INTRODUCTION

Violence against children and adolescents is a serious global social problem in developed and developing countries¹. It is characterized as a public health issue, considering the impact and its consequences in the area of individual and collective health, being a relevant topic for Nursing.

In a Foucauldian conception, the relationships of family violence against children and adolescents do not seem to be about relations of power, mobile, unstable, spaces of resistance, but, predominantly, states of domination: “In many cases, power relationships are fixed in such a way that they are perpetually dissymmetrical and that the margin of freedom is extremely limited². Data from a study carried out by the United Nations Children´s Fund³ in 190 countries show that around 120 million girls and young women under 20 years old (approximately one in ten) were forced around the world having sex or practicing other sexual acts. Regarding physical violence, about 17% of young people in 58 countries were targets of harsh forms of corporal punishment practiced as a disciplinary form³.

The complexity of the phenomenon, usually treated in a veiled way by both aggressors and victims, justifies and demands the involvement of the professionals who assist these people to notify the cases, especially regarding the relevance of the problem dimension, priorities for victims´ attention in different populations and to the definition of planning and implementation of strategic policies and programs for prevention and intervention⁴. It is considered that the notification of violence against children and adolescents constitutes a relationship of power and resistance² of the notifier against the aggressor and an attempt to break the reproduction of violence.

In Brazil, knowledge about the extent of violence in health services is still scarce, and the frequency of cases of violence against children and adolescents is unknown⁵ since the practice of reporting it is still unevenly implemented. Little is known about the political and institutional context and the patterns adopted for its effective operationalization in the different states. Nor is their flow widely known and the mobilization of resources effectively triggered by compulsory notification by health professionals⁴.

The adoption of information standardization, such as the construction of databases and information systems on situations of violence, becomes relevant because it allows monitoring the problem, issuing periodic and current reports with agility, and producing reliable and timely information⁶. For the authorities, professionals, and citizens who deal with situations of violence, accessing to information means the possibility of saving lives, asserting rights and guaranteeing the physical and psychological integrity of people.

The municipality of Rio Grande, where this study was conducted, is particularly vulnerable to situations of violation of children and youth people. It is a port city with approximately 207 thousand inhabitants, located in the southern half of Rio Grande do Sul, with the second largest port in charge of cargo handling in Brazil⁷. Data from the most recent mapping of vulnerabilities to the sexual exploitation of children and adolescents on Brazilian federal highways - 2013/2014, conducted by the Federal Highway Police, together with other bodies such as Childhood Brazil and the International Labor Organization (ILO), reveal an increase of 12% in the points considered vulnerable in Rio Grande do Sul⁸.

Besides this scenario, there is an important expansion of the naval center in the municipality, transforming the region into large construction sites with workers, predominantly male, enhancing the socio-environmental vulnerability already present in the municipality regarding violence and, especially, in sexual exploitation of children and adolescents.

However, while the municipality is advancing regarding population growth to meet this demand for economic development, there is only one Specialized Referral Center in Social Assistance (CREAS), and it is also systematically unaware of the situation of violence against children and adolescents in the municipality. It should be noted that in 2009, the notification of violence and accidents became part of the Notification of Injury Information System (SINAN).

Although the municipality recently implemented the Police Department for Protection of Children and Adolescents (DPCA) and the Program of Integrated Reference Actions to combat sexual violence against children and adolescents in Brazil (PAIR), as well as the Accident and Violence Surveillance System, we do not yet have information to assess the magnitude of the problem of violence against children and adolescents, and it is relevant to question: What is the epidemiological profile of violence against children and adolescents assisted at a Specialized Referral Center for Social Assistance (CREAS)?

The answer to this question can contribute to the elaboration of strategies for intervention and control of this aggravation to avoid that new cases of violence occur or even continue to be perpetrated in a vicious circle of impunity and injustice against children and adolescents. It can also provide information for the evaluation of the local situation, subsidize the identification of problems, propose solutions and make decisions, such as the creation of public policies directed to the researched profile. Thus, the results of this study can demonstrate the importance of knowledge of the profile of violence against children and adolescents for intervention and elaboration of public policies promoting health and quality of life in this region of Brazil.

