The Suspected Child Abuse and Neglect (SCAN) Programme in Malaysia: From Inception to Present

Issues on child abuse are very critical considering the many incidents of abuse and violence against children. Experiencing abuse in childhood has lifelong impacts on the health and well-being of children, their families and communities. Suspected Child Abuse and Neglect (SCAN) service is centralised, multidisciplinary team management in the government hospital and serve as a supportive service or programme to children, families and hospital staff. This paper outlines the history and the SCAN service available in Malaysia.


Introduction
Child abuse and neglect is a societal and global phenomenon for centuries (Alrimawi, Rajeh Saifan, & Abu Ruz, 2014) and a great public health concern. Reports of infanticide, mutilation, abandonment and other forms of violence against children date back to ancient civilizations (Arruabarrena, 2014). Child abuse and neglect occurs in a variety of forms and is deeply rooted in cultural, economic and social practices. Different standards and expectations for parenting behaviour in the range of cultures around the world helps define the generally accepted principles of child-rearing and care of children (Bornstein, 2012). There is general agreement across many cultures that child abuse should not be allowed, and virtual unanimity in this respect where very harsh disciplinary practices and sexual abuse are concerned WHO, 2014). Almost all nations (196 countries) ratified the 1989 United Nations (UN) Convention on the Rights of the Child, which recognizes freedom from violence as a fundamental human right of children (Assembly, 1989). According to World Health Organization (WHO), child maltreatment sometimes referred to as child abuse and neglect, by definition includes 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 (Butchart, Phinney Harvey, Mian, & Furniss, 2006). Based on the WHO Consultation on Child Abuse Prevention, there are four types of child maltreatment (child abuse and neglect): physical abuse, sexual abuse, emotional and psychological abuse, and neglect (Butchart, Phinney Harvey, Mian, & Furniss, 2006;Butchart, Mikton, Krug, Hogan, Laych, & Upton, 2014). The WHO 2002, estimated that worldwide around 875,000 children under the age of 18 years died as the result of an injury [WHO, 2005]. Shockingly, over the past decades, the WHO in 2016, the WHO estimated globally that up to 1 billion children under 18 years, have experienced injury in the past year, or half the children in the world (WHO, Fact Sheet 2018;Hillis, Mercy, Amobi, & Kress, 2016). United Nations (UN) has launched sustainable development goals (SDGs) to end all forms of violence against children (United Nations General Assembly, 2015). Global status report on violence prevention 2014 by WHO reported over half of the 133 reporting countries have child protection services . The National Health and Morbidity Survey (NHMS) conducted in 2016 revealed the prevalence of injury among children aged 12 to 59 months in the past one year was 3.8% (95% CI: 2.80, 5.22), which is proportionate to approximately 77,000 children in Malaysia (Institute for Public Health. National Health and Morbidity Survey, 2016).

Objective
This paper aims to describe the outlines the suspected child and neglect (SCAN) service/ programme in the public hospitals under the Ministry of Health (MOH), Malaysia.

History of SCAN
SCAN programme is an initiative undertaken by the Hospital Kuala Lumpur (HKL), Ministry of Health (MOH), Malaysia over the past 33 years (Ahmad, Denise, Arunachalam, & Niner, 2015). It is one of the major programme or initiative provided by the government facilities in dealing with child abuse cases in Malaysia. Apart from SCAN service, other services provided by government agencies include; the Child Protection Team (CPT), overseen by the Department of Social Welfare under Ministry of Women, Family and Community Development Malaysia, and (2) the Child Protection Unit (CPU) carried out by the Royal Malaysian Police. Each of the three programmes has a specific approach to the child abuse problem and different operational objectives, largely driven by the different roles, profiles and characteristics of the agencies themselves (Ahmad, Denise, Arunachalam, & Niner, 2015).
As early as 1974, Hwang et al stated many issues on child abuse in Malaysian hospitals (Hwang, Leng, & Chin, 1974). Child abuse is an important issue but often been neglected by healthcare providers, policy health makers and community, due to its sensitive information and social taboo (Hwang, Leng, & Chin, 1974). SCAN team was established in 1985 in view of the number of children maltreatment cases seen in Paediatrics wards at the HKL suffering from injuries deliberately inflicted by those taking care of them (Schwartz-Kenney, McCauley, & Epstein, 2001). The first SCAN team formed in 1985 was a prototype of the SCAN team available in Australia (Tomison & Tomison, 2002). It was a multi-disciplinary team comprised of medical doctors, medical social workers and police officers. The SCAN team managed any child abuse cases that were brought to the hospital as a team and followed up those cases. The SCAN team became the media focus in 1990 following the tragic death of a 26-month-old severed abused child. The SCAN team was the only organisation in Malaysia dealing with child abuse and used its advocacy role to lobby the Malaysian government for changes in protecting the child. The SCAN team involved with other agencies in preparing the Child Protection Act 1991, and later in year the 1998 received international recognition by the United Nations 'for protecting the lives of children'. Later, the Child

