Child abuse and neglect is an important phenomenon with a long and complex history. The Bible refers to the near sacrifice of Jacob by Abraham. Throughout much of history, children were treated as chattels (movable property), with them being bought and sold. Given the lack of birth control, infanticide and child abandonment were common (see Chapter 1
). Foundling hospitals were equipped to accept infants or children who otherwise would have been abandoned. In the Middle Ages, attempts were made by the Church to provide alternatives to abandonment, for example, the anonymous Rota (see Figure 24.1
), where a child could be placed in a rotating device in a monastery or convent—the parents would ring a bell and the child would be moved around to the care of the brothers or sisters in that community (see Boswell, 1989
, for a discussion of this whole phenomenon). Children on the streets of New York were swept into “orphan trains” (Holt, 1994
) and taken out to what presumably were healthier environments as farmers or others selected them.
Probably the first well-documented case of child abuse was that of Mary Ellen Wilson in 1874, whose foster parents severely abused her (Figure 24.2
). She was removed from her home and her story led to the formation of the New York Society for the Prevention of Cruelty to Children.
Beginning in the early 1900s, increasing attention was drawn to the plight of children who were abused or neglected with a White House conference recommending local foster placement rather than institutional care. By the 1920s states began to regulate this process, and the foster care system, as we know it today, began to emerge.
Only in relatively recent times has child abuse come to be regarded as a medical condition—terms like the battered child syndrome
and shaken baby syndrome
came to be used as physicians appreciated the physical findings associated with abuse. Similarly, interest in the response to trauma is also relatively recent (see Chapter 23
Child abuse and neglect are frequently intertwined. Abuse can be physical, psychological, or sexual in nature. Neglect can also take various forms, ranging from physical or psychological to educational. It is important to note that other problems, like child trafficking or sexual exploitation, are also sometimes included in the broader view of child abuse. Abuse and neglect often co-occur to varying degrees. The term maltreatment
is used to cover a broader range of problems, including sexual exploitation and trafficking (Kaufman & Hoover, 2018
It is interesting to note that awareness of physical abuse and its sequelae is a much more recent historical phenomenon. In the 1940s, there was awareness of the unusual presentation of children with subdural hematomas and multiple fractures of unknown etiology. It was only in 1962, with the publication of “The Battered Child Syndrome” by Kempe and colleagues, that there was
recognition that these injuries were inflicted by parents. Before this, accounts by parents to (often poorly) explain injuries were simply accepted. After Kempe’s paper, pediatricians, radiologists, and others began to pay much more attention to unusual injuries and trauma.
FIGURE 24.1. The Rota or foundling wheel from the Ospedale degli Innocenti, Florence, Italy. (Photo by F. R. Volkmar.)
FIGURE 24.2. Mary Ellen Wilson. (Photo courtesy of New York Society for Prevention of Cruelty to Children.)
Children and adolescents who are neglected or abused are at increased risk for a range of mental health problems. They may exhibit posttraumatic stress disorder (PTSD), anxiety disorders, mood problems, and aggressive behavior. Severely neglected children may exhibit reactive attachment disorders (RADs). Sexual abuse may have special sequelae in terms of depression, substance abuse, low self-esteem, and dissociative states. Although poverty and low parental education are risk factors, abuse and neglect are observed in families from all social situations and the clinician should be constantly alert to the possibility of abuse or neglect. In some instances, the medical system itself becomes involved in the cycle of abuse—as in the case of the so-called Munchausen by proxy syndrome. Children exposed to trauma within or outside the family are prone to exhibit a range of difficulties, including PTSD (see Chapter 23
and Kaufman & Hoover, 2018
DEFINITIONS AND CLINICAL FEATURES
Physical abuse entails the intended injury of a child by the caretaker (McCoy & Keene, 2014
). For infants, this may take the form of shaking or beating, resulting in the shaken baby syndrome
(see Box 24.1
). Injury may come from inappropriate or excessive punishment. The term battered child
is often used to refer to victims of physical abuse. In sexual abuse, an adult or older child engages in inappropriate sexual behavior with a child. Psychological abuse takes the form of repeated threats of abandonment or repeated statements to children that they are unwanted, unloved, or damaged. The term neglect
is generally used to refer to situations where the parent or caretaker does not provide appropriate care (see Kaufman & Hoover, 2018
). This can take the form of failure to provide sufficient food, adequate supervision, adequate medical care, or education. Physicians, other health and mental health care providers, teachers, and others are mandated reporters of suspected abuse or neglect. Legal definitions of abuse and neglect vary from state to state; therefore, it is important for health care providers to be
aware of the mandates for reporting in their own locations. Unfortunately, the various forms of abuse or neglect frequently co-occur.
