Review Paper Asia-Pacific Journal of

Public Health
Volume 20 Number 4

The Evolving Evidence Base October 2008 267-276

© 2008 APJPH

for Child Protection in

10.1177/1010539508325047
http://aph.sagepub.com
hosted at

Chinese Societies http://online.sagepub.com

Michael P. Dunne, PhD, Jing Qi Chen, MD, PhD, and

Wan Yuen Choo, PhD

Child maltreatment is a substantial public health problem worldwide. Although extensively studied in
Western countries, until recently little systematic research had been published about the sit-uation in
the world’s most populous nation and ethnic diaspora. In this review, we examine trends from
community-based research with Chinese young people and parents in mainland China, Hong Kong
SAR, Taiwan, Singapore, and Malaysia. It is clear that many Chinese adolescents experience a
substantial burden from various forms of maltreatment and the psychological and behavioral correlates
are similar to those found in other cultures. However, the research reveals a large gap between this
reality and Chinese adults’ perceptions about emotional, physical, and sexual abuse. Comprehensive
awareness programs are needed to close this information gap and thereby mobilize support for
prevention and care initiatives.

Keywords: child maltreatment; Chinese adolescents; psychological correlates; behavioral corre-lates;

child sexual abuse

R esearch into child maltreatment does not have a long history in any society. It is not yet 50

years since the “battered child syndrome” was first described in the medical literature. 1 That
pioneering work by Henry Kempe and colleagues was influential because it gave a name and
shape to a complex pattern of injuries and health problems that were familiar to physicians but for
which no likely cause had been identified. Subsequent clinical and community-based studies
confirmed that great harm, including deaths of children, could be directly attributed to physical
abuse by parents and caregivers. According to Leventhal2 this early research helped physicians to
“see” what they had not seen before. By identifying the child, family, and social factors associated
with battered children, it has become possible to design and implement programs that seek to
intervene before harm
occurs, or before such harm is repeated.
Most research into child abuse has been conducted in English-speaking nations. There is now
a substantial body of evidence that identifies the types of physical abuse and neglect, emotional
abuse and neglect, and sexual abuse to which children are exposed. This includes

From the School of Public Health, Queensland University of Technology, Brisbane, Australia (MPD); Institute of Child and
Adolescent Health, Peking University, Beijing, China (JQC); and Department of Social and Preventive Medicine, University of
Malaya, Kuala Lumpur, Malaysia (WYC).
Address correspondence to: Michael P. Dunne, PhD, School of Public Health, Queensland University of Technology,
Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia; e-mail: [email protected].

267

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268 Asia-Pacific Journal of Public Health / Vol. 20, No. 4, October 2008

large national surveys of the prevalence and health consequences of child maltreatment and
adversity in the United States, 3 the United Kingdom,4 Ireland,5 Sweden,6 and Australia,7 among
others.
Overall, the most important conclusions from research worldwide are as follows:

1. Child maltreatment has been found in all countries in which it has been measured. 8,9
2. Boys experience greater physical violence than girls, whereas girls are much more likely to be sex-ually
victimized. Emotional abuse appears to be fairly equal for boys and girls, 9,10 although in the United
Kingdom, it may be a more frequent experience for girls than boys. 4
3. A personal history of child maltreatment is strongly associated with poor mental and physical health,
suicidal ideation, adult sexual dysfunction, and higher rates of behaviors that pose risks for health,
among children, adolescents, and adults. For some people the effects may be life-long, whereas others
appear to recover and do not suffer long-term effects. 11-14
4. It is difficult to prove whether child abuse alone is sufficient to cause health problems, or whether the
strong links between abuse and poor health are best explained by a complex web of childhood
adversities, such as poverty, parental divorce, parents’ mental illness and/or drug abuse, family
disharmony, intrafamilial violence, and dangerous neighborhood environments. 3,15-17

The most substantial and sustained research and action for child protection has occurred in
the United States and there is now compelling evidence that sexual abuse and physical violence
against children are decreasing. This positive trend is robust and broadly observed nationwide. 18,19
It may be occurring in response to comprehensive social market-ing and community-based
prevention efforts that increase awareness among parents, pro-fessionals, and the general public.
Special prevention programs designed for school children can have beneficial effects. 20-22
Unfortunately, such work in most parts of the world is rela-tively sparse and unsystematic.23

Child Maltreatment in Chinese Societies

There has been no comprehensive, representative, national survey of child maltreatment in China
or any Asian country with large ethnic Chinese communities. However, growth in research in
recent years is revealing some patterns. In this review, we describe findings regarding the three
major categories of physical, sexual, and emotional abuse. We adopt the standard WHO
definitions of these types of abuse 23 although we recognize that there is much overlap among
them. Next, we discuss various studies of adults’ perceptions of vio-lence against children in
Chinese communities, examining levels of awareness and popular attitudes, particularly those
held by parents.

