Child Maltreatment

Child maltreatment is a broad term encompassing child neglect and abuse. It has been identified at the national and international levels as a tragedy of drastic proportions, drastic in the number of people it affects and drastic in the costs it exacts from the individual, the family, and society. Concern about the problem of child abuse in the past century has grown out of two important social phenomena: the development of a specialized group of medical and mental health care professionals, educational specialists, and legal professionals concerned with children and families, and the women’s rights movement. Together, both have contributed to a social and political environment that has changed our view of children and how to work on their behalf.

Incidence of Child Maltreatment

In 2004, child protective agencies investigated approximately 3,503,000 children for maltreatment. Nearly 872,000 of these reports were substantiated. The majority of these children experienced neglect (62.4%), followed by physical abuse (17.5%), sexual abuse (9.7%), psychological abuse (7%), and medical neglect (2.1%). There is often overlap in these cases: For example, most children who are physically abused also experience neglect. In addition, 14.5% of victims experienced abandonment, threats of harm, or congenital drug addiction. Children under the age of 4 were most vulnerable for severe injury or death: 81% of the 1,490 children who died of maltreatment in 2004 were in this age group.

Approximately 54% of all victims in 2004 were Caucasian, followed by African American (25.2%) and Hispanic children (17%). African American, Pacific Islander, and American Indian or Alaska Native children had the highest rates of victimization at 19.9, 17.6, and 15.5, respectively, per 1,000 children of their own race. Caucasian, Hispanic, and Asian children had rates of approximately 10.7, 10.4, and 2.9, respectively, per 1,000 children of their own race.

Child Maltreatment Definitions

Generally, child maltreatment is differentiated into acts of omission and acts of commission, with the former describing neglect and the latter abuse. Neglect is the failure to provide for a child’s basic needs and includes physical, emotional, medical, mental health, and educational neglect. Examples include parents or caretakers failing to provide adequate food, clothing, shelter, or supervision; refusal to seek or delay in seeking medical or mental health care that has been prescribed or highly recommended; abandonment; permission to engage in chronic truancy; inattention to special educational needs; domestic abuse in the child’s presence; or permission for the child to abuse drugs or alcohol. It is important to distinguish between willful neglect and failure to provide caused by poverty. It is also critical to consider cultural norms and for professionals to develop cultural competence when working with families.

Abuse includes an injury done to a child or acts that could cause physical injury. Abuse can be psychological, physical, and sexual, although these commonly overlap: A child who is sexually abused is often physically and psychologically abused as well.

The term psychological maltreatment is a broader term than emotional abuse. It includes behaviors that could cause serious behavioral, cognitive, and emotional disorders. Examples include spurning, terrorizing, isolating, exploiting, and denying emotional responsiveness to a child. Behaviors might include constant belittling and rejecting of a child, or bizarre forms of punishment, such as locking a child in a closet.

Physical abuse consists of nonaccidental injury that is often characterized by punching, beating, kicking, biting, burning, or otherwise physically harming a child. Injury may result from discipline that is inappropriate to the child’s age, but it is abuse, nonetheless.

Sexual abuse, or the more broadly encompassing term sexual exploitation, includes molestation, fondling a child’s genitals, intercourse, sodomy, exhibitionism, incest, prostitution, and exposure to or involvement in the production of pornography.

Signs and Symptoms of Child Maltreatment

It is difficult to identify specific symptoms for specific types of abuse, as many children experience multiple types of abuse. Age, severity, and duration of abuse are also factors in how symptoms are manifested. For example, babies who are shaken (shaken baby syndrome) may experience vomiting, respiratory distress, seizures, concussion, and death. However, general indicators of child maltreatment include a sudden change in behavior or school performance, untreated medical problems, learning problems or difficulty concentrating that cannot be attributed to specific psychological or physical problems, hypervigilance, lack of adult supervision, or overly compliant or withdrawn behaviors. These children may come to school activities early or stay late and sometimes do not want to go home.

In terms of symptoms specific to abuse type, indicators of neglect may include small physical size for age, dirty or inadequate clothing, poor hygiene, malnutrition, begging, lack of medical care, failure to thrive, poor school attendance and academic functioning, and disruptive behavior. In contrast, children who are physically abused often have unexplained burns, bruises, broken bones, or black eyes. These frequently appear after an absence from school or day care. The child may express fear at the approach of adults or may appear frightened of the parents or caregivers. Children who are sexually abused may experience nightmares or bed-wetting, show a sudden change in appetite, express bizarre or unusual sexual knowledge for the child’s age, have difficulty with walking or sitting, may run away, and may refuse to participate in physical activities.

