SUBMITTED 5 SEP 21 1 REVISIONS REQ. 24 OCT 21 & 4 JAN 22; REVISIONS RECD. 23 NOV 21 & 18 JAN 22 2 ACCEPTED 2 MAR 22 3 ONLINE-FIRST: MARCH 2022 4 DOI: https://doi.org/10.18295/squmj.3.2022.026 5 6 Severe Injuries in 9 Children: Is it due to child neglect? 7 Case series from a regional hospital in Oman 8 Shamsa S. Al Balushi 9 10 Department of Pediatrics, Ministry of Health, Muscat, Oman 11 E-mail: shamsalkone@yahoo.com 12 13 Abstract 14 Child Abuse and Neglect (CAN) is a global phenomenon and has many forms. Child neglect is the 15 most common form observed. CAN are serious incidents with medicolegal implications for the 16 caregivers. The recognition of CAN is still in its early stages in the Middle Eastern cultures such as 17 in Oman where parental authority over children is traditionally sacrosanct. This case series presents 18 nine serious incidents from a regional hospital in Oman that appears to fulfil the definition of child 19 neglect. All cases presented were diagnosed by Suspected Child Abuse and Neglect (SCAN) team. 20 This paper provides evidence that child neglect exists in Oman and had resulted in death of some 21 children and led to significant physical, psychological and social sequelae in others. It also 22 addresses risk factors and management recommendations. The article also highlights SCAN team 23 experience along with the limitations of the current Child Protection Services (CPS) in Oman. 24 Keywords: Child Abuse; Child Neglect; Child Protection Services; Case Series; Oman 25 26 Introduction 27 Child Abuse and Neglect (CAN), also known as Child Maltreatment, is a global problem. 1 As per 28 World Health Organization (WHO), it includes all forms of physical and/or psychological ill-29 treatment, neglect or negligent treatment, sexual abuse and commercial or other exploitation, 30 resulting in actual or potential harm to the child‘s health, survival, development or dignity in the 31 context of a relationship of responsibility, trust or power. 2 Child neglect, the most common form of 32 CAN, can occur in physical and emotional forms. 3 The prevalence of child neglect is estimated at 33 163/1000 for physical neglect and 184/1000 for emotional neglect. 1 In 2008, one-third of CAN 34 investigations in Canada involved neglect. 4 35 mailto:E-mail:%20shamsalkone@yahoo.com mailto:E-mail:%20shamsalkone@yahoo.com 36 Though well-studied and socially accepted in the Euro-American populations, the concept is still 37 relatively new in the Arabian Gulf region. There is scarcity of studies reporting CAN in the Arab 38 Peninsula, which is sometimes attributed to a ‗culture of silence.‘ 5 Medically reported cases thus 39 may represent the tip of the iceberg. 6 In Oman, the available limited data suggest that all known 40 forms of CAN are prevalent. 7 41 42 The Sultanate of Oman ratified the Convention on the Rights of the Child (CRC) in 1996 8 and the 43 country‘s Ministry of Health has sought to implement international norms for management of CAN 44 as laid out in its Clinical Guidelines on Child Abuse and Neglect. 9 However, the traditional Omani 45 Arab society (like its Middle Eastern peers) has a culture that consider parents—especially the 46 father—as the final authority for the wellbeing of their offspring. Understandably, there is some 47 resistance from the community regarding medico-legal interference in child welfare. 5 Thus, legal 48 action for CAN cases often tend to be avoided as demonstrated by the cases discussed below. 49 This paper aims to add to the emerging evidence that child neglect exists in Oman and is associated 50 with significant trauma in children and even occasional deaths. The nine cases reported here have 51 been evaluated by the team that monitors Suspected Child Abuse and Neglect (SCAN) at Rustaq 52 Hospital (a regional hospital in Oman) in 2020–21 and are proposed as examples of child neglect. 53 The fact that all the nine cases have emerge from a small region over just 9 months indicates the 54 necessity to study and act on this much-ignored problem. 55 56 This paper briefly recounts the nine cases of child neglect and how the hospital SCAN team 57 experienced and managed each. It brings out the risk factors, management recommendations, as 58 well as the practical limitations of the current Child Protection Services (CPS) in Oman. Ethical 59 permission was obtained from Research and Ethics Review Approval Committee at the Regional 60 Health Directorate, Rustaq. Verbal consent for the publication of each case was obtained from the 61 guardians. 