Search Strategy
The focus was on research that includes data collected from community-based surveys of children
or young adults (up to age 25) about their own history of child abuse, and reports by parents and
professionals regarding their perceptions of child abuse. Scientific publica-tions in English-
language journals over the past 30 years (1978 to July 2008) were captured from the Web of
Science database using the following search terms: [child or children or adolescent or youth] and
[abuse or maltreatment or violence or neglect or punishment or discipline] and [China or Hong
Kong or Taiwan or Macau or Singapore or Malaysia or Chinese]. This yielded 35 articles, of
which 18 (51%) included primary data collection from youth or adult samples, 5 described
treatment methods, 4 were clinical case reports, 5 dis-cussed general professional issues, and 3
other (e.g., psychometric validation report). The

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 Evidence Base for Child Protection in Chinese Societies / Dunne et al. 269

great majority of this work has been published since 1993 (85%). In addition, we include
reference to a limited number of articles published in Chinese language and some reports accessed
through search of reference lists.
The articles report on the situation in mainland China, Hong Kong SAR, Taiwan, and also
from large Chinese communities in Singapore and Malaysia. We searched unsuccess-fully for
peer-reviewed articles on maltreatment of Chinese children living in Asian countries such as the
Philippines, Indonesia, and Thailand that have substantial ethnic Chinese minorities. We have not
included studies of people of Chinese ethnicity living in North America, Australia, or elsewhere,
as the focus is limited to Asia. Although there are many articles on child abuse presentations in
hospitals and clinical case series in Chinese populations 24-28 and other studies of the child
protection workforce and system manage-ment,29,30 these issues are outside the scope of the
review. Furthermore, we have not included discussion of some severe forms of child abuse, such
as commercial sexual exploitation, forced labor or trafficking, as there is little published,
community-based epi-demiological research into these problems in Asia.

Child Physical Abuse

The first surveys of child maltreatment in Chinese societies provided basic descriptions of the
types of physical abuse and harsh discipline practices within families. Almost 10 years ago in
Hong Kong, Samuda31 asked 100 mostly male university students about their experi-ences of
discipline and attitudes toward typical forms of punishment. Nearly all respondents (95%) said
that physical punishment was used in their homes, with acts ranging from enforced kneeling and
“sitting in an empty chair” to physical contact such as spanking, kick-ing, and beating. Although
some of these acts were considered appropriate for discipline by many young people, kicking and
hitting the head were approved of by none.
During the mid-1990s, Tang32 and Tang and Davis33 in Hong Kong and Kasim et al,25 in
Malaysia described physical violence experiences of young adult students and patients admitted to
hospital or reported to child protection teams. The patterns observed with the students were
similar to those found in Hong Kong by Samuda, 31 although Tang32 asked about a wider range of
abusive experiences and found somewhat lower prevalence of spe-cific acts of forceful discipline.
The studies of registered child abuse cases in Malaysia and Hong Kong illustrated the diversity in
clinical presentations and the family risk factors. 24-26 The Hong Kong study was particularly
interesting because data from 1995 were compared with official records from 1979, and revealed
an increase in the proportion of females who had been victims of severe physical child abuse, and
an overall increase in official reporting of sexual abuse of children.33

In the late 1990s, there were several reports from community-based and school-based
samples in Hong Kong adults and adolescents 34,35 and elementary school children in China.36 In
Hong Kong, nearly half of the sample of 1019 adults admitted to committing acts of “severe
violence” on their own children at some time during the preceding year, including hitting with an
object (very common), or more rarely beating, punching, kicking, or biting their children. Mothers
were the perpetrators more often than were fathers. Kim et al 36 interviewed children in China and
Korea, and found that nearly 1 in 4 Chinese children reported abuse by parents and/or teachers
that could be classified as “serious.” Lau et al 34 examined corporal punishment, being beaten “for
no apparent reason” and being beaten to injury by parents, by asking 3355 secondary school
students about such experi-ences in the preceding 3 months. Overall, 6.6% reported at least 1 of
these 3 events recently, and there were no significant differences between males and females, or
between children whose parents had high or low levels of education.