Historical Perspective on Child Maltreatment

Recent statistics may give the appearance that child abuse is increasing. However, gathering statistics on child maltreatment is a recent practice, so it is difficult to be certain if there is more abuse now than in ancient times or earlier in the last century. It is important to think about how children are viewed as we try to understand abuse through history. In modern times, children are often seen as having inherent worth and deserving of protection, but it has not always been this way. There is evidence of child welfare from ancient Mesopotamia, 6000 years ago, when orphans had their own patron goddess. According to the Regveda, one of the oldest sacred Hindu texts, a deity among the ancient Hindus looked after abandoned children. More than 4,000 years ago, there were laws pertaining to child abuse from the Code of Hammurabi, king of Babylon. However, in ancient times and in some cultures, until the right to life was bestowed, the infant was a nonentity who could be disposed of. A father had to acknowledge a child and he had ultimate authority over the child and over the mother.

In 17th- and 18th-century Europe, children might be seen as property belonging to the father, as low-wage workers, or as “blank slates,” or innocents, worthy of care. Children are often depicted as miniature adults in artwork from this time. European writers wrote treatises urging parents to adopt nonviolent childrearing methods, as children were commonly beaten and sometimes killed. The character Cosette in Victor Hugo’s Les Miserables was used as a metaphor to admonish French society for its severe punishment of children and its lack of concern for abandoned children. Johann Peter Frank, the founder of the public health field, advocated for child labor laws in the 18th century, but it took 100 years before such laws were developed and enacted.

Developments in the 19th century include the first commissioned study on abuse, in 1860, from France, to determine why some parents kill their children. In 1866, the Society for the Prevention of Cruelty to Animals was established. The case of “Mary Ellen” is well known in the child maltreatment field. Mary Ellen was a severely abused little girl, and there were no laws to protect her. Her protection was ultimately undertaken through the New York Society for the Prevention of Cruelty to Animals, which was established prior to the Society for the Prevention of Cruelty to Children. In 1876 these two organizations joined together to form the American Humane Association.

In the 20th century many changes were designed to benefit children. One of these changes was compulsory school for both genders. Prior to the 20th century, girls often stayed home, where there was more opportunity for abuse as they had little exposure to the public. Child labor laws were enacted during the industrial revolution, and laws were developed against harsh physical punishment. Very important, the development of child welfare agencies spread. In 1961, Henry Kempe, a Denver pediatrician, and his colleagues developed the model for child abuse law that has since been adopted throughout the United States.

In 1974, the Child Abuse Prevention and Treatment Act (CAPTA) was passed, and the National Clearinghouse on Child Abuse and Neglect (NCCAN) was established. In 1978, child sexual abuse was incorporated into the federal law, expanding the scope of mandatory reporting requirements. In 1978, the Indian Child Welfare Act became law. This law was designed to keep Indian children more closely connected to their families, or to other tribal members in the cases of necessary adoptions. The 1984 publication of the American Humane Association’s book Making an Issue of Child Abuse: Political Agenda Setting for Social Problems was influential in making child abuse an important political agenda item. In 1993 the United Nations adopted the resolution on the Rights of Children.

Clearly there have been improvements over time as views of children have changed and laws have been enacted for their protection. Organizations abound to provide education to parents and caregivers. Nevertheless the problem of child maltreatment persists, and it is important to have some understanding of the circumstances and dynamics that lead to it.

Causes of Child Maltreatment

There is a considerable body of research examining why maltreatment occurs in the most vulnerable of our population: children. Most recent research suggests that models studying interactive processes taking multiple variables into account will be the most fruitful for understanding the causes of child maltreatment. Although models vary, all consider at least three common dynamics that interact together: the parent (or caretaker), the child, and the environment.

Parents

The vast majority of child maltreatment occurs within the family. Certain parental factors are significant predictors of maltreatment. These may include depression, lack of impulse control (especially when stressed), excessively high and developmentally inappropriate expectations of the child, lack of empathy, or an impaired attachment with the child. Parents may themselves have a history of victimization as a child, but most abused children do not become abusive parents. Those who do become abusive often have unresolved issues regarding intimacy, trust, autonomy, and dependency. Other risk factors for parents include young age, being a single or nonbiological parent, lack of knowledge about childrearing, a chaotic lifestyle, and low frustration tolerance. Lack of social support is a very significant finding in research examining child maltreatment potential. Parents’ reluctance to admit they need help, and their lack of knowledge about how to ask for or access help, is also critical. We live in a culture that emphasizes independence and autonomy. Asking for help may be perceived as a weakness. If a parent at risk is not part of a cohesive community, his or her increased isolation contributes to a sense of estrangement that further exacerbates stress.

