Abstract
BACKGROUND:
Child maltreatment (CM) is a global public health problem that affects countries at variable rates. Many factors can reduce this problem, but the existence of national law is an essential factor. The objective of the study was to compare reporting patterns of CM after the implementation of the Saudi Child Protection Law to the prelaw period.
MATERIALS AND METHODS:
This cross-sectional study retrospectively reviewed the cases of CM cases reported in the registry of King Abdullah Specialized Children Hospital, a governmental tertiary care hospital in Riyadh, Saudi Arabia. The registry data from 2014 to 2022 were compared with CM cases evaluated at the same institution from 2000 to 2008, prior to the implementation of the child protection law.
RESULTS:
From 2014 to 2022, 1370 patients were referred to the child protection team; of these, 878 (64.1%) patients were confirmed as CM and entered into the CM registry. For 878 confirmed cases of CM, the issue was that of neglect (58.3%), followed by physical abuse (27.8%), emotional abuse (8.4%), and sexual abuse (5.5%). Most prevalent finding in physical abuse cases was bruises (26.2%) followed by fractures (16.0%). Parents were identified as the perpetrators in 77.9% cases of CM. Comparing the current data to the prelaw data, the reported CM cases increased from 6 cases per year in 2000 to over 200 cases in 2022, with a 7-fold increase in the reporting rate between the two periods. The reports of neglect increased by 89.2%, physical abuse increased by 38.9%, and sexual abuse decreased by 14.3%. Case fatality rate decreased from 8.3% to 3.2%.
CONCLUSION:
The implementation of the child protection law led to an increase in CM reporting. Data from the registry will enable decision makers to analyze types, trends, and magnitude of CM, and provide a foundation for the development of effective prevention programs.
Keywords: Child abuse and neglect, child maltreatment, child protection law, hospital registry
Introduction
Child maltreatment (CM) is a common worldwide problem. In 2002, the World Health Organization (WHO) recognized child abuse as a global public health problem in its report on health and violence.[1,2] This world report estimated that nearly 3 out of 4 children aged 2–4 years regularly suffered from physical abuse and/or psychological abuse. 1out of 5 women and 1out of 13 men had been sexually abused in their childhood.[2] In the US Federal annual report of 2018, child protective services (CPS) agencies across the United States received an estimated 4.3 million referrals involving alleged abuse of approximately 7.8 million children, 56.0% of referrals were screened for investigation and assessment by CPS agencies.[3] Approximately one-fifth (16.8%) of the children investigated were found to be victims of abuse or neglect at the rate of 9.2/1000 children in the population. Furthermore, of those who suffered from maltreatment, 1770 children died of abuse and neglect annually in the United States.[3]
Despite the WHO international surveys and global reports, data in regard to the incidence and prevalence of CM in low- and middle-income countries are still lacking.[2] Over the past two decades, CM has increasingly been recognized as a public health issue in Middle Eastern countries, Saudi Arabia not excepted.[4] Early publications on CM in Saudi Arabia were primarily limited to case reports from the healthcare sector. However, in recent years, there has been a significant shift towards more comprehensive studies, including cross-sectional research, as well as incidence and prevalence studies from various regions across the country.[5,6,7,8,9,10,11,12,13,14] This evolving body of evidence reflects a growing recognition of the issue and provides a broader understanding of its scope and impact in the country.
Few studies and reports from Saudi Arabia have been on the incidence, risk factors, and prevalence of adverse childhood experiences and sexual abuse at the country level.[10,14,15,16] However, no studies have examined the effect of the service provision or the implementation of the law on the incidence of CM.
