The Cultural Reinforcers of Child Abuse

Mistreating children at the hands of parents or caretakers has a long history. Sari and Buyukunal (1991), in a study on the history of child abuse, report that from ancient times up to present many societies have exercised what it is recognized today as child abuse for various reasons. On reviewing child abuse literature in the Tobkabi Museum in Istanbul, they report that in ancient Greece fathers were permitted to practice infanticide whereby many infants who had any serious malformations were killed in order to preserve the race characteristics. Greek physicians during the second century were in the habit of advising midwives to examine each newborn and to get rid of those who were considered not fit to be raised. The study also presented the picture of Zal, the first known albino in the literature, exposed at the bottom of a mountain by his father because he was born with white hair. Stories of children being slaughtered in addition to other severe practices of child abuse were also illustrated. Such practices were said to be part of the lifestyle until approximately two centuries ago. Sexual abuse was reported to be common among Eskimos (Sari and Buyukunal, 1991). Their daughters were presented to their guests as an act of hospitality, and the death of those children during their first sexual experience was not a rare event. In India, the girls used to get married very early because it was considered disgraceful for a girl to remain unmarried until the time of menstruation.


Introduction
Mistreating children at the hands of parents or caretakers has a long history. Sari and Buyukunal (1991), in a study on the history of child abuse, report that from ancient times up to present many societies have exercised what it is recognized today as child abuse for various reasons. On reviewing child abuse literature in the Tobkabi Museum in Istanbul, they report that in ancient Greece fathers were permitted to practice infanticide whereby many infants who had any serious malformations were killed in order to preserve the race characteristics. Greek physicians during the second century were in the habit of advising midwives to examine each newborn and to get rid of those who were considered not fit to be raised. The study also presented the picture of Zal, the first known albino in the literature, exposed at the bottom of a mountain by his father because he was born with white hair. Stories of children being slaughtered in addition to other severe practices of child abuse were also illustrated. Such practices were said to be part of the lifestyle until approximately two centuries ago. Sexual abuse was reported to be common among Eskimos (Sari and Buyukunal, 1991). Their daughters were presented to their guests as an act of hospitality, and the death of those children during their first sexual experience was not a rare event. In India, the girls used to get married very early because it was considered disgraceful for a girl to remain unmarried until the time of menstruation.
Historically, parents used their children for profit. Among the poor families, children were put to work at early ages doing activities such as working on the family's own farm or elsewhere. Generally, boys were more likely to work earlier than girls who usually stay home to help their mothers. In large families, some children were sent to school to receive elementary education or were taught by their parents at home to acquire the necessary knowledge they would need to work and support their families. Only in wealthy families that boys, and to a lesser extent girls, would receive higher standards of education. Not until mid-nineteenth century that compulsory schooling was introduced and education became a common experience for all children.
Although the history of child abuse remains obscure in many parts of the world, it is argued that as from the late seventeenth century onwards children can be seen playing, sketching, and amusing themselves in portraits, which shows that there was a growing concept of childhood. Nevertheless, the number of abused children in modern times generally is still alarming, since the natural state of affairs is a zero-tolerance to child maltreatment, especially the forms of abuse that lead either to death or permanent physical or emotional impairment. In the USA, more than 4 million children were reported to child protection services as alleged victims of child maltreatment in 1999 alone, of which an estimated 1401 child abuse and neglect related fatalities were confirmed by the child protection services' agencies (Nation Committee for the Prevention of Child Abuse [NCPCA] 2000 Annual Fifty State Survey), while the confirmed child abuse deaths in 2002 were about 1400 children (National Data of the U. S. Department of Health and Human Services, April 2004).
The practice of child abuse was based on kinds of philosophies, cultural beliefs and understandings that gave way to a system of laws that, in turn, gave children few, if any, rights. Under the English Common Law, for example, children were considered as property owned by the parents, particularly fathers, who had great latitude over the treatment and discipline of their children. Such legal view was eventually incorporated into early laws in the United States as well. Common law tradition held that the male was head of the household and possessed the authority to act as both disciplinarian and protector of those dependent on him, including his wife and children as well as extended kin, servants, apprentices, and slaves. While common law obligated the male to feed, clothe, and shelter his dependents, it also allowed him considerable discretion in controlling their behavior. Domestic violence, however, was dealt with on the basis of local community standards, which were the most important yardsticks. Puritan parents in New England, for example, felt a strong sense of duty to discipline their children, whom they believed to be born naturally depraved, in order to save them from eternal damnation. Although Puritan society tolerated a high degree of physicality in parental discipline, the community did draw a line at which it regarded parental behavior as abusive, and those who crossed the line would be brought before the courts.
The complexity of the sociocultural underpinnings of child abuse is evident from the historical fact that the legal protections from cruelty was granted to animals long before they were granted to children. One of the first cases in the United States (the case of 8-year-old Mary Ellen Wilson) that arose national attention to child abuse in the early 1870s, got through the legal arguments only after an attorney for the then well-established American Society for the Prevention of Cruelty to Animals (ASPCA) took her case to court and successfully argued for children as being, just like all humans, members of the animal kingdom, hence entitled for the right to be treated with the same legal protection from cruelty as are animals (Shelman and Lazoritz, 2005;Watkins, 1990).

