1. PHYSICAL ABUSE AND NEGLECT AMONG 13-15 YEAR OLD CHILDREN OF MIGRANT MOTHERS IN KANDY DISTRICT
DR. W.A.D.S. JAYASINGHE
M.B.B.S., MSc, MD
THIS THESIS IS SUBMITTED TO
THE POST GRADUATE INSTITUTE OF MEDICINE, UNIVERSITY OF COLOMBO
AS A PARTIAL REQUIREMENT FOR THE DEGREE OF DOCTOR OF MEDICINE
IN COMMUNITY MEDICINE
AUGUST, 2005

2. ABSTRACT
The issue of child abuse which has not been adequately highlighted in the past is now coming into the open with the increase in research and awareness. However it may still only be revealing the tip of the iceberg. Increasing socio-cultural changes occurring in society, may negatively affect the families, and thus increase the likelihood of child abuse.
Physical abuse and neglect are the main categories of child abuse, but the information available about these in Sri Lanka is limited. Considering available information from other developing countries, one cannot underestimate the potential seriousness of the problem.
Foreign employment of mothers is currently a popular theme for discussion and debate, because these mothers contribute to the national economy. However child abuse is reported to be more prevalent among single parent families. Therefore this study was to investigate physical abuse and neglect of 13-15 year old children of migrant mothers in rural areas of the Kandy district.
Literature search did not reveal any culturally appropriate instruments to identify physical abuse and neglect. Thus it was an essential pre-requisite to develop, validate, and pretest a new instrument to measure physical abuse and neglect. A cross sectional study compared randomly selected 850 children (index group) between the ages of 13-15 years whose mothers were employed abroad with similar group of children who were living with their mothers (comparison group). The two groups were from the same neighbourhood and were matched for gender, age and socio-economic factors. The data were analyzed using the chi square and other non parametric tests.
In the index group the grandmother is now the primary caregiver. As reported by the children in the index group the care provided by the main caregiver was inferior to the quality of care given by the mother in the following domains; help with school work, care during illness and protection. The prevalence of severity of the outcome following physical abuse was higher among children in the index group. But mild forms of physical abuse like smacking (hitting by hand) are higher among children in the comparison group.

3. Neglect in the physical, educational and emotional domains was higher among the children of the index group. All the children who dropped out from the school (n=25) were from the index group.
The types and frequency of physical abuse (corporal punishment) in the schools were higher among the children from the index group. Poor school performances and behavioural problems in the schools were significantly higher in the index group.
Mothers’ employment abroad as a solution for economic hardship has serious consequences to the children left behind. According to the previous studies even the expected financial gains were not met with satisfaction of the families. This study shows the adverse consequences on the children’s behaviour as well as on school performances. It is known that adults with history of abuse in childhood, may in turn abuse children later. Therefore abuse and neglect of children of the next generation may happen as proven in other studies.
If the cost implications of physical abuse and neglect can be estimated, it can be compared with the economical gain from the employment. It appears that the negative impact outweigh the financial benefits. Therefore cost effectiveness of maternal migration for employment needs to be assessed in a future study.

4. CHAPTER ONE
INTRODUCTION
1
1.1 Background Information 1
1.2 Justification 8
1.3 General Objective 10
1.4 Specific Objectives 10
CHAPTER TWO
LITERATURE REVIEW 11
2.1 Child abuse 11
2.1.1 Definitions of Child Abuse 11
2.1.2 Physical Abuse and Neglect 13
2.1.2.1 Physical Abuse 14
2.1.2.2 Neglect 16
2.1.3 Child Abuse International Situation 17
2.3 Child Abuse in Sri Lanka 22
2.4 Factors Affecting on Child Abuse 24
2.4.1 Socio-cultural Factors Influence on Child Abuse 24
2.4.2 Family Factors Influence on Child Abuse 25
2.5 Mother Migration for Foreign Employment 29
2.6 Outcome of Child Abuse 33
2.6.1 Personal Impact of Victimization 33
2.6.2 Socio-cultural and Economical Impact of Child Abuse 38
2.7 Child Protection
39
2.7.1 Legal Provisions
39
2.7.2 Organizations
41
2.8 Assessment of Child Abuse
46
2.9 Methods of Data Collection
47

