelines should be developed and implemented to promote standardized identification and reporting of child maltreatment.
Tertiary Prevention. Tertiary prevention focuses efforts and resources on families in which child
Assessment. Once CPS receives reports of child maltreatment, CPS caseworkers should conduct an initial 39
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assessment to identify the occurrence of child maltreatment and investigate family conditions. This assessment should be followed by a family assessment, should the initial assessment suggest that ongoing services are needed. Whereas the aim of the initial assessment is to identify problems, family assessment gains a greater understanding of needs and resources. To be effective, family assessment must acknowledge the diversity of families and respect each family’s values and beliefs. Upon the completion of family assessment, CPS caseworkers should have identified critical factors contributing to the maltreatment and services needed to reduce the risk of future maltreatment. These results can then be translated into the best possible intervention plans. Once individualized intervention plans are established, CPS caseworkers should provide or request services suggested in the plans to help strengthen families’ capacity to provide sufficient care for their children. Depending on the target of specific services, intervention services provided by CPS can be classified into three categories: services provided to the entire family (e.g., financial aid, housing assistance), services provided to parents or caregivers (e.g., parent education, substance abuse treatment, psychological treatment), and services provided to maltreated children (e.g., medical treatment, counseling services, life skills education). In addition, intervention services may be provided according to the family’s level of risk for child maltreatment. For families at low risk for child maltreatment, general support services (e.g., parent education) can be provided to prevent child maltreatment before it occurs. For families at moderate risk for maltreatment, individualized remedial services (e.g., counseling services) should be provided to reduce the risk for future maltreatment. For families whose children are at great risk for future maltreatment, adoption or foster care services may be required to ensure the child’s safety and well-being. Finally, the family’s progress should be evaluated to ensure the effectiveness of the services provided and to decide whether additional intervention services are needed or ongoing interventions can be terminated. Evaluation of family progress should begin as soon as interventions are implemented and continue at regular intervals until expected outcomes have been achieved. The evaluation of family progress should address the following issues: What changes have occurred to the family’s level of risk for child maltreatment?, Has the risk of maltreatment been reduced to a level that the 40
parents or caregivers are capable of providing sufficient care to their children, allowing the interventions to be terminated?, If not, what adjustments need to be made to further reduce risk factors of maltreatment?, and If the maltreated child was removed from home, is family unification possible or is an alternative plan needed?
Conclusions and Implications for Future Research Addressing child maltreatment is a difficult task in any society. A systems approach has proven to be the most effective in preventing child maltreatment worldwide. To effectively address child maltreatment in China, a formalized child protection system needs to be established. To be most effective and sustainable, this child protection system should be tailored to reflect China’s unique cultural and socioeconomic characteristics. Upon the establishment of an effective child protection system, the Chinese government should implement evaluation programs to monitor the progress of child protection services with the goal of determining whether a particular child prevention or intervention service is effective, what improvements should be made to the service, and what adjustments need to be made to improve the delivery of the service. All evaluation programs should seek to identify the positive and negative effects that child protection services may have on children’s safety and well-being. To better understand the potential for improved wellbeing of Chinese children, more research will be needed. The government should offer more funding opportunities to promote research about child maltreatment and the child protection system in China. Future research efforts should be directed toward generating more innovative intervention programs. In particular, efforts should be focused on developing culturally responsive programs that take into consideration China’s unique cultural and socioeconomic characteristics. Research projects are unlikely to be successful without the availability of systematic baseline data. Thus, the government should develop national databases to allow the estimation of the prevalence, patterns, and trends of child maltreatment in China. These data could be obtained by conducting national surveys or collecting reports from local child protection agencies.
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Acknowledgement This study was funded by the Ohio State University International Affairs Gateway Research Seed (Grant PI: Dr. Huiyun Xiang). Dr. Huiping Zhu was supported by the National Natural Science Foundation of China (Grant #: 81402688). The views expressed here are solely the responsibility of the authors and do not necessarily reflect the official views of the funding agencies.
Keywords: child maltreatment; physical child abuse; child protection system; culturally responsive interventions
Suggestions for Further Reading Duan, C., & Zhou, F. (2005). Wo guo liu shou er tong zhuang kuang yan jiu [Research on the left-behind children in China]. Population Research, 29, 29–36. Goldman, J., Salus, M. K., Wolcott, D., & Kennedy, K. Y. (2003). A coordinated response to child abuse and neglect: The foundation for practice. Child abuse and neglect user manual series. Washington, DC: United States of America: Office on Child Abuse and Neglect, U.S. Department of Health and Human Services. Leung, P. W. S., Wong, W. C. W., Chen, W. Q., & Tang, C. S. K. (2008). Prevalence and determinants of child maltreatment among high school students in Southern China: A large-scale school based survey. Child and Adolescent Psychiatry and Mental Health, 2, 27–48. Liao, M., Lee, A. S., Roberts-Lewis, A. C., Hong, J. S., & Jiao, K. (2011). Child maltreatment in China: An ecological review of the literature. Children and Youth Services Review, 33, 1709–1719. Liu, C., Jiang, Q., Luo, X., Chen, G., Zhang, D., & Xiang, G. (2010). Wu han shi cheng qu xue ling qian er tong hu shi xiang zhuang ji qi ying xiang yin su fen xi [Analysis on the influencing factors of child neglect among preschool children in Urban Wuhan]. Chinese Journal School Health, 31, 307–308. Qiao, D. P., & Chan, Y. C. (2005). Child abuse in China: a yet-to-be-acknowledged ‘social problem’ in the Chinese Mainland. Child & Family Social Work, 10, 21–27. Ross, C. A., Keyes, B. B., Xiao, Z., Yan, H., Wang, Z., & Zou, Z. (2005). Childhood physical and sexual abuse in China. Journal of Child Sexual Abuse, 14, 115–126. Tao, F., Xie, Q., Kim, S., Huang, K., Sun, Y., & Zhang, Ch. (2006). Qin shao nian tongnian qi fan fu shen ti he qing gan nue dai jing li ji qi xiang guang yin su yan jiu [A study of childhood physical and emotional abuse among Chinese adolescents]. Chinese Journal School Health, 27, 310–314. Tao, F., Zhang, H., Wang, D., Yang, Sh., Su, P., & Feng, E. (2004). She hui wen hua yin su dui An Hui sheng nong cun er tong ti fa xing wei de ying xiang [The influences of socio-cultural factors on the prevalence of physical punishment among children from rural areas in An Hui province]. Chinese General Practice, 7, 172–174. Wulczyn, F., Daro, D., Fluke, J., Feldman, S., Glodek, C., & Lifanda, K. (2010). Adapting a systems approach to child protection: Key concepts and considerations. New York, NY: United Nations Children’s Fund. Zhou, C., Song, X., Wang, J., Sun, H., Wang, X., & Zhang, X. (2006). Wei hai shi ju min er tong nue dai tai du ji qi ying xiang yin su fen xi [A study on attitude of child abuse and influencing factors among residents in Weihai City]. Chinese Journal of Child Health Care, 14, 276–278.
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