CHILD ABUSE

Definitions of Child Maltreatment

The phrase "child abuse" often immediately brings to mind the image of a child beaten black and blue by an angry parent or caregiver. This is merely one scenario and perhaps the easiest to contrive because one can see what has been done to the child. It sparks people's emotions and a desire to take action against the offending adult. In reality there are many faces of child abuse and many more acts that leave scars "invisible" to the naked eye. There is a tendency to ignore children who display no physical or outward signs of abuse. A large number of these children go unrecognized, living in environments that hinder their potential and their development as secure, healthy individuals.

"Child maltreatment" is a term designed to draw attention away from the purely abuse-related acts or injuries that children suffer. It is an all-inclusive term to describe, in essence, when a caregiver does something or fails to do something that has harmed or threatens to harm a child in his or her care. Child abuse refers to acts of commission, which are done to a child and cause harm (or the threat of harm), whereas child neglect refers to acts of omission, acts that are not done to or for a child, which result in harm (or the threat of harm). In using the separate categories of child abuse and child neglect there are further distinctions that can be made. Abuse is often categorized into physical, sexual, psychological, and emotional abuse. Neglect is often categorized into physical, emotional, medical, and educational neglect. The most commonly reported statistics are those for physical abuse, sexual abuse, and overall child neglect.

How are child abuse and neglect manifested? Physical abuse involves harming the physical body with such acts as kicking, punching, stabbing, or beating a child with an object; whereas physical neglect involves not taking care of the needs of the physical body with food or shelter. A child's exposure to a harmful environment (such as one in which drug use is occurring) could also be construed as physical neglect because of the threat of harm to the child (i.e., if the child were capable of getting to the drugs himself, or if the drugs impaired the ability of the caretaker to adequately supervise the child). Similarly, emotional abuse might involve harming a child emotionally by yelling, threatening the child, or calling the child demeaning names, such as "stupid." Emotional neglect would be failing to provide emotional support for a child such as happens when a caretaker abandons a child or lacks any affection for a child. For many children, different forms of maltreatment occur at the same time.

While these definitions seem self-explanatory, there is much debate about what constitutes abuse and neglect in the United States. In other words, the practical application of these terms is not always easy. At the broad ends of the spectrum, there is usually little argument about whether abuse or neglect has occurred. If a parent takes an iron and intentionally burns his two-year-old child just because the child wet the bed at night, few would argue that this was child abuse. Yet, if a single parent working two jobs to support the family has no time at the end of the day to interact with his children, is this neglect? The larger issue is that having such definitions implies that there are certain standards for parenting or caring for children. With such a diverse and multicultural population, clear differences in parenting styles and standards exist. The task of deciding where abuse and neglect fall in that spectrum is challenging.

Another issue of debate in defining child maltreatment involves the societal response to child maltreatment. Social workers, medical professionals, and law enforcement personnel are most often involved in cases of child maltreatment. Each profession has its own criteria for identifying abuse and neglect. Law enforcement, for example, is concerned with proof of abuse or neglect and assigning culpability; in other words, who is to blame? The law requires respondents to look for and present "evidence" of maltreatment, when evidence may not be readily apparent. In many sexual abuse cases, for example, a child has made statements that indicate abuse, but the physical exam of the child is normal. Despite what the child has disclosed, it is rare for these cases to be brought to trial without physical evidence of abuse being present.

Incidence of Child Maltreatment

Annual data on the occurrence of child maltreatment in the United States are collected and analyzed by the National Child Abuse and Neglect Data System (NCANDS). This is a systematic, nationwide effort that was launched to collect data from state child protective service agencies, the primary state agency responsible for responding to child maltreatment. Each state reports the numbers of children reported for suspected maltreatment, investigated, and subsequently determined to be abused or neglected.

The NCANDS report for 1998 states that the estimated number of children reported for suspected maltreatment was more than 2.8 million. The estimated number of children abused or neglected in the United States during that year was 903,000. Of this number, more than half were victims of neglect, nearly one-quarter were physically abused, and approximately 12 percent were sexually abused. Approximately 25 percent of the children experienced multiple forms of abuse. These percentages are typical of the breakdown from year to year.

The rate of abuse and neglect for 1998 was 12.9 per 1,000 children less than eighteen years of age. This is actually a slight decrease from the previous year. Since records have been maintained by NCANDS, however, there has been an upward trend in the number of maltreated children. In 1974 the number of reports for suspected maltreatment was merely 60,000; in 1980, the number increased to greater than one million. Several factors contribute to this dramatic increase, including changes in child abuse reporting laws and an increased recognition of abuse and neglect as real societal problems. Early laws governing reporting of suspected child maltreatment required only professionals to report to the state child protective service agencies. By the late twentieth century, most states required anyone with a suspicion of maltreatment to make a report. There is also evidence that the level of violence in society has increased such that it has been declared a public health epidemic. Violence toward children and violence involving children (as witnesses) are both on the rise.

