Reporting of violence against children and adolescents in a protective institution in southern Brazil

Notificación de la violencia contra los niños y adolescentes en una institución de protección en el sur de Brasil

Notificação de violência contra crianças e adolescentes em uma instituição de proteção no sul do Brasil

Priscila Arruda da Silva¹;Valéria Lerch Lunardi²; Guilherme Lerch Lunardi³;Simone Algeri⁴;Tamara Souza⁵

¹Nurse, Ph.D. Federal University of Rio Grande - FURG-/RS - Brazil. email: patitaarruda@yahoo.com.br.

²Nurse, Ph.D. Professor,FURG, Brazil. email: vlunardi@terra.com.br.

³PhD. Professor, FURG, Brazil. email: glunardi@furg.br.

⁴Nurse, PhD. Professor, FURG, Brazil. email: salgeri@terra.com.br.

⁵Psychologist. Host institution: Casa do Menor in Rio Grande / RS - Brazil. email: tamarasouza88@gmail.com.

Receipt date: June 9, 2015. Approval date:December 4, 2015.

Article linked to research: Notification of family violence against children and adolescents as an exercise of power and resistance.

Subventions: PhD Scholarship - FAPERGS/CAPES.

Conflicts of interest: none.

ABSTRACT

Objective.This study aimed to analyze the reports of violence against children and adolescents in the period between January 2009 and May 2014 in a municipality protection institution of Rio Grande, RS. Methods. This is a descriptive and documentary study with a quantitative approach that analyzed 800 medical records of Specialized Reference Center for Social Assistance (CREAS), from the development of a research instrument containing the study variables. Results. The results show that 44.5% of the notifications sent to the protection of organs were carried out by family members and evidence of physical signs was the reason that triggered them (34%). The dismissing by abandonment of families is very present in the institution (36.9%), which possibly supports the maintenance of the cycle of violence. Conclusion. The results of this study show that although there were improvements regarding the notification by the family, the number of notifications made by the health and education sectors are still reduced, thereby increasing the need for more effective and articulated actions in these sectors.

Key words: nursing; mandatory reporting; domestic violence.

RESUMEN

Objetivo.Analisar las notificaciones de violencia contra niños y adolescentes en el período comprendido entre enero de 2009 a mayo de 2014 en una institución de protección del municipio do Rio Grande, RS. Métodos. Se trata de un estudio descriptivo y documental de abordaje cuantitativo en el que fueron analizados 800 prontuarios del Centro de Referencia Especializado en Asistencia Social (CREAS), a partir de la elaboración de un instrumento de investigación que contenía las variables de estudio. Resultados. El 44.5% de las notificaciones remitidas a los organismos de protección fueron realizadas por los familiares y una proporción pequeña fue reportada por las instituciones de salud y por las escuelas (4% cada una). La evidencia de signos físicos de violencia fue el principal motivo que desencadenó la denuncia (34%). El desligamiento por el abandono de las familias fue bastante frecuente en la institución (36.9%), corroborando posiblemente el mantenimiento del ciclo de violencia. Conclusión. Los resultados de este estudio muestran que el número de notificaciones realizadas por los sectores salud y educación son muy reducidas, y que se necesitann acciones más efectivas y articuladas de estos sectores para la atención.

Palabras clave: enfermería; notificación obligatoria; violencia en la familia.

RESUMO

Objetivo.Analisar as notificações de violência contra crianças e adolescentes, no período compreendido entre janeiro de 2009 e maio de 2014 em uma instituição de proteção do município do Rio Grande, RS. Métodos. Trata-se de um estudo descritivo e documental, de abordagem quantitativa em que foram analisados 800 prontuários do Centro de Referência Especializado em Assistência Social (CREAS), a partir da elaboração de um instrumento de pesquisa contendo as variáveis de estudo. Resultados. A 44.5% das notificações encaminhadas aos órgãos de proteção foi realizada pelos familiares e a evidência de sinais fisicos foi o motivo que as desencadeou (34%). O desligamento por abandono das famílias é bastante presente na instituição (36.9%), corroborando possivelmente a manutenção do ciclo de violência. Conclusão. Os resultados desse estudo mostram que embora tenham ocorrido avanços em relação à notificação pelos familiares, destaca-se que o número de notificações realizadas pelo setor saúde e educação ainda se mostra reduzido, reforçando, assim, a necessidade de ações mais efetivas e articuladas desses setores.