Objectives of SCAN
The objectives of the SCAN team are as follows: (1) to define hospitals' responsibilities regarding management of SCAN cases; (2) to provide a guide to the development of hospital protocols and procedures; and (3) to define organisational structure and role of SCAN team and members, at various levels of hospital care (Guidelines for the Hospital Management of Child Abuse and Neglect Malaysia: Ministry of Health Malaysia, 2009).

SCAN Team Composition
SCAN team is a centralised, multi-disciplinary and multi-agencies communications, management, database and supportive services to the suspected child abuse and neglect, adolescents and families. The goal of SCAN team is to reduce trauma to the child, by the professionals to communicate from the earliest opportunity, limit repeat interviews by different agencies and multiple interviewers, and continue to share information throughout the pendency of the case, improve coordination of service delivery, ensure forensic defensibility of services, and enhance the courts' ability to protect families (Guidelines for the Hospital Management of Child Abuse and Neglect Malaysia: Ministry of Health Malaysia, 2009). The SCAN approach does not require a formal centre. The SCAN team composition is depending on the type of hospital category. The hospital can be divided into three categories: (1) Level A: Hospital Kuala Lumpur (HKL) and state Hospitals; (2) Level B: other hospitals with specialists; and (3) Level C: hospitals without specialists. Level C hospitals are expected to refer all cases of child abuse and neglect to hospitals with specialists.
The SCAN teams include accident and emergency staffs, paediatricians, gynaecologists, forensic pathologists, nurses, and medical social workers who work with designated welfare officers from Department of Social Welfare  Vol. 11, No. 7;2019 local data and sent the local data returns by 3-monthly to the Violence and Prevention Unit at Non-Communicable Disease Section under the Disease Control Division, MOH. It helps to identify risk factors, the vulnerable groups, to improve the networking, referral system and emphasis on effective prevention programme using the multiagency approach.

Local SCAN Data
SCAN data were collected from sources at 3-level hospitals, once every 3 months. The SCAN data were categorised into cause of injury: unintentional and intentional injury. Unintentional injury subsided into Physical and sexual injury, where else the intentional injury subsided into shaken baby syndrome, physical and sexual, emotional abuse or neglect, and physical neglect/ abandonment. SCAN data were categorised further by gender, location of incidence and suspected perpetrator. In this report, we are revealed some of the SCAN data results in 2 years in 2015 and 2016 due to limited data.  (0%) in the year 2016. The most common causes of SCAN cases in both years are the sexual, followed by the physical, the emotional abuse/ neglect cause, the baby shaken syndrome cause, and other causes revealed different frequency for each year. Among 893 cases in year 2016, the proportion of females was higher (80%) than males (20%), with a sex ratio of 4 girls per each boy (4:1) meanwhile in year 2015, no gender data were available during this reporting. Mother/ father the most common perpetrator (25%), followed by others (25%), babysitter/ childminder (22%), siblings (12%), stepparent (6%), relatives (5%), child (2%), and girlfriend/ boyfriend (2%) in year 2015, which means that 25% of perpetrator of child abuse/ neglect is their own parent. Among perpetrators in year 2016, the others (31%) showed the highest percentage then the rest perpetrators which were the Mother/ father (25%), followed by girlfriend/ boyfriend (25%), step-parent (5%), relatives (5%), and siblings (2%), which showed the girlfriend/ boyfriend as perpetrator shoot up to 25% from 2% in the past a year, is an alarming figure of the perpetrator as an immediate family members has been awarded temporary guardianship or being close to the child to provide protection. There was no perpetrator data available for child-category during this reporting.