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270 Asia-Pacific Journal of Public Health / Vol. 20, No. 4, October 2008

Lau’s study was the first in any Chinese community to show that physical abuse by parents is
strongly associated with a range of adverse health-related outcomes, such as anx-iety, stress,
somatic illness, and risky behaviors such as smoking, alcohol consumption, and involvement in
fighting (although the authors acknowledged that these behaviors may some-times precede and
perhaps prompt the severe punishment). The authors discussed the pre-vailing attitude in Hong
Kong that strong corporal punishment is a right of parents and may be considered a duty to instill
filial piety in their children, a point that has also been made about harsh parenting practices in
Taiwan.37
Lau et al,38 further explored the prevalence and possible consequences of these types of
parental abuse in a survey of 489 secondary school students. Corporal punishment (unspec-ified)
was not significantly associated with poor health status of adolescents. However, being beaten for
no apparent reason and being beaten to injury were strongly linked with psychi-atric morbidity,
drug abuse, and adolescents’ thoughts or actions toward self-injury. This study was followed by an
extraordinarily large survey of 95 788 Hong Kong adolescents 39 that included a few questions
about violence. There were modest associations between a history of corporal punishment and
usage of alcohol, tobacco, and other psychoactive sub-stances. The strongest associations were
between a history of ever being beaten to injury by a family member without provocation, and use
of heroin or other illegal drugs. In a recent study of Chinese families in rural Taiwan, about 1 in 5
adolescents reported serious physi-cal abuse. 40 Consistent with research in many countries, those
abused tended to live in families with high levels of conflict and frequent parental alcohol use.

Child Sexual Abuse

Although there have been quite a few case reports of child sexual abuse, the first significant
clinical studies of child sexual abuse (CSA) in Chinese communities published in English were an
in-depth qualitative study of sexual abuse survivors in Taiwan 27 and a case–control study of
sexual abuse victims in Beijing.41 In the mid-1990s in Malaysia, Singh et al, 42 sur-veyed 616
student nurses and trainee medical assistants attached to a hospital in Ipoh City regarding
unwanted sexual experiences. Compared with surveys of students in Western societies at that
time, the prevalence of any form of sexual abuse (6.8%) was considered to be quite low, although
the authors suggested that the self-reports might have underesti-mated the true incidence because
of reluctance to disclose.42
In mainland China and Hong Kong SAR, the first community-based research into ado-
lescents’ early sexual abuse experiences included surveys of 985 female students and 239 male
students in Liaoning province in the north of China 43,44 and 2147 college students in Hong
Kong.45 This has been followed by surveys of 892 medical students in Shenyang, 46 2300
secondary school students in 4 provinces (Hubei, Henan, Hebei, and Bejing 47), 351 female
secondary medical secondary school students in Henan province, 48 and 3577 ado-lescents in
schools and colleges in 6 eastern and southern provinces.49
Several trends are apparent. When we consider all reports of any type of sexual harass-ment
or abuse, we find that about one in four young Chinese people have at least one unwanted
experience before the age of 16 years. Generally the abuse is reported more often by females than
males, although it should be noted that many males report sexual abuse. For example, Chen et al 47
found that sexual abuse involving physical contact was reported by 8.9% of girls and 5.0% of
boys.
A second trend is that the rate of the most invasive sexual abuse (forced intercourse) appears
quite low by international comparative standards. Tang 45 in Hong Kong and the studies by Chen
et al 43,44 in Liaoning and the 4-province survey 47 estimated that 1% or less had been forced to
have intercourse before age 16 or 17, which is about one half to one

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 Evidence Base for Child Protection in Chinese Societies / Dunne et al. 271

eighth of the rates observed in Western countries. 7,9,10 In Singapore, Back et al,50 compared a
primarily Chinese sample of university students with their peers in the United States and found a
rate of CSA among young Singaporeans only one-third of that reported by the US sample. This
finding is consistent with an observation among Asian Americans (broadly defined) resident in the
United States: When sexual abuse cases are clinically substantiated, the violence against Asians
compared with children in other ethnic groups tends to be less invasive, including less rape. 51
It should be noted however that further Chinese surveys of 892 female college students in
Shenyang47 and in Henan49 yielded somewhat higher estimates of unwanted intercourse of 1.9%
and 2.6%, respectively. These higher rates of forced penetration during childhood or early
adolescence are quite similar to those found in community-based studies of a large, recent
multiethnic sample in Malaysia52 and population-based studies in the United Kingdom,
Switzerland, and Sweden.4,6,53
A third pattern in Chinese populations is that CSA is strongly linked with poor mental health
and may lead to the uptake of risky personal behaviors. 46-49 Adolescents who report sexual abuse
—particularly where it involved physical contact—have high rates of depres-sion, suicidal
thoughts, use of substances such as alcohol or tobacco, had signs of harmful eating disorders
(females), or were involved in physical fighting (males). In these respects, Chinese young people
with a history of CSA appear to have similar reactions to abused ado-lescents and adults in other
countries.54

