26. Child Abuse

If child abuse is not the most serious crime facing our society today, it is certainly one of the most heart-wrenching. There are many attempts under way to remedy the underlying causes of child abuse, but, until it is eliminated states have unanimously responded with laws specifically designed to identify and punish child abusers.

Child abuse is an insidious type of crime where the victims are, for many reasons unable to, or are fearful of confronting or reporting the perpetrator to authorities. Therefore, the laws surrounding abusive activity contain an element not found in many other criminal statutes. Under the laws of many states, third parties with knowledge of, and reasonable cause to believe that abuse has occurred, are under a legal obligation to report the situation to the authorities.

The reporting provision is the most controversial and the most problematic of this area of the law. In our society, many relationships are held in particularly high regard and communications in those relationships are given special protection. For example, the law seeks to encourage communication between patient and doctor, client and attorney, and congregant and clergy, and protects the content of any communication between them from discovery by third parties by providing a “privilege,” or a rule, that prohibits the doctor, lawyer or clergy from revealing the content of any communications that take place within that particular professional relationship. There are also certain occasions, not covered by the privilege where parties may presume their relationship to be confidential, such as between parent and teacher. Under the child abuse laws for some of these relationships, the professional in such relationships must now report any known or suspected abusive behavior to the proper authorities.

Virtually every state requires doctors, teachers, day care providers and law enforcement officers to report child abuse, but there is less uniformity among the states with regard to lawyers, clergy, therapists, or counselors. A few states require commercial photographic film processors to report to the proper authorities evidence of abusive activity. Some states are very specific in stating exactly who may be protected by the privilege, but some are noticeably vague. This is because the privilege itself is considered so important that a general abrogation of the privilege may be generally detrimental to the important relationships involved. For example, some states require health care professionals to report incidences of abuse, while others list as many as 20-29 professions, including dentists, chiropractors, nurses, hospital personnel and Christian Science practitioners.

The loss or abuse of privilege is not the only controversial or problematic provision of these laws. In many states, the definitions of what constitutes abuse is so broad as to cover a number of different circumstances, including some that may not be abusive at all. Coupled with the fact that in many states one need only have a reasonable suspicion that abuse has occurred in order to report it to the authorities, the laws have left many people fearful that innocent behavior may be misinterpreted by well-meaning, or worse, ill-meaning, private citizens.

The agency to whom suspected abuse is reported is often a state child protection office that is not hindered by the same constitutional restrictions to which traditional law enforcement agencies are subject. These agencies are sometimes allowed to take custody of children prior to actually proving that abuse has occurred. This is done in order to protect the child in question from potential abuse when the agent believes that there is a strong likelihood that the child will be, or continue to be harmed. Some critics of these laws fear the potential of extreme invasions into relationships between parent and child on the basis of very little evidence. Indeed, there have been cases where significant charges of child abuse have been made against individuals and severe action taken against them, such as children taken away from parents, day care centers closed down, only to have the charges later dismissed as lacking any concrete evidence whatsoever. For these reasons most states have passed laws that impose penalties not only for failure to report suspected abuse, but also for false reporting.

In the last few years state laws have changed in two significant ways. Several more states have added enticing or forcing children into sexually exploitive activity to the definition of child abuse. This represents a new definition of abusive activity distinct from sexual abuse. Obviously this new definition results from increased attention being given to child pornography. Another change is the addition of pre-natal child abuse to the state statutes of South Dakota, Wisconsin and, arguably, Texas. These provisions raise some difficult questions (to the modern mind at least) about the definition of a “child” in the eyes of the law. It is very likely that these laws may find their way into the courts for further definition.

