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INTRODUCTION
Mental health of children is a major issue worldwide. Worsening socioeconomic conditions associated with urbanization and migration have resulted in the need for societies to develop institutions that advocate for the protection of children. The Caribbean nations have attempted to highlight the issues of child abuse in the region through conferences and training seminars.

Child abuse is described as deliberate violence to a child and/or the intentional withholding of care by parents or adults responsible for the child (Kempe and Hefler, 1972). There has been a significant increase in reported cases of various types of child abuse including physical, sexual and the newer categories of mental injuries (emotional abuse/neglect) in most parts of the world. More than 3.1 million reports of child abuse were recorded in the USA in 1994, an increase of more than 50 percent over the 1985 figure (Alexander, 1995).

In the Caribbean island of Dominica, the incidence of reported cases doubled between the years 1990 and 1993 from 127 to 252 (Taylor, 1997). This figure reached a high of 416 in 1994 and dropped to 260 in 1995. The reported incidence continued to rise in subsequent years reaching 267 in 1997 and 303 in 1998, a trend that is probably due to issues of sensitization and service access.

Sexual abuse was the most prevalent form of child abuse in Dominica in 1998, comprising 41.6% of cases registered in the Child Abuse Register (1999). It is defined as "sexual exploitation of a child through violent and nonviolent molestation. This includes a spectrum of behaviors from violent rape to inappropriate touching or seduction" (Eldemire, 1992).

Neglect represents the second highest number of cases reported in Dominica for the periods 1995 to 1998. It is defined as gross or repeated failure to provide for child’s physical or emotional needs such that there is harm or threatened harm to the child’s health or welfare (Sharpe, 1992). Physical abuse is the next most common form of child abuse. It is defined as any act by "parent" which results in non-accidental physical injury to the child. The word "parent" in the broad sense means both parent and caretaker or guardian (Eldemire, 1992).

In all cases of abuse, the psychological scars last a lifetime. This dictates that the event must not be allowed to occur. The significant predictors of child sexual abuse perpetrated by a family member were physical abuse, having no one to confide in, having no caring female adult, and having an alcoholic father (Fleming, 1997).

In order to manage the problem of child abuse in Dominica more effectively, a comprehensive health plan must be established which would attempt to identify the children at risk. It is believed that biological, psychological and social indicators of child welfare are strongly associated with the occurrence of childhood abuse. The loss of significant relations early in childhood, their living arrangements coupled with the use and/or abuse of alcohol and other drugs by parents predisposes children to abuse.

The aim therefore was to determine whether living arrangements and personal experiences of childhood influence the occurrence of abuse of children in Dominica.

The objectives of the study were to:

1) determine the living arrangements of the abused children;

2) determine the psycho-social status of abused children;

3) compare abused children, with their age-specific population.

The use of substances of abuse by parents represented a significant problem. Alcohol use among the parents of abused children was significantly higher than their non-abused partners . These children also identified alcohol use at a significantly higher proportion among their mothers

The OR is 8.68 and the AR is 88.5%.

The fathers were more likely to be alcohol users than mothers in both groups, but the prevalence was higher in the abused children . In addition, there were significant differences between the two groups as more abused children remembered seeing their parents in a state of drunkenness. The AR is 82.5%. Furthermore a significant number of abused children acknowledged that their parents used illicit drugs. The OR is 6.39 and the AR is 84.3%.

A much higher number of abused children remembered seeing their parents involved in family violence. The attributable risk is 64.6%.

DISCUSSIONS
This study has demonstrated that the living arrangements of children, the absence of one or both parents, the shared activities between parents and children and the use of drugs by parents are predictive of childhood abuse in Dominica.

Living arrangements of children
Only one-quarter of abused children lived with both parents when compared with more than one-half of the control group. This finding was significant and illustrates the importance of family setting as a protective factor in the wholesome development of children. The nuclear family type is probably not the most common form of family organization in the Caribbean (McKenzie,1990) and social problems such as economic deprivation, child abuse among others can probably be traced to the other forms of relationships that prevail in the society.

As expected the children from the control group expressed greater interest in their family relationship. Those who lived in other homes apart from parents’ actually lived for longer period in those homes than their abused counterpart who themselves were more likely to live in other homes. This symbolized the significance of stability to these children and its' protective impact on their lives.

Loss of parents
The majority of the children interviewed lost one or both parents (67.1%). This experience had a significantly worst outcome for the abused children (81.3%). Although family separation was the most frequent form of loss reported, migration was a major factor contributing to the lost of one or both parent.

