Child abuse and neglect
David P. H. Jones
Introduction
Child abuse and neglect (child maltreatment) is a combination of a consensus about what comprises unacceptable child rearing/care, together with what children have a right to be free from. This is made explicit in the United Nations Convention on the Rights of the Child,(1) which sets out basic rights and standards for judging children’s welfare, including, but not limited to, maltreatment. It incorporates both maltreatment of children within families and that arising from wider social influences, including child labour and sexual exploitation, and children in war zones.(1)
Maltreatment affects the healthy and normal course of development. It causes deviation from an expected trajectory, preventing the developing child’s negotiation of sequential tasks and disrupting normal transaction between different facets of development.(2) Therefore maltreatment is the very antithesis of adequate child care and rearing, posing a major public health threat.(3)
Adequate rearing of the young is such a fundamental activity that the state must be concerned with the overall welfare of children within its society; in family settings where they are normally brought up, and in schools, hospitals, and residential settings.
While the Convention provides a framework, several states have developed a children’s ombudsman, with wide-ranging powers to oversee the status of children’s welfare and to tackle obstacles to it.
While the Convention provides a framework, several states have developed a children’s ombudsman, with wide-ranging powers to oversee the status of children’s welfare and to tackle obstacles to it.
There are laws within each society to regulate the care and welfare of children, specifying the consequences if children are maltreated. In England and Wales, the Children Acts 1989, and 2004 address the overall welfare of children, including those deemed in need of extra help and support, and provide a legislative structure for those children who are at risk of, or are actually being, significantly harmed (child maltreatment).
Countries vary in their response to child maltreatment. In the United States, any professional who has reason to suspect that a child is being maltreated is legally required to inform the local child welfare agency (mandatory reporting). Some countries in Europe (e.g. Belgium and Holland) have a system whereby childmaltreatment concerns are dealt with confidentially, through health and social care supportive systems, rather than through primarily legal methods. The United Kingdom lies between these extremes, but relatively closer to the United States model than to the ‘confidential doctor’ system. Whatever system is in place, it is clear from the scope of the problem of child maltreatment that multidisciplinary working is a core requirement.
A developmental-ecological model is the most useful conceptual framework, which draws together the various factors known to contribute or be associated with the predisposition, occurrence, course and effects of child maltreatment.(3,4) It incorporates individual and interpersonal factors, family influences, immediate neighbourhood ones, together with broader social influences on child rearing and care. However, these layers of increasing social complexity, which surround the individual child, are not static. In addition to transactions between factors, there are important influences historically, and subsequent to any maltreatment, which have an impact on outcome. This inclusive conceptual framework enables genetic and environmental factors to be integrated in a manner that can inform clinical assessment and intervention.
Types of maltreatment
Identification of different types of maltreatment may be necessary for social and legal purposes, but epidemiologically, co-occurrence of varieties of maltreatment is more usual than singularity.(3,5) Official registers often record predominant type or that perceived to be the most serious. This knowledge is one of several methodological problems that affect confidence in research findings. However separate types are retained here, for descriptive purposes, while encouraging the reader to consider likely overlap in individual cases.
Epidemiology
Accurate figures for incidence and prevalence are bedevilled by ascertainment and recording difficulties, including secrecy and shame which are often associated. These influences are illustrated by the wide gulf between incidence and prevalence rates.(3)
Incidence rates increase from reported cases to higher rates obtained from representative community samples. The incidence of significant violence to children varies between 50 to 90 per thousand across cultures in community samples, and dropping to the mid-20s per thousand for cases known to professionals working with children. Cases known to social welfare agencies departments only comprise a minority of these. However, officially reported maltreatment ranges from 2 to 12 per thousand in England, North America and Australia. Neglect is commonest (34 to 59 per cent of cases); physical abuse (15 to 28 per cent); sexual (10 to 28 per cent); and emotional (7 to 34 per cent).
Most prevalence figures for each of physical, emotional and neglect range between 5 and 10 per cent. The equivalent rate for contact sexual abuse is 10 per cent (15 per cent of girls; 5 per cent of boys). Children with a disability are three times more likely to be maltreated.(3)
Life-threatening maltreatment rates have remained relatively constant, currently 0.1 to 2.2/1000 children in industrialized countries, rising to two to three times this in low to mid-income countries. Children are at their most vulnerable during infancy and neonatal periods.
Child sexual abuse
Definition and clinical features
This is defined as sexual activities which involve a child and an adult, or a significantly older child. There are two elements: the sexual activities and the abusive condition.(6) Contact sexual activities include penetrative acts (e.g. penile, digital, or object penetration of the vagina, mouth, or anus) and non-penetrative acts (e.g. touching or sexual kissing of sexual parts of the child’s body, or through the child touching sexual parts of the abuser’s body). Non-contact sexual activities include exhibitionism, involving the child in making or consuming pornographic material, or encouraging two children to have sex together.
