Child abuse is a global problem. The World Health Organization (WHO) estimates that 40 million children between birth and 14 years of age are abused or neglected annually around the world. Thus, child abuse is found across all societies and cultures, almost always surrounded by secrecy and denial. The exact number of children who are abused is not known due to underrecognition and underreporting. Children are often too young to understand or to communicate what is happening. Moreover, because abuse is often perpetrated by parents or caregivers, even when children understand that they are being abused, they often feel loyalty, dependency, and emotional ties to the perpetrator, which keep them from reporting the abuse. In the United States alone, an estimated 879,000 children suffered from abuse and neglect in 2000. In 2001, about 2,475 children were abused daily, and more than 50,000 reports of possible child abuse and neglect were reported to child protective services.
Historical And Cultural Perspective
Cultural differences in attitudes toward child rights, child labor, and corporal punishment (physical discipline of a child such as spanking, beating, and whipping) contribute to wide cultural differences about what is considered abusive toward children. Wealthy industrialized, technology-based nations hold different perspectives. By such nations’ standards, the living conditions, quality, and/or lack of water, food, and shelter for children in developing nations is commensurate with child maltreatment. In some developing nations, cultural rituals involve mutilation of children’s genitals (often females only), while male children are sent off to war. The conceptualization of what is child abuse and maltreatment is subject to wide cultural variation.
In the United States, belief in a child’s right to humane treatment and adequate care evolved from an initial perspective that children were possessions to be treated as their parents or caregivers saw fit. For example, the Massachusetts Stubborn Child Act of 1654 permitted parents to put stubborn children to death for noncompliance. Throughout the colonial United States, children were virtually enslaved as apprentices or otherwise engaged in hard labor for barely enough money to pay for their own food. In 1870, the Census Bureau reported that one of every eight children was employed. By 1900, the figure had dropped to one in six. Abandoned, runaway, or maltreated children were also sent “out West” as laborers. Child abuse and maltreatment gained focus in 1874 with the case of Mary Ellen Wilson, a child of somewhere between 8 and 10 years of age, who was severely abused by her stepmother. Concerned citizens turned to the Society for the Prevention of Cruelty to Animals because at that time there were no formal organizations to help abused children. This incident led to the birth of child protection groups, and represented a growing shift in the public’s perception on the treatment of children. As a result of the Mary Ellen case, the Society for the Prevention of Cruelty to Children was established in New York in 1875, pioneering the development of other advocacy and protective organizations for children across the United States.
What Is Child Abuse?
Federal legislation provides the basis for the definition of child abuse in the United States, although each state has its own statutes as well. In 2003, the Federal Child Abuse Prevention and Treatment Act (CAPTA) was amended by the Keeping Children and Families Safe Act to define child abuse as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation.” A “child” is typically defined as any person under the age of 18 years, although for some state definitions of sexual abuse, the definition of the age of a child is specified otherwise.
Child abuse includes acts of commission or acting upon a child. Mental health professionals typically question any actions by caregivers that result in marks, swelling, bruises, burns, or breaks to the child’s skin; obviously even more severe injuries such as bone fractures or internal injuries are considered abusive. Falling within the acts of commission are sexual abuse and exploitation.
Child abuse also includes acts of omission or neglect that involve failure or lack of action by the parent or other caregiver to protect or care for the child. Such acts of omission include, but are not limited to, failure to provide adequately for the child’s basic physiological needs such as food, water, clothing, and shelter; failure to provide adequate supervision from harm or failure to tend to a child’s medical needs. There are exceptions to what is considered an abusive act of omission. U.S. state statutes often exempt parents who do not obtain medical intervention for their children due to religious beliefs. Cultural values/practices and poverty also cause wide differences in the standards of care set by parents and caregivers across cultures.
Types Of Child Abuse And Neglect
Child maltreatment is a general term used to encompass all types of child abuse and neglect, including physical abuse, neglect, emotional abuse, sexual abuse, and exploitation. Neglect is the most common type of maltreatment, making up about 62.8% of known victims in 2000, followed by 19.3% being physical abuse cases, 10.1% sexual abuse, and 7.7% emotional abuse and neglect.
