Child Abuse and Neglect

Joan Kaufman

Introduction

By all standards of measurement, the problem of child maltreatment is enormous in terms of both its cost to the individual, and its cost to society (1). Child abuse occurs at epidemic rates, with nearly 1,000,000 substantiated reports of child maltreatment each year (2), many reported cases of actual abuse that are not verified (3), and countless other cases which never come to the attention of authorities (4). Victims of abuse comprise a significant proportion of all child psychiatric admissions, with lifetime incidence of physical and sexual abuse estimated at 30% among child and adolescent outpatients (5), and as high as 55% among psychiatric inpatients (6). While not all abused children develop difficulties, many experience a chronic course of psychopathology (7).

This chapter reviews definitions, prevalence, and sequelae of abuse. It then discusses genetic and environmental modifiers of child outcomes, and briefly describes treatment strategies. Problems within the child welfare system are delineated, and the value of utilizing translational approaches in the area of child maltreatment research highlighted. A central tenet of translational research is that preclinical studies— especially animal studies on the effects of early stress— can help to guide hypotheses regarding the etiology, pathophysiology, prevention, and treatment of stress-related disorders. The topics surveyed in this chapter are broad, but together support the following conclusions: 1) Maltreated children are at elevated risk for a whole host of negative outcomes; 2) these bad outcomes can be avoided; 3) multiple genetic and environmental factors modify risk for adversity; 4) the quality of the subsequent caregiving environment is critical in determining the long-term impact of child maltreatment; and 5) research foci that span from neurobiology to social policy are essential to improve the knowledge base necessary to facilitate the development of effective interventions for this vulnerable population.

Definitions

Definitions of the various maltreatment categories were drafted by the American Academy of Child and Adolescent Psychiatry (8). They are summarized here. As the legal definitions related to child maltreatment vary from one part of the country to the next, clinicians are encouraged to learn the specific definitions used in their state.

Generally, neglect occurs when caretakers fail to appropriately provide for and protect children. It may involve failing to meet the child’s nutritional, supervision, or medical needs.

Physical abuse involves the intentional injury of a child by a caretaker. It may take the form of shaking, beating, or other forms of violence that lead to injury, and frequently occurs in the context of discipline.

Sexual abuse of children refers to sexual behavior between a child and an adult or between two children when one of them is significantly older or uses coercion. The perpetrator and the victim may be of the same or opposite sex. The sexual acts may include exhibitionism; nongenital or genital fondling; fellatio; cunnilingus; or vaginal or anal penetration. Pornographic photography is usually considered sexual abuse as well. It is important to think about context and developmental factors in determining whether sexual behaviors between two children are abusive.

Psychological abuse occurs when an adult repeatedly conveys to a child that he or she is worthless, defective, unloved, or unwanted. The child may be isolated and locked in a closet or otherwise restricted. Psychological abuse can also be caused by repeatedly taking a child for unnecessary medical treatment (see Forsyth, 5.15.4, p. 719). It may also involve threatened or actual abandonment. Psychological abuse most often cooccurs with neglect, physical abuse, and/or sexual abuse.

Failure to thrive was previously believed to be due to abuse or neglect. The best available evidence now suggests that child abuse and neglect are implicated in failure to thrive in less than 10% of all cases (9). Child abuse and/or neglect should be ruled out, but not assumed to be of etiological significance, in cases of failure to thrive (see Woolston and Hasbani, 5.7.1).

The maltreatment of children occurs in a wide range of circumstances. It may constitute an isolated incident or represent a chronic pattern of childrearing. Given there are wide variations in acceptable parenting practices, it is important to consider cultural and religious beliefs when evaluating suspected abuse and neglect.

Prevalence

Each year there are approximately 3,000,000 reports of child maltreatment, and approximately one-third of these are substantiated (2). Within 4.5 years, however, 50% of all cases will be re-referred to protective services, and 20% will have a new substantiated report of child maltreatment, with no difference in the rate of re-referral or new reports of abuse between cases that are substantiated or unsubstantiated at time of initial referral (10). The process of case substantiation is extremely idiosyncratic, with substantiated and unsubstantiated cases at equally high risk of recidivism.

Of the cases that are substantiated, approximately 60% are for neglect, 20% for physical abuse, 10% for sexual abuse, and 10% for other forms of maltreatment (e.g., psychological abuse, abandonment, congenital drug addiction) (2). Over time, however, it is estimated that the average child receiving protective services experiences two or more forms of maltreatment. Comorbidity is the rule, not the exception.

Since a peak in 1993, rates of substantiated cases of child maltreatment have declined more than 20%, with decreases greatest in rates of physical and sexual abuse. The decline is believed to be “real,” and has been attributed to prevention efforts, more aggressive criminal prosecution of perpetrators, and increased dissemination of psychiatric medications targeting behaviors that increase risk for abuse (11). Despite the decline in substantiated reports, over a similar time frame child
fatalities related to abuse and neglect have increased 35%, with 1,490 child maltreatment–related fatalities documented in the last recorded year (2). There continues to be a long way to go for the eradication of abuse and neglect in this country.