Child abuse in Saudi Arabia
Saudi Arabia is a country occupying most of the Arabian Peninsula with a population of about 27 million who are entirely Muslims. The country is governed according to the Islamic Sharia law whereby the Islamic orthodoxy and conservatism generally dominate the social and cultural characteristics and mechanisms of the Saudi society. Traditional tribal principles and customs, however, have significant influence over a wide range of cultural, behavioral, and attitudinal manifestations in the society. Children are usually well taken care of in terms of basic needs, and are expected to show almost total subordination and obedience to their parents. Corporal punishment by parents is a common practice, especially in less modernized portions of the society. The country generally has one of the lowest rates of serious crimes compared to other countries, despite the fact that nearly 8 million expatriate workers dwell in the country. This fact has been largely due to strict laws that organize all spheres of life, reinforced by the regular police force and members of an official body monitoring the public's compliance with the prevailing religious norms and rules. For the last twenty years or so, most families adopted the tradition of having expatriate housemaids to take care of household menial works including looking after the children in the home.
The first program for detecting, reporting, and working towards preventing child abuse in Saudi Arabia was initiated by one of the leading hospitals in the country in 1994 as a Child Advocacy Committee, with an internal policy and procedure for dealing with all cases of child abuse that reached the hospital. The policy involved the hospital's security department and a mechanism to report cases of suspected or proven child abuse encountered in or admitted to the hospital to legal authorities in the city.
Subsequently, the National Family Safety Program (NFSP) was established in 2005 by a Royal Decree with a vision to establish a foundation that promotes a safe community and help victims of domestic violence Including child abuse victims. The strategic objectives of the NFSP include promoting awareness among individuals and institutions on the damage to individuals and the society caused by domestic violence and child abuse, and training staff members to deal appropriately and effectively with cases of domestic violence and child abuse. Since the implementation of the NFSP in 2007, the numbers of child protection centers that provide NFSP services have increased From 4 to 41 centers.
The National Family Safety Registry (NFSR) was established in 2009 as a web-based data registry system to provide a centralized database for child abuse cases from all over the country. It is aimed to provide a ground for collecting and analyzing data on child abuse cases in order to define the magnitude of the problem and to identify the risk factors leading to child abuse in the country, which is likely to help in formulating prevention strategies and policies. A total of 616 child abuse cases have been registered in a period of 16 months between October 2010 and February 2012. Of these, 315 (51.1%) are males and 301 (48.9%) are females. The Saudi nationals among the abused children comprise 92.0% of the cases; however, non-Saudi children are mostly treated in private health sectors which are not yet represented by CPC. Figure 1 shows the age distribution of the abused children included in the registry, , whereby the ages in a small proportion of the cases (2.8%) are missing. The figure shows that 15.9% of the total number of cases involves children younger than one year of age, as shown in Table 1 below.