Child Abuse

physical abuse and neglectbeth m. schwartz-kenney, michelle mccauley

psychological maltreatmentstuart n. hart, marla r. brassard, nelson j. binggeli, howard a. davidson

sexual abusekathleen kendall-tackett

PHYSICAL ABUSE AND NEGLECT

Child abuse and neglect is a social problem faced by individuals and societies around the world; however, few works exist that compare this problem across national boundaries. The International Society for the Prevention of Child Abuse and Neglect (IPSCAN) is an international organization focused on prevention and treatment issues associated with child abuse and neglect, and provides researchers in a number of disciplines with the opportunity to communicate about global issues of child abuse. One forum for this communication is Child Abuse and Neglect: The International Journal. One text, Child Abuse: A Global Perspective, by Beth Schwartz-Kenney, Michelle McCauley, and Michelle Epstein (2001), takes an extensive global view of all areas of child abuse among sixteen countries worldwide. This comparative perspective describes the nature of child abuse within each country and the countries' responses to abuse with regard to prevention and treatment.

Defining Child Physical Abuse and Neglect

The definition of abuse and neglect is difficult to determine even within a particular country. For example, Joaquín De Paúl and Olaya González (2001) note that before 1987 professionals in Spain could not reach an agreement concerning how one should classify child maltreatment cases: There was no commonly used definition of child abuse and neglect. Given the many cultural and societal influences affecting the way in which a country defines abuse, defining abuse globally is obviously a formidable task, although definitions of abuse and neglect do contain commonalities across countries. Child maltreatment includes both the abuse and neglect of a child, two different types of problems with slightly different causes, perpetrators, and outcomes. Furthermore, abuse occurs in a number of different forms including physical abuse, psychological maltreatment, and sexual abuse. These categorizations of abuse are fairly common across cultures.

Physical abuse often is described as a situation in which a child sustains injury due to the willful acts of an adult. This type of abuse can be defined very loosely, where abuse is defined as the illtreatment of children. However, the definition may be as specific as stating that the injuries are inflicted by particular acts such as hitting, biting, kicking, or slapping; and/or occur through the use of objects such as belts, sticks, rods, or bats. These more specific definitions are usually the result of laws created to protect children. For instance in Spain the 21/87 Act improved the consistency of definitions used throughout the country in identifying child abuse (De Paúl and González 2001). In Israel in 1989 an amendment was passed known as the Law for the Prevention of Abuse of Minors and the Helpless. Specific types of abuse were defined within this amendment, creating a more definitive classification of each type of abuse in Israel (Cohen 2001). In many countries, the definition of physical abuse involves the presence of a physical mark created by intentional physical contact by an adult. One advantage of clear definitions is that they result in a more accurate reporting of physical abuse to authorities (Kasim 2001).

Physical abuse can also be a result of parental and/or school discipline in which a child is punished by beating or other forms of corporal punishment. It should be noted, however, that there are large cultural differences in the interpretation of corporal punishment as abuse. Many Western countries classify corporal punishment of any kind as physical abuse, although this is not true for the United States or Canada. In fact, twenty-three U.S. states allow corporal punishment in the public school system (National Coalition to Abolish Corporal Punishment in Schools 2001). Corporal punishment of children is also accepted in other countries. In Sri Lanka, caning a child is still a permitted form of punishment in government schools, and parents and teachers believe they have the right to impose corporal punishment (de Silva 2001). This is also the case in Kenya, where physical punishment is an acceptable way of disciplining children (Onyango and Kattambo 2001). In Romania 96 percent of the population are comfortable with beating a child as a form of discipline and do not feel that this beating would have any negative impact on the child's development (Muntean and Roth 2001). In India, Uma Segal (1995) examined the incidence of physical abuse defined as "discipline." Her results indicate that 57.9 percent of parents stated that they had engaged in "normal" corporal punishment, 41 percent in "abusive" discipline, and 2.9 percent in "extreme" discipline.