In 2014, the prevalence rate of major forms of CM in Saudi Arabia was found to be between 10%–65% using the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool-Child.[15] The survey was conducted in middle and high schools of the 5 major regions of the country, which cover approximately 70% of Saudi Arabia’s population. The prevalence rate of violence, exposure, neglect, and psychological abuse was significantly higher among girls, while sexual abuse was higher among boys.[15] There was no gender difference with regard to physical abuse.[15,17,18]
In addition to the progress made in CM studies and data collection in the country, there was parallel work to approve legislation on the rights and protection of children.[19] In 2013, the royal cabinet approved “the protection from Domestic Abuse” law that mandated the reporting of all cases of CM to national child protection authorities. In addition, in 2014, a more comprehensive law addressing all aspects of children’s rights was approved under the title “Child Protection Law.” This legislation not only emphasized the rights of children to protection from abuse and neglect but also mandated the reporting of such cases to designated protection units and reinforced measures to ensure their overall well-being, safety, and development. The aim of this mandatory reporting was to improve the identification of cases, provide insights into trends, assess the magnitude of the problem, and ultimately contribute to a more comprehensive understanding of the problem in Saudi Arabia, to guide targeted interventions.[20,21]
The child protection team at a tertiary care children’s hospital began collecting data on CM cases in 2000. After the implementation of the child protection law in 2014, the hospital launched the CM registry in which more detailed data on CM cases were collected. Currently, no published studies have explored the impact of legislation on the trend, magnitude, demographics, and characteristics of CM in the country. The child protection team at King Abdullah Specialized Children Hospital (KASCH) has maintained records of CM cases since 2000. A previous publication from the same institution reported cases evaluated between 2000 and 2008 before the enactment of the child protection law.[5] Since data collection was not conducted systematically between 2009 and 2013, these two periods represented the most complete dataset available before and after the implementation of the law. Therefore, the current study compared cases recorded during 2014–2022 and from 2000 to 2008 from the same institution to evaluate changes in the reporting pattern following the enactment of the child protection law.[22] In addition, the comparison will help determine whether mandatory reporting has contributed to a better understanding of the scope of the problem, the response, and the impact of policy changes on child welfare to guide future reform and improvement of child protection efforts. It is important to note that the increase in the reported cases may reflect improved identification and recognition following implementation of mandatory reporting requirements, rather than a true increase in the incidence of maltreatment.
Materials and Methods
CM data were collected retrospectively from the electronic database of the CM registry at KASCH in Riyadh, Saudi Arabia, from January 2014 to December 2022. The year 2014 represented a transition period during which the Saudi Child Protection Law was enacted, and a mandatory reporting procedure was implemented. The data were entered by the child protection team, a multi-disciplinary professional team chaired by an attending pediatrician and composed of members from social services, mental health, and the legal departments, as well as other medical disciplines as needed. The social worker of the child protection team is responsible for entering the data of all patients evaluated and diagnosed with CM. The entered data is verified by the medical staff and child protection attending pediatricians before final registration and acceptance in the registry. Only substantiated cases are entered in the registry, and this is defined as “any case that has been investigated by the child protection team and deemed to have occurred according to evidence”. For the purpose of this study, “suspected cases” refer to all children referred to the child protection team for evaluation.
The registry database was developed and maintained by an institutional public health and research unit using a secure electronic data capture system. The data collected contains information about victims and perpetrators with demographic data, type of abuse, patterns of physical injuries, risk factors, child disposition, referrals to child protection units and legal services, and final outcomes. Children could be assigned more than one maltreatment category and more than one risk factor when applicable; therefore, the total number of abuse types and risk factors exceeds the number of individual patients. For the purpose of evaluating the impact of the child protection law, data from the hospital CM registry (2014–2022) were compared with data from the CM cases evaluated at the same institution between 2000 and 2008 and previously reported by the same child protection team.[5] The historical data were obtained by reviewing the original cases and published reports from the same center.[22] Data were not consistently available between 2009 and 2013 because no formal registry system had yet been established; therefore, these years were not included in the comparison. Ethical approval was obtained from the Institutional Review Board with study number NRC21R/131/03 dated 06 September 2021. There were no direct contact with patients, therefore informed consent was not obtained.
The study hospital, a specialized tertiary care facility for children, uses an integrated electronic medical record system. To address any gaps in registry data, electronic medical records were reviewed. Referrals to the child protection team were assessed for maltreatment, with substantiated cases reported to national authorities and subsequently referred to legal agencies as necessary. All substantiated cases received follow-up through outpatient child protection services for continued management and support. National reporting mechanisms, including electronic and hotline systems, were available for professionals to report suspected child abuse and neglect. Statistical analyses were performed using STATA version 15.0 (StataCorp, College Station, Texas, United States). Categorical variables are presented as frequencies and percentages, while continuous variables are summarized as means. P ≤ 0.05 was considered statistically significant.