Defining child abuse
Definitions of child abuse or maltreatment have two main components: harm, which may be a harmful action or a harmful consequence, and a person or persons responsible for the harm (Gough, 1996). As has been pointed out by Gough (1996), childhood itself is a social construct in which ages defining childhood have varied throughout history and across various sociocultural groups of the human societies. However, the word child, in its broad literal meaning, refers to "a person between birth and full growth; a boy or girl". The Convention on the Right of the Child (CRC), however, defines a child as "every human being below the age of 18 years unless under the law applicable under the child majority is attained earlier" (Ref: http://www.unicef.org/crc/crc.htm). Age of majority pertains solely to the acquisition of control over one's person, decisions and actions, and the correlative termination of the legal authority and responsibility of the parents (or guardian, in lieu of parents) over the child's persons and affairs generally. On the other hand, literally speaking, the word abuse is defined as "to use wrongly or improperly; to misuse, or to treat in a harmful, injurious, or offensive way; to speak insultingly, harshly, and unjustly to or about" (Collins English Dictionary, 2009).
A review of the literature on child abuse reveals several definitions to the term that are quite similar in content. For example, a definition of child abuse, as stated in a report on the consultation on Child Abuse Prevention Geneva (World Health Organization, 1999), refers to "any act, or failure to act, that violates the rights of the child that endangers his or her optimum health, survival and development". It adds that "child abuse, or maltreatment, constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power". A similar definition of the term is stated in the Child Abuse Prevention and Treatment Act (CAPTA), of the federal government of the USA, which states "…at a minimum, 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." (The Child Abuse Prevention and Treatment Act, the Federal Government of the United States, 2011).
The various definitions of child abuse seem to imply a consensus on several implicit criteria. First, it implies that an act against a child is considered abusive if that act has the potential or likelihood of causing harm to the child, even if no harm has actually resulted from it. Second, it also implies that the forms of acts coming under the definition of child abuse do not always require to have been committed more than once in order to be considered abusive; that is, a single commission of an abusive act may warrant the application of the definition and, where applicable, the activation of subsequent relevant implications and interventions. Third, while most definitions of child abuse assert the non-accidental nature of such acts, they also do not assume the existence of an intention to harm in the part of the perpetrator who commits the abusive act. For example, an angry parent may, for example, throw a heavy object at the child that injures him or her, without a pre-existing intention to injure or harm the child; the parent's behavior in this respect, nevertheless, is considered by many as an abusive one.
It is generally agreed that most perpetrators of child abuse are parents or close relatives. For example, the 2002 national data on child abuse in the USA released by the U. S. Department of Health and Human Services (April, 2004) revealed that parents were the abusers in 77 percent of the confirmed cases, other relatives in 11 percent. In addition, Sexual abuse was more likely to be committed by males, whereas females were responsible for the majority of neglect cases.
On the other hand, Table 2 shows data on the relationship of the abused child to the perpetrators extracted from the NFSR, Saudi Arabia. It illustrates that slightly more than one-third of the total cases of child abuse (37.9%) were reported by either of the parents or relatives, while approximately two-third of the cases were reported by others (which include: teachers, friends, house maids, neighbours, and healthcare professionals). Obviously, this data is not claimed to be representative of the status of child abuse in the whole country since both the registry and the program are at their early stage of life. In addition, these child abuse reports failed to specifically identify the exact perpetrators of the child abuse incidents involved in the reports. Similarly, the section on Saudi Arabia, in the article by Al-Mahroos (2007) that reviewed child abuse and neglect in the Arab Peninsula, did not mention the perpetrators of child abuse cases that the article has outlined with the exception of two reported cases of child abuse committed by two housemaids and were documented by secretly hidden cameras. This shortcoming in data collection is probably related in some way to a lack for a system of obligatory official legal and social interventions in child abuse cases in Saudi Arabia.

Controversies surrounding child abuse
In reality, the terms child abuse and child neglect are socially defined phenomena. Viewed on technical and legal basis, beating up a child severely, or breaking his or her bones by a total stranger, is likely to be considered by most, without hesitance, as a crime punishable by the law. However, the same act of violence on the child, when committed by the child's parent, may, in many societies, raise some second thoughts that, despite the probable unequivocal condemnation, may delay or prevent the initiation of necessary and appropriate forms of intervention. In other words, child-abuse laws globally raise difficult legal, cultural and political issues, putting the right of children to be free from harm on one hand, against the right of families to privacy and the rights of parents to raise and discipline their children without external interference, on the other. Accordingly, a number of complex issues are at hand when trying to define a specific form of maltreatment. That is because definitions of child abuse or maltreatment reflect cultural values and beliefs. Behaviors that are considered abusive in one culture may be considered acceptable (e.g., corporal punishment) in another culture. Likewise, parental behaviors that are appropriate at one stage in a child's development may be inappropriate at another stage of development. For example, the level of supervision needed for toddlers may differ from that for adolescents. On the other hand, another issue of dispute is the categorical definitions of child abuse or maltreatment. In other words, while some consider a child as either abused or not abused, still others hold the notion that the categorical definition approach fails to acknowledge that abusive and neglectful behaviors can differ markedly in terms of severity, the frequency and duration of occurrence, and the likelihood that they will cause physical or emotional harm. Another disputable dimension of defining child abuse is whether child maltreatment is defined on the basis of the abusive or neglectful adult behaviors committed against a child (e.g., hitting or shaking), or rather on the basis of the harm caused to the child as a result of such behaviors (e.g., displayed physical symptoms such as bruising or swelling). Further, as mentioned above, there is the justified question of whether the intent to maltreat a child is a necessary indicator of child maltreatment. In reality, there can be instances where abuse or neglect can occur even though the perpetrator did not intend to commit it (for example, neglectful parents may have had no intention of neglecting their children).