In this perspective, the study aims to present the epidemiological profile of violence against children and adolescents assisted in the (CREAS), from the records of the notifications in the period between January 2009 and May 2014. Specifically, it is sought to draw a profile of the children and adolescents assisted in this service, the profile of the aggressors and the forms of violence suffered.

METHODOLOGY

This is a descriptive study, with a quantitative approach, and documental analysis in medical records developed at CREAS in the Municipality of Rio Grande. It is an institution configured as a public and state unit, which offers specialized and continuous services to families and individuals in situations of threat or violation of rights, according to Article 86 of the ECA⁹.

The service has a team of eight psychologists, three social workers, a social educator and an administrative assistant. Approximately 200 families (victims and guardians) are assisted monthly, through referral of cases by the Guardianship Council or denunciations of neighbors, schools, health services. After receiving the child and/or adolescent and their person responsible in the institution, the reception is carried out, followed by a psychosocial evaluation and the opening of a medical record.

Thus, it was decided to proceed with the analysis of medical records opened between January 1, 2009, and May 31, 2014. Data were collected by a single examiner, from January to May 2014.

Of the 931 medical records of children and adolescents’ victims of violence, the sample consisted of 800 medical records of victims of intrafamily violence, aged between zero and 18 years old. As exclusion criteria, all medical records of persons not in the stipulated age group were considered; records before 2009 and victims of extra-family violence.

A collection instrument was developed with the following variables: victim information (gender, age, skin color, education and neighborhood); Characteristics of the aggressors (gender, age, education, relationship with the victim); Violence. After its testing by the professionals of the service, a pre-test was carried out with thirty medical records, not identifying any difficulty for its filling and subsequent analysis.

The data were inserted into spreadsheets of the Excel® type, and the descriptive statistical analysis was carried out with the statistical software SPSS version 17.0. The project was approved by the Research Ethics Committee under number 105/2013.

RESULTS

From the analysis of the 800 medical records, the characteristics of the victims, aggressors, and violence were identified.

Characteristics of the victims

The prevalence of the incidence of violence in children and adolescents of the female sex, corresponding to 64.7% of the total notifications, was observed. In the analysis by age group, there was a higher incidence of cases of violence in the 7 to 12 year age group with 71.9% of the cases reported. As for skin color, the prevalence of white children and adolescents was shown in Table 1.

Table 1 Frequency distribution of victims of violence according to variables, gender, age, skin color, education and neighborhood. CREAS, 2009 to May 2014. Rio Grande, RS, Brazil. 

Regarding the education, considering the victims whose data regarding education was identified, 53.9% of children and adolescents attended or are attending elementary school. As to the place of residence of the victims, their prevalence in peripheral neighborhoods was verified, representing 72% of the total.

Characteristics of the aggressors

In the analysis carried out (Table 2) on the profile of the aggressors, in 64% of cases, the aggressor was male, and the prevalent age range was between 20 and 40 years old (36.2%). As for education, they present different levels of education, with 66.6% of the aggressors, whose data referring to education were identified, attended elementary school incomplete or complete, characterizing the predominance of low education. However, 18 aggressors (6.8%), reached the upper level.

Table 2 Frequency distribution of aggressors according to gender, age group, education and relationship with the victim. CREAS, 2009 to May 2014. Rio Grande, RS, Brazil. 

⃰They refer to the denunciations made through Dial 100 and Guardianship Council

As for the relationship between the victim and the aggressor, in 30.3% of reports, the mother was the main aggressor, followed by the father with 27.1% of the cases and the stepfather/stepmother in 17.3%. It should be noted that, in addition to these, in 24.2% of the cases, the authors were close relatives of the victims (siblings, grandparents, uncles, brothers-in-law).