The abusive condition is founded on the premise that children cannot generally give consent to sex, because of their dependent condition. Consent can be difficult to assess in older children or if there is a small age gap between abuser and abused. Considering whether exploitation has occurred can aid this decision: it comprises misuse of authority or age differentials through deceit, unreasonable persuasion, coercion, or overt force.
Half the sexual abuse cases coming to the attention of welfare agencies involve penetration or orogenital contact. The proportion is less in community samples, because reported cases tend to be more serious in nature.
Abuse perpetrated by a caretaking adult normally consists of increasingly severe sexual contact over time, with parallel increases in coercion and threats to the child if the ‘secret’ is disclosed. As the physical acts and psychological climate worsen, so the child’s reluctance to disclose the predicament deepens.
Diagnosis
The most common presentation is through a statement from the child.(7) Unless the child is responded to sympathetically at this point, they may be reluctant to reveal the full nature of their plight. More than half of those who are abused do not disclose the fact, especially if they are male.
Less commonly the child’s behaviour can draw attention to abuse, particularly if the child shows sexual behaviour problems, either directed towards themselves or towards other children. However, behaviour and emotional difficulties are normally nonspecific, occurring in about two-thirds of children. Older children and adolescents show behaviour difficulties which are unexpected for themselves or their peer group, including substance abuse, suicide attempts, running away from home, or becoming unpredictably
out of control. Not surprisingly, high rates of prior sexual abuse are noted among young people involved in prostitution.
out of control. Not surprisingly, high rates of prior sexual abuse are noted among young people involved in prostitution.
Medical presentations do occur, for instance venereal diseases, evidence of acute assault, or an otherwise unexplained pregnancy.
Prior to investigation, one-third of reported cases are already known to child welfare agencies for other reasons. Children are more likely to disclose their predicament if they have first made a spontaneous statement to someone before being interviewed by professionals.
Child psychiatric services may assist social workers interviewing children and young people with a psychiatric disorder, or very young children. Other specialists should be enlisted for those with communication problems and learning difficulties. The aim of interviewing is to help a child describe their predicament whilst avoiding suggestion.(8) Child psychiatry also has a role to play in providing psychological treatments for symptomatic children and working with disturbed families.
Screening for the possibility of child sexual abuse increases recognition in both adult and child populations, revealing information that can be essential for psychiatric management. Adult services have a role to play in addressing psychiatric problems in family members, including treatment for paraphilias, often in conjunction with the probation service or other specialized provision.
Aetiological and background factors
(a) Characteristics of abused children
Sexual abuse affects children of both sexes and all ages. The most common age when children are abused is between the ages of 7 and 13 years, but up to one-quarter of reported cases comprises the under-fives. Race and socio-economic status are not major risk factors, but there are increased rates of sexual abuse among children living with parents who are emotionally unavailable, psychiatrically disturbed, violent, or who abuse alcohol or drugs.(9) Children from lower socio-economic groups are over-represented in child protection samples, but in adult retrospective surveys there is a weaker link with economic status. Children who have been in substitute care are at higher risk.
Girls are more than twice as likely to be victimized. Boys are less likely to be reported or discovered to have been abused during their childhood. Compared with girls, boys are more likely to be older when first victimized and to be abused by someone from outside the immediate family, and more likely to be abused by women or by offenders who are known to have abused other children. The risk of sexual abuse is almost doubled for children with a disability.(10)
(b) Characteristics of abusers
Most abusers are male, but up to 10 per cent of children are abused by a female, though this figure is higher when the victim is male. Of abusers, 70 to 90 per cent are known to the child, with family members comprising between a third and a half of those who abuse girls, and between 10 and 20 per cent of abusers of boys.
Up to one-third of children are abused by a person who is under 18 years of age. Young abusers are, on average, 14 years old, while their victims are 7 years old and usually known to them.(11) The abusers lack social skills and assertiveness, and show impulsecontrol problems, learning difficulties, and clinical depression. Their home environments are characterized by instability, family violence, and sexual problems in their parents. Parental loss or separation is common among adolescent abusers.
Between 20 and 50 per cent of abusers have a history of childhood sexual abuse themselves. Physical abuse histories are even more common, together with deprivation and periods of substitute care in childhood. These characteristics are common among other offenders for non-sexual abuse offences, and thus do not explain the aetiological pathways through which some young people and adults develop a pathway of sexual attraction or desire to sexually assault a child. Marshall and Barbaree(12) have drawn together psychological, biological, and social factors into an integrated theory of aetiology.