5. CHAPTER THREE
METHODOLOGY
50
3.1 Study Design
50
3. 2 Phase I
51
3.2.1 Designing the Questionnaire on Physical Abuse and
Neglect (Q-PA&N)
52
3.2.2 Validation of the Questionnaire on Physical Abuse and
Neglect.
55
3.2.2.1 Face, content, and consensual validity
55
3.2.2.2 Convergent validity of the questionnaire
57
3.2.3 Drafting of the Q-PA&N
60
3.2.4 Reliability of the Q-PA&N
60
3.2.4.1 Selection of the sample
60
3.2.4.2 Data collection
60
3.2.4.3 Data analysis
61
3.2.5 Consistency of the questionnaire PA&N
61
3.2.6 Pre-testing of questionnaire PA&N
62
3.2.6.1 Pre-testing
62
3.2.7 Drafting of Questionnaire for the caregiver of the child (Q- CG)
63
3.2.8 Reliability of the Q-CG
63
3.2.8.1 Selection of the sample
63
3.2.8.2 Data collection
63
3.2.8.3 Data analysis
64
3.2.9 Pre-testing of the Q-CG
64
3.2.10 Reliability of the Rutter’s behaviour checklist
65
3.2.10.1 Selection of the sample
65
3.2.10.2 Data collection
65
3.2.10.3 Data analysis
65
3.2.11 Pilot study
65
3.3 Phase II
66
3.3.1 Study Setting
66
3.3.2 Study population and study unit
70
3.3.2.1 Inclusion criteria
71
3.3.2.2 Exclusion Criteria
71
3.3.3 Sample Size
71
3.3.3.1 Formula used to calculate the sample size
72
3.3.3.2 Sample size
72
3.3.4 Sampling method
73
3.3.4.1 Sampling frame
73
3.3.4.2 Selection of the sample
73
3.3.5 Study instruments
74
3.3.5.1 Questionnaire for care giver of the child (Q-
CG )
74
3.3.5.2 Questionnaire to identify physical abuse and neglect of children (Q-PA&N)
75
3.3.5.3 Rutter’s Behaviour Checklist
78
3.3.5.4 Assessing the school performance of children
80
3.3.6 Training of Research Assistants
80
3.3.7 Field work
81

6. 3.3.7.1 Planning of data collection in the DDHS office
81
3.3.7.2 Accessing to the family
81
3.3.7.3 Administering the Q-CQ
82
3.3.7.4 Obtained informed consent
83
3.3.7.5 Data collection from comparison families
83
3.3.8 Data collection for physical abuse and neglect of children
83
3.3.8.1 Planning of data collection
83
3.3.9 Administering the behaviour check list
85
3.3.10 Assessing the school performance of children
85
3.4 Steps to improve the quality of the study
85
3.5 Ethical considerations
87
CHAPTER FOUR
RESULTS
88
4.1 Development of Q-PA&N
88
4.1.1 Operational definitions
88
4.1.2 Item generation for the questionnaire
89
4.1.3 Validity of physical abuse and neglect items/phrases
91
4.1.4 Convergent validity of physical abuse and neglect phrases
94
4.1.5 Reliability of Q-PA&N
96
4.1.6 Consistency of the Q- PA&N
96
4.2 Results of Study Phase II
97
4.2.1 Demography of the sample of children
97
4.2.2 Baseline comparison of both groups
97
4.2.2.1 Age comparison of children
97
4.2.2.2 Gender comparison of children
98
4.2.2.3 Educational status of the study sample
98
4.2.2.4 Comparison of the standard of living
99
4.2.2.5 Comparison of the total family income
100
4.2.3 Comparison of socio-demographic characteristics
101
4.2.3.1 Primary caregivers of children
101
4.2.3.2 Age of primary caregivers
101
4.2.3.3 Educational status of primary caregiver
103
4.2.3.4 Sinhala literacy of primary caregivers
104
4.2.3.5 English literacy of primary caregivers
104
4.2.3.6 Occupation of primary caregiver
105
4.2.3.7 Occupation of father
106
4.2.3.8 Expenses family members’ for alcohol
107
4.2.3.9 Expenses family members’ for smoking
107
4.2.4 Family support for the children
108
4.2.4.1 Family size
108
4.2.4.2 Supportive family members
109
4.2.4.3 Involvement of children in household activities
109
4.2.5 Physical abuse of children at home
111
4.2.5.1 Prevalence of physical abuse at home
111

7. 4.2.5.2 Types of physical abuse
112
4.2.5.3 Frequency of physical abuse
113
4.2.5.4 Main perpetrator of physical abuse
114
4.2.5.5 Outcome of physical abuses
115
4.2.6 Physical abuse in the school
116
4.2.6.1 Prevalence of physical abuse in the school
116
4.2.6.2 Types of physical abuse
117
4.2.6.3 Frequency of physical abuse in the school
118
4.2.6.4 Outcomes of physical abuse in the school
118
4.2.7 Neglect of children
119
4.2.7.1 Prevalence of neglect
119
4.2.7.2 Types of neglects
120
4.2.7.3 Frequency of neglect
120
4.2.8 Behaviour problems of children
123
4.2.8.1 Distribution of behaviour problems
123
4.2.8.2 Types of behaviour problems
124
4.2.9 School performance of children
124
4.2.9.1 Average marks of children
124
4.2.9.2 Marks for Sinhala subject
125
4.2.9.3 Marks for mathematics
126
4.2.9.4 School attendance children
126
4.2.10 Views of family members on mother expatriation
127
4.2.10.1 Main reasons for mother expatriation:
Caregivers’ view
127
4.2.10.2 Main reason for mother expatriation:
Children’s view
128
4.2.10.3 Child’s willingness of mother’s migration
128
4.2.10.4 Reasons for children’s unhappiness about mother’s migration
129
4.2.10.5 Changes of home with mother’s migration
130
CHAPTER FIVE
DISCUSSION
131
5.1 Summary of the main findings
131
5.2 Comparison with the other studies done in Sri Lanka
132
5.3 Methodological issues
133
5.3.1 Methodological issues in the development of study instrument
133
5.3.2 Methodological issues of data collection
135
5.3.3 Inclusion and exclusion criteria
136
5.3.4 Selection of comparison group
136
5.4 Demographic characteristics of the sample
137
5.5 Baseline comparison of two samples
137
5.6 Comparison of socio-demographic characteristics
138
5.7 Family support to the children
139
5.8 Physical abuse of children
140
5.9 Neglect of children
142
5.10 Classroom behaviour of children
144
5.11 School performance
145