62 63 The SCAN Team: Constitution and Management 64 The SCAN team at the Rustaq Hospital (a regional secondary hospital) was constituted in 2020, led 65 by a pediatrician specialized in child abuse and neglect (the author of this paper). The medical 66 evaluation of the identified cases by SCAN team was conducted according to the international 67 standards. 10-12 As there is no qualified social worker in the hospital, the team has appointed a nurse 68 with a bachelor‘s degree in community health. There are physicians assigned from different wards 69 in the hospital including the ER to notify the SCAN team of suspected cases. A radiologist and an 70 ophthalmologist are also part of the team when such evaluation is required. 71 72 In the cases described below, the history was obtained in a non-leading manner by interviewing the 73 caregivers, and where possible, the child. The SCAN team also interviewed other family members 74 where required to triangulate the data. The family‘s perceptions and concerns were acknowledged 75 and the team avoided the common pitfall of blaming the caregivers, rather engaged them in the 76 management plan. All children were medically examined for signs of other types of abuse or 77 neglect and to rule out other medical diagnoses. Where CAN was suspected, there was continuous 78 liaison with the police, general prosecution, and the child protection delegate (social worker 79 assigned by Ministry of Social Development (MOSD). 80 81 Case Reports 82 Case one 83 A 2-year-old toddler presented with chemical burn involving 20% body surface including eyes, 84 face, chest, and limbs. He required intubation and admission in the paediatric intensive care unit 85 (PICU). His mother had an untreated mental disorder. Born ‗unwanted,‘ the child was in the care of 86 an aunt since birth. On the day of injury, this aunt had a job interview, and she left the child in the 87 care of the mother at the latter‘s house. In the toilet used by the child, the father had left an opened 88 bottle of highly corrosive acid (sewage opener) for two days, and the child consumed it. The mother 89 later admitted of being aware of the bottle while the child was in toilet. The father of the child 90 admitted that the care of three other siblings of the child were also being neglected due to maternal 91 mental illness and his work commitments. The information provided in the case were mainly taken 92 from his primary caregiver (his aunt) which are consistent with the physical examination of the 93 child and with information given later by both parents. 94 95 The child remained hospitalised for two months and underwent multiple operations. He developed 96 significant disfigurement of his face in addition to vision and breathing problems. He also showed 97 symptoms of post-traumatic stress disorder (PTSD). Meanwhile his caregiver (aunt) also admitted 98 being stressed with her own social and financial pressures. They were both referred for 99 psychological support in a specialised centre. The team was able to procure psychological and 100 financial assistance to them. The mother was encouraged to attend her missed psychiatric sessions. 101 However, efforts to bring the child‘s three siblings for medical examination were unsuccessful and 102 the current child protection system in Oman failed to take further intervention. 103 104 Case two 105 A baby boy, diagnosed with trisomy 21 at birth, was lost to follow up and then seen at age of 6 106 months when he was brought to the Emergency Room (ER) by his grandmother with fever and 107 breathing difficulty for one week. He was diagnosed with heart failure (HF). Before starting 108 treatment, the grandmother took away the child against medical advice claiming that his primary 109 caregiver (parents) were refusing admission and that they would take him to another hospital. 110 SCAN team tried to call the parents to ask about the child but received no response. Child 111 protection delegate was involved but failed to bring the child back to hospital. The child was 112 brought again at age of 8 months with HF but again taken away against medical advice. SCAN 113 team was not involved this time. The child was brought back at age of 9 months for a routine 114 appointment and was found to have severe pulmonary hypertension and huge tamponade which 115 required pericardiocentesis. No home visit or legal escalation for child neglect was conducted. 116 117 Case three 118 A 10-year-old boy was brought to ER in critical condition which required immediate ventilation 119 and PICU admission. The child sustained severe traumatic brain injury, grade IV liver injury, grade 120 V kidney injury, multiple fractures and lung contusion. He stayed for two months in PICU and 121 underwent multiple operations. He had seizures and was on multiple anticonvulsants. On discharge, 122 the child was in a vegetative state. 