Physical abuse involves causing bodily injury to a child, including but not limited to hitting, punching, kicking, burning, beating, or shaking. Such actions are considered physically abusive whether or not the parent or caregiver intended to inflict injury. Physical abuse can be deliberate or can be the result of excessive corporal punishment.
Shaken baby syndrome, known medically also as whiplash-shaken infant syndrome, involves injury caused to an infant by shaking a baby by the arms, legs, shoulders, or chest. As a result of the shaking, the infant’s head is forced forward and backward, causing the brain to collide with the inside skull. Severe brain injury and death may result. Even mild shaking of an infant can lead to injury or death. The estimated number of cases of shaken baby syndrome is between 600 and 1,400 annually in the United States, although this number may be too low due to underdiagnosis or underreporting of incidents. Babies cannot talk to explain what happened, and parents/caregivers do not readily admit to such conduct.
Munchausen’s syndrome by proxy, also called factitious disorder by proxy, is a psychological disorder in which a parent, almost always a mother, lies about their child having physical symptoms or actually deliberately induces physical symptoms, for example, through poisoning or suffocation. The parent does so in order assume the role of concerned parent and to receive attention from the medical community. Such parents are deliberately fabricating or inducing their child’s illness for their own psychological/emotional reasons, rather than for financial or material gain (such as disability income.) An estimated 400 to 500 cases are diagnosed annually, although certainly others go undetected.
Child neglect can be physical, educational, or emotional. It involves acts of omission. In addition to physical neglect such as the failure to provide for the child’s basic needs (such as food and shelter), educational neglect involves allowing a child not to attend school or willfully disregarding a child’s special educational needs. Emotional neglect can be the most difficult form of neglect to detect. It involves failure to provide basic levels of nurturing to the child such as verbal or physical affection. Emotional neglect can also involve violence toward a parent in the presence of the child or condoning the child’s use of alcohol and drugs.
Emotional abuse moves from acts of omission to also include acts of commission that result in emotional injury or trauma to the child and/or serious behavioral or mental disorders. Emotional abuse may involve use of extreme punishments beyond what a reasonable adult would consider appropriate such as locking a child in a dark closet or less florid acts such as repeated scorning and verbally degrading the child, habitual scapegoating (blaming the child for causing any and all problems or stressors in a family), or rejecting the child. This form of neglect is the most difficult to detect because the harm is not physical.
Sexual Abuse and Exploitation
Sexual abuse and exploitation involve any inappropriate sexual behavior toward the child such as touching a child’s genitals, sexual or anal intercourse, incest, rape, oral sex acts performed on the child, or forcing the child to perform them. It also includes forcing the child to watch sexual acts performed by others, exposing a child to sexual material or behaviors, or exposing or otherwise exhibiting one’s genitals to the child. Sexual exploitation of children for financial gain involves child prostitution and production of child pornography. Whether the child is physically raped or otherwise touched against his or her will, or, more commonly, when the child is bribed, persuaded, tricked, coerced, or seduced, the activity is considered sexual abuse.
When the sexual abuse is occurring inside the family by an immediate family member such as the child’s parent, it is referred to as incest. Unlike physical abuse and neglect, sexual abuse is much more premeditated and planned by the perpetrator. When a child is victimized by either a person in or outside of the family, there are steps that these perpetrators take in order to gain and maintain access to a child. This process is frequently referred to as grooming a child for abuse. Perpetrators of sexual abuse will often try to create a special trust or bond with the child. They strive to convince the child that they are a special or unique friend, and may do so by confiding in the victim or telling the victim of their loneliness and that the child can help. The perpetrator will also give the child gifts or special privileges. Next the pedophile attempts to alienate the child. Alienation is easier to accomplish when the sexual abuse occurs within a family. The child is alienated from the mother and siblings because of special privileges or status afforded by the perpetrator. As the abuser dominates the life of the victim, access to friends, support, and sources of help are minimized, creating dependency on the perpetrator. Next, secrecy is emphasized. The child is either directly instructed not to tell anyone about the abuse, or the perpetrator is more subtle and convincing about the need for secrecy. The process of committing the actual sexual abuse typically involves progressive boundary violations. For example, first the perpetrator will simply be where they do not belong such as in the child’s bed or in the bathroom with the child. Such boundary violations progress to inappropriate touching of the child and so on. The sexual abuse expands from inappropriate looks, conversation, and touching to more and more intense abuse. Specifically, a child abuse accommodation syndrome (CAAS) has been identified among girls who have been repeatedly sexually abused by a male perpetrator over time. This syndrome involves stages of secrecy; helplessness; entrapment and accommodation; delayed, conflicted, and unconvincing disclosure; and retraction. The common experience of the victims recognized by the CAAS include the ideas that sexual abuse is almost always shrouded in secrecy and feelings of helplessness in the victim; fear and ambivalent feelings (especially toward a perpetrator who is a family member) cause victims to disclose abuse in delayed and unconvincing ways and often to recant their disclosure later; and it is common for sexually abused children to show little emotion about the abuse and to delay for long periods of time before disclosing the abuse.