The Child

It is important to understand the bidirectionality of the parent-child relationship, as each party fundamentally influences the behavior of the other. The following types of children are overrepresented in maltreatment situations: normal infants who were unwanted or are the product of an untimely pregnancy, children with disabilities, “difficult” children (that is, those who are difficult to soothe, feed, or take care of in other ways), and adopted or foster children. Certain child characteristics (e.g., behavior problems such as hyperactivity, irritability) may also increase the risk of maltreatment.

The Environment

This term refers to the immediate and personal environment as well as the broader cultural environment. Stressors associated with the more immediate environment include economic problems, unemployment, chaos, violence between parents, overcrowding, and isolation. Within the broader cultural environment, certain attitudes, beliefs, and practices of the culture can contribute to an environment ignorant or tolerant of maltreatment. These include an emphasis on individual rights, male supremacy or aggression, tolerance for abuse, and isolation from family and community.

Consequences of Child Maltreatment

Not all children who suffer maltreatment exhibit significant effects as a result of their maltreatment. Personal characteristics such as optimism, high cognitive ability, high self-esteem, or a sense of hopefulness in spite of the circumstances may function as a buffer to the potentially damaging effects. Other children experience a wide range of cognitive, emotional, psychological, behavioral, and relational consequences of child maltreatment. These effects are determined by factors such as age, type, severity, and chronicity of abuse.

Maltreatment during infancy and early childhood may restrict healthy brain development. For example, insufficient nutrition and emotional stimulation can have an impact on the release of important growth-regulating hormones. This affects the physical development of both the body and the brain, which can lead to severe and irreversible damage. Without remedial interventions, developmental damage in these early stages may result in deficits that follow the child into later developmental stages, producing a variety of problems. Long-term consequences of shaken baby syndrome can include blindness, mental retardation, learning disabilities, paralysis, and cerebral palsy.

In general, child maltreatment has been linked to the development of internalizing disorders such as depression, anxiety, somatic complaints, suicidal intention, and posttraumatic stress. It is also linked to externalizing disorders such as acting out, aggression, eating disorders, impulsivity, anger, delinquency, hyperactivity, attachment disorder, sexual acting out, and cognitive impairments or delays. Physically abused children tend to be aggressive toward peers and adults and to have difficulty with empathy and establishing relationships with others. Neglected toddlers may have difficulty trusting others. This may lead them to feel unloved and unwanted and may inhibit their ability to learn the social skills they need to develop lasting and meaningful relationships, thus becoming a lifelong problem. Adult survivors of childhood maltreatment are 3 times more likely than other adults to suffer mood disorders and 2 to 4 times more likely to suffer from an anxiety disorder.

Like physical abuse, the consequences specific to sexual abuse vary by age, severity, and chronicity of abuse and number and relationship of perpetrator(s). Research indicates that symptoms vary over time, and some symptoms may be more transient than others. Not all sexually abused children experience these adverse effects. Approximately one third of victims show no clinical symptoms. The most common symptoms identified in preschoolers are anxiety, nightmares, posttraumatic stress disorder, inappropriate sexual behavior, and internalizing and externalizing behaviors. Somatic problems include enuresis, stomachaches, headaches, and developmental delays.

School-age children may display fear, aggression, nightmares, school problems, hyperactivity, and regressive behavior. Like the preschoolers, they may exhibit inappropriate sexual behaviors. They may also experience dissociation and difficulties with peer relationships. In the academic domain, they may receive poor performance ratings from teachers and have low achievement test scores, and they frequently receive diagnoses of attention deficit hyperactivity disorder (AD/HD). Adolescents may exhibit depression, withdrawal, somatic complaints, running away, eating disorders, substance abuse, suicidal or self-injurious behaviors, and delinquent behaviors. In adulthood, survivors may abuse alcohol or drugs and may experience externalizing problems such as diagnoses of antisocial personality disorder. They also may experience depression and anxiety, greater revictimization rates, and problems with child rearing.

In addition to individual effects, child maltreatment affects families and society. A 2001 report by Prevent Child Abuse America estimates the cost of health system, judicial, and law enforcement responses at $24 billion a year. In addition, there are also indirect costs associated with maltreatment, such as the cost of providing special education services for affected children and providing treatment for mental illness, substance abuse, domestic violence, and juvenile and adult criminal activity. These indirect costs may cost more than $69 billion per year.