The numbers of maltreated children are impressive, but it is commonly accepted that these numbers are inaccurate. The cases reported to social services represent only the "tip of the iceberg" of all maltreated children. There are several ways researchers know this to be true. One indication that some children are missed comes from studies of child fatalities. Many children are killed as a result of abuse or neglect, but not all are identified as victims of abuse or neglect at the time of their death. Second, parent surveys and other periodic national surveys obtain higher rates of abuse and neglect than that counted by social services. In some cases the difference in rates is not trivial. For example, a nationwide telephone survey of parents found a nearly tenfold increase in rates of physical maltreatment compared to rates reported by social services.

Obtaining accurate numbers of maltreated children is difficult for other reasons. A fundamental reason is that simply defining what constitutes child maltreatment, as previously mentioned, is problematic. Maltreatment definitions also vary from state to state. The potential for missing abuse clearly exists when only two-thirds of reported cases are investigated, in part because of an overburdened social services system.

Consider also the process by which children are identified as being maltreated—someone has to make a report. This process relies on individuals recognizing abuse and taking action. Several studies have identified resilient kids—where abuse or neglect is occurring at home but the children find ways to cope. These children are less likely to be identified, as are very young children who cannot relate what has happened to them. Then there are biases (based on race, gender, and socioeconomic status) that make individuals more likely to suspect and report maltreatment. Poor families are notoriously suspect because of presumably higher financial stress and the frequently associated lack of education and resources. The opposite also happens: there are biases that prevent suspicion of abuse, leading to many maltreated children being missed. Girls are traditionally viewed as the only victims of sexual abuse, and young boys who act out are labeled as hyperactive but the question of sexual abuse is never entertained. Even if abuse is recognized and suspected, someone must take action, which is a well-known barrier to intervention. People are reluctant to become involved in family matters even if it means helping a child.

Developmental Perspectives of Child Maltreatment

It is very important to have an understanding of the relationship between child development and child maltreatment. Childhood is typically a time of rapid change and growth. Each stage of development brings new challenges and changes in the physical, cognitive, and behavioral makeup of a child. These changes are reflected in the epidemiology of maltreatment, which is the pattern of abuse and neglect that is commonly seen. Child development affects all of the following: the precipitating factors that lead to maltreatment; the susceptibility of a child to different types of maltreatment at different ages; the physical findings of abuse or neglect; the treatment options following maltreatment; and the likelihood of long-term sequelae (secondary effects) from abuse or neglect.

Infants are at the greatest risk for all types of maltreatment, including fatal maltreatment. This is relatively easy to understand from a developmental standpoint. Child neglect occurs commonly as infants are the most dependent on their caregivers to provide the basic necessities of life in a stable, secure environment. Parents who are overwhelmed by life stressors and have personal limitations, or have certain cognitive or medical conditions (such as mental retardation or depression) may become caregivers who cannot pick up on infant cues. In these situations there is a risk of poor attachment and emotional neglect. Parents can also be easily frustrated by an infant whose crying or temperament makes them difficult to handle, leading to the potential for physical abuse. This risk is dangerously high given that infants are already at higher risk for physical abuse because of their physical attributes, such as softer bones, small size, and the inability to resist physical harm or verbalize what happens to them. The "shaken baby syndrome" illustrates this principle. An infant has limited muscle tone, particularly in the neck, and an infant's head size is proportionately larger than other parts of its body. An infant that is forcibly shaken can get a form of whiplash, which creates forces that shear the delicate and developing brain. These infants suffer significant neurological damage and often die as a result of the brain injury and swelling.

The toddler and preschool years provide new challenges as children are growing and developing new physical skills. These physical skills enable children to run, climb, and openly explore in areas they previously could not, so caregiver supervision becomes increasingly important. A neglectful caregiver will not make the environment safe or provide appropriate boundaries. Verbal skills increase and children vocalize their emerging independence. A parent unprepared for the typical use of the word "no" may interpret this as defiant behavior and resort to harsh physical punishment that becomes abusive, not recognizing the appropriateness of the child's behavior for this developmental stage. Toilet training during these years is one of the more common parental stressors and precipitant of abuse.

School-age children and adolescents have a lower overall risk of maltreatment. They spend less time in the presence of caregivers because of school, after-school activities, and peer interactions. They are also less dependent as their physical and cognitive development allows them to do many things for themselves. Physically they are larger in size, stature, and strength, and it takes more force to cause injury. Sexual abuse, however, is more prevalent among school-age children and teens, particularly girls. The reason for this increase is related in part to the physical developmental changes that occur in both boys and girls as they enter puberty.

