Introduction

“My son, when he was one year old, I had to go to work to make my ends meet. So I had to send him to a nearby childcare center in our neighborhood. Gradually, he started crying when I reached the childcare center gate. I thought that [young] children do this. And I also could not leave my job so I kept on sending him to the center. Then one day, I received a call from the daycare that my son was injured. When I went to the center, he was bleeding from his head. I took him immediately to the hospital and he got stitches. When I inquired about this later, I came to know [about] some horror stories. The supervisor used to lock the children in dark room, make them stand in cold water in the winter and hit them on head with a comb. This is what she did with my son that day. I took him out of the center and even now, whenever I even pass that lane, my child refuses to go with me. My child is now 8 years old.”

This is a very unfortunate but real situation for countless young children. The above situation occurred with a male child in one of the childcare centers in Karachi, Pakistan. As identified by WHO, numerous children suffer child abuse or maltreatment in their lives all over the world (Hyder & Malik, 2007). Children in Pakistan also suffer harsh physical maltreatment such as severe beating, shaking, burns, fractures attempted suffocation or strangulation or drug abuse (Mehnaz, 2018) by their parents, teachers or relatives for disciplinary purposes. Sometimes, the physical injuries are devastating, causing the children to run away from home (Malik, 2010). Being a part of cultural norm, child battery is perceived as a means to discipline children. As a result, teachers and caregivers are also given permission to use battery in schools and childcare centers by many parents.

Physical maltreatment is under reported in Pakistan (Zafar, Naeem, Zehra & Khalid, 2020). Approximately 50,000 children experiencing physical injuries are not reported (Malik, 2010). Thus, no reports with regards to children’s physical maltreatment are available in Pakistan. A systematic review on violence against children in Pakistan revealed that only 15 published papers; three editorials, 10 original research papers, and two review papers, were found between 1984 and 2003, while 11 unpublished data was found in organizational reports were available from 1998 to 2003. The type of child maltreatment in these studies was not physical violence, rather child labor; sexual abuse; and child neglect (Hyder & Malik, 2007). 

Childcare centers are relatively a new concept in Pakistan, and very few private and Government-run childcare centers exist in urban and semi urban areas (Zahidi, 2019), while none are found in rural areas (Khan, 2018). In many countries, childcare centers are regulated and licensed (NACCRRA, 2010), yet, in Pakistan, there is no accreditation body that regulates the childcare centers or any regulation for ongoing training of caregivers. Compounding the situation further, children are exposed to major safety issues that pose a serious risk to their life long physical and mental health.

Children who utilize childcare centers spend most of their early years at these facilities. The quality of care that they receive during these years impacts the personality of the child as a whole (Jamieson, Bertrand & Ibrahim, 2005; Massee & Barnett, n.d., Canadian Council on Learning, 2011). A study done by Crowley, Jeon and Rosethal (2013), that analyzed 676 routine, unannounced audit reports conducted by the Connecticut Department of Public Health licensing over a 2-year period, also concluded the same. Donoghue and Council on Early Childhood (August 2017) reiterated that there is a positive health outcome on children when there is consistent developmentally appropriate and emotionally supportive care while poor quality can lead to unmet socioemotional needs of children, less preparedness for schools and increased school dropouts, lower cognitive and social skills (Crowley, Jeon, Rosenthal, Oct 2013; Donoghue and Council on Early Childhood, 2017, National Institute of Child Health and Human Development NICHD, 1997; Schpancer, 2017, Sylva, Stein, & Leach, 2010; Huntsman, 2008; Weaven & Grace, 2010; Schpancer, 2017; Espey, 2003; Workman & Ullrich, Feb 2017; Etse, 2004).

Literature Review

Child maltreatment, or child abuse, has many definitions. The Child Abuse Prevention and Treatment Act (CAPTA) defines child maltreatment as:“Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” (Font and Maguire-Jack, 2021).

Child maltreatment in the early years leaves a negative imprint on the child’s brain. Regardless of age, socio economic background, religion and culture, millions of children worldwide experience child maltreatment every day (Chitiyo & Pietratoni, 2019). World Health Organization (WHO) estimates that approximately 3 in 4 children or 300 million children aged 2 to 4 years, experience physical maltreatment by parents or caregivers (2020). Child maltreatment or child abuse exists in many types, such as physical, emotional, sexual and neglect. Out of them, available research shows that emotional abuse is the most common form of abuse, physical abuse is the most reported form of abuse while sexual is the least reported one (Foster, Olson-Dorff, Reiland, & Budzak-Garza, 2017).

Young children are most vulnerable to child abuse, merely because of their dependency on their caregivers (Fang et al, 2012). Data from HHS (2017) revealed that children under three are more prone to child abuse, with boys more vulnerable to physical abuse and girls to sexual abuse (Chitiyo & Pietratoni, 2019). Approximately 80% of children experience physical abuse by their parents, primary caregivers (Crosson-Tower, 2003), family members, teachers, health care workers, employers and acquaintances (Zafar, Naeem, Zehra & Khalid, 2020). Various factors lead to child maltreatment, such as parental stress, parental health, parental drug use, and parental belief in corporal punishment.