Results
From January 2014 to December 2022, a total of 1370 cases of suspected child abuse and neglect, with a mean of 13 referrals per month, were referred to the child protection team at the study hospital for evaluation. Of these, 878 (64.1%) were substantiated as CM and entered in the CM registry. Figure 1 displays the overall increase in reported cases to the child protection team in 4 years interval from 2000 to 2022, and Figure 2 illustrates the trend in substantiated and unsubstantiated cases from 2014 to 2022, when the unsubstantiated cases increased from 19% in 2014 to 45% in 2022, and the substantiated cases decreased from 80% in 2014 to 55% in 2022.
Figure 1.
Average referrals to child protection team at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia, 2000 to 2022 (4-year intervals)
Figure 2.
Total numbers of substantiated and non-substantiated cases managed by child protection team at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia, from 2014 to 2021
A total of 979 maltreatment events were identified in 878 patients, because some children experienced more than one form of maltreatment in the period of 2014–2022. Neglect was the most commonly reported form and noted in 571 (58.3%), followed by 272 (27.8%) of the cases of physical abuse, 82 (8.4%) cases of emotional abuse, and 54 (5.5%) of sexual abuse. Reports of neglect have increased by 89.2%, physical abuse increased by 38.9%, but sexual abuse has decreased by 14.3%.[Figure 3]. The demographics of CM cases, and the frequencies of different patterns of inflicted physical injuries in the two periods are shown in Table 1.
Figure 3.
Forms of child maltreatment evaluated by child protection team at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia, from 2014 to 2021
Table 1.
Demographic and clinical characteristics of child maltreatment cases evaluated by child protection team at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia, during the prelaw period (2000–2008) and the postlaw enactment period (2014–2022)
| Variable | Prelaw period (2000–2008) N (%) | Postlaw enactment period (2014–2022) N (%) | P-value | |||
|---|---|---|---|---|---|---|
| Substantiated cases | 133 (71.0) | 878 (64.1) | ||||
| Unsubstantiated cases | 39 (29.0) | 492 (35.9) | ||||
| Child gender (n=878) | ||||||
| Male | 71 (53.4) | 477 (54.3) | 0.839 | |||
| Female | 62 (46.6) | 401 (45.7) | ||||
| Age (years) | ||||||
| Mean age | 5.0 | 5.3 | 0.798 | |||
| <2 | NA | 268 (30.5) | ||||
| 2–5 | NA | 251 (28.6) | ||||
| >5 | NA | 359 (40.9) | ||||
| Form of abuse (n=979) | ||||||
| Neglect | 43 (32.3) | 571 (58.3) | <0.001 | |||
| Physical | 65 (48.9) | 272 (27.8) | ||||
| Emotional | 5 (3.8) | 82 (8.4) | ||||
| Sexual | 20 (15.0) | 54 (5.5) | ||||
| Perpetrators | ||||||
| Parent | 65 (48.9) | 684 (77.9) | <0.001 | |||
| Others or unknown | 10 (7.5) | 62 (7.1) | ||||
| Relative | NA | 53 (6.0) | ||||
| Domestic worker | 12 (9.0) | 34 (3.9) | ||||
| Sibling | 18 (13.5) | 37 (4.2) | ||||
| Teacher | NA | 8 (1.0) | ||||
| Patterns of physical abuse (n=325) | ||||||
| Bruises | 18 (16.8) | 85 (26.2) | <0.001 | |||
| Fracture | 11 (10.3) | 52 (16.0) | ||||
| AHT/SBS | 24 (22.4) | 43 (13.2) | ||||
| Laceration | NA | 29 (8.9) | ||||
| FDP | NA | 23 (7.1) | ||||
| Burn | 11 (10.3) | 20 (6.2) | ||||
| Others | 36 (35.6) | 73 (22.5) | ||||
| Outcome upon discharge | ||||||
| Death | 11 (8.3) | 27 (3.1) | 0.003 | |||
| Disposition | ||||||
| Follow up in child protection clinic | 71 (53.5) | 686 (78.1) | <0.001 | |||
| Referral to child protection services/Ministry | NA | 512 (58.3) | ||||
| Legal services referral | 62 (46.6) | 244 (27.8) | <0.001 |
AHT/SBS=Abusive head trauma/Shaken baby syndrome, FDP=Factitious derider by proxy, NA=Not Available
A comparison of the two periods of the pre (2000–2008) and post law (2014–2022) era reveals a significant increase in the total number of referrals to the child protection team, with a total of 188 cases in 2000–2008, to 1370 cases in 2014–2022, a 7-fold increase in the recognition and referral [Table 1]. There was a significant shift in the forms of abuse from physical abuse being most common in 2000–2008, as against neglect in 2014–2022 (for physical abuse 48.9% vs. 27.9%, and for neglect 32.3% vs. 58.3%, for the pre and post law implementation, respectively) [Table 1].