Causes of child abuse
Child abuse occurs across socioeconomic, religious, cultural, racial, and ethic groups. The causes of child abuse or maltreatment are numerous, multiple, and complex. There is no single profile that describes all families within which child abuse occurs. On the other hand, supportive, emotionally gratifying relationships with a healthy network of relatives or friends may help minimize the risk of parents abusing their children, especially during stressful life events. Based on this understanding, research has recognized a number of risk factors commonly associated with child maltreatment. However, the presence of these factors does not necessarily always result in child abuse and neglect. In other words, the factors that may contribute to child maltreatment in one family, such as poverty, may not result in child abuse in another family.
Risk factors associated with child maltreatment have been grouped in four domains: parent or caregiver factors, family factors, child factors, and environmental factors. The interaction of multiple factors across these four domains is recognized to be underlying child maltreatment incidents.
Parent or caregiver factors are related to personality characteristics and psychological wellbeing, history of maltreatment, substance abuse, attitudes and knowledge, and age. Family factors that may increase the likelihood of child abuse include marital conflict, domestic violence, single parenthood, unemployment, financial stress, and social isolation. Child factors do not imply that children are responsible for being victims of maltreatment. Rather, certain factors can make some children more vulnerable to abusing behavior. The age of the child, his or her physical, mental, emotional, and social development, may increase the child's vulnerability to maltreatment, depending on the interactions of these characteristics with the parental factors outlined above. Environmental factors are often present in combination with parent, family, and child factors. They include poverty and unemployment, social isolation, and community characteristics such as violent neighborhoods, societal attitudes, and promotion of violence in cultural norms and the media.

Types of child abuse
Child abuse constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, exploitation (commercial or other types of exploitation), resulting in actual or potential harm to the child's health, survival, development or dignity. The abuse takes place in the context of a relationship of responsibility, trust or power. Some types of child abuse are naturally more common, such as cases of child neglect, than other types, such as sexual abuse. Further, certain types of abuse are often difficult to document or characterize, compared to other types that are readily evident in a number of ways.

Physical abuse
Child physical abuse refers, generally, to the non-accidental use of physical force against a child that results in harm to the child. Physically abusive behaviors include shoving, hitting, slapping, shaking, throwing, pushing, kicking, biting, burning, strangling and poisoning. A parent does not have to intend to physically harm his or her child to have physically abused him or her. For example, physical punishment that results in bruising would generally be considered physical abuse. Depending on the age and the nature of the behavior, physical force that is likely to cause physical harm to the child may also be considered abusive; that is, a situation in which a baby is shaken but not injured would still be considered physically abusive. The fabrication or induction of an illness by a parent or carer (previously known as Munchausen syndrome by proxy) is also considered physically abusive behavior (Bromfield, 2005; World Health Organization, 2006).

Emotional abuse
Emotional abuse (also called emotional maltreatment, psychological maltreatment or psychological abuse) refers to a parent or caregiver's inappropriate verbal or symbolic acts toward a child and/or a pattern of failure over time to provide a child with adequate non-physical nurture and emotional availability. Such acts of commission or omission have a high probability of damaging a child's self-esteem or social competence (Garbarino, Guttmann, and Seeley, 1986;World Health Organization, 2006). According to Garbarino, et al. (1986), emotional maltreatment takes five main behavioral forms. Rejecting is whereby the adult refuses to acknowledge the child's worth and the legitimacy of the child's needs. Isolating, involves the adult cutting the child off from normal social experiences, preventing the child from forming friendships, and making the child believe that he or she is alone in the world. Terrorizing is that the adult verbally assaults the child, creating a climate of fear, bullying and frightening the child, and making the child believes that the world is capricious and hostile. Ignoring involves the adult deprives the child of essential stimulation and responsiveness, stifling emotional growth and intellectual development. Finally, corrupting involves the adult 'missocializing' the child, stimulating the child to engage in destructive antisocial behavior, reinforcing that deviance, and making the child unfit for normal social experience. However, some scholars classify emotionally neglectful behaviors, such as rejecting and ignoring, as a form of neglect. Obviously there is common conceptual ground between some types of emotional maltreatment and some types of neglect, which serves to illustrate that the different maltreatment or abuse subtypes are not always neatly demarcated.