Male and female children are about equally likely to experience neglect and physical abuse. Girls are almost five times more likely than boys to be sexually abused. Boys are more likely to be sexually abused by male nonfamily members such as teachers or coaches, whereas girls are more likely to be sexually abused by male family members. Thus, girls and boys have different patterns of vulnerability that should be taken into account for prevention purposes.
No group of children is immune from child abuse, and children of all ages experience abuse. Younger children from birth to 3 years old have the highest rates of victimization; they comprise the largest number of neglect cases (which is the most common form of abuse.) It is theorized that abuse rates drop with older children who are better able to understand what is happening and to disclose the abuse to others. One exception to the decline in abuse rates with age occurs with sexual abuse. The median age for female sexual abuse victims is 11 years and for males it is 8 years. Half of all victims of abuse or neglect are white, 24.7% are African American, about 14.2% are Hispanic. American Indian/Alaskan Natives make up 1.6% of victims, and Asian/Pacific Islanders account for 1.4% of victims.
Signs of Abuse
A child may show signs of being abused, including nervousness around adults; avoidance or fear of going home; low self-esteem; aggressive or sexual themes in their art, play, or interactions with others; developmentally inappropriate knowledge of or interest in sex; frequent physical injuries; and poor hygiene and grooming. Having many psychosomatic complaints (such as headaches, stomachaches) and difficulty sleeping, especially nightmares, is also common but in no way unique to abuse.
For physical abuse, injuries that are in the shape of a specific object (such as a belt buckle or a handprint) are suspect, as is a discrepancy between the parent’s and the child’s accounts of how the injury occurred. For sexual abuse specifically, genital or rectal pain, redness, itching, swelling, and sexually transmitted diseases are all strong indicators of possible sexual abuse. Regressive behavior and the occurrence of accidents after being solidly potty trained frequently signals the onset of some stressor strongly impacting a child.
The most tragic result of child maltreatment is the death of a child. Annually in the United States, an estimated 1,300 child deaths result from abuse and/or neglect. Fatalities are composed primarily of very young children, with more than 84% being less than 6 years old. The most common age of death is infancy (birth to younger than 1 year), which makes up more than 40% of the fatalities. Fifty-six percent of the deaths are male children, with the remaining 44% female. Neglect and/or the combination of both neglect and physical abuse cause almost all of the fatalities. For 82.8% of the total fatalities occurring annually, the abuse/neglect is perpetrated by one or both parents. Only a small percentage occurs when the child is in an out-of-home placement such as a foster home, group home, or residential treatment setting, although it is not rare for children to be abused and maltreated in such settings.