Detection and Disclosure of Child Abuse

In one study, the rate of sexual abuse in a cohort of child psychiatric outpatients increased from 6% to 31%, when instead of requiring spontaneous independent reporting of these experiences, children were specifically asked about a possible abuse history (5). Clinicians sometimes hesitate to query children about abuse, out of fear of generating “false memories.” The potential for suggestibility is greatest in preschoolers (12), but even very young children are capable of recalling much that is forensically relevant and providing reliable reports of abuse experiences. Suggestibility is minimized by promoting free recall and asking open-ended questions (13).

Children are more likely to deny true experiences when initially asked, than fabricate false experiences. For example, in one study of children with sexually transmitted diseases, 43% of the children initially denied sexual contact when queried, and most children required support and time to reveal ultimately their past abuse (8). Given the high prevalence of abuse experiences in child psychiatric populations, maltreatment experiences should routinely be screened in all mental health evaluations.

Mental health providers are mandated reporters. They are required by law to report suspected abuse. There is no systematic research on optimal procedures for handling mandated reporting requirements. In our clinical experience, it is usually best to inform the parent or guardian of one’s intention to file a report, and to suggest that the parent or guardian call in the information as well. The parent’s response to this fact will provide valuable information in evaluating the parent’s capacity to support and protect the child, and determine the safety of the child staying in the immediate custody of the parent. It also gives the parent a sense of control at a very stressful time, and in truth, protective service workers look favorably upon a parent who calls to report a problem independently. Regardless of whether the parent agrees to call in the alleged abuse or not, the mental health professional is obligated to make the report. Given the data discussed above regarding the idiosyncratic nature of case investigation and substantiation, the mental health professional should be prepared to advocate for the child’s best interest, and provide ongoing clinical support for the parent and/or child.

For guidelines on forensic evaluation of physical and sexual abuse cases, see the Practice Parameters drafted by the American Academy of Child and Adolescent Psychiatry (8). In addition, the interested reader is referred to the following excellent resources for the medical detection of physical abuse (14,15) and sexual abuse (16).

Coassociation of Child Maltreatment, Poverty, Domestic Violence, and Substance Abuse

Child abuse most often occurs in the context of other risk factors. Child abuse can and does occur across all socioeconomic classes, but is most prevalent among the poor. Families earning $15,000 or less per year are 22 times more likely to abuse or neglect their children than families with annual incomes of $30,000 or more (17). While most poor families do not maltreat their children, poverty is a significant risk factor for child abuse and neglect, with more than half of the families participating in a large-scale representative sample of protective services cases falling below the federal poverty line (18). The association between poverty and child maltreatment does not appear to be merely a reporting or detection bias, as a study of a national probability sample of 6,002 households surveyed via telephone also found the highest rate of abusive violence in families whose annual income is below the poverty line (4).

Substance abuse and domestic violence are two other problems that frequently cooccur in association with child maltreatment. It is estimated that 60% of cases involved with protective services have histories of severe domestic violence (18), and close to 80% of parents who lose custody of their children have a substance use disorder (19). Unfortunately, less than one-quarter of the families involved with protective services who are struggling with these issues receive any services for these problems (20), and there is no evidence that the services being offered decrease risk for re-abuse (21).

Sequelae

Indices of Adaptation and the Intergenerational Transmission of Abuse

A history of maltreatment is associated with deficits on numerous indices of adaptation across the lifecycle. When compared to community controls, maltreated children have significantly more disturbances in attachment relations in infancy, delays in autonomous functioning and deficits in frustration tolerance in toddlerhood, and problems with self-esteem and peer relations in later childhood (22,23). Problems in language development and school performance have also been reported, including below average standardized achievement test scores, frequent repeated grades, low cumulative grade point averages, and significant social and behavior problems in class (24,25,26). In one study examining resiliency in maltreated children (27), few children could be classified resilient when multiple domains of functioning were considered. Approximately half the children in the maltreated sample had significant academic, social, and behavioral problems, and less than 5% of the sample was functioning well in all three domains.

In addition to these indicators of functional impairment, in adolescence (28) and adulthood (29), victims of child maltreatment are more likely than controls to be involved in intimate partner violence. They are also more likely to experience teen parenthood (30), and have difficulties parenting their children. While approximately 80%–90% of abusive parents have a history of child maltreatment, and being abused puts one at risk of experiencing parenting problems, only approximately one in three individuals who were abused as children repeats the cycle in the next generation (31,32). Most break the cycle (or there would be exponential increases in rates of abuse with each generation), and there are many factors, as will be discussed later, that can help promote positive outcomes in maltreated children.