Neglect
Neglect refers to the failure by the parent or caregiver to provide a child, where they are in a position to do so, with the conditions that are culturally acceptable as being essential for their physical and emotional development and wellbeing (Broadbent and Bentley, 1997;World Health Organization, 2006). Neglectful behaviors can be divided into different subcategories. Physical neglect is characterized by the parent's or caregiver's failure to provide basic physical necessities, such as safe, clean and adequate clothing, housing, food and health care. Emotional or psychological neglect is characterized by a lack of parents' or caregivers' warmth, nurturance, encouragement and support; it is noted here that emotional neglect is sometimes considered a form of emotional abuse or maltreatment. Educational neglect is characterized by a parent's or caregiver's failure to provide supportive educational opportunities for the child. Finally, environmental neglect is characterized by the parent's or caregiver's failure to ensure environmental safety, opportunities and resources (Dubowitz, Pitts, and Black, 2004).

Sexual abuse
Sexual abuse is complicated to define. Some behaviors are considered sexually abusive by almost everyone; for example the rape of an 11 years old child by a parent. Other behaviors are much more equivocal, at least among certain sociocultural groups, such as consensual sex between 19 years old and 15 years old individuals. To judge whether behaviors such as the latter example constitute abuse or not requires a sensitive understanding of a number of definitional issues specific to child sexual abuse. A general definition of child sexual abuse proposes that child sexual abuse involves "the use of a child for sexual gratification by an adult or significantly older child/adolescent" (Tomison, 1995). Similarly, Broadbent and Bentley (1997) define child sexual abuse as "any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards". Sexually abusive behaviors can include the fondling of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, fondling of breasts, voyeurism, and exhibitionism and exposing the child to or involving the child in pornography (Bromfield, 2005;US National Research Council, 1993). Unlike the other abuse types, the definition of child sexual abuse varies depending on the relationship between the victim and the perpetrator. For example, any sexual behavior between a child and a member of his or her family, such as parent or uncle, would always be considered abusive, while sexual behavior between two adolescents may or may not be considered abusive, depending on whether the behavior was consensual, whether any coercion was present, or whether the relationship between the two young people was equal (Ryan, 1997). A cross-cultural review of child abuse concepts, however, brings into consideration issues of religion and societal norms wherein all sexual behaviors outside the boundaries of marriage are outlawed or criminalized. In societies such as in many Muslim countries, the question is not whether sexual acts are consensual or not; rather, it is about whether or not the sexual acts are occurring between married individuals. In other societies, Australia for instance, consensual sexual activity between 20 years old and 15 years old is considered abusive, while the same activity between unmarried 20 years old and 17 years old is not considered abusive. In some traditional societies, a marriage between an adult male and a below 18 years old girl can be legalized, and there does not seem to be a cutoff age for females at which the marriage is permissible. In fact, in some instances, some females may be made to agree to be married while they are as young as 16 years old or below. The child abuse perspectives related to such instances are very controversial even within such societies themselves.

Other forms of child abuse
There are additional forms of child maltreatment or abuse that have been identified by some researchers (e.g., Corby, 2006;Miller-Perrin and Perrin, 2007). They include fetal abuse, which involves behaviors by parent mothers that could endanger a fetus, such as the excessive use of tobacco, alcohol, or elicit drugs. Other suggested forms of child abuse include bullying or peer abuse, sibling abuse. One may argue that all these latter forms can indeed be re-classified under the major subtypes of child abuse outlined above. The same argument applies to the so-called institutional abuse (which involves the abuse that occurs in institutions such as foster homes, group homes, voluntary or charity organizations and child care centers) and organizational exploitation (e.g., child sex rings, child pornography, child prostitution), and state-sanctioned abuse. One of the examples given for statesanctioned abuse is the so-called female genital mutilation in parts of the world, which refers to the circumcision practice. This latter example is particularly controversial on crosscultural grounds.
It is occasionally argued that to distinguish between the different subtypes of child abuse may be useful for better understanding and to identify them more thoroughly. However, others argue that such a distinction may be slightly misleading because the reality tells us that often there are no strong lines of demarcation between the different abuse subtypes, and that abuse subtypes seldom occur in isolation. The existing evidence shows that the majority of individuals with history of maltreatment report exposure to two or more subtypes (Arata, Langhinrichsen-Rohling, Bowers, and O'Farrill-Swails, 2005;Higgins and McCabe, 2000;Ney, Fung, and Wickett, 1994). In addition, some acts of violence against children involve multiple maltreatment subtypes. For example, an adult who sexually abuses a child may simultaneously hit them (i.e., physical abuse) and isolate or terrorize them (i.e., emotional abuse). Similarly, when parents subject their children to sexual or physical abuse, the emotional harm and betrayal of trust implicit in these acts can indeed be thought of as a form of emotional maltreatment.
The Saudi Arabian National Family Safety Registry (NFSR) has documented not only various types of child abuse but also multiple abusive events occasionally against the same victim. Figure 2, therefore, shows the registered events of abuse across subtypes of abuse. The physical abuse events represented 64.4% (N=397) of all events of abuse, followed by neglect (N=286; 46.4%), sexual abuse (N=136; 22%), and finally emotional abuse (N=76; 12.3%) which is traditionally a more difficult to document than other types of child abuse. The registered physical abuse incidents are further classified into sub-categories as shown in Figure 3. Further, incidents of neglect are also classified into medical (25.9%), educational (7.7%), nutritional (10.5%), abandonment (9.8%), and general (35.3%) subcategories of neglect. The sexual abuse events are classified into two subcategories: assault (50.9%) and exploitation (49.1%).