Characteristics of the violence

Considering all forms of violence and the year, there was an increase in the number of notifications, especially in 2013. However, it is worth mentioning that in May, 97 cases of violence involving children and adolescents were reported, representing a rise in numbers compared to years before 2013. It may also be noted that sexual abuse ranked first, followed by physical violence. It is noteworthy that even psychological violence, so difficult to detect, emerged as the third most reported modality. When two or more modalities are identified in the same case, physical violence associated with psychological violence is the one with the highest number, representing 40 reported cases, as can be seen in Table 3.

Table 3 Distribution of reports of intrafamily violence against children and adolescents according to the type of violence and year of incidence. CREAS, 2009 to May 2014. Rio Grande, RS, Brazil. 

* The year 2014 corresponds to the month of May^.

DISCUSSION

The reality analyzed allows us to infer that the phenomenon of violence against children and adolescents is significant in our society. Although the total number of reported cases over five years is very significant (800), this number probably does not represent the actual incidence of violence against children and adolescents in the municipality, since the number of reports of intra-family violence is still unknown throughout the world^4),(10)-(11.

In this sense, it is defended that the notification of intra-family violence against children and adolescents is a manifestation of the complainant's exercise of power, which may require confrontation courage and fear of reprisals. For Foucault, power is exercised in different and varied directions, as a network that encompasses all of the society: no one is free from it. Power is conceived as a strategy, so it is not a privilege¹².

Because of the difficulty of the child and/or adolescent in revealing the violence suffered, by their extreme vulnerability and by the aggressor, they usually constitute a loved one and want to be loved, besides being a phenomenon commonly covered by the family and society¹¹, together with the fragility of the system, institutional slowness and legal procedures, many victims can be revivified, either by minimizing the seriousness of the facts or by the little importance given to the cases by the institutions¹³.

Although the notification is important in the fight against violence, producing benefits for reported cases and constituting an instrument of resistance¹² and epidemiological control, underreporting of violence is still a reality in many countries because notification is culturally recognized as a process of punishment, and not as assistance and help, harming the true dimension of violent events¹¹.

Thus, the results presented here depict only an approximation of reality, since the decision to notify is not restricted to the legal determinations, but rather to the peculiarities of each case, being influenced by personal factors, exercising freedom for an ethical behavior, the specificities of the case and the very structure of the health services, which, for the most part, are deficient, constituting one of the main challenges for society to make the notification.

Regarding the profile of the victims, the female sex and the age group of 7 to 12 years old prevailed among the victims of this study in 64.7% and 44.1%, respectively, demonstrating similarity when compared with other surveys^14)-(15) also identifying the predominance of females among the victims, with 64% and 56%, and the age range from eight to 12 years old, corresponding to 38% and 36% respectively. Incomplete or complete primary education prevailed in 53.9% of the cases among the victims of this investigation, corroborating with other studies^16)-(17. Regarding color, the predominance is white (82.3%), unlike national studies^18)-(19) and international studies, such as in Canada^15),(20, which show an association between juvenile color victimization, following an ethnic pattern, especially brown and black people. Therefore, based on these findings and their complexity, the urgent need to break cultural barriers and pre-judgments of a possible association of domestic violence against children and adolescents with low levels of education and blacks is underscored.

As for the characterization of the aggressors, the results are similar to the study by Oliveira et al²¹, presenting the highest number of cases of violence in male aggressors in 63.7%. The data referring to the identification of the age group and the level of education indicated a lack of registration in 330 and 536 medical records, respectively, hindering to analyze these variables. However, it should be noted that elementary education and the age group of 20 to 40 years old prevailed among the aggressors of this study, corroborating with other studies^6),(21.

The study identified the mother as the main responsible for the aggressions, followed by the father, similarly to national studies^6),(22 and international studies^3),(23, which identify parents as the main responsible for intra-family violence against children and adolescents.

This fact corroborates the reflection that many parents still consider the use of violence as a disciplinary and educational measure, possibly constituting the reproduction of practices adopted by their parents and they were already victims in their childhood and adolescence. Thus, because they do not recognize the harm to the health of their children, not only physically, but in the emotional and social spheres, parents can adopt violence as an educational practice, teaching their children the practice of violence as a practice culturally accepted, which can be reproduced on a regular basis.