8. CHAPTER SIX
LIMITATIONS OF THE STUDY
147
CHAPTER SEVEN
CONCLUSION AND RECOMMENDATIONS
148
7.1 Conclusion
148
7.2 Recommendation
150
REFERENCE
151
Page 1- 148 Removed

9. CHAPTER SEVEN
CONCLUSION AND RECOMMENDATIONS
7.1 Conclusion
i. Primary caregivers of the index group are the grand mother, father or elder sister, but in the comparison group, it is the mother. Compared to 6% in the comparison group, 18% of primary caregivers of the index group had not attended school at all (p=0.001). The educational level of the primary caregivers in the index group was also lower than the other. Primary caregivers in the age extremities (below 20years & over 61) were found only in the index group (30.2%). Smoking and alcoholism were higher among family members of the index than in the comparison group. Help with school work at home was lower in index than the comparison group.
ii. Prevalence of physical abuse at home is higher in the comparison group (43.2%) than the index group (37.3%) (p=0.013). While the ‘mild’ physical abuses were higher within the comparison group, the prevalence of severe outcomes (Sprain, fracture and medical treatment outdoor as well as indoor) due to physical abuses were higher among the index group. The main perpetrators of physical abuse were fathers (57%) and mothers (37%) in the comparison group while fathers (54.6%), grand mothers (17.7%) and elder brother (13.2%) were main perpetrators in the index group.
iii. Prevalence of physical abuse occurring in school was higher among index (40.1%) than in the comparison group (36.8%), (p=0.165). The frequency of physical abuse occurring in school was also higher among index than the others. The prevalence of physical abuse was significantly higher among the boys in the index group (55.9%) than boys in the comparison group (43.3%) (p=0.0007).
iv. Neglect in the physical, educational and emotional domains was higher among the children of the index group (58.2%) than the comparison group (54.7%), (p=0.14). All the children who dropped out from the school (n=25) were from the index group.

10. v. Behavioural problems in the class room were higher in the index group (42.2%) than in the comparison group (18.7%), (p=0.0001). This may have been due to poor family support, and significantly high prevalence of severe physical abuse and neglect. The prevalence of emotional, undifferentiated and conduct disorders were significantly higher among the children of the index group. Their school performances were also significantly lower than that of the comparison group. These behavioural disorders and poor performances in the school are associated with the physical punishments, they were subjected to, at school.
vi. The main reason for mother working abroad is to earn money for the children’s education (35%), but average marks (p=0.0001), marks for Sinhala (p=0.0001) and marks for mathematics (p=0.15) are lower among them than the mother available group.
vii. The materialistic gains for children after mothers’ migration had improved. But most children (82%) were not happy about their mother going abroad. The main reasons for their unhappiness were lack of love and affection, and no one to discuss their grievance with. It appears that the surrogate cannot replace mothers’ role to the satisfaction of the children.
viii. Most of the local researches done before have discussed the materialistic gain of families where mother has migrated albeit to the fullest expectation. But the impact on children had not been reported adequately. This study contributes to fill this void in research.
7.2 Recommendations
i. The instruments developed and validated in this study can be used to study physical abuse and neglect (Q-PA&N), and socio-demographic and economical characteristics of primary caregivers (Q-CG). Validated Sinhala version of the Rutter’s behaviour check list is reliable to asses the class room behaviour of 13-15 year aged children.
ii. The findings of this study should be widely disseminated among all the stakeholders including potential migrants for employment for informed decision making.

11. iii. Authorities responsible for the foreign employment should arrange special programmes not only for the migrants, but also for children left behind, teachers and other potential caregivers. Identifying psychological and materialistic needs of children and responding to them and reacting to problems of children appropriately are some of the skills needed to be imparted in these groups.
iv. Sensitising and awareness raising about physical abuse and neglect of children and their associated factors may reveal unreported instances of child abuse.
v. Sensitising and awareness raising on child abuse among school teachers and the special needs of children of mothers who have migrated will be useful to prevent the children being abused at school.
vi. Conducting training programmes for the school teachers to identify the children having behavioural problems and solve them.
vii. Training school teachers about alternative methods to maintain discipline among children instead of corporal punishment.
viii. Integration of divisional level child protection activities with the district child protection committees.