Figure 2. Registered Events of Child Abuse across Types of Abuse
Of the total cases of child abuse (N=616), some cases involved multiple events of abuse hence raising the total events of child abuse registered in the registry to 630 abusive events. Of these events, 303 did not require admission to the hospital, while 327 were serious enough that they required admission to various medical services as shown in Figure 4 below.

Psychological sequelae of child abuse
Some stringent systems that organize actions related to child abuse cases are in place in several countries. As a result, some parents who were proven to be abusive to their children were separated from their children temporarily until remedial steps were taken to ensure that harm was contained or removed and measures were in place to prevent recurrence. In some instances, such separation was permanent. The central issue in this respect is whether the abusive behaviors against a child by his or her biological parent are serious enough to warrant the potential of severing the fatherhood and/or motherhood relationship with the victim child despite the eternal biological connection linking both. In some countries, Saudi Arabia included, despite the establishment of somewhat elaborate governmental bodies and regulations for addressing the problem of child abuse, the courts remain reluctant to allow such bodies and regulations to intrude too far into the private relations between parents and children. The result of such reluctance is that children are not allowed to enjoy an affirmative right to be protected by the official bodies from violence and other forms of maltreatment committed by their custodian parents in the privacy of the home.
The Cultural Reinforcers of Child Abuse 31 With regard to the experience of the NFSP in Saudi Arabia, even after admission, there seems to be some socio-medico-legal challenges that still face the NFSP and will require further legislative and legal workup. To illustrate this point, some abused children who were admitted to the hospital for medical intervention, were soon discharged by their guardians against medical advice (see Figure 5 below), as there yet to be a legal system and binding regulations that protect the abused child under treatment from being discharged against medical advice by his or her guardian and, in some instances, to return to the same environment in which the abuse took place. To promote an adequate understanding of the gravity of the psychological impact that child abuse behaviors might inflict on their victims and the society as a whole, it is important first to outline the normal basic needs of a child that are necessary for him or her to develop and grow normally.
Child development is a result of a complex and dynamic process of interplays and shifting influences on physical, emotional, sexual, social and cognitive development. However, the development of the individual child is primarily a social process and the family is the central social context within which this development occurs. In other words, the psychosocial variables and encounters in the immediate surrounds of a child since birth are both intrinsic components of his development and determinants of the outcome of the developmental process. A family is a unique social system, whereby its membership is based on a combination of biological, legal, affectional, geographic and historical ties (e.g., Carr, 2003); entry into the family system usually is through birth (or, less frequently, adoption), and members can leave only by death. Severing all family connections is never possible, a reality that often explains the deep and lasting psychological impacts of some subjectively significant events experienced within the family boundaries by some individuals. In modern times, with new forms of family structures such as single parenthood, the traditional definition of the family may not be very useful (Walsh, 1993). Hence, a child's family may be conceived as a network of people in the child's immediate psychological field, which may include members of the child's household and others who, while not members of the household, play a significant role in the child's life; for example, a separated parent living away with whom the child has regular contact; a grandmother who provides informal day care, and so forth. In clinical terms, the primary concern is the extent to which this network meets the child's developmental needs.
It is important that child abuse and neglect are placed in the context of what is more typical for children to experience as they grow up. Studies that examined family life, in general population samples reveal very great differences within the range of 'normal' family life and childrearing patterns, with social class being one of the strongest influences (Creighton and Russell, 1995).
