Journal of Indian Association of Pediatric Surgeons Medknow Publications on behalf of the Indian Association of Pediatric Surgeons ISSN: 0971-9261 EISSN: 1998-3891 Vol. 12, Num. 2, 2007, pp. 76-79

Journal of Indian Association of Pediatric Surgeons, Vol. 12, No. 2, April-June, 2007, pp. 76-79

Original Article

Corporal punishment-related ocular injuries in Nigerian children

Oluwakemi AdegbehingbeBernice, Kayode Ajite

Ophthalmology Unit, Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife
Correspondence Address:Ophthalmology Unit, Department of Surgery, College of Health Sciences, Obafemi Awolowo University, Ile-Ife berniceola2003@yahoo.co.uk

Code Number: ip07027

Abstract

Keywords: Blindness, corporal punishment, ocular injuries

Introduction

Pediatric ocular injuries are frequent emergencies in an ophthalmologic clinic and these often require urgent attention. Corporal punishment has been documented as a major cause of injuries in children all over the world. ^[1],[2] Ocular injuries resulting from assaults inflicted during administration of corporal punishment in schools and at home have been reported in previous studies. ^[3],[4] It has been demonstrated that corporal punishment is being used extensively to discipline erring children both in schools and at home ^[2],[3],[5] and this has been responsible for severe forms of ocular injuries on several occasions. ^[3],[5]

The extent of these injuries varies depending on the mechanisms of the injury and involvement of ocular tissue. Understanding the fundamentals of eye trauma evaluation and management will help decrease associated ocular morbidity and visual loss. Many eye injuries are preventable and effort should be made to reduce ocular accidents in children. In some cases, a full visual rehabilitation may not be achievable, thus, resulting in blindness. A hospital-based study of domestic ocular and adnexae injuries in southeastern ^[3] Nigeria revealed that corporal punishment was responsible for a significant percentage of the recorded injuries. ^[3]

Also, in southwestern Nigeria, corporal punishment was responsible for about 10% of eye injury cases in children. ^[5] An epidemiological study of the outcome of ocular injuries during the administration of corporal punishment is important to reduce ocular morbidity and consequent visual impairment and blindness. The Obafemi Awolowo University Teaching Hospital complex (OAUTHC) is a tertiary healthcare institution which subserves most of Osun, Oyo, Ondo, Ekiti states and a part of Kwara state of Nigeria. Corporal punishment is commonly used to correct erring individuals all over Nigeria. There is no legislation against this form of punishment in Nigeria. This study is aimed at determining the pattern and visual outcome of corporal punishment in Nigerian children seen at the OAUTHC, Ile-Ife, Nigeria. We are not aware of any similar report of such a study in Nigeria.

Materials and Methods

All patients aged 15 years or younger seen at the eye clinic of Obafemi Awolowo University Teaching Hospital, Ile-Ife between January 2000 and December 2003 were fully assessed using a pro-forma that had been formulated to that effect. Patients who sustained ocular injuries from corporal punishment formed the subject of this study. The initial assessments were made in most of the cases by the corresponding author who would have been informed by the resident ophthalmologist on call. Where the author could not attend to the patients personally, the resident doctors who were already trained to complete the pro-forma assisted in doing so.

Information documented included patient demographics, types and sources of ocular injury sustained, visual acuity (VA) at presentation, two weeks and three months after presentation, type of treatment given and visual outcome after three months post-injury. Visual acuity was tested using Snellen's chart and Illiterate E-chart in children who could not read the alphabets. All patients were given appropriate treatment and the final visual outcome was documented after 3 months. A good visual outcome was taken as a VA of 6/18 or better. Visual impairment and blindness were defined according to WHO criteria for classification. Data was analyzed by simple descriptive statistics using SPSS statistical package, version 10 data analysis software. The level of statistical significance using chi-square test were all determined at P < 0.05.

Results

A total of 186 children were seen within the study period. Of these, 89 (47.8%) had ocular injuries and 27 (30.3%) had ocular injuries resulting from corporal punishment. The age and sex distribution of the patients are shown in [Table - 1]. Boys (66.7%) outnumbered girls (33.3%) with a male to female ratio of 2:1, but this ratio changed to 4:1 in the age range of 13-15 years. The ages of the 27 children with corporal punishment-related ocular injuries ranged from 3-15 years (mean = 8.5 ± 2.4.years). Corporal punishment-related Injuries (CPI) occurred with increasing frequency after the age of six years and most commonly between the ages of 7-9 years [10 (37.1%)], followed by seven (25.9%) in the age bracket of 10-12 years.

The agents causing ocular injuries are shown in [Table - 2]. The objects mostly implicated in causing ocular injuries were sticks (48.2%), belts (18.5%) followed by whips (14.8%) and missiles (14.8%). The injuries were most commonly sustained in schools: 13 (48.2%), homes: eight (29.6%), followed by the market place: three (11.1%), workshop: two (7.4%) and worship houses: one (3.7%) as shown in [Figure - 1]. Reasons why CPI occurred were mostly attributed to lack of "cooperation" in the case of 9 (33.33%) patients while anger in 9 cases (33%). Other reasons were poor judgment in five cases (18.5%) and wrong application of the agents by the person administering punishment in four (14.8%).