Palavras chave:enfermagem; notificação de abuso; violência na família.

INTRODUCTION

Violence against children and adolescents, because of its impact on the lives of thousands of victims, has emerged as a serious public health problem. Numerous physical, emotional and psychological consequences resulting from violence can become irreparable and manifest in adulthood, such as anxiety, depression, pessimistic view, relationship problems, in addition to the reproduction of violence that contributes to its perpetuation.^1-3 There is an urgent need to prevent violent acts, since their sequelae reach expressive dimensions and gravity. The large proportion of physical and psychological sequelae points to the need not only to prevent violence and treat victims, but also to the reporting of cases to the relevant authorities so that this cycle is broken.⁴

The growing need to bring up the issue that comes to the various bodies that deal with victimized children and teenagers, the structural weaknesses of the protection system and the difficulties of professionals to assist and support victims have contributed to the recurrence and worsening of cases due to the lack of implementation of protective measures, such as notification of situations of violence.⁵ This fact requires that professionals and managers who deal with the phenomenon of violence in their fields contribute to fight the problem, since it has been one of the most alarming demands in the routine of services that focus on the child and the teenager. Thus, spaces, whether they are social, educational or health spaces, play an important role in implementing the strategies needed against this problem, by presenting themselves as potential sites to disclosure and reporting of cases.⁶

According to Brazilian law, all forms of violation of children's and adolescents' rights are plausible of notification, whether physical, psychological, sexual or neglect. This obligation is properly qualified in the Federal Constitution, in the Statute of Children and Adolescents and in the Brazilian Penal Legislation.^7,8 More recently, through the Ordinance MS / GM no. 104/2011, violence has been included in the list of diseases and grievances of mandatory reporting throughout the country, that is, has become a grievance of universal notification in all health services in Brazil.⁹ It must be noted that, compared to other countries, mandatory reporting of violence is recent in the Brazilian scene. In the United States, since the late 1970s, all the American territory had already established mandatory reporting of cases of violence against children and adolescents, although this action does not follow a standard, and varies according to the specific laws and policies of each state. Still, in different countries, specific websites are available to guide practitioners on how to access the legislation and other mandatory information resources.¹⁰

The notification of family violence against children and adolescents, however, is justified not only for its legal requirement, but mainly because it is an ethical issue involving people in vulnerable situations that suffer violence silently because they fail to get rid of the relation of domination they experience. For Foucault, "the relations of domination can be understood asa relationship of violence that acts upon a body; it forces, it bends, it destroys, it closes the door on all possibilities. Its opposite pole can only be passivity".^11:243

The municipality of Rio Grande, by constituting a port city with an estimated population of 207,000 inhabitants,¹² is characterized as especially vulnerable to situations of violation of children and teenagers. Latest data mapping vulnerabilities to sexual exploitation of children and adolescents on Brazilian federal highways - 2013/2014 - reveal the growing increase in its numbers, with highlight to Rio Grande do Sul, as the second state with more vulnerabilities to sexual exploitation of children and adolescents, second only to Minas Gerais. The large flow of people has possibly favored the creation of sexual exploitation points in the highway access to the city.¹³ Thus, this study arose in an attempt to establish an overview on notifications of violence carried out in that city, which will allow a better understanding of the phenomenon. The notification of violence and accidents, only in 2009, started to join the Information System for Notifiable Diseases (SINAN). Although the city has advanced in terms of population growth, especially to meet the demand of economic development due to the expansion of the naval polo, there is only one Specialized Reference Center for Social Assistance (CREAS), deployed since 2001 in the municipality, which is a pioneer in the implementation of this service in Rio Grande do Sul. This fact justifies the choice of this institution to conduct this study.