The development of parenting roles entails what Carr (2003) refers to as 'routines' for meeting children's needs that include safety, care, control, and intellectual stimulation. Developing routines for meeting children's needs for safety include protecting children from accidents by, for example, not leaving young children unsupervised, and developing skills for managing the frustration and anger that the demands of parenting young children often elicit. Failure to develop such routines may lead to accidental injuries or child abuse. Routines for providing children with food and shelter, attachment, empathy, understanding and emotional support need to be developed to meet children's needs for care in these various areas. Failure to do so may lead to various emotional difficulties. Developmental needs for control involve routines for setting clear rules and limits; for providing supervision to ensure that children conform to these expectations; and for offering appropriate rewards and sanctions for rule-following and rule-violations that meet children's need for control. Conduct problems may occur if such routines are not developed. Parent-child play and communication routines for meeting children's needs for age-appropriate intellectual stimulation need to be developed as well, otherwise developmental delays in emotional, language and intellectual development may result.
The impact of child mental health on child development and on the society as a whole is well documented but under recognized. There is limited public awareness of how mental health affects child development and societal wellbeing in general, and of how important mental health needs can and should be met. The importance of mental health for normal child development can hardly be over-estimated. Provision and supporting children's optimal social and emotional development results in positive outcomes for individuals and society, including healthier behavior, greater school successes, improved relationships, and economic savings. Parents, families and other significant caregivers, who are readily available, responsive, and stable, are crucial for children's optimal mental health, and these relationships influence brain development from birth (Carr, 2003). Parents, teachers, and other child-caregivers who care for and work with children need to be better informed about milestones of normal, healthy child development to both reassure caregivers when development proceeds within typical limits and to identify early warning signs that indicate when assistance is necessary. Children and their families can be prepared, in situations of unavoidable life challenges, for stress points and transitions, hence learning the skills to be resilient in periods of stress and challenge, thus protecting and promoting mental health.
There are strong association between exposure to child abuse in all its forms and higher rates of many chronic conditions. There is strong evidence from the Adverse Childhood Experiences series of studies (Middlebrooks and Audage, 2008) that show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions, high-risk health behaviors and shortened lifespan. Child abuse is a major life stressor that has consequences involving the mental health of an adult. For example, it has been identified that childhood sexual abuse is a risk factor for the development of substancerelated problems during adolescence and adulthood (Dolezal, McCollum, and Callahan, 2009). The early experiences of child abuse can trigger the development of an internalizing disorder, such as anxiety and depression. For example, adults with a history of some form of child abuse, whether sexual abuse, physical abuse, or neglect, have more chances of developing depression than an adult who has never been abused.
The psychological effects of child abuse are well documented. Children with history of neglect or physical abuse are at risk of developing psychiatric problems (Gauthier, Stollak, Messe, and Aronoff, 1996;Malinosky-Rummell, and Hansen, 1993), or a disorganized attachment style (Lyons-Ruth and Jacobvitz, 1999;Solomon and George, 1999;Main and Hesse, 1990) that is associated with a number of developmental problems, including dissociative symptoms, as well as anxiety, depressive and acting out symptoms. Further, a study by Cicchetti (1990) found that 80% of abused and maltreated infants exhibited symptoms of disorganized attachment, and when some of these children become parents, especially if they suffer from posttraumatic stress disorder, dissociative symptoms and other sequelae of child abuse, they may encounter difficulty when faced with their infant and young children's needs and normative stress, which may in turn lead to adverse consequences for their child's social-emotional development.