Physical abuse also includes acts of exploitation. This type of physical abuse is prevalent in a number of countries such as Sri Lanka, the Philippines, and Thailand where sexual exploitation of children is well documented (de Silva 2001). Exploitation is also seen in the form of child labor in a number of countries, such as India (Segal 2001), and in the conscription into the military of children in Sri Lanka (de Silva 2001). Finally, one less common form of psychical abuse results when a caretaker fabricates a child's illness, known as Munchausen Syndrome by Proxy. The pattern of events accompanying this syndrome often results in physical injury to the child (Wiehe 1996). Munchausen Syndrome by Proxy has been identified in a number of different countries (Schwartz-Kenney, Mc-Cauley, and Epstein 2001).

In the United States, following C. Henry Kempe and his colleagues' (1962) identification of battered-child syndrome, physical abuse was identified more objectively through the use of medical definitions. The Child Abuse Prevention and Treatment Act of 1974 led to a federal definition of child abuse and neglect. This Act provided definitions for all types of abuse and led to greater public awareness and response to problems associated to child maltreatment. This federal definition was changed in 1996 by the U.S. Congress. Child abuse and neglect in the United States is now defined as ". . . any recent act or failure to act on the part of a parent or caretaker, which results in the death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which present an imminent risk of serious harm" (42 U.S.C. §5106g[2] [1999]). This change gave greater discretion to the states, allowing each state to define abuse more broadly.

Child neglect also can take on a number of different forms. For instance a child's nutritional needs can be ignored, resulting in a deficient diet and, in turn, a "failure to thrive." This nutritional neglect is not necessarily intentional and may result from a parent's lack of knowledge regarding a healthy diet or from poverty. Physical neglect results when a child is not provided with adequate food, shelter, and clothing. Neglect can also come in the form of inadequate medical care, lack of proper supervision, and lack of educational opportunities. Finally, neglect also includes inadequate emotional care, where a child experiences a continuous lack of response to his or her crying or any other behavior in need of a response.

The type of neglect experienced by children is dependent upon the culture in which one lives. For instance, in India one problem still faced by many young women is child marriage. Due to extreme poverty, many girls are perceived as a financial burden to their families and are in turn forced to marry in exchange for money. In some cases, young women are sold to brothels. As Segal (2001) notes, under both circumstances these children are inevitably physically abused.

A very distinct type of neglect occurs in Japan, where coin-operated lockers have been a part of the problem. For years, unwanted children were placed in these lockers and, in many cases, died when not found in time. This became a serious social problem in the mid-1970s. According to Akihisa Kouno and Charles Felzen Johnson (1995), approximately 7 percent of infanticides in Japan during this period were of coin-operated locker babies. Since that time, this type of neglect has dropped dramatically due to an increase in locker inspection and relocation and to educational programs on contraception.

Abuse and neglect in Romania often takes the form of child abandonment, believed to be due to poverty, lack of education, and lack of assistance to families in need (Muntean and Roth 2001). Additional abuse and neglect takes place within the family given the existing living conditions. Ana Muntean and Maria Roth state that the "emotional, physical, and even sexual abuse is quite frequent within the Romanian-family system, as well as neglect" (p. 185).

Differences in prevalence of particular subtypes of abuse are therefore evident when examining child maltreatment from an international perspective. Although evidence of abuse can be found in all countries, how abuse is defined, prevented, and treated is often determined by social agencies such as the U.S. Department of Health. The definition itself is dependent upon the national boundaries in which the agency exists. One common thread within the prevalence data in most countries is that the individuals responsible for collecting these data often state that it is likely that the numbers underestimate the degree of child abuse due to the underreporting of incidents to legal authorities (Schwartz-Kenney, McCauley, and Epstein 2001).