Physical Abuse and Neglect
Maltreatment is linked with poverty and economic disadvantage. Conditions associated with lower socioeconomic status such as limited child care options, crowded and substandard housing, and limited access to adequate health care provide the backdrop for maltreatment. Parents account for more than 78% of all abuse or neglect cases, which is not surprising in that they are the primary caretakers of children. Parents who are physically abusive or neglectful often come from homes in which they also were abused and neglected. This is part of a multigenerational cycle of abuse. Therefore, these parents lack successful, positive parenting role models. On average, most abusive parents are young—in their 20s— near or below poverty level, lack high school education, and have been victims of childhood abuse themselves. These parents lack economic resources and social support and have inadequate coping skills. They are isolated, perhaps living away from or estranged from family and friends. However, it is important to remember that no profile fits all abusers, and abuse permeates across gender, all races/ethnicities, and all social classes. Abusive and neglectful parents generally interact less with their children. They often appear uninvolved or uninterested in the care and well-being of their children. They may also appear overly critical of their children and very rigid about discipline. A major risk factor for violence in any home is active substance abuse by a parent. Forty percent of known cases of child abuse and neglect involve substance abuse.
Physical abuse can be triggered by stresses related or unrelated to the child. Stressors related to the child include excessive crying, such as with a young child or an infant with colic, feeding or potty training challenges, unrealistic expectations of a child, and holding highly exaggerated perceptions of the child’s disobedience. Stresses unrelated to the child include economic, housing, or personal problems, loss of a job or a loved one, physical or mental illness of the parent or caregiver, and legal difficulties. In addition to active substance abuse in the home, another major risk factor for child abuse is domestic violence. Children who live in homes where a male caregiver is physically abusive to another adult in the home are at severe risk for being victims of physical abuse as well.
Perpetrators of sexual abuse are also referred to as child molesters or pedophiles. Sexual abuse is perpetrated more than 90% of the time by males. The vast majority of cases are committed by someone who is known to the child, and as much as 80% of these cases involve a family member such as a father, stepfather, or uncle. Moreover, the child who is sexually abused by a family member is likely to experience repeated and more severe levels of abuse than those children abused by nonfamily perpetrators. As a result of the repetitive and severe nature of the abuse as well as the emotional betrayal of the adult family member who perpetrates the abuse, these cases also tend to result in more serious psychological damage and consequences for the child.
Perpetrators of sexual abuse often have deviant sexual arousal patterns that emerged in adolescence. Many of them have specific gender and/or age preferences for victims. Other than the large majority of sexual abusers being male, no other characteristics such as personality traits, occupation, or age can be used to predict who is an abuser.
Consequences Of Abuse
Child abuse and neglect do not affect all children in the same way. The impact of the abuse on the child depends on the nature, severity, and length of time over which the abuse occurred, as well as the child’s temperament, personality, and level of functioning prior to the onset of the abuse. The level of emotional support and assistance received by the victim is also critical. Whether the child has just one positive, consistent, and nurturing relationship with a person in his or her life has been shown to significantly mediate or protect the child from the potential effects of the abuse.
Abuse can seriously interfere with a child’s normal development, resulting in emotional and behavioral symptoms in the child. Chronic, repeated abuse, especially by a parent, may interfere with a child’s ability to formulate an attachment or bond with a parent. Later, these children have difficulty establishing healthy, reciprocal emotional connections with others.
Children who are abused or neglected also tend to have difficulty coping with their own emotions. They are likely to have inhibited emotional expression and may engage in unusual, maladaptive, and self-injurious behaviors, such as cutting themselves or abusing substances. Children who are abused are at severe risk for developing a wide array of psychological disorders. Girls who have been abused tend to develop more shame, self-blame, and internalizing disorders such as anxiety and mood disorders. Boys tend to show more problems associated with acting-out behavior such as physical and verbal aggression and defiance and the development of conduct disorders. These girls and boys lack self-esteem and positive beliefs about themselves and their world. Frequently they feel like they are unworthy of love and blame themselves for the abuse.
In general, maltreated children evidence one of two patterns in their peer relationships. The first pattern is one of hostility. Abused children, especially in the case of physical abuse, tend to interpret ambiguous or even friendly behaviors as hostile or threatening. They are more physically and verbally aggressive toward others and tend to have limited social networks, with aggressive and attention-seeking behaviors. The second pattern, associated with neglect, involves withdrawal and avoidance of peers. Such children are withdrawn, passive, and therefore as socially isolated as the children who display the aggressive pattern.