123 124 SCAN team interviewed the mother, step-father, older brothers and uncles. The child was living 125 with his maternal grandparents as his father had died and his mother had married an old man and 126 was living in a very small accommodation. He was visiting his mother frequently. On the day of 127 injury, child was visiting his mother at her home when a cooking gas cylinder burst severely 128 injuring him and three others. The cylinder was kept in the narrow kitchen, just beside the 129 bedrooms and living room even though there was space for it outside the kitchen. The mother and 130 her husband had underestimated the safety risk. The child‘s uncles and older brothers raised their 131 concerns on the safety of the children at their mother‘s home. Multidisciplinary team meeting was 132 conducted to plan social assistance for childcare after discharge. SCAN team has been following up 133 the child and his family situation. Though the child protection delegate was involved, no home visit 134 was conducted by him and no legal action was taken. 135 136 Case four 137 A 2-year-old girl was found drowsy, excessively sweating and very warm to touch after being 138 entrapped in a car for two hours. Her mother had been driving with five children. When they arrived 139 home, she locked the car assuming everybody was out and then got busy with cooking. Even 140 though the mother was notified that the child was not around, she assumed that she was playing. 141 On presentation to the hospital, the child had abnormal movements and features of heat stroke with 142 deranged liver and renal functions. She was managed in PICU and recovered within 48 hours with 143 no neurological or behavioural sequelae. The liver and renal functions were normalised. The SCAN 144 team extensively counselled the parents and discussed the case with the child protection delegate 145 who interviewed the family by phone. 146 147 Case five 148 A 13-month-old girl developed severe upper airway obstructive symptoms which required 149 ventilation and PICU admission after ingesting hot water. Her father had boiled water to prepare 150 formula, poured it into an open container which he left on the floor. Though her parents were in the 151 same room they were not actively supervising her, and were alerted by her screams. With burns 152 involving anterior neck and upper anterior chest area, the child was ventilated for two days due to 153 severe airway obstruction. On follow up, she had no breathing or feeding issues. The SCAN team 154 gave extensive counselling to the parents. 155 156 Case six 157 An 18-month-old boy sustained skull-fracture, intracranial and lung contusion and liver hematoma 158 that required PICU admission after a fall from staircase at home. The balustrade had holes that 159 enabled the child to climb onto the guard-rail and ride down. He did this repeatedly. One week prior 160 to the injury a fall was prevented as his clothes became stuck. Despite that incident, no effective 161 preventive measures were taken by the caregivers. In this case the child‘s injuries healed with no 162 sequelae. SCAN team counselled both parents. The child protection delegate was involved, but did 163 not engage in communication with the family. 164 165 Case seven 166 A 4-year-old boy presented with burns involving 20% of the body surface area. He was intubated in 167 ER due to peri-oral burn and lips swelling. At the day of injury, his uncle had taken him and other 168 four children, all below 12 years of age, to watch him burn dry grass in a small, closed room to get 169 rid of insects that infested the goats he had been keeping there. As the children huddled at the 170 entrance to watch, the uncle doused the grass with petrol and set light to it. Fire went out-of-control, 171 severely burning this child and causing milder burns in other two children. After hospitalisation, the 172 uncle was counselled by SCAN team and the child protection delegate was informed. No further 173 actions were taken. 174 175 Case eight 176 A15-month-old toddler was brought to the ER with no breathing and no pulse after drowning in a 177 home swimming pool for an unknown period. The event happened when the mother was busy in the 178 kitchen. The pool was unfenced with easy access to small children. Child survived after 20 minutes 179 of resuscitation however remained ventilator-dependent with severe neurological sequelae and died 180 after 3 months. The event was witnessed by four older siblings aged below 12 years. They 181 developed symptoms of PTSD, and SCAN arranged a management plan. However, the children did 182 not show up as the parents did not consider the intervention necessary. 