Table of Contents

HK J Paediatr (New Series)
Vol 10. No. 2, 2005

HK J Paediatr (New Series) 2005;10:96-100

Original Article

Responding to Domestic Violence in Yuen Long District

ACW Lee, KT So


Abstract

Yuen Long District, the most northwestern part of Hong Kong, is remarkable with the highest incidence of child maltreatment and spouse abuse compared with the rest of the Special Administrative Region. Following a tragic and widely publicised case of domestic violence in the district, the Director of Social Welfare appointed a 3-membered review panel to look into the provision of family services in that region. The incident has also stimulated much discussion among the public and also the professionals. This article presents the views of the paediatricians working in the region. Changes in the existing deployment of human resources, fostering of expertise and training, management of organisation and staff anxiety, and independent assessment of child welfare are needed. However, the situation of the social problems encountered in this region is not unique, and territory-wide improvement objectives are essential.

Keyword : Child abuse; Domestic violence; Multidisciplinary case conference; Social work


Abstract in Chinese

Introduction

Yuen Long District is situated in the most northwestern part of Hong Kong. It is one of the most rapidly developing areas in the whole territory. Its population has almost doubled over the past decade, rising from 229,724 in 1991 to 449,070 in 2001, while the figure grew by 18% for the whole population during the same period.1 Approximately 50% of the populations are living in Tin Shui Wai, 20% are living in Yuen Long town, and 30% are living in the rural areas.2 Yuen Long District is characterised by a young population, with a median age of 33 years compared with 36 years for the whole population, and children under 15 years comprise 20.7% of the population compared with

16.5% for the whole of Hong Kong.1 The proportion of new immigrants from Mainland China, however, does not appear to be different from other regions.2 Along with these population changes, an increasing demand on social support has been observed. Of the 289,538 cases receiving Comprehensive Social Security Assistance, almost 10% (28,443 cases) are residing in Yuen Long District.2 Financial difficulties associated with unemployment and single parent families are particularly prevalent in this region. Given these social characteristics, it is therefore not surprising to see an increasing incidence of child abuse, spouse abuse, and youth problems. Indeed, Yuen Long District is leading the rest of Hong Kong in terms of new cases of child abuse, spouse abuse, and delinquency in juveniles and young people.2,3

On April 12, 2004, a case of suspected homicide-suicide took place in Tin Heng Estate, Tin Shui Wai. A 45-year-old man was suspected to have killed his 31-year-old wife and a pair of 6-year-old twin daughters. The man was also seriously injured and died subsequently in the hospital. The incident proved to be extremely shocking to the public and made headlines in the press in the subsequent fortnight. On April 20, the Director of Social Service appointed a

3-membered Review Panel to look into the family services in Tin Shui Wai. As Tuen Mun Hospital has been a representative organisation in the Yuen Long District Committee on Family and Child Welfare and the former District Committee on Child Abuse, this report is made for submission to the Review Panel to address our concerns from the medical perspectives.

The Department of Paediatrics and Adolescent Medicine has been providing services to the healthcare needs of the children living in both Tuen Mun and Yuen Long Districts. The opinion expressed in this report is essentially based on our working experience and is primarily made from the perspectives of promoting child health. The discussion below is based not only on our own experience, but also from the experience of other colleagues from close collaborations and the medical literature. It is believed that the social problems encountered in Yuen Long District or Tin Shui Wai are not qualitatively unique but it may be quantitatively different. Hence, a tunnel vision on the problems should be avoided if significant improvements are to be made.

Domestic Violence: Has the Problem Been Clearly Defined?

Domestic violence can be broadly defined as the occurrence of physical, sexual or emotional maltreatment of one member by another in the family,4 the basic social unit of the society that is usually headed by parents or parent-like figures with or without children. Domestic violence may also be extended to include intimate partners who are not married, or are separated or divorced.5 Depending on the relationship between the perpetrator and the victim, domestic violence is subdivided into child abuse, spouse abuse, and elderly abuse. Dating violence is a closely related form of interpersonal violence that overlaps with child and spouse abuses.6 It cannot be overemphasised that domestic violence seldom occurs in pure forms. For instance, child abuse and spouse abuse commonly co-exist in the same family.