Abuse interferes with a child accomplishing what is developmentally expected of them, including impairing academic achievement. It is common for abused children to have poor grades. A dramatic drop in grades can be a strong indicator of the onset of some significant stressor in a child’s life.
Not all abused or neglected children develop psychopathology that can follow them throughout adulthood. Yet, all are at increased risk for doing so. The negative outcomes stemming from abuse can be avoided if children receive social support from nonoffending family members in addition to other intervention. However, without such support and the opportunity to develop healthy coping and interpersonal skills as well as a renewed ability to trust others who are worthy, these children are at tremendous risk for developing mood disorders (such as clinical depression and even suicidal behavior), posttraumatic stress disorders and other anxiety disorders, dissociative disorders, sexual adjustment problems in adulthood, and criminal and antisocial behavior.
Parents and caregivers most in need of treatment because they are perpetrating child abuse are actually the least likely to seek it. Child abusers may feel shame and guilt and fear losing their children. Abusers who are non–family members fear criminal repercussions. Most often, treatment only comes as the result of legal mandate once the abuse is discovered.
Since the 1960s in the United States, a protective, social work approach to child maltreatment has been the prevailing standard. Currently all 50 states and the District of Columbia have mandatory reporting laws that require professionals and other individuals who work or interact with children to report suspected abuse to child protective service (CPS) agencies. False and malicious reporting occurs and is highly problematic.
Many CPS agencies have child protection teams (CPTs). These are multidisciplinary teams that are called into action immediately when a reasonable suspicion of child abuse has come to light. The CPT includes pediatricians who are trained in the medical examination of a possible victim and mental health clinicians who are trained in how to conduct forensic interviews to address the possibility of abuse. Clinical social workers and clinical psychologists on the team coordinate evaluation of parents, treatment planning for the perpetrators and victims, and referrals for all necessary services.
The prevailing philosophical emphasis related to the mandatory reporting legislation and child protective services for within-family abusers is family preservation (maintaining a child in the home rather than removal whenever possible), which is considered to be in the best interests of most abused children (except in extreme, horrific, or treatment-resistant cases) as well as cost effective compared with out-of home placement of children in foster care, group homes, or other residential settings. More evaluation and research on the outcome of these programs is needed in order to determine their effectiveness in rehabilitation of the abuser and treatment effectiveness with the abused children.
In the United States, family preservation programs are modeled after the Washington State Homebuilders Program. These programs provide individualized treatment plans for each family. Treating abusive or neglectful parents frequently involves counseling multiproblem, complicated families. Counseling interventions are intensive and frequently referred to as “wraparound” services. Treatment for the abusers commonly involves individual and group counseling, including strong parent education and counseling in relaxation training, stress and anger management skills, cognitive restructuring to assist the parent in interpreting and responding to the child’s behavior more appropriately, problem-solving skills, and training in basic child-rearing skills. Parents are provided with exposure to positive parenting models and skills and may practice them through role playing and coaching from a clinician. Abusive parents may also need intensive substance abuse/dependency intervention, assistance with job training, and other social and financial assistance. Neglectful parents also frequently require training in how to manage everyday demands of living such as money management and housekeeping. Neglectful parents need to break a cycle of avoidance of interaction with their children and of daily responsibilities, replacing this with positive parent-child interactions and active care for their children and daily life responsibilities.
Treatment for the victims of abuse is also important. For children who have been physically abused, play therapy, individual therapy, group therapy with other children, and on-site therapeutic interventions at the child’s school, day care, and home focus on rebuilding the child’s battered self-esteem and self-concept. Related goals include restoring the child’s sense of self-efficacy (sense of power or ability to have some control over themselves and their environment) and improving the child’s social behavior, cognitive development, and academic achievement.
For sexually abused children, treatment is aimed at helping the child realize that what they experienced was abuse, that it was wrong, and that it was not their fault. These children need to slowly, in a paced manner and safe environment, share and release their memories and feelings about the trauma in order to prevent or extinguish posttraumatic-stress-related symptoms and alleviate guilt, shame, and self-blame. As is the case with physical abuse, rebuilding the child’s self-esteem is an important therapeutic goal, as is helping the child to regain a sense of safety. Educating the child about sexual abuse and ways to prevent it from occurring (“I know I can tell my mommy if anyone tries to touch my private parts, or makes me feel uncomfortable”) is important.