This finding substantiated an earlier report on the Situation Analysis of Children and their Families in Dominica (UNICEF, 1996). It reported that out-migration impacted significantly on family life in Dominica as women were more likely to migrate than males. Dominica's children therefore are likely to lose their main caregivers at crucial stages in their development exposing them to all kinds of social and economic risk.

In this study the majority of abused children lost their mothers and even more lost their fathers (72%). Almost forty percent of the abused children were growing up with neither their biological mother nor father. It is interesting to note that more than one fifth of the reports of abuse occurred around the time of parental loss. In an Argentine study (Morales et al, 1997) social support was noted as a crucial protective factor against child abuse.

Sharing activities with parents
It is quite normal for children to share activities with their parents and in this study the majority of the children interviewed were actively involved with their parents. However the control group of children reported deeper relationship with their parents. This difference was most significant in terms of social activities shared such as playing games and having fun-time.

The activities assessed in this study are all parameters to measuring the functional state of the family. The noted trend of parents assisting their children with schoolwork at home or sharing conversations and social activities favored the non-abused children. This is similar to findings by Paradise et al. (1994) where he illustrated those preexisting poor family interactions may contribute importantly to persistent problematic behavior among abused children.

The abused children were more likely to be involved in extracurricular activities on schooldays rather than go straight home. On the other hand the control group attended church more frequently and this may have served as a protective factor to child abuse. It is clear therefore that social activities by the children can impact positively or negatively on their personality shaping. The church can be seen as a medium of controlled interaction while the extra-curricular activities after school may not be so well supervised and posed more risk for unpleasant experiences.

Alcohol and other drug use
The findings of this study supports previous work done on the predictive value of substances of abuse on the occurrence of child abuse (Chaffin, 1996; Fleming, 1997; Miller, 1999; Kotch, 1999; Ammerman, 1999). The abused children were more likely to report alcohol use in their parents. It is interesting to note however that the mothers of the abused children were consumers of alcohol at a significantly higher proportion than their female counterparts of the control group. Miller et al (1999) reported that mothers with that problem were more punitive towards their children.

Furthermore, the abused children reported that a significantly higher proportion of their parents were seen in a drunken state (p= 0.001) and that they used illicit drugs (p= 0.004). Ammerman et al (1999) confirmed that emotional dysregulation resulting from substance use disorders predicted the occurrence of child abuse. In another study done in the United State of America (Chaffin et al, 1996) substance abuse disorders were strongly associated with the onset of both abuse and neglect. Sexual abuse was the most common form of abuse suffered by the children in this study and Fleming et al (1997) reported in an Australian study that having an alcoholic father and/or alcoholic mother were significant predictors of childhood sexual abuse.

Physical aggression
The exposure of children to physical confrontation between their parents appears to be associated with child abuse. There was a tendency, in this study, for abused children to report that form of family violence. In a New Zealand study, Rodriguez and Green (1997) reported that anger expression was positively correlated with child abuse potential. Miller et al (1999) also supported this finding when he reported that history of partners' violence and parental violence among mothers predicted a higher level of mother-child punitiveness.

Conclusions
In this study, the psycho-social factors that predisposed children to abuse were loss of one or both parents, not living with both parents, not sharing social activities with their parents or irregular attendance at church services. Also children who identified their parents as users of alcohol, who saw their parents in a drunken state or reported their parents as illicit drug users were at an increase risk of abuse. Children who were not interesting in living with their parents trended towards having an abusive experience.

Recommendations
Health and social workers should be sensitized to the heterogeneous risk factors associated with child abuse in Dominica. The bio-psychosocial model must be used to promote awareness and a holistic management plan.
Intervention strategies aimed at decreasing the risk of childhood abuse must focus on the social integration of the families at risk. Families where children are socially isolated must be targeted.
There is need to develop treatment and preventive interventions for parents who use alcohol and other drug. Self-help groups must be available and accessible for the affected persons; both parents and children.
There is need for cohort studies to be done that would seek to verify the strength of association between the risk factors for child abuse identified.

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Dr Griffin Benjamin

Dr George Mahy

Dr Sharon Harvey

Dr Liris Benjamin

Increased Risks
Research has shown that families with an alcoholic member live in environments that are disorganized and unstable, said Dr. Grant. "Children of alcoholics may be neglected or abused and frequently face economic hardship and social isolation.
They also are vulnerable to psychopathology and medical problems, including an increased risk for themselves developing alcohol abuse or alcohol alcoholism."

According to Dr. Gordis, "These findings once again call attention to the enormous impact of alcohol in our country and the need to confront its social, health, and economic consequences head on."

http://alcoholism.about.com