Learning from the Experience of Child Abuse

Child abuse is the prototype of all forms of domestic violence, which has been widely studied. An understanding of child abuse and its management provides a helpful starting point to understand other forms of domestic violence. Maltreatment of children can be further classified into 4 different categories: physical abuse, neglect, psychological (or emotional) abuse, and sexual abuse.7 Child victims are often subjected to more than one form of abuse, although it is customary to classify child abuse according to the most predominant type of maltreatment.

Child abuse has existed for centuries, and there is no good evidence to suggest an increasing incidence. The rise and fall of the child abuse statistics often reflect the changing system of child protection and community awareness in bringing the maltreated children to the attention of the authority.8

Inadequacy of Official Statistics

The Child Protection Registry (CPR), the only official data on the statistics of child abuse in Hong Kong, reports annually on the incidence of various forms of child abuse and the related social characteristics.3 Only children who are considered to be "genuinely" abused or at risk of abuse are registered, often following the conclusions reached in the multi-disciplinary case conference (MDCC).

Information provided by the CPR suffers from several drawbacks. Firstly, the severity of the abuse cannot be discerned. Fatal child abuse, for instance, is not included because apparently people believe risks no longer exist.9 Abandoned children and children who have been left unattended at home are usually not registered because the situation does not often lead to a MDCC, while some frontline workers do not consider this to be a kind of child neglect. Neonatal abandonment and neonaticide are not usually considered to be child abuse despite its apparent nature and the serious consequences.10 A recent case of abandoned newborn has been taken into institution after surviving extreme hypothermia without any statutory enrolment into the CPR. She was rescued from a rubbish collection station when a passer-by noticed her cry.11 Otherwise, her life would have ended like the other 3 babies who had been uncovered dead in a similar manner in 2004.

The second problem of the CPR is that the entry of victims relies heavily on the human factor and the statistics may not reflect the true incidence. The MDCC, despite its multiple professional representation, is often influenced by personal bias and experience, as reflected by the differential rate of positive identification of cases among the various regions.9 Similar discrepancy in relation to the understanding of child maltreatment in different regions has also been reported.12 The incidence of child abuse cases registered has remained more or less the same in the past

3 years after surging over the previous ten years, while similar figures took almost 30 years to reach a steady state in the United States of America.13 Rather than reflecting a leveling of the new cases of child abuse, the recent CPR data may suggest a saturation of the current child protection system in handling and identifying one of the most pervasive problems in our community.

Discrepancies Among Frontline Workers*: Professional Versus Personal Bias

To certain extent, child abuse challenges our concepts of the role and adequacy of parents in child up-bringing. As beauty is in the eyes of the beholder, parents and individual workers have their own understanding of "good" or "bad" parenting, especially on the use of corporal punishment. While physical punishment and abuse are probably part of a continuum, there has not been a commonly agreed standard in differentiating the two. Working definitions, such as those provided by the Procedures on Handling Child Abuse Cases,7 help to unify views when controversies arise. However, alternative interpretations are not uncommon which may be driven by personal bias or experience.14 In a recent MDCC, one of the representatives commented, "My supervisor told me that from the perspectives of our discipline, this is a case of child abuse. Personally, I do not agree".

From the child's perspective, the paediatricians' view may be a useful guidance15-17 ?healthy child growth and development does not need pain; the use of violence in the family should be condemned; and corporal punishment resulting in injuries, including bruising, is child abuse. Similar terms can be applied to intimate relationships.

(*In this document, the term "frontline workers" refers to social workers, police, doctors, teachers and other professionals who actively participate in the management of child abuse or domestic violence.)