More data on consequences and outcomes were collected in the current period, but we were unable to compare them to the prelaw era. However, there was a significant decrease in the fatality rate resulting from maltreatment, from 8.3% to 3.1% [Table 1]. Of the total substantiated cases, the referral to legal services (local police) has decreased from 46.6% to 27.8% in the current period, while follow-up in the child protection clinic has increased from 53.5% to 78.1% [Table 1].
Multiple risk factors could be identified in maltreated children and their families; a total of 1436 risk factors were identified in 878 patients, with a mean of 2 risk factors per patient [Table 2]. Lack of awareness and poor parent education were noted 686 (47.7%) times, with poor parenting skills the most prevalent at 259 (37.7%) [Table 2]. Family dysfunction situations were noted in 358 (24.9%) times, domestic violence against the mother in 126 (35.1%), drug/alcohol abuse by the parents noted in 105 (29.3%) cases, and divorce in 91 (25.4%). Young parents defined as aged <20 years old were noted in 36 (10%) of the cases only. The third risk factor category was health and financial stressors in the family, which was noted 309 (21.5%) times. Financial strain and unemployment were noted 92 (29.7%) times, child disability or chronic illness in 128 (41.4%), and parents’ chronic illness in 89 instances (28.8%) [Table 2]. Risk factors were not collected in the prelaw period to allow for comparison.
Table 2.
Risk factors for child maltreatment among cases reported to child maltreatment registry at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia, during the postlaw period 2014–2021
| Risk factors | N (%) | |
|---|---|---|
| Lack of awareness/Poor education | 686 (47.7) | |
| Poor parenting skills | 259 (37.7) | |
| Unawareness of laws/legislation | 230 (33.5) | |
| Wrong beliefs and attitudes | 197 (28.7) | |
| Family dysfunction | 358 (24.9) | |
| Domestic violence | 126 (35.1) | |
| Drug/alcohol abuse | 105 (29.3) | |
| Divorce/separation | 91 (25.4) | |
| Young parents (Age <20 years) | 36 (10.0) | |
| Medical/Financial stressors | 309 (21.5) | |
| Chronic illness/disability of a child | 128 (41.4) | |
| Unemployment/financial stressors | 92 (29.8) | |
| Chronic illness of one/both parents | 89 (28.8) | |
| Others | 83 (5.7) |
One hundred and twenty-seven (14.5%) of CM cases were admitted to the ward, while 67 (7.6%) required Pediatric Intensive Care Unit admission, 686 (78.1%) cases were discharged with follow-ups in the child protection clinic, and 12 (1.4%) cases were discharged to foster care/government social institutions. The most common internal referral was to psychiatry services, where 174 (19.8%) of cases (parent/child pair) had a psychiatry evaluation, 244 (27.8%) cases were referred to the police, while 512 (58.3%) were referred to the national child protection services for further services and follow-up. For outcomes, 453 (51.6%) had no injuries that required immediate care; however, 97 (11.0%) developed a new physical injury/disability, while 181 (20.6%) had a deterioration of their underlying clinical status, and 113 (12.9%) of the children were diagnosed with psychosocial and behavioral disorders. A total of 27 children (3.1%) died as a consequence of their injuries, and it is believed that CM contributed to their deaths.