Discussion
In this report, stated the frequency and comparison of SCAN data in Malaysia of all its categories in both the year 2015 and 2016. An increased 11% SCAN cases in year 2015 from 802 cases to 893 cases in year the 2016, might due to the current gazettement of the Child Act (Amendment) 2016 as a revision from previous Child Act 2001 (Child Act (Amendment), 2016) in the Parliament, is a positive step. The Child Act (Amendment) 2016 has four main amendments: child registry, enforcing the community service order (CSO) for child offenders, improving child protection through the National Council for Children and Child Welfare Teams and stricter penalties. Under Section 31 with jail term doubled to a maximum of 20 years and the fine increased to RM50,000 from RM20,000 for child abuse and neglect cases. The child offenders will be rehabilitated under the CSO through the communal work, counselling, parental and reconciliation programmes, in addition to a jail term or a fine. Details of all those convicted of any offence will be kept in the Register of Children. Affected children or victims of abuse or neglect will be placed with their families or relatives. It will also be an offence for not to report incidents of child abuse.
Another possible increased number of reported SCAN cases due to activation of a free call initiative programme in 2015 from local telecommunication company to the 24-hour helplines of Talian Nur and Childline 15999 in partnership with the government agency-Ministry of Women, Family and Community Development and Childline Malaysia is another good example to provide easy, better and protective access. Talian Nur is a hotline link to enable early intervention for victims of domestic violence and Childline 15999 initiated by the Malaysian Children TV Programme Foundation in 2008 is a confidential 24-hour helpline for children and young people to seek information, share feelings and get needed help.

Child Abuse and Neglect Registry/Information System
Child abuse and neglect is an important cause of childhood morbidity in terms of its impact on physical health and disability, emotional health and healthy child development (Taib & Filzah, 2015). The SCAN local data reported from various related government hospitals using the administrative or conventional system by filling up the reporting forms and sent through electronic via email. These reports derived from various sources from the doctor, staff nurse, social worker, other authorities such as the police officer about suspicion of child abuse and neglect. Variation in standard definition for child maltreatment even within various agencies is problematic and cannot be compared. Official statistics or child abuse and neglect data are important specifically designed to measure the incidence or prevalence of child abuse and neglect (child maltreatment). Survey data, particularly on those using group data, are not adequate to represent Malaysia population and less reliable. It needs a most robust survey involving a large representative sample of the population. This might incur more cost to do a population-based survey. A similar survey was done in UK 2009 showed an overall response rate was 60.4% (Radford, Corral, Bradley, & Fisher, 2013). A survey data or population-based survey or study, although useful, cannot be compared to official statistics of child maltreatment by either the child survivors or the suspected perpetrators. A good quality epidemiological data on child injury and its determinants are essential for identifying priority issues, risk factors, high-risk groups, and also for understanding the underlying causes of child injury in Malaysia. Detailed analysis of sound SCAN data has undoubtedly been instrumental in achieving the high rates of success in SCAN prevention programme in Malaysia. A few countries have robust child abuse and neglect information systems for example in Australia, Belgium and Canada (AlEissa et al., 2009). There is a need to develop a national child abuse and neglect registry or comprehensive and data-driven national action plans as a monitoring or screening platform to formulate effective national plans of action or other policy frameworks for the safety of children in Malaysia.

Research and Prevention Programme
Reductions in child injury, morbidity and mortality as a result of the application of evidence-based programmes based on rigorous research and priority-setting, have been achieved in some countries. Research into the whole spectrum of SCAN, from the primary prevention through to rehabilitation, deems much higher levels of funding.
There are not much current published studies to reflect the extent of child injury in Malaysia nor the gaps in prevention programming and service delivery. It is vital to have a national action plan are driven by good epidemiological data, as the findings provide pointers for government agencies, other non-government agencies as well as international violence prevention partners. SCAN prevention programme should be a responsibility shared between multiple government agencies, non-government organisations, academic institutions, mass media and private sectors. A well-targeted investment of funding resources is needed to tackle the problem of child injuries, besides address the infectious diseases, the major killer of children under five years of age. Effective injury prevention is a very cost-effective public health strategy and is usually much lower than the cost of the consequences of injury.

Conclusion
A reliable and cost-effective SCAN registry or data collection system is needed to integrate into other child health screening or programme and enables the Government to do comprehensive and effective policy formulation related to the care, protection, rehabilitation, development and the participation of children at the national, regional and international levels. It will provide a thorough understanding of the true epidemiology of the problem as well as the burden of SCAN injuries on the vulnerable and victimised child.