183 184 Case nine 185 A 4-year-old girl diagnosed with sickle cell disease (SCD) was brought to the ER in a state of 186 cardio-respiratory arrest with deep jaundice and severe pallor. The investigation results were: Hb: 187 0.5 g/dL (N:11.5-15.5), platelets: 10x9/L (N:150-450), reticulocytes: 5% (N:0.2-2), urea 13mmol/L 188 (N:3.5-5.5), C-reactive protein: 243 (N<5), bilirubin: 117.5 umol/L (N<20). The child died despite 189 resuscitation attempts. SCAN team interviewed the parents who explained that the child had pain in 190 limbs, lethargy, and loss of appetite for two days, which was managed at home with pain 191 medications. On the morning of the day of presentation, the lethargy increased and child was 192 moaning. Mother went to sleep and left the child and her siblings in the living room, and the father 193 left for work. When he returned, he found the child unconsciousness and brought her to the ER. 194 Parents have another child with SCD and they acknowledged that they had been counselled about 195 the disease, but that this child‘s disease was mild. Medical records indicated that her SCD was not 196 being followed up, nor was she on any treatment, which the parents confirmed during the interview. 197 One year earlier the same child had been brought to the ER with deep laceration near the eye after 198 falling from the staircase. The mother developed prolonged grief disorder and was referred for 199 treatment. The delegate called the caregiver by phone. No further action was taken in this case. 200 201 Discussion 202 Child neglect is the most common form of CAN. 3 At its core, neglect is a situation where the 203 child‘s normal development and safety is impeded by the failure of the caregiver to meet the child‘s 204 basic needs. 13,14 There are various types of child neglect as shown in Table 1. 205 206 This paper features nine serious cases attributable to child neglect that were presented at the ER of 207 Rustaq Hospital, a secondary regional hospital in Oman, during a period of nine months. All cases 208 required PICU admission except for one child (case 9) who died in ER. Eight out of the nine cases 209 were below the age of 5 years. At least in six cases there were preventable factors and warning 210 signs. If these signs had been heeded and timely action taken, the injuries might have been avoided. 211 A likely case of chronic neglect of several children in a family is illustrated by case-1. Leaving an 212 ―unwanted‖ child even for a short time with his mentally ill mother seems prima facie an instance 213 of neglect by the caregivers, the aunt, and the father. It also represents significant neglect of home 214 safety by leaving open a dangerous chemical in a child‘s toilet. The fact that the father did not 215 present the remaining children for counselling despite invitation from the SCAN team is yet another 216 indication of ongoing chronic child neglect. 217 218 Case-2 and case-9 represent severe professional challenge for any dedicated pediatrician. Here the 219 caregivers not only neglected their child‘s serious symptoms, but after presentation refused medical 220 care. Such phenomenon has been studied in Oman and remedial procedural changes have been 221 made in hospitals. 17-19 The difficulty lies in the implementation, as the Omani-Arab tradition gives 222 primacy to parental authority over external intervention. However, over the years the state has been 223 increasingly able to intervene in clear cases of child neglect. 20 224 225 Case 3 is an example of suboptimal home environment in the home of a non-custodial parent. The 226 child was exposed to physical neglect and ended up in a vegetative state due to explosion of gas 227 cylinder placed in a narrow kitchen. On the other hand, factors beyond parent‘s control such as 228 economic deprivation might explain the lower safety levels. Therefore, various factors need be 229 considered before attributing cases to child neglect. 230 231 The economic deprivation argument may be less relevant in cases 4-8. These cases illustrate the 232 lack of caregiver attention to toddlers and perhaps a lack of awareness on child safety among 233 caregivers. In case 8, absence of physical safety provisions in a home swimming pool and absence 234 of supervision took the life of a toddler. In case 4, a mother fails to check for her infant left in the 235 car even after being reminded. Similar cases with heat stroke and lack of supervision have been 236 reported in Omani literature. 