In relation to the treatment of sexual abusers, unfortunately the outcomes of treatment programs are poor, with very high recidivism rates. Thus, the criminal court systems tend to focus on incapacitation (removing access to victims) and retribution. Research into treatment options is expanding, as is the availability of prison treatment programs for pedophiles, despite limited treatment success at this time.
In the area of prevention of child abuse, prevention can occur at the cultural level. Cultural violence, as evidenced by strong violence in the media, has been linked as a promoter of violence within families. On a cultural level as well, the link between poverty and child abuse has been established. Thus, efforts to reduce cultural violence and poverty are theorized to have a direct impact on the welfare of children.
Breaking the multigenerational cycle of violence is a direct way to prevent future child abuse. Because many abusers were abused themselves, these individuals need specific intervention before or while being parents in order to prevent the cycle from perpetuating. Because substance abuse is also so strongly linked with child abuse, substance abuse prevention and intervention with parents is another way to prevent child abuse.
Prevention and education services aimed directly at future parents have a strong impact as well. Prenatal medical care protects the health of the new mother and allows her to be in a better state to care for a baby. Prenatal programs, family-centered birthing and coaching classes, infant care classes, and parenting classes do everything possible to educate and prepare parents for the demands of caring for a baby, with the goal also of facilitating emotional bonding between the infant and the family. Careful attention by the medical profession and the members of a new mother’s support system is recommended, so that postpartum psychological symptoms and disorders can be treated, preventing neglect and maltreatment of the infant, and alleviating the mother’s intense suffering caused by these often unrecognized and untreated disorders.
Support groups, parenting education, and community programs can also assist in relieving parental stress. Food banks, shelters, thrift stores, and emergency assistance programs can provide some help to parents. Some communities even offer respite child care services where parents who are on the verge of abusive actions can leave their children temporarily. Schools provide safety education to children (programs on topics such as stranger danger) and teach children what to do if they are being abused. The National Child Abuse Hotline at 1-800-422-4453 is available for all members of the community.
Despite increased preventative and intervention services and strong public awareness and concern about child abuse, this problem is far from going away. Only through continued education of parents and changes at all levels of society can the problem of child abuse be prevented and eliminated.
- Childhelp (n.d.). Treatment and prevention of child abuse. Retrieved from http://www.childhelpusa.org/hotline.htm
- Connelly, E. R. (2000). Child abuse and neglect: Examining the psychological consequences. Philadelphia: Chelsea
- Dorne, K. (2002). An introduction to child maltreatment in the United States: History, public policy and research (3rd ed.). New York: Criminal Justice Press.
- Finkelhor, (1994). Current information on the scope and nature of child sexual abuse. Future of Children, 4, 31–53.
- Finkelhor, , & Dzuiba-Leatherman, J. (1994). Victimization of children. American Psychologist, 49, 173–183.
- Grapes, J. (Ed.). (2001). Child abuse: Contemporary issues. San Diego, CA: Greenhaven.
- National Clearinghouse on Child Abuse and Neglect Information, http://nccanch.acf.hhs.gov
- Ney, T. (Ed.). (1995). True and false allegations of child sexual abuse: Assessment and case management. New York: Brunner/Mazel.
- Schwartz-Kenney, M., McCauley, M., & Epstein, M. A. (Eds.). (2001). Child abuse: A global view. Westport, CT: Greenwood.
- Sgroi, M. (Ed.). (1982). Handbook of clinical intervention in child sexual abuse. Lexington, MA: Lexington Books.
- Sgroi, S. M. (1988). Vulnerable populations: Evaluation and treatment of sexually abused children and adult survivors, Volume I. New York: Free
- Summit, C. (1983). The child sexual abuse accommodation syndrome. Child Abuse & Neglect, 7, 177–193.
- S. Department of Health and Human Services, Administration for Children and Families. (n.d.). Children’s Bureau fact sheets and reports/publications. Retrieved from http://www.acf.hhs.gov/programs/cg/publications