Recognition of Child Abuse - Diversity Versus Stereotypes

Domestic violence, like child abuse, does not present in a uniform, stereotyped manner. The perpetrator may not have an ill intention. Indeed, they often claim for their good wills. A 4-year-old boy suffered a penetrating injury to his palm with a lead pencil because his mother believed that physical punishment would help him to do his homework, even though he might have learning disability.18 Some patients suffer from multiple, telltale injuries or even fatal abuse,19 while other may only present with a single injury, like the case exemplified above. As a result of such a diversity of maltreatment, the corresponding management should be flexible. At the milder end of the spectrum, a gradual and progressive approach in winning the rapport of the parents may be useful. At the more severe end, an immediate and often decisive action is required in order to safeguard the lives of the victims.20 However, the necessity for such diversified approach may not be well received by some frontline workers. On one occasion, a father tried to kill himself and his two sons by burning charcoal and drugging the two children at home. He aborted his plan in the middle and called his social worker. They were later left alone at home when the social worker saw that the burning charcoal had extinguished.21

The Lack of a Clear Direction

To summarise, child abuse and domestic violence encompass a wide variety of interpersonal conflicts, but a uniform understanding and handling of the problem is lacking among different professionals. A clear direction, such as the paediatricians' views on pain, violence and injury as specified above, is needed. Any suggestions to improve the handling and risk assessment of domestic violence cases must take this specific issue into consideration.

To What Extent is the Problem Over-identified? (Is the Work on Domestic Violence Unrewarding or Disgusting?)

The occurrence of domestic violence is a crisis meant not only to the victim, but also to the frontline child protection workers. To the victim, the crisis means sufferings and life endangerment. To the workers, the crisis means exploring matters behind closed doors, confronting aggressive people with little backup, and challenging the blood-tie between the victim and the suspected perpetrator. When the situation becomes unbearable, victims may lapse into denial, avoidance, or even dissociation as a defence against the maltreatment. When the frontline workers are overwhelmed by the anxiety of the environment, emotional defensiveness gradually deepens into cognitive distortion whereby the painful reality is warded off through denial of dissonant information and attitudes, offering a temporary but false sense of security. Far too often, a child who recants her history of sexual abuse and the woman who retracts her account of battering are taken as an opportunity to close a case. The process, in which an individual or organisational service provider adopts a willing ignorance of a difficult situation by denial or defensiveness, has been described as dysfunction learning cycle by Vince & Martin.22 At the organisation level, a similar strategy could develop. Morrison,23 quoting Menzies, describes socially structured defense mechanisms resulting from collusive interactions among members of the organisation in order to avoid the experience of anxiety, guilt, doubt and uncertainty,

which are felt to be too deep and dangerous for confrontation.

How do frontline workers rate their jobs? What are the levels of anxiety and frustrations? How much support and guidance are they receiving from their managers? A recent case of inquiry in the United Kingdom concern a fatally abused child reveals how fragile the training and experience of the frontline workers was and how often they were blamed when a child slipped away from the child protection system when managers in the social service were supposed to be supervising and matching the service needs to staff mix.24

Children - The Often Ignored Party in Domestic Violence

In domestic violence, children are the ultimate, and often the most seriously affected, victims. They are traumatized by the intra-familial conflict as well as the simplistic approach of the current welfare system.

Children Need Independent Assessment in Domestic Violence

More often than not, the welfare of children is subordinate to that of their parents in cases of domestic violence. Children are often not the discernable victims because actual physical injuries may not be present or readily detected.25 In a recent case where 3 young children of ages 3 to 10 were evaluated for suspected parental neglect, their mother decided to enjoy her own life and left the care of the children to their 15-year-old elder brother. It was finally concluded that the elder brother was also a victim of chronic neglect/domestic violence. Indeed, he was considered to be the most severely affected child of the family because he had dropped out of school and had completely lost his interest in career development. A chronic history of wife battering had been known to the agency

4 years ago, but the issue was thought to be over when the parents finally divorced and separated. When the case was re-activated, the children were found living in a disgusting place with a pack of flies amidst a foul-smelling atmosphere.