Child maltreatment has been found to be under reported, particularly if the school personnel lack training to identify and report such cases (Altafim & Linhares, 2016). A study done by Usakli in 2012, revealed that though the teachers and school counselors were aware of the effects of child maltreatment, yet they reported being unprepared to tackle child maltreatment at school, including identification of the issue, reporting and resolution. 

The effects of maltreatment on children are detrimental. Children who undergo child maltreatment have poor developmental outcomes, affecting their physical, psychological, emotional and academic performances later in life. Unfortunately, children are unable to discuss their experiences and feelings with anybody, due to perpetrators being their parents and caregivers. As a result, they do not receive the required support and care and feel devastated emotionally and psychologically.

Besides having fractured bones, bruises and pain all over body, young children experiencing physical abuse eventually have difficulty coping emotionally with the situation. The most critical development in the early years is healthy emotional development. Yet, children who are maltreated early cannot differentiate between emotions such as sadness and anger. If this continues, the child may develop a condition called alexithymia, which is the inability to “read emotions”, consequently, lacking the ability to recognize own and other’s emotional responses (Stirling and Jackson 2008). Since children are unable to verbalize their feelings, they may undergo anxiety, depression (Zafar, Naeem, Zehra & Khalid, 2020) , feelings of social isolation, lower self-esteem (Nyarko, Addai & Amissah & Dedzo, 2014) and Post Traumatic Stress Disorders (PTSD), leading to suicide, difficulty sleeping, oppositional behaviors, attachment and trust issues, violent behaviors (Stirling and Jackson, 2008), alcohol, cigarette or drug abuse later in life (Chitiyo & Pietratoni, 2019). A prospective cohort design study by Chauhan and Wisdom (2012) was conducted in the mid-Western area of USA, consisting total 1575 individuals as case and controls with a documented history of child abuse and neglect from court documents. The individuals were interviewed at age 29 years from 1989 to 1995, at age 40 years from 2000 to 2002 and again at age 41 years from 2003 to 2005. The study found that individuals who were maltreated as children were found to be living in neighborhoods with more disadvantage, social isolation and drug use, as compared to the control group.  Another systematic review of 124 studies conducted by Norman et al (2012) also revealed an association of physical maltreatment of children with negative health outcomes such as mental disorders, drug use, suicide attempts, Sexually Transmitted Infections (STI’s) and unsafe sexual behaviors. Stirling and Jackson (2008) further reiterate that early maltreatment alters physiological response to stressful stimuli, consequently altering the child’ socialization. Additionally, it also affects children’s physical health in later life, making them prone to diabetes, hypertension, stroke and Cancer.

Children experiencing maltreatment also face negative consequences in their academic performance with lower academic, language and cognitive performance (Romano, Babchishin, Marquis, Frachette, 2015; Stirling and Jackson, 2008), lower levels of school preparedness and behavioral problems like aggression and tantrums (Chitiyo & Pietratoni, 2019). Multiple studies suggest that children experiencing maltreatment had poor performance in exams lower GPA, and problems with completing homework assignments due to attention deficit (Almuneef & Altamimi, 2015; Slade and Wissow, 2007; Romano, Babchishin, Marquis, Frachette, 2015). Due to poor academic performance, there is an increase in school dropout rates, criminal activities, and inability to be economically efficient, resulting in dependency on welfare programs and homelessness.

Caregivers work with children in childcare centers, in the absence of their parents. Their relationship with the children is imperative for children to thrive. The children form secure attachments to their caregivers and may experience negative health outcomes due to lack of thereof. According to Bowlby’s attachment theory, children biologically behave in ways that gain their caregiver’s attention and love. Caregiver response and touch foster security, positive emotions and attention of children, promoting a positive nurturing environment. Attachment involves hugging, cuddling and caressing, which promotes a child’s secure internal working model. On the contrary, poor attachment forms such internal working model that interferes with relationships, leading to feelings of neglect, feelings of isolation, poor self-esteem and anxiety (Nyarko, Amissah, Addai & Dedzo 2014). The supervisor of the center mentioned earlier physically and emotionally abused the child, which eventually posed him on physical and mental health risk. Due to her punitive behavior, the child experienced both physical and emotional trauma, which he could not erase from his memory for a long time.

Key Learning for Practice

Child maltreatment is preventable. There are several strategies that can be used to decrease its prevalence in our society. Training of caregivers can be used as a tool to prevent child abuse in childcare centers to reduce the prevalence of maltreatment and early recognition of the issue. Yet, teachers working with children were found to be unaware of signs and symptoms of maltreatment (Usakli, 2012). Therefore, the schools and childcare centers should make it mandatory for all caregivers to receive ongoing training in this area. Additionally, schools and childcare centers should have a clear reporting policy for child maltreatment, which is well communicated to them. Most importantly, a quality assurance mechanism should be in place, especially in countries like Pakistan, where no monitoring and evaluation system for schools and childcare centers exist. Regular audits and inspections should be conducted, in order to identify and report such issues. A child who is maltreated may require professional help and therapy. Early identification by parents or childcare providers and referral to a child psychotherapist will help the child heal and be able to form secure relationships again. Training and support for parents and teachers also need to be established and the stress level at the school and childcare center environment should be kept at a minimum. Happy caregivers will be able to nurture happy children. Ensuring support groups for both teachers/caregivers and parents, professional counseling, ongoing training workshops, awareness programs can help the school and childcare center administrations achieve this goal.