Physical abuse should be suspected if a child has injuries that appear to be unexplained or when the history provided does not correspond to the findings. The child who has been abused may look anxious, fearful, depressed, or agitated; older children may be very reticent to reveal the abuse. Marks or bruises, for example, to the face or head, back or buttocks may suggest inappropriate punishment; these are often symmetric (unlike most accidental injuries). Similarly, a belt or rope may leave a characteristic pattern. Burns, for example, from cigarettes, may be noted. The infant or young child may exhibit multiple and spiral fractures. Severe shaking of an infant can lead to the shaken baby syndrome, with characteristic retinal hemorrhages. In Munchausen by proxy syndrome (discussed subsequently), there may be a history of repeated emergency department or hospital visits for treatment of unusual problems.
Child neglect may present to the physician with signs of malnutrition and/or with signs of lack of care of the child. Such children may be withdrawn and may be indiscriminate in their affection. These children may exhibit poor hygiene or failure to thrive.
Sexual abuse is often never revealed or comes to light only after a long pattern of abuse (Kaufman & Hoover, 2018
). Uncovering the abuse may be difficult. Obvious indicators are unexpected trauma or sexually transmitted diseases. The young child who is sexually abused may display inappropriate sexual knowledge or preoccupation; behavioral manifestations can include mood problems or aggression. The child may be fearful, for example, of men if the perpetrator is himself a male. In interviewing the child with suspected child abuse, the examiner should understand that the child may not always be consistent given understandable anxiety. False allegations of sexual abuse do occur, and in many cases, there is not sufficient evidence to substantiate the claim of sexual abuse. Very young children may have great difficulty providing a coherent verbal account of the abuse. The use of play materials can be helpful, but it is important that the interviewer not inappropriately lead
the child. Incestuous behavior is most common between older male relatives (fathers, brothers, uncles, stepfathers) and girls. Risk factors include poverty, absent or impaired maternal presence, and substance abuse. Acting out and self-destructive behavior may be a sign of sexual abuse (Wright et al., 2004
EPIDEMIOLOGY AND RISK FACTORS
During fiscal year 2018, the U.S. Department of Health and Human Services reported that over 4 million who work with children had been referred for investigation of possible abuse/neglect. Professionals of all types (teachers, medical personnel, and others) reported about 70% of the abuse, whereas the remaining cases were reported by friends, neighbors, relatives, and other nonprofessionals. There were approximately 678,000 documented cases for a rate of about 9.2 per 1000 children. The youngest children had the highest rates of
abuse (see Figure 24.3
). Girls were more likely (9.6/1000) to face abuse compared with boys (8.57/1000). In terms of ethnicity, Native American families have the highest victimization rates (15.2/1000) followed by African American families (14.0/1000). Whereas most victims suffered from one type of maltreatment, about 15% have faced more than one. Neglect was observed in about three fifths of the cases. It was estimated that 1770 children died because of abuse or neglect. Parents were the perpetrators in most cases (77%). Prenatal substance abuse (drugs or alcohol) results in a substantial number of referrals (McLaughlin et al., 2010
; Vanderminden et al., 2019
). Risk factors for parents and families include poverty, single-parent household, and parental impairment due to substance abuse (Ben-Arieh, 2010
FIGURE 24.3. Rates of child abuse by age (per 1000 children). Data adapted from U.S. Department of Health and Human Services. (2018). Child maltreatment 2018. https://www.acf.hhs.gov/cb/report/child-maltreatment-2018
Those most likely to die as a result of abuse and neglect are infants and toddlers. These data must be interpreted with some caution, however, because many child fatalities are not correctly reported as abuse (Kaufman & Hoover, 2018
). Once a case has been reported, there is increased risk for subsequent referrals. It is typical for the child in protective care to have experienced at least two forms of abuse. Children who suffer from abuse/neglect may exhibit any of several potential risk factors. These include a history of prematurity, physical or cognitive disability, or children who are viewed (rightly or wrongly) as demanding, difficult, or overly active. Girls are at a slightly higher risk than boys.