Discussion
CM is gaining increasing attention and recognition in Saudi Arabia, not only among healthcare professionals but also by the general population, governmental agencies, and the social services department. A comparison between the current data (postlaw implementation era) and previous data from the same institution reveals a significant increase in physical abuse and neglect referrals.[22] Importantly, the observed increase in reported cases should not be interpreted as evidence of a true increase in the incidence of CM. The increase is likely to reflect an improvement in case recognition, awareness, referral pathways, documentation practices, and compliance with mandatory reporting requirements. Evidence from Saudi Arabia suggests that healthcare providers have a high level of awareness and knowledge regarding CM, and generally demonstrate a positive attitude towards the identification, reporting, and management of suspected cases.[23,24,25,26,27] In addition, the rigorous enforcement of mandatory reporting laws through institutional policies and procedures by various organizations has played a significant role. A study found that the number of cases of abusive head trauma increased dramatically from 2010 to 2020, with a particularly significant spike after 2014.[28] This finding raises the possibility that institutional policies have increased awareness of the issue and the reporting systems to address it.[28,29] Therefore, the concealed cases may be coming to light because of mandatory reporting. Finally, national authorities have facilitated the reporting mechanisms through 24-h hotlines and email services. In contrast, our data show a slight decrease in reports of child sexual abuse. Cultural sensitivities and stigma may continue to contribute to underreporting by affected families and healthcare professionals in Saudi Arabia and in many other societies.[30]
The impact of mandatory reporting laws on CM varies across countries and depends on factors such as enforcement, professional training, public awareness, and the availability of child protection services. While some countries have reported reductions in severe forms of child abuse with the introduction of child protection legislation, others have observed changes in the reporting patterns rather than a reduction of overall maltreatment.[31,32,33,34,35]
In addition, barriers such as limited training, uncertainty in recognizing abuse, unfamiliarity with reporting procedures, and negative experiences with child protection agencies may continue to affect reporting practices despite the existence of mandatory reporting laws. These findings suggest that legislation alone is insufficient and must be supported by effective implementation strategies, professional education, and robust child protection systems.[36]
The 2014 Saudi protection law has notably increased reported cases from healthcare sectors, possibly greater awareness of professionals and better reporting mechanisms. To enhance its effectiveness, the law should be integrated into a wider strategy that promotes children’s rights, preventive measures, awareness campaigns, and strong support services for at-risk families.
When examining the risk factors for CAN in Saudi Arabia, ignorance of the laws and legislation (29.8%) and misguided social beliefs (25.5%) were identified as the most prevalent contributors to CM. This reveals a significant gap in public awareness of child protection laws and the roles of parents and professionals in protecting children. It emphasizes the need for targeted educational initiatives to clarify legal obligations and children’s rights. Developing and disseminating public education materials through various media is essential for increasing awareness and fostering a culture of accountability to reduce child abuse.
The outcomes of CM cases in our report are consistent with international reports.[4] Our findings demonstrate that CM is associated with significant morbidity and mortality, disability, and deterioration of existing health conditions, which underscore the critical importance of prevention, early detection, and timely intervention.
Although this report provides the largest national data registry on CM cases in Saudi Arabia, detailing demographics, risk factors, types of abuse, and the impact of the enactment of the law on reporting, it has several limitations. First, this was a single-center hospital-based study, which limits generalizability to other healthcare settings. Second, the comparison between the prelaw (2000–2008) and post-law (2014–2022) periods was based on two distinct time intervals separated by a period (2009–2013) during which systematic data collection was not available. Although both data sets originated from the same institution and the same child protection service, differences in data collection methods before and after the establishment of the registry may have influenced some comparisons. In addition, several variables collected in the current registry were not available in the earlier dataset, limiting direct comparison across all outcomes. Finally, the cross-sectional design allows identification of temporal association but does not permit causal conclusions regarding the effect of legislation on the reporting mechanism.
The findings of this study will support ongoing efforts to strengthen CM surveillance in Saudi Arabia through the development of a national registry that integrates data from healthcare, child protection services, social services, and the legal authorities. Standardized definitions, reporting procedures, and data collection tools will improve monitoring of trends and facilitate evaluation of prevention and intervention programs. Future policy efforts should focus on enhancing mandatory reporting systems, increasing workforce training, and ensuring consistent implementation of child protection procedures across institutions. Multicenter studies and more advanced analytical methods are needed to better evaluate the long-term impact of child protection legislation on reporting practices and child outcomes.
Conclusion
The implementation of the Saudi Child Protection Law was associated with a substantial increase in the reporting and registration of CM cases at a tertiary care center. The observed changes possibly reflect enhanced awareness, strengthened reporting mechanisms, and improved institutional capacity to identify and document suspected cases of CM. However, owing to the retrospective single-center design and potential changes in referral patterns, surveillance practices, and healthcare infrastructure over time, these findings should not be interpreted as evidence that the law has reduced the incidence of CM. Rather, the study demonstrates an association between the legislative framework and increased detection and reporting of cases of child abuse. Continued efforts to strengthen surveillance systems, standardize reporting practices, and conduct multicenter longitudinal studies are needed to better understand the long-term impact of child protection legislation on child safety and well-being.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
References
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