Striving for our most vulnerable children: Buffering against the impact of child maltreatment

One of the fundamental pillars of our society is the presence of strong and stable families. In 2024, the inaugural edition of the Domestic Violence Trends Report¹ by the Ministry of Social and Family Development, which provides an overview of key domestic violence trends in Singapore, was published. From 2021 to 2023, the number of new Tier 2 cases (those with high safety and risk concerns for the vulnerable person, which may warrant more intrusive statutory intervention to keep the individual safe) decreased. However, the number of new Tier 1 cases (those with low-to-moderate safety and risk concerns for the vulnerable person) increased, suggesting greater awareness and willingness by survivors and the public to report abuse and seek help early.

This greater awareness and willingness to report abuse is reflective of Singapore’s persistent efforts at tackling child maltreatment across multiple domains and agencies. These include addressing upstream factors that are linked to prevention of abuse to tackling the myriad of downstream effects on these children. Such efforts have been multidisciplinary, across-agencies and requiring community involvement and participation as well. One of the aspects of such work, especially pertinent to the medical community, is specifically looking after the developmental and behavioural needs of these children.

Negative developmental implications for victims of child maltreatment have been widely researched. It is well established that child maltreatment has an immediate² and long-term^3,4 negative impact on children’s physical, mental, academic and emotional health. In addition, the detrimental effects of Adverse Childhood Experiences (ACEs) including child maltreatment have been found to be transgenerational. This could be mediated by social circumstances, emotional regulation difficulties or mental health issues, and physiological mechanisms.^5,6 Addressing these effects requires targeted rehabilitation efforts catered to the needs of this vulnerable group of children. In this context, it is important to note that keeping victims of abuse safe is distinct from providing rehabilitation for them.

In this issue of the Annals, Chan SH et al. report on a new home visitation programme,⁷ Anchor, that was specifically set up to support preschool children who have been exposed to maltreatment. The aim of the programme was to assess and address the potential impact of the ACEs that these children were exposed to in a holistic cross-disciplinary manner. The focus was on working with these families to address and improve the child’s health, development and behaviour, early relational health, caregiver mental health and lastly, building community partnership to ensure ongoing support for the families. The programme centred around home visits, done by community health visitors who conducted visits based on a tiered risk-based model (up to 2 times a month for higher-risk families and once every 2 months for lower-risk families). The health visitors were supported by a team of social workers, psychologists and paediatricians who conducted regular assessments and addressed medical/developmental concerns appropriately. This is a first in Singapore and the Anchor team has done the important job of setting up and studying the impact of the programme in supporting the unique developmental needs of these children as well as their families.

The key findings as outlined by Chan SH et al. include that among the study cohort of 125 children, a substantial 73.6% of them were at risk of developmental delay upon entry into the programme, with scores on developmental screeners within the at-risk range. These delays were predominantly in the personal-social and communication domains, with almost half the cohort having at-risk scores in each of these domains. Further, nearly one-third of the cohort (31.7%) had behavioural concerns such as significant tantrums and aggressive behaviour. These findings are comparable to other studies^8,9 that show a higher prevalence of developmental and behavioural concerns in this group as compared to the population. This highlights the importance and need to systematically screen for developmental and behavioural issues in this population locally. Encouragingly, many children in the Anchor study cohort showed improvements in their development, through the course of the programme; specifically in the gross motor and fine motor domains. This is a testimony of the resilience of these young children when specifically nurtured and given targeted support. Although the improvements were not demonstrated across all developmental domains or behavioural concerns, this shows the potential for tailored programmes like this to support development holistically in these children.

Singapore has a robust jurisdictional system to penalise offenders.¹⁰ The Singapore Children and Young Persons Act (CYPA) protects our persons under 18 years old. Over the past decade, the CYPA has been amended to increase penalties for child abuse with new laws against domestic violence being introduced. These laws, which are constantly reviewed and act as deterrence for future offenders, are a critical component of reducing rates of child maltreatment. Despite these, maltreatment does occur and in such instances, when a child has been harmed, there is a need for time-sensitive, prompt action, with the priority being the safety of the child. After this has been accomplished, it is then important to provide trauma-informed care and rehabilitation as justice for the affected child beyond ensuring safety. Safety is a prerequisite for rehabilitation but must be differentiated from rehabilitation in itself.  Every step of this process is important to the child’s recovery. In addition, although children are the primary target, it is important to realise that a child is always part of a system consisting of the family, peer group, school, neighbourhood and the community.

Hence, together with other programmes offered by the family service centres and the child protection specialist services, we need trauma-informed rehabilitation programmes to deepen our expertise and widen our reach in society. The Anchor programme is one such programme. While promising in potentially being able to ameliorate some of the developmental sequelae of child maltreatment, this current programme and many other such programmes tend to be resource-intensive due to the nature of this type of work. Implementation of a programme like Anchor, on a wide-scale will require significant resources and commitment from the relevant government agencies. Yet, such investments in this arena are warranted, especially for a high-income country like Singapore, where human capital is our primary natural resource and children are the future of our society.  In parallel, we must also explore other models of rehabilitative care to cater specifically to this group of children within the educational, medical and social settings.

Ultimately, preventing and effectively dealing with child maltreatment when it does occur, is everyone’s responsibility as a collective society. These children are among our most vulnerable and should not be failed by society, especially when they have already been let down once for allowing the maltreatment to occur in the first place.

References

1. Ministry of Social and Family Development. Domestic Violence Trends Report 2024. https://www.msf.gov.sg/research-data/research-reports-data/help-those-in-need/article/domestic-violence-trends-report-2024. Accessed 19 February 2024.
2. Ngiam XY, Kang YQ, Aishworiya R, et al. Child maltreatment syndrome: demographics and developmental issues of inpatient cases. Singapore Med J 2015;56:612-7.
3. Lansford JE, Dodge KA, Pettit GS, et al. A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Arch Pediatr Adolesc Med 2002;156:824-30.
4. Herrenkohl TI, Hong S, Klika JB, et al. Developmental Impacts of Child Abuse and Neglect Related to Adult Mental Health, Substance Use, and Physical Health. J Fam Violence 2013;28:10.1007/s10896-012-9474-9.
5. Boullion AM, Brott H, Oren T, et al. Transgenerational impact of maternal adverse childhood experiences on children’s mental health among families experiencing homelessness, Child Protection and Practice 2024;3:100063.
6. Holuka C, Grova N, Charalambous EG, et al. Transgenerational impacts of early life adversity: from health determinants, implications to epigenetic consequences. Neurosci Biobehav Rev 2024;164:105785.
7. Chan SH, Yeleswarapu PS, Oh JY, et al. The impact of Anchor, a home visitation programme for maltreated children, on child developmental and behavioural outcomes. Ann Acad Med Singap 2025:54:208-18.
8. Maughan A, Cicchetti D. Impact of child maltreatment and interadult violence on children’s emotion regulation abilities and socioemotional adjustment. Child Dev 2002;73:1525-42.
9. Strathearn L, Giannotti M, Mills R, et al. Long-term 449 cognitive, psychological and health outcomes associated with child abuse and neglect. Pediatrics 2020;146:e20200438.
10. Singapore Courts. Care and Protection Orders: Overview. https://www.judiciary.gov.sg/family/care-protection-order-overview. Accessed 20 February 2025.