The types of injury sustained are depicted in [Table - 3]. Eight patients (29.6%) had contusion injuries, seven (25.9%) had hyphema, four (14.8%) had subconjunctival hemorrhage, iris damage and corneal ulcer were seen in three (11.1%) patients and two patients (7.4%) had globe rupture. As indicated in [Table - 4], based on WHO criteria; only seven (25.9%) of the patients had normal vision in the injured eye at presentation. Majority (48.2%) had moderate degree of visual impairment three (11.1%) had severe visual impairment and four (14.8%) had uniocular blindness at presentation. Two thirds (nine) of the patients had good visual outcome (VA ≥ 6/18) in the affected eye, six (22.2%) had visual impairment and three (11.1%) were found to be blind at the three month follow-up visit.

Discussion

Corporal punishment is a major cause of morbidity and mortality in the USA and other countries where the subject of child abuse has been studied. ^[1] The use of instruments on erring children is a common practice in Nigeria. During the application of corporal punishment, usually no part of the body is spared and as such it is very easy to inflict injury on the face, head and especially the eyes while the child is struggling to beg for pardon / mercy from his assaulter.

Corporal punishment-associated ocular injuries (CPI) occurred in 30.3% of all cases of ocular injuries studied over a four year period. This incidence rate is much higher than the 10.3% reported by Adeoye in a previous study of eye injuries in the young from the same centre. ^[5] This could be due to the difference in study design and selection of the study population. The children in this study were between the ages of 3 and 15 years as opposed to 0-17 years in Adeoye's study. In 2003, ocular injuries were reported as a result of trauma inflicted by a parent or caretaker during administration of corporal punishment in a group of children aged 4-14 years seen at a pediatrics referral centre in Memphis, Tennessee. ^[4] Injuries inflicted on children of this age could be a significant cause of childhood visual impairment and blindness in a community.

Our findings are consistent with the result of other studies. ^[2] A substantial proportion of patients (66.7%) were boys, this is in agreement with the report from a survey of the prevalence of corporal punishment among middle and high school students in Alexandria. ^[2] Also male preponderance ratio of at least 2:1 had been quoted in other studies. ^{[6],[8],[9],[10],[11]} Materials commonly used to inflict corporal punishment in children have been implicated as causes of ocular injuries leading to significant visual impairment and blindness. ^[5],[7] Teachers were found to use their hands, sticks, straps, shoes and kicks to inflict such punishment without sparing a part of their students'bodies. ^[2]

About half of the children studied sustained ocular injuries during the administration of corporal punishment in schools while another third sustained them at home. Other centres were the market, workshops and worship houses like churches, mosques and traditional worship centres. Corporal punishment in schools is extensively used to discipline students whose behaviour doesn't conform to the desired standard of educational institutions. However, in some workshops where children are often apprentices to mechanics, vulcanizers and carpenters; ocular injuries from severe form of physical assault in the form of corporal punishment are not uncommon in Nigeria as documented in other studies. ^[7],[8] A few of the cases of pediatric ocular injuries secondary to corporal punishment were also seen in the market places and worship houses. These practices could be a result of lack of adequate knowledge on the negative effects of child maltreatment by the assaulters.

Generally, most ocular traumas are contusion injuries although penetrating injuries predominate in children. ^[7],[8],[10] This is a significant factor in predicting final visual outcome. ^[11],[12] Predictors of final visual outcome included damage to multiple ocular structures, severity of initial injury, late presentation and treatment. ^{[9],[13],[14],[15]} Traumatic hyphemas in children secondary to corporal punishment have been reported in a number of children in the USA. ^[4] In this study, penetrating eye injuries were not as common as contusion injuries and hyphemas. Children with initial poor visual acuity were the ones who presented with penetrating eye injuries and damage to multiple ocular structures.

Two-thirds of the patients had moderate to severe (VA < 6/18-3/60) degree of visual impairment and about 15% were blind (VA < 3/60) in the injured eye at presentation (WHO definition). Poor final visual outcome VA < 6/18 was obtained in about one quarter (25.9%) of the eyes compared to vision in the better eye. However, only three (11.1%) were blind by the WHO criteria although higher values have been reported by other workers. ^[5],[7],[9] This difference could be due to differences in the study population and sampling method. Also, these other reports did not discuss ocular injuries secondary to corporal punishment in Nigerian children. However, since it is no longer perceived as a method of discipline in many western countries / communities, the effects of corporal punishment on child health, especially childhood blindness, may not be apparent worldwide.

In Nigeria, other alternatives can be used or parents and teachers should be equipped with necessary skills for the application of corporal punishment on children if we have to successfully wage war against childhood blindness and achieve the goal of sight for all by the year 2020 "Vision 2020." We concluded that ocular injuries to a child can result from trauma inflicted during corporal punishment and may result in permanent loss of vision. A change in method of corporal punishment in schools and homes is advisable. Other forms of punishment for children whereby physical injuries are not likely to be inflicted, are recommended to all those involved in dealing with children. It is strongly recommended that the use of corporal punishment be eradicated in Nigeria and it should be made an offence under the law.

References

Copyright 2007 - Journal of Indian Association of Pediatric Surgeons

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