Treatment and System Responses

When it is determined that a child has been abused or neglected, the system will intervene. The primary state agency responsible for children is social services, but children are first identified in any number of ways: by neighbors, relatives, day-care staff, teachers, or medical professionals. Medical professionals and day-care staff often identify young children, because the doctor's office and the day-care center are common places for children to be seen on a regular basis. School personnel frequently identify older children when changes in behavior, attendance, or school performance are noticed. Suspicions of abuse or neglect are then referred to the appropriate social services agency for a more thorough investigation.

One of the first concerns for social services is the safety of the child. The agency's primary purpose is to ensure that no further harm comes to the child. If the perpetrator of maltreatment (the person suspected of abusing or neglecting the child) is to continue to have access to the child, this can be handled in several ways. What happens next will depend on the type and severity of abuse or neglect and the mandates of the state. The perpetrator will often contract with social services and agree not to maltreat the child. The person can agree to leave the home temporarily. The child can also be removed from the unsafe environment and placed in the care of a relative or foster family.

Many times children will require a medical evaluation to determine what harm has been done, document the extent of harm, and treat any new or existing medical conditions. The needs of the whole child should be addressed during a medical evaluation, although emergent needs are prioritized. In the case of shaken baby syndrome, for example, the majority of these children are brought in on an emergency basis when they stop breathing at home. Obviously these children require intensive care even before the determination of abuse is made. For other children, the medical evaluation may entail treating a broken bone, tending to lacerations, evaluating bruises, or examining for sexually transmitted diseases. It can also involve recommending a developmental evaluation for a child who is developmentally delayed or recommending medical and behavioral treatment for depression.

Further treatment usually involves obtaining mental health services or additional services for the family. The goals of these services are to assist the child and family in coping with the maltreatment and to restore family functioning. Mental health services can be directed to the child or to the child's caretakers, if the child is too young or unable to participate actively in treatment sessions on her own. Play therapy is very commonly employed in this setting. For the family, evaluating the home environment and the circumstances surrounding the abuse or neglect is critical to assisting the family and preventing maltreatment from reoccurring. There may be social services such as food stamps or parenting education that can assist the family and reduce family stressors. Parents and caregivers may also be prior victims of child maltreatment and/or violence in other forms and benefit from mental health, substance abuse, or domestic violence resources themselves.

Consequences of Maltreatment

The consequences of maltreatment for children who are abused or neglected vary a great deal. There are many factors that affect what happens after maltreatment, including: the developmental stage of the child at the time of the abuse or neglect, the type and chronicity of abuse or neglect, the relationship of the perpetrator to the child, and the child's temperament and natural ability (intelligence). There are also several different categories of consequences, including: medical or physical consequences; emotional, behavioral, or cognitive consequences; short-term versus long-term consequences; and consequences with or without intervention by social services or others.

One significant principle that appears in the child maltreatment literature repeatedly is that children suffering multiple types of abuse or neglect tend to have a poorer outcome than children who suffer only one type or incident of abuse or neglect. Studies that document the long-term effects of child abuse and neglect mirror these findings. These studies show that lifestyle choices and responses to stress may be altered, leading to greater risk for adult criminal behavior and significant health problems (such as heart disease) in adulthood.

Prevention of Maltreatment

Unfortunately, there is little data on how to prevent child maltreatment. Home visiting programs have shown the most promise in the primary prevention of maltreatment, which is preventing abuse or neglect before it occurs. Home visiting programs involve pairing new parents with someone trained or experienced in child development so that the new parents can learn how to care for and respond to the needs of their infants. The most widely modeled programs, when studied, have been successful in reducing the incidence of but have not entirely eliminated child maltreatment in the study populations. Issues of funding in many geographic regions have limited the availability of such services to those families considered at higher risk for maltreatment.

Efforts in the prevention of maltreatment primarily function on the level of secondary prevention. Intervention by social services or other professionals occurs when maltreatment has already taken place or when children are considered already at risk for abuse or neglect. In these situations the focus is on preventing further abuse or neglect, as well as treating and minimizing complications of the maltreatment that has occurred.

There is no doubt that prevention of child maltreatment is a complex issue. There are multiple factors involved when a child is abused or neglected, factors related to the individual child, the family structure, and other environmental stressors (such as poverty). The cycle of violence is a well-known phenomenon, where today's victims become tomorrow's perpetrators. In order to prevent child maltreatment, prevention itself must become a priority. This will require commitment and collaboration from many sources, including individuals, professionals, community groups, and government agencies. All of these sources must be willing to work together to make a difference for children.

See also: DOMESTIC VIOLENCE

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Adrea D. Theodore