Child Maltreatment and Cultural Considerations

Lisa Aronson Fontes, an expert on multicultural counseling and child abuse, emphasizes the importance of taking an ecosystemic perspective for understanding child maltreatment. This includes examining all relevant social worlds the child inhabits. Professionals need to consider the individual—including the child’s genetic makeup, developmental status, and home and family situation; the ethnic culture—including gender roles, religion, and worldview; the proximal social system—including school, neighborhood, and peer group; and the wider social system—state and national policies that impact all other systems. If counseling professionals are too close to the individual perspective, they may miss contextual variables that could assist them in helping a person. Conversely, if they have too wide a lens, they may miss important cultural variables, such as native child-rearing practices important for appreciating the child in his or her context.

This ecological model is useful in three ways: (1) It deemphasizes the individual, who is otherwise the focus in much of Western culture, (2) it indicates various levels where professionals can intervene for the child, and (3) it shows professionals where they fit in the child’s ecosystem. If they are not from the same culture, they are one step further away; they need to have culture-specific knowledge to get closer. Professionals can also see how they are influenced by the proximal and wider social systems. It is critical to be aware of their own professional ethnocentrism, that is, to understand how the culture of their profession influences how they see the world. This requires them to be conscious of their own biases, to confront stereotypes, and to have culturally relevant information. This information should include knowledge of how child maltreatment is defined and of traditional help-seeking behaviors, including unfamiliar disciplinary methods and medical interventions. They must also consider issues of language and the appropriate use of interpreters. With low-income clients, professionals need to be aware of the influence of poverty in their clients’ lives and recognize that what may look like neglect may be related to poverty.

Writers in the child advocacy and multicultural counseling fields emphasize that professionals need to work within a systems framework. For example, they need to ask how nonabusive family members can help. Fontes notes that the main predictor of success for recovery from incest is the mother believing the disclosure. A few guidelines for working with families include knowing who is considered “family”; it may include godparents and close friends who are not related by blood. Professionals should understand family structure, gender roles, and respectful ways of addressing clients. Families often appreciate mental health professionals who help them access community and social resources other than counseling.

Child Maltreatment Counseling Interventions

Early interventions are necessary to reduce the severity and chronicity of abuse symptoms and alter family and environmental factors contributing to maltreatment. Services and interventions for maltreatment should be multidimensional, including individual, family, and societal interventions. Research studies on intervention effectiveness indicated that individual, group, family, milieu, or multilevel forms of treatment are equally effective. Surprisingly, treatment effects did not vary based on voluntary versus mandated treatment.

Individual interventions may include providing appropriate medical care, helping the child express his or her emotional experiences (verbally or through drawing or play), processing trauma or neglect, reducing or overcoming general feelings of shame resulting from maltreatment, finding educational services to improve cognitive ability and academic performance, and teaching personal safety skills, empathy, assertiveness, and relationship-building skills appropriate to the child’s age.

Since nearly 84% of victims of maltreatment are abused by a parent, family interventions should address issues such as improving parenting skills. This can include education on nonviolent discipline strategies, child developmental stages, effects of maltreatment, anger management, and communication skills. Interventions should also assess and address family mental health or substance abuse issues contributing to family dysfunction and explore gender roles that may contribute to abuse.

In a broad general sense, the treatment process consists of three phases: (1) acknowledgment of the abuse and its subsequent effects, (2) development of parenting competencies and sensitivity to the child, and  (3) resolution either through reunification of the child with the family or relinquishment of parental rights.

Individuals involved in providing support and assistance to children and families involved in maltreatment often include nurses, doctors, teachers, school counselors, social services staff, therapists, foster care providers, law enforcement officers, and individuals in the judicial system. However, while these services focus on the protection of children and punishment of abusers, they rarely provide assistance in addressing the unemployment, poverty, and substance abuse that frequently play a role in child maltreatment. These issues need to be addressed at the societal level to effectively combat child maltreatment. Similarly, non-English-speaking minority families may feel isolated from community services that could help them cope with financial, cultural, and familial stressors. Federal and local governments and communities need to provide services for these families to prevent them from having to enter the child protection and legal systems.

Finally, a significant and badly needed intervention in maltreatment is developing effective prevention programs. Primary prevention interventions begin with raising the awareness of the public and decision makers about maltreatment. These include public service announcements regarding available programs and services, school safety programs, free parent education programs, and information on how and when to report abuse.

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