The prevalence of sexual abuse, physical and psychological violence, verified in this study coincides with other national ^{21)-(22),(24)} and international³ investigations. In the United States, according to the National Survey on the Exposure of Children to Violence (NatSCEV II) conducted in 2011, sexual victimization rates were registered in girls between the ages of 14 and 17 in 35% of cases³.

In Switzerland, a national survey of girls and boys aged between 15 and 17 in 2009 found that 22% of girls and 8% of boys had experienced at least one incident of sexual violence involving physical contact³.

Regarding physical violence, as already discussed, it can be considered that a large number of children are subjected to situations of physical violence as discipline. On average, about six in 10 children worldwide, ages two and 14, are regularly subjected to physical (corporal) punishment by their caregivers. On average, about 17% of children in 58 countries are experiencing severe practices. In 23 countries, severe physical punishment is widespread, affecting more than one in five children. In Chad, Egypt, and Yemen, more than 40% of children between the ages of 2 and 14 suffer from rigid forms of physical punishment³.

UNICEF findings reinforce the idea that culturally accepted physical violence is present in all walks of life and is still perceived as an effective method of regulating children's behavior and their use as a benefit. However, the use of corporal aggression, whether light or heavy, deters the child and the adolescent because although its use can interrupt inappropriate behavior, instantaneously, in the medium and long-term, it can lead to a vicious cycle²⁵. Another point to be considered for a large number of cases of reported physical violence is possibly associated with the fact that physical aggression can produce injuries that are more easily observable, favoring denunciations.

Psychological violence, which has most recently attracted the attention of researchers, appears to be the third most reported, although it is considered more difficult to identify due to its high degree of tolerance by our society²⁶. Associated with physical violence, this modality contributes even more to the increase of statistics, corroborating with studies that show this reality^21),(26.

Psychological violence does not involve a bodily attack, as it is expressed by words, gestures, looks that humiliate, disrespect and promote low self-esteem in the victims. However, it can be confirmed through the findings that physical violence is always accompanied by psychological violence, since the act of physically or sexually assaulting a child causes fear and dread, hindering their reaction²⁷.

Although neglect was the least reported form of violence, unlike other studies²⁸, such as the one on violence against children in Canada that identified up to 78.3% when associated with other forms of violence, its frequency has increased, according to data from Table 3. This finding leads to the conclusion that psychological violence and negligence permeate practically all situations of violence against children and adolescents, but they are not often the main reason for notification, either because of its difficulty of detection or by the non-production of visible lesions or even by the difficult suspicion and confirmation.

CONCLUSION

The study enabled to highlight that intra-family violence is a complex problem, since the perpetrators are not unknown people, but adults, parents, mothers, members of families that have close relationships with children and adolescents. Also, deep-seated conceptions about child-rearing practices and the trivialization of violence treated as a private problem, corroborate both to hinder to confront and denounce and to understand its notification as a necessary exercise of power and resistance.

Although the study focused on the analysis of the notifications made to know the profile of victims, aggressors, and forms of violence, it is important to highlight the need to prevent violence, that is, to act as the child and/or become a justification for a police bulletin, a court case, or newspaper news.

The confrontation of the problem of violence is also complex, requiring immediate protective measures, actions of psychosocial care for children and adolescents in situations of violence, as well as those who are identified as aggressors and, mainly, preventive actions through groups of parents, educators, health professionals, allowing the exchange of experiences and reflections on family relationships.

Regarding the limitations of the study, the results were only about the records of cases denounced in the reference instances, possibly not portraying their real incidence in the municipality as a whole, considering the repertoire of known difficulties worldwide for the identification and notification of every case of rape perpetrated in children and adolescents. However, this limitation did not enable to carry out this study, whose characteristics make it contributive to the rethinking of professional practices, and to research in nursing/health, since the profile of children and adolescents identified in the 800 registers present similarities described in the Literature, corroborating the need for the creation of public policies directed to the researched profile.