Emotional (or Psychological) Abuse and Neglect

Although emotional maltreatment has become a focus for research in some countries, 10,15,55
relatively little is known about this problem in Chinese communities. An early survey of
Catherine Tang32 in Hong Kong used the Conflict Tactics Scale, which includes questions about
verbal aggression and emotional manipulation, and she found these to be the most frequent forms
of maltreatment by parents.
The most substantial Chinese work has been done in Hong Kong by Daniel Shek 56-62 on
parenting styles and parent–child communication in relation to children’s psychological well-
being, adjustment to school, and behavior. One clear conclusion is that males experi-ence more
“harsh” parenting (including physical force) than do females, whereas females encounter more
demanding, controlling parenting. Shek58 noted that these data reflect pre-vailing cultural
stereotypes. One important aspect of the research in Hong Kong, both by Shek 62 and by Chang et
al 63 is that they have followed up children over time. These stud-ies suggest that harsh parenting
styles, including severe corporal punishment and little com-munication or overt affection, may
precede poor outcomes for young people, which strengthens the argument for a causal connection.

In a survey of adolescents in 6 Chinese provinces, Chen and Dunne 49 asked respondents

whether they had ever experience a variety of humiliating or distressing types of emotional abuse.
Around one third of males and females said they had been humiliated in front of other people, and
one third witnessed severe hitting or beating of family members or friends. Approximately 1 in
every 10 said they had been told by a family member that they wished they had never been born
or were dead, and a similar proportion had been threatened by somebody in the household that
they would be abandoned or banished from the house.
There remains a need for specific research that uncovers the ways in which children are
emotionally abused and neglected. The little research to date has focused on parental disci-pline
and communication styles. Future work should assess the quality of children’s inter-actions
outside the family, especially with teachers, classmates, health care workers, and others with
whom they have regular contact.

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272 Asia-Pacific Journal of Public Health / Vol. 20, No. 4, October 2008

Reflection on the Overall Value of This Research

It is not easy to determine the practical value of social research into phenomena such as child
maltreatment. At one level, it can seem to offer little more than confirmation of com-mon sense
by showing that some Chinese children are maltreated, as they are in every society. However, one
of the driving forces behind this field of research is to build the base of evidence for public health
solutions. As evidence is gained from different researchers in diverse sections of any community,
we learn about patterns that are consistent throughout the population and identify the limitations
of observations that cannot be replicated. One of the most important contributions of this research
is that it allows us to compare the differ-ences between the lived reality and adults’ perceptions of
the situation. Once these differ-ences are identified, we can commence the long process of change
that is necessary to raise awareness, deepen knowledge, improve attitudes, and mobilize resources
to modify the social conditions that promote child abuse.

Adults’ Perceptions of Violence Against Children

Attitudes about what should, or should not, be classified as unacceptable behavior toward children
vary considerably among adults and young people in every culture. 64,65 In Chinese societies there
are strong traditional beliefs about what constitutes acceptable use of disci-pline and force to
control or punish children37,58,61,66 although of course there is also wide variation between
Chinese families in parents’ beliefs and practices.62
Parental discipline in Singapore was first examined in 1997 by Elliot et al 67 and it was found
that caning, slapping, and shaking were not considered to be abusive by more than half of an adult
sample. In Hong Kong around that time, Lau et al 68 surveyed 1001 randomly selected adults.
They commenced by asking them to name different types of child abuse (without any prompting
from the interviewers). They then recited to these adults various scenarios depicting child abuse
and asked whether these should be classified as abuse. The adults were then asked about how
common they thought various types of child abuse were in Hong Kong, whether they personally
were aware of cases, and whether they would report abuse to authorities in the future.