17,21 237 238 Challenges faced and Management Recommendation 239 Deciding whether a caregiver‘s behaviour was neglectful is often difficult. Each case is unique with 240 many causative factors. Therefore, attention and sensitivity while working with the family and the 241 child protection team is important. The team should aim to identify harm and to explore the factors 242 that led to neglect and with the intention to prevent similar occurrences, rather than presuming any 243 intentionality from the side of the parents because most seek the child‘s welfare. 22 244 245 Several factors usually interact and result in neglect. 23 Parental factors such as mental health issues 246 as in case 1 and child-related factors such as younger age. 23-26 Lack of community centres and other 247 supportive resources are also associated with higher prevalence of neglect. 23 In case1, for example, 248 if there were alternative supportive resources such as a nearby nursery, the injury could have been 249 prevented. Economic deprivation, as in case 3, might explain some unsafe home environments. 250 Additionally, the traditional status of the father as having the ultimate say on the child makes 251 medical non-compliance more likely, as in cases 2 and 9. 252 253 It is apparent from the discussed cases that there is suboptimal management of CAN cases. In any 254 of these cases no legal action was taken, or home visits made. Randomized controlled trials have 255 demonstrated that home visits are effective in reducing CAN in a society. 27 In addition, requests for 256 bringing siblings of the injured child for medical examination were not complied with. In fact, cases 257 4, 5, 6 and 8 give sufficient grounds for investigating the home environment of the caregivers. 258 There is also insufficient monitoring of home environments where children visit their non-custodial 259 parents and relatives. Possible causes for such deficiency may include the underestimation of the 260 importance of the situation among professionals working with children. 28 Traditional reticence in 261 the Arab Omani population against revealing family matters to outsiders may also play a role. 262 These can be modified over time through public education. Health professionals need to be trained 263 to change false attitudes and to be more alert to abusive practices and behaviours of parents and 264 other caregivers 28 and to intervene (in a culturally appropriate manner) not only in one‘s own 265 family but also in one‘s neighbourhood. 266 267 Conclusion 268 Child neglect does exist in Oman as it does elsewhere but is less visible here due to cultural factors 269 and inadequate social monitoring systems. The nine cases discussed in this paper, emerging from a 270 small region from Oman during a short period, add to the evidence for occurrence of serious 271 incidents that sometimes result in death, as well as the medical and psychological sequalae in the 272 survivors and their families. This report highlights the need to upgrade and implement effective 273 community-based services and provide proper social support to victims and their families. There is 274 an absolute need for culturally adapted community awareness campaigns to help prevent child 275 neglect and minimise its significant adverse short- and long-term impacts. 276 277 References 278 1. Stoltenborgh, M., Bakermns-Kranenburg, M. J., Alink, L. R. A., & van Ijzendoorn, M. H.. The 279 prevalence of CAN across the globe: review of a series of meta-analyses. Child Abuse Rev 2015; 280 24(1), 37–50.DOI: 10.1002/car.2353. 281 2. World Health Organization. Child maltreatment, 2020. 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Poster presented at: ISPCAN Asia Pacific Regional Conference on Child Abuse and 351 Neglect; 2015 Oct; Malaysia. 352 353 https://doi.org/10.1016/s0140-6736(08)61708-0 Table 1: Types of neglect 354 Type of neglect Defention Physical Inadequate food, clothing, shelter, hygiene Medical Failure to provide prescribed medical care or treatment or failure to seek appropriate medical care in a timely manner Dental Failure to provide adequate dental care or treatment Supervisional Failure to provide age-appropriate supervision Emotional Failure to provide adequate nurturance or affection, failing to provide necessary psychological support, or allowing children to use drugs and/or alcohol Educational Failure to enroll a child in school or failure to provide adequate home schooling, failure to comply with recommended special education, allowing chronic truancy Other Includes exposing children to domestic violence, or engaging or encouraging children to participate in illegal activities such as shoplifting or drug dealing Adapted from Reference 15&16. 355