Addressing the issue of violence against children requires the commitment of all, including the professionals who deal with this situation in their workplaces, as educators and health professionals, defensive services such as Civil Police, Child Protective Services, Childhood and Youth Court, as well as society. Thus, it is relevant questioning: who has made the notification? Which reasons has led to its realization? How have cases of violence against children and adolescents referred to specialized service in the municipality where the study was conducted evolved? From this perspective, this study aims to analyze the reports of violence against children and adolescents in the period between January 2009 and May 2014 in a municipal protective institution of Rio Grande, RS.

METHODOLOGY

It is a descriptive and documentary research, with a quantitative approach, developed in CREAS in Rio Grande / RS. This service has a team of psychologists, social workers, social educator and administrative assistant. It meets families (victims and legal guardians) through the referral of cases by the Child Protective Service or complaints from neighbors, schools and health services. Upon receiving the child and / or adolescent and their legal guardian in the institution, their record is open, and their psychosocial evaluation is performed by professionals, from which the victim and his family start receiving psychosocial follow-up from the service. When there is need for health professionals intervening due to comorbidities and / or sequelae related to violence, cases are referred to the proper authorities.  

The sample consisted of 800 medical records opened from January, 1, 2009 to May, 31, 2014, involving children and adolescents, victims of domestic violence, aged from zero to 18 years old. All records of people who are outside the stipulated age group; records made before 2009 and victims of extra-familiar violence were excluded. Data were collected by a single examiner, during the period from January 2014 to May 2014, from the elaboration of a research instrument with the study variables, regarding the notification: origin, reason for notification and outcome of cases in the institution. From the entering of data on Excel® spreadsheets, its analysis was performed through descriptive statistics, using the statistical software Statistical Package for Sciences SPSS version 17.0. Then, the specific variables with respect to the notification as its origin, reason that led to the notification and outcome of cases were identified quantitatively by simple frequency. It was also developed possible relations between the variables notifier and reason that led to notification, and notifier and outcome of cases. The project was approved by the Research Ethics Committee under number 105/2013.

RESULTS

In the period established for the collection, 800 reports of domestic violence against children and adolescents were recorded in CREAS. It was identified its origin, the reason for notification, and the outcome of cases seen in the institution. The majority of reports of domestic violence against children and adolescents referred to protective agencies are held by family members (44.5%), as shown in Table 1. It is also noted that services Dial 100 (27.3%) and Anonymous Report to the Child Protective Service (13.9%), respectively, were the most resources used by people to report domestic violence against children and adolescents, possibly because there is no need for revealing their identity. Although the Anonymous Report service to the CPS has originated the notification, it is important that all the notifications are passed on to the Child Protective Service.

In contrast, the host institutions were identified in this study as places where fewer people reported situations of violence, similarly to schools and health institutions (Family Health Strategy, Psychosocial Care Center, Center for Support to Family Health and Hospitals). Thus, it is emphasized the need for greater coordination of these sectors with the child and adolescents protection network, since the school is characterized as a place to detect possible evidence of violence, as well as health services, because they are places sought by many victims, whether explicitly or not, in face of violence.

With regard to reasons for notification of violence against children and adolescents, 34% were due to the identification of physical signs presented by victims and, in 32% of cases, the behavior of the child.

As the relationship between the notifier and his reasons for seeking the protective bodies and carrying out the notification, it was found that the vast majority was motivated by physical signs presented by the victims, with highlight to the Dial 100, the victim himself and health institutions, with 40.4%, 55.9% and 45.5% respectively. In contrast, 62.2% of the notifications made by the host institutions and 34.4% by family members were motivated by the child's behavior, as shown in (Table 1).

Table 1.

Regarding the outcome of cases of domestic violence against children and adolescents referred to CREAS, 36.9% of cases were dismissed of the institution due to abandonment. In 25.1% of cases, family members are still being seen by the protective service and 21.8% were discharged. Also, 16.2% of reports were considered to be unfounded, according to (Table 2).

