SECTION II Literature Review
4.4. Risk factors relevant for children in high prevalence HIV/AIDs communities
4.4.5. Child abuse
At the concrete operational stage, children attribute the aetiology of illness to contamination in which they consider an external person, object or action that was harmful to, or bad for, the body (O'Dougherty & Brown, 1990), or internalisation that occurs when the child realises that the cause of illness is either an external contaminant that was internalised (through breathing or ingestion), or an unhealthy internal state such as old age or high blood pressure (Bibace & Walsh, 1980). At the stage of formal operations, the child's rapid cognitive advances facilitate an understanding of illness, the body and body systems (Crider, 1981, in O'Dougherty & Brown, 1990). Adolescents come to realise that illness is triggered by internal bodily dysfunction. They begin to differentiate between various aetiological factors, speculating and hypothesising about cause-and-effect relationships (O'Dougherty & Brown, 1990, p. 243). Therefore, illness is perceived to be caused by external events, but the source and nature of the illness lies in specific internal structures and functions.
Psychophysiological explanations are considered to represent the most mature explanations of illness as the child is now able to describe an illness in terms of internal physiological processes and also suggest that thoughts and feelings can affect bodily functioning and be related to the onset of illness (Bibace & Walsh, 1980).
These western theories are based on the assumption of opportunities to acquire both formal and informal knowledge about illness and death. For example, adolescents who attend biology classes are likely to develop more mature concepts of illness and death. When one experiences a linear process of symptoms, diagnosis, treatment, amelioration of symptoms, one internalises the meaning of medical intervention (Saler & Skolnick, 1992; Siegel & Gorey, 1994; Siegel, Mesagno, Karus, Christ, Banks & Moynihan, 1992). In the absence of these opportunities an entirely different process may occur in terms of children's understanding of illness and death.
frequently reported form of child abuse and neglect that was encountered within the partnering communities in this research was child sexual abuse. It is the researcher's opinion however that physical abuse of children occurs frequently under the guise of discipline, with most communities favouring corporal punishment as their disciplinary technique of choice. In addition neglect of children was under most probably under-reported although it was probably a frequently occurring phenomenon
Sgroi (1982) has provided one of the most useful definitions of child sexual abuse. She defines child sexual abuse as a sexual act imposed on a child who is still developing emotionally physically and cognitively. The adult or adolescent perpetrator lures the child into the sexual activity on the basis of their powerful and dominant position over the child's subordinate and dependent status, such that it is the implicit or coercive authority and power of the perpetrator that ensures the child's compliance. Thus, child sexual abuse can be considered to reflect highly gendered power relationships (Levett, 2004) in which children, and girl children in particular, have a lower status and worth than men. Sadly the most prevalent form of child sexual abuse is incest, with extra-familial abuse occurring less frequently.
Some reports suggest that there has been a recent increase in the sexual abuse of children, while other report maintain that there is simply an increase in the number of cases that are brought to the attention of the helping professions. Whichever position one adopts in terms of these arguments, most accept that the abuse of children is fundamentally wrong and unacceptable. It is clear that the high levels of child abuse and child sexual abuse are a major indictment against a country's ability to protect the rights and integrity of its children.
Many victims of child sexual abuse experience their first incident of abuse while they are still pre- pubescent. The research suggests that the average age at which child sexual abuse is likely to commence is at about the age of 11 years (Townsend & Dawes, 2004). However, van Niekerk, (2004) states that Childline has witnessed a steady decrease in the age of child sexual abuse victims, with 50% of children attending therapy services in KwaZulu-Natal, South Africa, being under the age of seven years.
The classic work by Belsky (1980, in KiUian & Brakarsh, 2004) applied the systemic model of Bronfenbrenner (1979) to develop an ecological integrated model of child abuse and neglect. He
identified four interactive and interdependent systems that are ecologically nested within one another: (i) ontogenic development, which includes the childhood histories and poor or abusive parenting in the perpetrators of abuse; (ii) the microsystem which takes into account the abused child, the parental, sibling and spousal relationships; (iii) the exosystem which comprises the neighbourhood, community, social support systems and the parent's world of work; and (iv) the macrosystem which encompasses the larger socio-economic, political and ideological variables.
From an aetiological perspective, the work of Garbarino, Dubrow, Kostelny and Pardo (1992) has shown that it is the exosystemic variables that are significant in predicting the rates and trends of child maltreatment.
The consequences of child sexual abuse (CSA) on the child victim's social and psychological functioning can be extreme. Assessment of the child victims of abuse consistently report debilitating fears, anxiety, regressive behaviours, nightmares, withdrawn behaviour, depression, anger and hostility, self-injurious behaviours, low self esteem, and inappropriate sexual behaviour (Kendall- Tackett, Williams and Finkelhor, 1993; Browne and Finkelhor, 1986). The meta-analysis conducted by Kendall-Tackett et al. (1993) suggested that there are two common patterns of psychological response: one which is associated with PTSD symptomatology and the other with an increase in sexualised behaviours. Long term sequelae of CSA may include depressive and anxiety disorders, psychiatric hospitalisations, substance abuse, suicidal behaviour, borderline personality disorder, somatisation disorder, eroticisation, learning difficulties, PTSD, dissociative and conversion reactions, revictimisation, poor parenting and an increased likelihood of becoming a perpetrator (Schetky, 1990). A significant percentage of psychiatric patients have been found to have a history of childhood abuse (Bryer, Nelson, Miller & Krol, 1987) with both empirical and clinical studies indicating that childhood physical and sexual abuse is more common among adults who develop major mental illness than previously suspected (Ibid.). It is clear therefore that CSA victims carry intrapsychic scars, with symptoms persisting over many years and into adult life.
The degree of impact of CSA needs to be understood in terms of the parameters of abuse: the frequency of abuse; the duration of the abusive relationship; the relationship of the perpetrator to the child; the type of sexual act; whether or not force was used; the age of the child at the onset of abuse;
the age of the offender; whether or not the abuse was disclosed; and the parents' reaction to the disclosure (Schetky, 1990; Browne and Finkelhor, 1986). Single events, whilst being extremely distressing, are not likely to produce effects as powerful as those caused by repeated abuse within
the context of a relationship in which the CSA is evidence of a betrayal of trust. Levett (1989) argues that individual circumstances need to be considered in order to understand the degree of impact on the child. These include the child's circumstances and her range of subjective responses, both at the time of these experiences and later, in retrospect (Myburgh, 1997). A wide range of emotions need to be considered, including possible feelings of warmth and affection towards the perpetrator. Complex, contradictory, or paradoxical feelings often result from abuse experiences.
However, the negative consequences attributed to CSA may not in fact be due to the abuse per se but due to an accumulation of variables and the interaction of various other factors, such as family dysfunction.