Conclusion
Human beings, and probably some animals, can go to great lengths and efforts in order to care for and protect their children. Nevertheless, one must be aware that occasionally two contradictory states may exist side by side: caring for children yet abusing them. Child abuse is a complex phenomenon with multiple causes. The work towards eliminating this phenomenon, therefore, is expected to be a task that is as complex as the phenomenon.
To address the problem of child abuse, one must first understand the causes in their real depths. Such understanding requires those concerned with child abuse to approach the issue on the basis of rational deliberations, rather than be driven by the passion and the sympathy with the victims alone. Prerequisites for preventing child abuse are believed to include understanding, in the first place, of why the abusive behaviors against children do occur. In other words, it is important to understand to what extent a particular child-rearing behavior is acceptable or deviant within a particular society or sociocultural group, and whether such a behavior is common or different between groups. The underpinnings of such thinking process include the acknowledgement of the ways in which children are viewed in a given culture. One of the main questions here is that whether children are considered to be the property of the parents. Subsequent issues include the age until which, according to cultural norms, the children require the protection and nurturance of their parents, and the extent until which physical abuse is considered educational and, thus, acceptable. For example, among certain cultural groups it is considered normal, or even desirable, that girls get married during their adolescent life. This desirability involves the girls themselves. Awareness of cultural factors, therefore, must remain high since they influence all aspects of child abuse, from the occurrence and definition through its treatment and successful prevention. Any intervention, to be successful whether for data collection, prevention or even increasing awareness, must take into consideration the cultural environment in which it is to occur. On the other hand, background or baseline conditions beyond the control of families or caretakers, such as poverty, inaccessible healthcare, inadequate nutrition, unavailability of education, can be contributing factors to child abuse. Social upheaval and instability, conflict and war, may also contribute to increases in child abuse and neglect. It is believed that the prevalence of the compromised conditions, such as poverty and political or social conflict, varies to considerable extents across the countries of today's world. Therefore, the means and mechanisms necessary for the fight against child abuse will obviously vary across countries or societies with varying social, cultural, religious, and resource factors. It seems, accordingly, that it is expected from those who are involved, at local or international levels, with the issue of child abuse to be equipped with a thorough cross-cultural understanding of the child abuse phenomenon.
Adequate data on child abuse in Saudi Arabia, and the whole Arabian Gulf region for that purpose, is scarce and scattered (Al-Mahroos, 2007). This is probably due to multiple social, cultural, and bureaucratic factors leading to seemingly a broad consensus at community level on unbroken silence regarding child abuse phenomenon. The few cases that made news in national media were involving tragic deaths or severe harm against children that were perpetrated by expatriate housemaids. Further, the vast majority of the proven or suspected child abuse cases were medically reported (e.g., Al-Mugeiren and Ganelin, 1990;Al-Eissa, 1991;Kattan, 1994). Very little is known about the less severe child abuse cases that might have occurred in the community and were perpetrated by parents or relatives, since lack of data does not necessarily imply low or no incidence of child abuse.
The religion of the country does not permit maltreatment of children. In the contrary, Islam prohibits all kinds of maltreatment against human beings and animals by means of clear verses in the Quran. Even the seemingly permissible corporal punishment has been narrowly restricted by Islam in such a way that it effectively resembles a gesture of disapproval rather than a means for bodily harm. To put it in the correct perspective, the patterns of the reported child abuse in Saudi Arabia are similar to what are seen in other parts of the world, proving that child abuse is an unfortunate tragedy shared by all communities of mankind and is resistive to the teachings of all religions known by humans.
An additional dimension of child abuse in Saudi Arabia that requires further study is the impact of the growth of wealth in the country during the last fifty years or so, which involves tremendous changes in the society including a shift from extended to nuclear family structures, changes from the traditional rearing up methods where grandfathers and grandmothers played significant roles to a modern shape of families where a housemaid plays a significant role in caring after the young ones in the family while both parents are at work. Such housemaids are by and large unskilled workers who have left their own families, and probably their own children, behind them for work in a culturally different country. Intentional and unintentional indiscretions involving children can occur in such a human context. However, this understanding can not attribute any significant portion of child abuse in Saudi Arabia to expatriate housemaid even if the potential does exist.
The Saudi Arabian experience in the realm of child abuse, as outlined above, seems to be in its conception stage. The workers in this realm, by and large, are driven by their own interest in and concern about child maltreatment and their involvement is never a full-time endeavor. The current state of affairs is reactive in nature, such that most of the NFSR child abuse cases were captured during routine hospital visits following the occurrence of injuries or other forms of child abuse that required medical consultation. One can not imagine the number of child abuse incidents that have not been accounted for. The data presented from the NFSR provides glimpses of the problem in rather a superficially descriptive fashion. The individual characteristics of the abused children and their psychological and social profiles would have provided an insight about why these particular children became victims of abuse. In addition, the social and psychological profiles of their parents and their abusers are likewise informative and necessary basis for future planning and legislating.
A full-fledging work against child abuse in Saudi Arabia is expected to include sound and obligatory training of individuals who are likely to work with children and families, such as physicians, psychologists, social workers, teachers, on all dimensions of child abuse issues in order to enhance their abilities to recognize, predict, and intervene. Public awareness of child abuse and its implications on the lives of children, families, and the society as a whole is probably a strategic objective for combating child abuse, and for which various official and non-official bodies in the society can be recruited, such as schools, religious authorities, security forces, etc.
As mentioned earlier, several abused children who were admitted to hospital for treating their physical and emotional injuries, were soon discharged by their guardians against medical advice. There were no guarantees that the same cycle of abuse did not continue against these children after their forced discharge from the hospital pre-maturely. The treating physicians or clinicians had no jurisdiction to prevent such discharge. This legal vacuum requires legislative efforts that are designed to allow children their right to be treated and to be protected from abuse.
Finally, there is active work at various governmental levels to establish a legal and official system to regulate child protection policies in the direction beneficial to the child. Until then, children are largely on their own.