As the relationship between the notifier and the outcome of cases, the results indicate that from the total number of notifications made through anonymous report to CPS, 41.4% are dismissed from the institution due to abandonment of treatment, as well as the notifications made through Dial 100 (36.7 %), by family members (34.6%), health institutions (48.5%) and the victim (44.1%). in contrast, 40% of notifications made by the school were discharged and 61.5% of cases notified by the social institutions are underway.

Table 2.

DISCUSSION

The notification of violence against children and adolescents is a legal commitment of all citizens. The act of notifying enables above all the knowledge of cases by the responsible bodies, and thus enables actions to be implemented in an attempt to break the situations of violation of rights and to ensure the protection of children and adolescents.¹⁴ It is stated that the notification of family violence against children and adolescents is on a complainant's manifestation of exercise of power. In this perspective, power is conceived as a strategy, so it is not a privilege that someone has or transmits.¹⁵ Thus, it should be noted that in the perspective of the network of protection against violence, everybody influences not only in regard to its discontinuation but also to its maintenance.

The notifier is the key element that makes violence public and should be considered a key player in the child protection network. Therefore, in this study, it was found that in 44.5% of cases, family members were notifiers. Similar results were found by Costa, Santana, Carvalho et al,¹⁶ when investigating the profile of sexual victimization of children and adolescents. These authors found that sexual violence was reported more often by the mother of the child or adolescent (29.9% of cases), by the father (20.8%) and by other relatives (25%). The "Dial 100" and the Report stood out as the second and third main vehicle for collecting notifications, corroborating studies that point anonymity as important identification strategy and facilitation of reports.^5,17 Anonymity ensures no involvement with the case and preserves the identity of the complainant. Today, Dial 100 acts as the main instrument for complaints of human rights violations in the country, contributing significantly to the "portrait" of violence against children and adolescents and the construction of public policies.^18,19

On the other hand, the lack of detail of information can make it difficult to obtain data that will contribute to the confirmation and elucidation of cases. Incorrect or incomplete data, not including the required information, as well as false reports are the problems that most have hampered the progress of cases received at Dial 100.¹⁹

Other sectors, such as health and education, were associated with the origin of the notification in the study, despite their number of notifications having been low, even in face of their obligation and the application of penalties in case of failure of notification. In the case of health institutions, the number of notifications was quite approximate the number of notifications made by the victim himself, which deserves some attention, since the Ministry of Health has invested in training professionals to face the problem of violence.⁹ It is clear, therefore, that children and adolescents have also broken the silence, possibly strengthening themselves, overcoming fears and guilt to reveal / notify experienced episodes and demonstrate resistance to those who have abused them.

It is considered that the disclosure / reporting of violence against children and adolescents is a relation of resistance ¹⁵ of the notifier against the aggressor and an attempt to break cycles of violence. Studies conducted in other countries were not different from the results of this study. In Canada, only 10% of reports sent to protection services were reported by health workers.²⁰ In the US, research involving the federal units found that 66.6% of the suspected cases of abuse were not reported to protective agencies, by professionals with a legal obligation to notify.²¹ In Jordan, research with 400 dentists found that 50.0% suspected of some form of abuse; however, only 12.0% reported their suspicions.²² These data suggest that the act of notifying violence against children and adolescents have not yet configured as a common practice in the routine of professionals in the health sector, even in countries where reporting has been established for about 40 years and attendance systems are more improved.

Notifying of violence as a manifestation of knowledge and exercise of power, strength and freedom favors the protection and defense of vulnerable people involved in this situation, especially children and adolescents, victims of violence, as well as the accountability of the perpetrators. To perform such an action, therefore, it is necessary that nurses and other health professionals opt for facing the situation, despite the possible risks involved, breaking silence pacts that also has fueled impunity and a vicious cycle, exposing victims of violence to unnecessary suffering, continuously. Health institutions showed a higher percentage of notifications related to the presence and identification of physical signs, corroborating with other national and international studies showing a significant increase in the number of reports of physical and sexual violence, which can be justified by the evidence of injury, thus indicating the existence of a possible violence.^23-25 It is noteworthy that host institutions and schools had the highest percentages of notification related to the child's behavior, having noticed 62.2% and 34.3%, respectively. The school is a privileged place to identify and report cases of violence due to the physical, emotional and behavioral indicators presented by the child and / or adolescent, as well as the host institutions, because the professional shares more time with the victims, which facilitates observation and identification of possible indications of violence.

