Violence and abuse of children and young people

What symptoms can violence and abuse against children and young people give rise to?

The injuries caused by violence and abuse during childhood can give rise to complex clinical pictures and health problems. None of the symptoms or signs unequivocally point to violence and abuse; they may also have other possible explanations. In some cases, the child shows no symptoms at all.

The most common symptoms are behavioural and emotional difficulties and physical and psychosomatic problems. Psychosomatic problems refer to bodily symptoms and conditions where a medical examination reveals no known physical explanation.

Behavioural and emotional difficulties

Amongst children who are struggling with problems relating to emotions and behaviour, this may be a sign of underlying violence, abuse and neglect. These children are often troubled and distracted, struggle to keep up at school and develop learning disabilities.

In children who are uncontrolled, aggressive and angry, this can be a sign of poor impulse control, which can be explained by abnormal development of the brain, which in turn can be linked to experiences of violence and abuse.

Children who struggle with social situations and find it difficult to establish stable relationships can quickly become involved in bullying, either as perpetrators or as victims.

Children can be depressed, sad and struggle to make friends.

When a child has poor self-esteem, this can be a consequence of the abuse. Children who have experienced violence and abuse are often plagued by feelings of guilt and shame; they believe they are to blame for the violations to which they have been subjected. In situations involving emotional abuse, the child may be subjected to persistent chronic verbal harassment, where it is told how useless and unwanted it is.

Physical and psychosomatic problems

These could be children who are experiencing:

• severe stomach pain, headaches and muscular pain in their back and chest. "Stomach pain" as a symptom is a particularly common health problem in children, often in combination with bowel problems, such as constipation and defecation.
• urination problems. This often occurs in the form of a child who has previously been dry starting to urinate during the day and/or night.
• pain in the genitalia, which comes and goes, especially transient pain when urinating. This can of course also be a symptom of an ordinary urinary tract infection, which is easy to determine by cultivating urine.
• nutritional problems. This can be in the form of either overnutrition or malnutrition.
• tooth decay and poor dental hygiene. A child’s teeth can easily be examined, and their dental status provides a lot of information about their nutrition and hygiene.
• unexplained injuries. This usually concerns skin injuries, often bruises and wounds, but visible fractures and head injuries also occur.

Self-harm

Children and adolescents who self-harm are a separate category. This could involve the child physically injuring themselves, often by scratching/cutting their own arms and legs. Transverse scars on the forearms of the non-dominant arm are most common.

Children can also self-harm through destructive behaviours such as eating behaviour, substance abuse and aggressive sexual behaviour. In such cases, underlying dysfunctional family relationships must always be investigated.

Causes of violence and abuse of children and adolescents

The reasons why children and adolescents are subjected to violence and abuse are many and complex, and a common denominator is a dysfunction family.

During investigations, vulnerability factors are often found in the parents, such as substance abuse problems, mental illness and the fact that they themselves have been the victims of violence and abuse. Factors that increase the level of stress on a family are also important, such as unemployment and poverty.

In some situations, factors relating to the child can also be a factor in increasing vulnerability, for example children who are often ill and cry a lot often tend to be a victim of violence

Investigation into violence and abuse of children and adolescents

If it is suspected that a child is being subjected to violence and abuse, the child will be examined by a paediatrician and nurse with specialist expertise in social paediatrics.

The specialists who examine the child attach great importance to ensuring that the child feels in control during the examination. This means that the child will not be forced to undergo examination if he or she does not wish to. The doctor and nurse will explain to the child what will happen during the examination, so that the child sees the examination as being predictable.

Key aspects of the examination are:

• measurement of height and weight
• examination of the oral cavity
• examination of the skin
• examination of the body
• examination to obtain a sample of biological material from any perpetrator. This is normally done if the child is examined within three days. The material could be blood residues, sperm, cells from the skin and mucous membranes.

The child's story is important, and it is vital to consider whether the story is consistent with the findings of the examination. As a general rule, the health professional will first collect information from the child’s guardians without the child being present in the room.

In addition to the reason for the concern and symptoms, it is important to ask about the child’s medical history. Disorders of the skin, intestines and urinary tract can be important alternative explanations if sexual abuse is suspected.

Where possible, the discussion with the child will take place without their guardians present. However, young children may be anxious, and it may be necessary for the caregiver to be present in such cases.

Follow-up in the event of child and adolescent abuse

Follow-up and treatment in the event of violence and abuse is highly multidisciplinary and often covers both mental and physical health. The treatment depends on which symptoms are dominant.

The role of the child welfare service is pivotal in ensuring that the child lives is well cared for. The police also have a very important role to play in safeguarding the child's safety. It is therefore crucial that health professionals are familiar with the regulations that apply regarding the reporting of concerns and the duty to report, so that the above agencies can be notified and involved.

Life after suffering violence and abuse

Many people who have been the victim of violence and abuse in childhood develop serious late injuries. Their life situation will vary depending on the ailments that are dominant and the help they receive.

Many people benefit from self-help organisations. The centres for victims of incest and sexual abuse (SMISO) are an example of such an organisation for victims of sexual abuse