Parents' Conflicting Interest - When Children Are Treated As a Source of Family Income

The usual parents are supposed to be advocating for the best interest of their children. Yet, in some families, for example some families who are receiving social security support, they may have a much bigger interest in the children as a source of income. When domestic violence, especially when child abuse, takes place, some parents prove to be uncooperative when child placement issues were put into the agenda for discussion. As a child is taken into residential care, the child's society security will be deducted from the family's income. When it comes to a decision of parental separation or divorce, the formal and informal fight for custody can be an extremely volatile issue.

Child Commissioner - A Missing Authority to Safeguard Children's Best Interest

Thus, a deficiency of independent assessment of children in cases of domestic violence prevails. There are currently no existing laws or legally binding documents to safeguard the best interests of children when matters involving family members with conflicting interests are concerned. Although Hong Kong has been a signing member of the United Nations Convention on the Rights of the Child since 1994 as an extended ratification from the United Kingdom, an independent authority with statutory power to enforce its implementation is non-existent. The appointment of a Child Commissioner, as proposed by the Hong Kong Committee on Children's Rights,26 is especially essential when complicated issues including social, medical, and educational services are involved.

Do We Have the Needed Professionals to Handle the Problem?

The welfare system in Hong Kong is, in many ways, comparable to that of most affluent countries. There is no reason to believe that there is a shortage of social workers, police, doctors, psychologist, and other supporting personals to handle domestic violence. The management of domestic violence including child abuse, however, requires knowledge and expertise. The formation of the Family & Child Protective Services Units (FCPSU) in the Social Welfare Department, the Child Abuse Investigation Unit (CAIU) in the Hong Kong Police, and the designation of Medical Coordinators on Child Abuse (MCCA) in the Hospital Authority respond in part to this requirement of knowledge and expertise. Two areas, however, become apparent where improvements are needed.

Handling by Frontline Workers Without Training in Domestic Violence

While most cases of child abuse are managed by the MCCA in the hospitals and the social worker from the FCPSU, the CAIU handles only a small proportion of the cases. In the Yuen Long District, for instance, the majority of child abuse cases are handled by the Criminal Investigative Department of the Police, where few officers, if any, have received training in this area.

Job Rotation - A Hurdle in Fostering Expertise

Frontline workers from the FCPSU and the CAIU are only working on a job rotation basis and will leave the corresponding units after 2-3 years, to be followed by a new batch of novice social workers and policemen. A new cycle of training will be needed. While knowledge can be passed from one batch of workers to another, expertise can hardly be built up in the disciplines. When a 16-year-old girl was evaluated for suspected child abuse, her single, divorced mother told the caseworker that she felt extremely stressed to look after the 3-year-old and 6-year-old half-siblings of the index case. When the index case was identified as a suspected victim of abuse in the school, her mother told the teachers not to bother her anymore. She asked them to report to the incident to the police and sent her into the jail. The caseworker, however, failed to appreciate the woman's cry for help as signals of a deep-seated depressive illness. At a subsequent case conference, the school social worker supplemented a piece of hitherto unknown information that mother had indeed attempted to jump two years ago. If not because of the index case pulling on her legs, she might have killed herself already. Further accounts from the index patient confirmed that she had longstanding alcohol abuse and repeated ideas of suicide. Fortunately, an appropriate management plan was formulated in time and the younger children were enrolled into the protection registry. Should the caseworker have better experience, an action plan could have been executed earlier.

Summary

In order to improve the management of domestic violence in Tin Shui Wai/Yuen Long District, changes in the existing deployment of human resources, fostering of expertise and training, management of organisation and staff anxiety, and independent assessment of child welfare are needed. Nevertheless, Yuen Long District is not the only area harbouring the social problems, and improvements should be targeted at the whole territory.


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