Lau et al68 found that there are significant discrepancies between concepts of child abuse held
by statutory agencies and randomly selected Chinese adults. Severe physical abuse was named
most often (79.9%) and it was felt to be common in Hong Kong by 41.2%. Fewer adults
spontaneously mentioned child neglect (21%), although once prompted most said it was common
(76.9%). Many fewer adults (13.4%) mentioned emotional (psycholog-ical) abuse and just over
half of those respondents thought it was uncommon.
Most striking was the finding that only 6.8% mentioned CSA, and when prompted, less than
one quarter felt that it was common in the population. It seems clear from that survey carried out
in the mid-1990s that most Hong Kong adults conceptualized child abuse pri-marily in terms of
severe physical assault, and although child neglect may not have a high level of awareness in the
minds of most adults, when asked about it specifically, the majority said that it was common in
society. However, there appears to be a distinct lack of aware-ness of sexual abuse.

The limited knowledge of CSA among many Chinese adults has been revealed in 3 sur-veys
in Hong Kong,69 Liaoning province,70 and Hubei province.71 Although this work by Tang and
Chen has been done independently, there are remarkable similarities in the findings. For example,
Tang and Yan69 found that 40.7% of adults believed that “only a few boys are

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 Evidence Base for Child Protection in Chinese Societies / Dunne et al. 273

targets of child sexual abusers,” whereas 34.7% agreed that “if a child does not look dis-turbed, it
is very likely that he/she was lying about being sexually abused,” and 33.1% said that if children
report CSA from a long time ago, we should doubt whether it really hap-pened. Similarly, in the
Chen and Chen69 Liaoning study, 21.3% of parents agreed that “Boys cannot be sexually abused”
(18.2% in Hubei) and only 40% of parents in both Liaoning and Hubei agreed that “children who
report being sexually abused can be believed almost all of the time.”

It seems that many adults in the general community define sexual abuse as acts that involve
physical force and injury. Tang and Yan 69 reported that 76.6% of adults believed that a “majority
of CSA situations involve physical injuries.” In Liaoning and Hubei, Chen et al 69,71 found that
only 1 in 4 parents agreed that “if a child has been sexually abused, there will usually be no
obvious physical evidence.” Together, these studies of Chinese adults’ per-ceptions signal an
urgent need to educate the population about the reality of CSA.

Closing the Gap Between Perception and Reality

In this brief overview, we have not attempted to derive summary estimates of prevalence of child
abuse by combining available data. There would be little benefit in searching for gen-eralizable
rates; the available work is too methodologically diverse and samples have not been population
based. Except for the past 5 years or so, the historical data are too sparse to draw any conclusions
about whether maltreatment might be increasing or decreasing over time.
One solid conclusion from this narrative review is that there is a distinct mismatch between
the experience of maltreatment as revealed by young people in mainly anonymous questionnaire
surveys and what their parents and other adults know and believe about child abuse. This is
especially clear regarding sexual abuse; many parents do not have a sophisti-cated understanding
of the varieties of sexual abuse nor the mental health and behavioral consequences. A similar
pattern emerges for physical abuse. Violent parenting and severe discipline in schools are illegal
in Chinese societies, yet there may be a high level of toler-ance of these acts by a substantial
minority of parents and other adults.
A second conclusion can be drawn from the research articles we did not find. There is very
little research into emotional abuse and neglect in Chinese communities. This indicates a general
lack of awareness, not just among the general public but also among public health researchers that
emotional maltreatment is more prevalent than other types of abuse and often is the most
damaging to young people.34,52,72
The gap between public perception and lived reality is not specific to Chinese societies; it has
long been observed in other cultures and the magnitude of the gap may vary in dif-ferent ethnic
and socioeconomic groups.64 By focusing on this gap, however, we can find directions both for
further research and public health action. In Chinese societies there is a clear need for more
research into public perceptions of child maltreatment and this should be linked directly with self-
reports from young people. Locally derived data can then be applied to social marketing
campaigns that are face valid and culturally appropriate. Such research is also a valuable tool for
advocacy for law reform and funding for prevention and care services to sometimes poorly
informed and reluctant policy makers.23
The Asia Pacific Journal of Public Health can play an important role. To date there has been
very little attention to child maltreatment as a public health issue in this journal. In fact, no
articles specifically on this topic appear to have been published. It is encouraging to see some
recent research into domestic violence and family disharmony in Malaysia 73 and Iran74 and an
analysis of the risks and sometimes serious social and health consequences of child-bearing by
adolescent mothers in Taiwan.75 The journal is now open and accessible

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274 Asia-Pacific Journal of Public Health / Vol. 20, No. 4, October 2008

worldwide. The relevance and power of this publication can be enhanced if we focus on the full
spectrum of the causes of global disease burden, especially depression, suicide, and self-harm.
Child maltreatment is strongly linked to these disorders. Prevention and care efforts will be
considerably strengthened if there is further research throughout the Asia-Pacific region.

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