Abusers typically deny sexual abuse allegations. Even measures of penile tumescence in response to childhood imagery are unlikely to discriminate a denying abuser from a falsely accused man. Some psychological features are common among abusers but are unlikely to be definitive, prior to any admission of guilt.(13) The demarcation between intrafamilial and extrafamilial abusers is less sharp than originally thought, and mixed abusers are relatively common.
(c) Family aspects
Up to half of all cases are abused by someone outside the family. In the majority of these extrafamilial cases the abuser is known to the child and in a position of trust, either providing care or supervision, or involved in an educational or recreational activity with the child. Among within-family cases, the original stereotype-of a closed family with a controlling abusive father and mother who is collusive with her husband’s abuse of her child-has been demonstrated to be inaccurate. Although such a pattern may be seen, a variety of family styles of functioning occur. However, investigators have found that families containing sexual abuse victims are less cohesive, more disorganized, and permit less healthy expression of emotion than comparison families.(14) These differences may pre-date the onset of sexual abuse or be a consequence of its occurrence.(9) Nonetheless, the observations are important for intervention purposes.
Support from non-abusive adult carers (usually mothers) in terms of belief, protection, and help for children to understand their victimization, is positively linked with the children’s response to their experience.(15) This is important for assessment and intervention purposes, because there is a significant link between sexual abuse and markers of parent-child relationship difficulties, such as emotional unavailability, interparental conflict, parental mental health, and substance abuse problems.
(d) Course and prognosis
A wide range of psychological sequelae in childhood and adult life are associated with prior childhood sexual abuse (Table 9.3.3.1).(9,15) However, these are linked with the effects of both the quality of the family environment at the time of abuse, and the nature of subsequent life events.(16) In particular, factors such as family disharmony and violence, existence of other forms of abuse and neglect, and parental mental health difficulties, in addition to subsequent events, such as losses through death or separation, combined with the child’s own method of coping with the abuse and ameliorative effects of positive school or social relationships, all contribute to outcome.
About one-third of children are symptom free. Approximately 10 per cent of children show worsening symptoms over time, including depression and post-traumatic symptoms. While effects on personality and social relationships can be disabling during development, other children are relatively unaffected.(16,17)
Table 9.3.3.1 Impairments and problems associated with childhood sexual abuse | ||||||||||||||||||||||||||||||||||||||||||||||||||||
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Physical abuse
Definition and clinical features
Physical abuse is the physical assault of a child by any person having custody, care, or charge of that child. It includes hitting, throwing, biting, inducing burns or scalds, poisoning, suffocating, and drowning.(3) In the United States and United Kingdom physical chastisement of children is commonplace, leading to problems of definition. In other parts of Europe and in some Eastern cultures physical chastisement is regarded as unacceptable. Legal definitions in the United States and Western Europe normally link physical acts to observable harm. However, for research and clinical purposes an endangerment-based definition is preferable, because of the widely different sequelae resulting from similar assaults.(18) Failure to prevent injury or suffering is preferably considered a manifestation of neglect. Other definition problems include the frequency or repetitiveness of the acts, their severity, and whether intent to harm should be included. In addition, developmental factors affect the recognition of abuse and possibly its definition also—a smack to the head of an 8-year-old, although unacceptable, will have significantly different consequences from that to an 8-month-old.
The distinction between accidental injury, non-accidental injury, and specific medical diseases is sometimes straightforward (e.g. particular types of fractures, burns, or bruising) but difficult diagnostic dilemmas do occur. It is important to resolve these dilemmas so that the way forward for psychiatric assessment and treatment can be clarified.(19)
The ‘battered child syndrome’ refers to young children with multiple bruises, skeletal injuries, and head injuries, often accompanied by neglect, malnutrition, and fearfulness, whose parents deny responsibility.(20)
Diagnosis and recognition
Physical abuse is detected through the observation of physical injuries without an alternative non-abusive explanation.(19) Less commonly, a direct account comes from a child or a witness, or through confession by a parent or carer. Usually, the diagnosis is based upon a discrepancy between the physical findings and the history provided. The history may be insufficient or simply improbable. When an explanation is forthcoming, trigger events or developmental challenges are common—for example, persistent crying in infancy, problems of toileting or feeding among toddlers, or issues of discipline in later childhood. In adolescents, conflict surrounding independence may coincide with parental midlife crises. Not all physical abuse can be related to loss of control, however, and the assessor has to consider planned or even sadistic activities, such as scalding, burning, or torture.
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