The legal definitions regarding child maltreatment vary from state to state. In general, neglect is the failure to provide adequate care and protection for children. It may involve failure to feed the child adequately, provide medical care, provide appropriate education, or protect the child from danger. Physical abuse is the infliction of nonaccidental injury by a caretaker. It may take the form of beating, punching, kicking, biting, or other methods. The abuse can result in injuries such as broken bones, internal hemorrhages, bruises, burns, and poisoning. Cultural factors should be considered in assessing whether the discipline of a child is abusive or normative. 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 more dominant. The sexual behaviors include the following: touching breasts, buttocks, and genitals, whether the victim is dressed or undressed; exhibitionism; fellatio; cunnilingus; penetration of the vagina or anus with sexual organs or with objects; and pornographic photography. Emotional abuse occurs when a caretaker causes serious psychological injury by repeatedly terrorizing or berating a child. When serious, it is often accompanied by neglect, physical abuse, sexual abuse, and exposure to domestic violence.

The psychiatric classification of abuse and neglect in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) appears in the chapter “Other Conditions That May Be a Focus of Clinical Attention” and in the section “Problems Related to Abuse or Neglect.” The categories of abuse and neglect take a number of factors into consideration including: whether the maltreatment consisted of physical abuse, sexual abuse, or neglect; whether the victim was a child or an adult; whether the focus of clinical attention is on the victim or the perpetrator; and whether, in the case of adults, the perpetrator was the victim’s partner or a person other than the victim’s partner. The DSM-IV-TR categories related to child maltreatment are in given in the Box above. These conditions are coded on Axis I.

DSM-IV-TR classification of child maltreatment

Practitioners in private practice, as well as those employed by courts or other agencies, see children who may have been emotionally, physically, or sexually abused. As a clinician, the practitioner may provide assessments and treatment for abused children and their families in both outpatient and inpatient settings. As a forensic investigator, the practitioner may work with an interdisciplinary team at a pediatric medical center and assist the court in determining what happened to the child.

Epidemiology

Each year about three million alleged incidents of child maltreatment are reported to protective services (U.S. Department of Health and Human Services, 2005). Of those reports, about one million are substantiated. Of the substantiated cases, about 60% involve neglect; about 20% involve physical abuse; about 10% involve sexual abuse; about 5% involve emotional abuse; and the rest are unspecified. About 1500 children die each year as a result of maltreatment.

Etiology

Child maltreatment is a tragic and complex biopsychosocial phenomenon. There are various models to explain why child abuse occurs, but generally they consider the interaction of five levels of risk factors and protective factors: (1) The individual biological and psychological makeup of the child victim is important. For example, children who are premature, developmentally disabled, and physically handicapped are more likely to be abused. (2) The individual characteristics of the adult perpetrator. For example, child abuse occurs in all strata of society, but it is associated with lower parental education, parental mental illness, and parental substance abuse, especially alcoholism. (3) The family system refers to the family environment, parenting styles, and interactions among family members. Risk factors include single parenting and domestic violence. (4) The community in which the family lives may relate to both risk and protective factors. In general, child abuse is strongly associated with poverty, financial stress, poor housing, and social isolation. However, there may be protective factors in the community related to the parent’s workplace, peer groups of family members, and formal and informal social supports. (5) Finally, the values and beliefs of the culture affect the occurrence of child maltreatment. During the twentieth century, for example, there were two major societal shifts that reduced the frequency of child abuse: the concept that child behavior should be socialized primarily through love, not harsh, physical discipline; and the realization that parental authority is not absolute, that is, parents are not entitled to unrestricted authority over their children.

Signs & Symptoms

Children who have been abused manifest pleomorphic symptoms in a variety of emotional, behavioral, and psychosomatic reactions. Abused children may have internalizing symptoms such as withdrawal, anxiety, depression, and sleep problems. Abused children may exhibit externalizing symptoms, such as aggression. Children who have been sexually abused are likely to display inappropriate sexual behavior. Table 42–1 lists symptoms that are associated with child abuse: they are not specific or pathognomonic; the same symptoms may occur in the absence of a history of abuse.

The parents of physically abused children have certain characteristics. Typically, they have delayed seeking help for the child’s injuries. The history given by the parents is implausible or incompatible with the physical findings. There may be evidence of repeated suspicious injuries. The parents may blame a sibling or claim the child injured himself or herself.

In cases of intrafamilial sexual abuse and other sexual abuse that occurs over a period of time, there is a typical sequence of events: (1) engagement, when the perpetrator induces the child into a special relationship; (2) sexual interaction, in which the sexual behavior progresses from less intimate to more intimate forms of abuse; (3) the secrecy phase; (4) disclosure, when the abuse is discovered; and (5) suppression, when the family pressures the child to retract his or her statements (Sgroi, 1988).

The child sexual abuse accommodation syndrome is sometimes seen when children are sexually abused over a period of time. This syndrome has five characteristics: (1) secrecy; (2) helplessness; (3) entrapment and accommodation; (4) delayed, conflicted, and unconvincing disclosure; and (5) retraction (Summit, 1983). The process of accommodation occurs as the child learns that he or she must be available without complaint to the parent’s demands. The child often finds ways to accommodate: by maintaining secrecy in order to keep the family together, by turning to imaginary companions, and by inducing in herself altered states of consciousness. Other children become aggressive, demanding, and hyperactive.

It is possible to distinguish the psychological sequelae of children who have experienced single-event and repeated-event trauma (Terr, 1991). The following four characteristics occur after both types of trauma: (1) visualized or repeatedly perceived intrusive memories of the event; (2) repetitive behavior; (3) fears specifically related to the trauma; and (4) changed attitudes about people, life, and the future. Children who sustain single-event traumas manifest full, detailed memories of the event; an interest in “omens,” such as looking retrospectively for reasons why the event occurred; and misperceptions, including visual hallucinations and time distortion. In contrast, many children who have experienced severe, chronic trauma (e.g., repeated sexual abuse) manifest massive denial and psychic numbing, self-hypnosis, dissociation, and rage.