Psychiatric Diagnoses

Child maltreatment is a nonspecific risk factor for multiple forms of psychopathology (7,33). Compared to community controls, maltreated children have elevated externalizing and internalizing behavior problems according to parent and teacher report (34). They also have increased rates of posttraumatic stress disorder (35,36,37,38); depression diagnoses (39,40);
reactive attachment disorder (41); dissociative symptoms (42); self-destructive behavior and borderline traits (29,43); sexually inappropriate behaviors (29,44); drug and alcohol problems (7,45,46); eating disorders (47); oppositional defiant disorder (48,49); and conduct disorder (48,49). When compared to psychiatric controls, however, elevated rates of externalizing and internalizing problems (44), and most psychiatric disorders, with the exception of PTSD (50), have not been found.

Sexual Behavior Problems and Sexual Offending Behavior

Sexual behavior problems are frequently utilized as indicators of child sexual abuse. While inappropriate sexual behaviors are strongly related to experiences of sexual abuse, they are also associated with histories of physical abuse, witnessing domestic violence, inappropriate exposure to family sexuality, and child psychiatric illness (51). Table 5.15.1.1 delineates behaviors that are highly suggestive of a possible sexual abuse history, behaviors that are relatively prevalent in abuse victims and psychiatric controls with no history of abuse, and behaviors that are frequently observed in these high risk groups and normal controls (51,52). Poor personal boundaries, increased sexual interest, and advanced sexual knowledge are reported at elevated rates in child psychiatric outpatients and child sexual abuse victims. These symptoms are not specific indicators of child sexual abuse, and neither are other common sexualized behaviors.

Fecal soiling has also in the past been attributed to a possible history of sexual abuse. In a recent large-scale study of 466 children with documented histories of sexual abuse, 429 psychiatric outpatients, and 641 normal controls, with the latter two groups carefully screened for abuse, there was no evidence that fecal soiling was a sensitive indicator of child sexual abuse (53). Ten percent of the children in both the abuse and the psychiatric control group reported soiling.

The question of whether child abuse victims are at high risk of becoming sexual offenders was addressed in a large prospective study of 908 maltreated children and 667 controls followed to adulthood (54). Victims of sexual abuse were more likely than physically abused, neglected, and control subjects to be arrested for prostitution, but no more likely to be arrested for incest, child molestation, or rape— all of which were relatively rare. Arrests for rape were highest among individuals physically abused as children, and although the rate was five times the rate observed in controls, the rate overall was quite low— 2.1% for physically abused individuals, 0.7% for sexually abused individuals, and 0.4% for controls.

While official arrest rates likely underestimate the rate of true sexual offenses, it appears most victims of abuse do not become sexual offenders. Like in the case of the intergenerational transmission of abuse, however, most sexual offenders have a history of some form of child maltreatment. Data from the National Adolescent Perpetrator Network, a representative sample of 1,616 youth sexual offenders, suggest approximately 40% of youth offenders have a history of physical abuse, a similar proportion have a history of sexual abuse, 25% have a history of neglect, and approximately two-thirds have a history of witnessing severe domestic violence (55). The majority of the youth (63%) also had a history of engaging in other antisocial acts (e.g., theft, assault).

Juvenile sex offenses are frequently serious. Within the National Adolescent Perpetrator Network, the average number of victims per offender reported at intake was between seven and eight. In addition, 67% of the assaults involved vaginal penetration, sodomy, and/or oral–genital contact. Despite the seriousness of documented cases, there is preliminary data to suggest these behaviors are not persistent. In a recent longitudinal study of 300 male registered sex offenders who were juveniles at the time of their initial arrest for a sex offense, less than 5% were rearrested for a sex offense by their early to mid-20s. This is in sharp contrast to the arrest rate for nonsexual offenses, which exceeded 50% (56). Although there has been relatively little research on the treatment and longitudinal outcome of juvenile sex offenders, preliminary findings suggest treatment outcomes are good, and few juveniles are repeat offenders in adulthood (57,58).

Neuroimaging Studies in Maltreated Children

As most of the neuroimaging studies of maltreated children have been limited to children who meet criteria for PTSD, these studies are only briefly discussed in this chapter (see Stover et al, 5.15.2, for further discussion). One of the best replicated findings in adults with PTSD is reduction in hippocampal volume (59,60,61,62,63,64,65). Multiple pediatric studies, however, failed to detect hippocampal atrophy in children with PTSD. Instead of hippocampal atrophy, children and adolescents with PTSD have been found to have reduced medial and posterior corpus callosum area (66,67,68). One recent study of adults with PTSD has similarly detected atrophy in the corpus callosum (69). Emerging preclinical and clinical studies suggest that alteration in corpus callosum and white matter tracts may be more prevalent early in development, although further systematic investigation is warranted.

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