Although rates remain concerning, it is the efforts at prevention and education, as well as prosecution of offenders, that have had a major effect. Following a peak in 1993, there has been a decline of more than 20%, particularly in the areas of sexual and physical abuse. Sexual abuse in the form of attacks by other children appears, unfortunately, to have increased. Perpetrators often have been abused themselves. Unfortunately, child abuse, spousal abuse, and substance abuse problems tend to co-occur. About 80% of parents who lose their child following investigations for abuse and neglect have histories of substance abuse, and domestic violence is reported in over half of cases involved with child protection services.
COURSE AND PROGNOSIS
Neglect and abuse have varied long-term implications for the mental health and life course of victims, as well as on the developing brain (Bick & Nelson, 2016
). Psychiatric problems of children who have experienced abuse/neglect include higher rates of PTSD, depression, attachment problems, dissociative symptoms, substance abuse problems, eating disorders, conduct or oppositional disorder, and borderline personality traits. Other issues may also be present, including problems with peers, low self-esteem, and poor academic performance. In one study, about half of the maltreated children had significant problems in academics, behavior, and social relationships; <5% functioned well in all these domains. In adulthood, these individuals are more likely to be involved in violence with partners and to have problems being parents. Although most parents who are abusive have experienced maltreatment themselves, fortunately overall only about one in three children who are abused go on to become abusing parents. Inappropriate sexual behaviors are possible indicators of sexual abuse but can also be associated with physical abuse, exposure to domestic violence or sexuality, and mental illness (Table 24.1
). In the past, it was believed that fecal soiling was an indicator of sexual abuse, but this has not been shown in recent work.
Most children who are sexually abused do not go on to become abusers, but most sexual offenders have experienced maltreatment in some form. Youth who are sexual abusers often have a history of abuse or maltreatment, and most engage in other antisocial activities as well. Fortunately, it appears that many youths who engage in sexual offenses do not do so as adults.
Children removed from parents often enter foster care. The number of children in foster care has increased dramatically over the last several decades. Although many of the over 500,000 children can return home, many of these, between 20% and 40%, will reenter the foster care system. Multiple placements are not at all uncommon, and about 5% of children in care have experienced 10 or more placements. Around 100,000 children live in group homes or institutional settings. Multiple foster placements significantly increase the risk for subsequent antisocial and violent behavior.
TABLE 24.1 Distinctiveness of Sexualized Behaviors in Indicating Abuse History
Moderately Prevalent in Sexually Abused Children, Exceedingly Rare in Psychiatric and Normal Controls
Moderately Prevalent in Sexually Abused Children and Psychiatric Controls, Uncommon in Normal Controls
Moderately Prevalent in Sexually Abused Children, Psychiatric Controls, and Normal Controls
Puts mouth on sex parts
Asks to engage in sexual acts
Masturbates with an object
Inserts objects in vagina or anus
Stands too close to others
Hugs adults they do not know well
Talks about sexual acts
Wants to watch movies that show nudity
Knows more about sex than other children their age
Masturbates with hand
Touches sex parts at home
Tries to look at nude pictures/undressing people
Reprinted with permission from Martin, A., Bloch, M. H., & Volkmar, F. R., (Eds.). (2018). Lewis’s child and adolescent psychiatry (5th ed.). Wolters Kluwer.
Important moderating variables in mediating the impact of maltreatment and subsequent difficulties have been identified. Caspi and colleagues identified a genetic risk between child maltreatment and later antisocial behavior—a functional polymorphism of the gene A (monoamine oxidase A, MAOA) involved in neurotransmitter metabolism (Caspi et al., 2002
). Children who had been maltreated and who had high levels of MAOA were less likely to develop antisocial problems. This finding has been replicated in other studies. In subsequent work, the same group found that a functional polymorphism in the promoter region of the serotonin transporter (5-HTTLPR) gene was similarly involved in the moderation of maltreatment and life stress or depression.
Other lines of research suggest that support and subsequent positive parenting can modify the effects of child maltreatment. Studies using animal models have shown the potential mitigating effects of support during separation of the young animal from its mother. Similarly, the presence/availability of a supportive caregiver is associated with better outcomes.