Considering that information is the raw material for knowledge and essential for decision making, the results of this study show an apparent lack of institutional culture that values the records. The precariousness of information on notification actions by different sectors such as health, social care and education indicate a problem that must be faced. The analysis of evolution of cases shows a considerable percentage of dismissing of families due to abandonment, corroborating other studies that show the difficulty of adhesion of families to the follow-up. Generally, legal guardians attend specialized services due to the recommendation or requirement of authorities; in some cases, they seek treatment only as a result of a court order.²⁶ Thus, it is interesting to highlight that the relief of suffering experienced by children and adolescents depends not only on treatment provided by professionals of the specialized care network, but also on the performance of those responsible for children and adolescents. Thus, one could question the existence of a failure of those responsible for the care needed for victims. Whom does the burden of this failure lies to when there is a law that guarantees treatment to the victims? Authors highlight the resistance of professionals in reporting cases due to disbelief in the effectiveness of the bodies and due to the lack of a sufficient structure to meet demand.^2,27 However, in 36.9% of the 800 reported cases of violence and forwarded to CREAS, there was the abandonment of treatment by family members, which possibly supports and maintains the cycle of violence and may exacerbate consequences arising from the non-treatment, as recurrence and even the victim's death.

By relating the outcome of cases with the notifier, the results show a large number of dismissing due to abandonment in virtually all categories of notifiers, with the exception of school, that had a higher percentage of discharge from treatment, in 40% of the notifications made. These findings show the need for greater involvement of professionals working in different sectors towards a single goal, namely the protection of children and adolescents, so that death is not the completion of a history of violence that could have been avoided if the indicators of violence had been noticed or considered with the seriousness that the gravity of the case required. Considering the number of notifications assessed as unfounded (130), it should be noted that the increase in these notifications increases the demand for protective agencies because they are responsible for investigating each of these situations. Therefore, taking time for this purpose prevents that they have to deal with more serious and real cases.⁶

Conclusion. Analyzing the reports of violence against children and adolescents enabled understanding that although silence can still be present in many situations involving family violence, there has been evidence of mobilization of the family and society in addressing the phenomenon. Although there have been advances in relation to the notification by the family, the number of notifications made by the health and education sectors are still reduced, thereby increasing the need for more effective and coordinated actions of these sectors, since they are relevant spaces of protection to children and adolescents and of disclosure of violence. In this sense, there is also need for a greater awareness of both society and the professionals involved in the care of children and adolescents on the responsibility and ethical commitment involved in reporting the phenomenon of violence.

This study may contribute to a better commitment of training and qualifying institutions in training staff in relation to the phenomenon of violence against children and adolescents in order to support the creation of public policies to combat it, as well as to show the importance of society in fighting this phenomenon. Similarly, knowing the reason which led to notification can direct the development of strategies to enable the notifiers to better recognize the indicators of violence, such as physical indicators on the victim, victim's behavior and family characteristics so that other forms of violence are also reported. Finally, knowing the outcome of cases of violence in seen at CREAS can reinforce the importance of the service network through integrated actions as well as training of workers to better serve families, thus ensuring an actually resolute service. Investments by the government in educational, preventive and protective measures to children and families living in situations of violence are also needed to make progress in fighting violence against children and adolescents. The results of this study demonstrate the importance of reporting, but also stress that focused interventions from the occurrence and reporting are not enough, as this is a problem that requires the development of collective action, organization of the care network to children and adolescents and mainly effectiveness and interaction of different sectors committed to social, educational and health policies.

As the limitations of this study, the results relate only to the records of cases reported in the reference instances, possibly not portraying their real incidence in the municipality as a whole, considering the repertoire of worldwide known difficulties for identification and notification of each case of violence perpetrated against children and adolescents.

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