Prevalence of Abuse and Neglect

Internationally, child abuse is more common than previously acknowledged. Historically, it was hard for many to believe that parents or caregivers would intentionally inflict harm towards their children. Thus, in many countries child abuse and neglect were often ignored or denied as a result of people's acceptance of violence in a given culture or due to their belief that the culture must focus on preserving the family (Schwartz-Kenney, Mc-Cauley, and Epstein 2001). Some cultures simply denied that child neglect or abuse occurred. For example, Mohd Sham Kasim (2001) states that in Malaysia the problem of abuse was at one time believed to be a problem only for Western cultures. This stemmed from the idea that the strong family ties and assistance from the extended family prevalent in Malaysia prevented the problem from occurring.

Internationally, it has always been the case that the culture had to acknowledge the problem of neglect and abuse before national organizations concerned with prevention and treatment could be created. Unfortunately, it took many years (often decades) before many societies recognized it as a problem worthy of governmental resources. As mentioned above, the noted physician C. Henry Kempe dramatically increased many countries' public awareness regarding the abuse and neglect of children in his lectures on the battered-child syndrome (Kempe et al. 1962).

The prevalence of each type of maltreatment is a question that can be answered in some countries but not others. For example, this type of data is available in the United States, Australia, Malaysia, and Ireland. Other countries, such as Canada, are studying this question, whereas others, such as Mexico and Romania, are grappling with how to identify children in need rather than placing their resources in the assessment of prevalence rates for each type of abuse. When comparing countries in which the numbers are available, it is evident that there are differences with regard to the prevalence of each type of abuse. For instance, in Australia, 31 percent of reports were of emotional abuse, 28 percent included physical abuse, 16 percent consisted of sexual abuse, and 24 percent represented neglect (Hatty and Hatty 2001). This is compared to the prevalence reports in Ireland, where 34 percent of reports involved sexual abuse, 8 percent included emotional abuse, 11 percent were identified as physical abuse, and 47 percent were of neglect (Ferguson 2001). In the United States, the Child Protective Services (CPS) state that neglect is the most prevalent type of maltreatment, accounting for 45 percent of all reports, followed by physical abuse in 25 percent of cases, sexual abuse in 16 percent of cases, and finally psychological abuse in 6 percent of all reports (Briere et al. 1996).

Thus, cultural differences significantly influence the way in which forms of abuse are defined and in turn the prevalence rates that result. Given differences in defining abuse, it is not surprising that the prevalence numbers such as those reported above differ dramatically from one country to the next. For instance, as Kouno and Johnson (2001) indicate, "the disparity between prevalence rates of report abuse cases in the United States and Japan may be the result of differences in lifestyle and reporting laws between Western countries and Japan" (pp. 102–103). Comparing abuse from one country to the next is a difficult task given the differences in definition, lifestyle, and legal system. In all cases, authorities believe the prevalence rates represent approximately one-third of all cases of child abuse because these statistics are based only on reported cases and therefore ignore the remaining two-thirds of all occurrences of maltreatment. With the introduction of mandatory reporting laws in numerous countries, however, these numbers are rising. In addition, an increase in public awareness of the problem of abuse and neglect directly relates to an increase in reporting of abuse to authorities.

Perpetrators and Families in which Neglect Occurs

Who is more likely to neglect a child? Researchers have examined the characteristics of families often associated with neglect. One finding is that the perpetrator of neglect in the United States and other Western countries is likely to be female (Ferguson 2001; Juvenile Justice Bulletin 1999). This may be a function of the fact that neglect is more likely to occur in single-parent families and homes in which the mother is young. Children born to women under the age of twenty in the United States are 3.5 times more likely to experience neglect and abuse than children born to older mothers (Lee and Goerge 1999). In addition, neglect occurs more often in families with mothers who are childlike in nature—for instance, those who are more dependent on others, act more impulsively, cannot assume responsibility for themselves or others, and show poor judgment. These mothers often receive very little social support, were neglected as children themselves, have higher rates of depression than the overall population, experience high degrees of stress, and were part of families that lived in environments that did not provide adequate mental and health services or educational facilities (Wiehe 1996). Domestic abuse has also been found related to maternal neglect in Western countries such as Ireland (Ferguson 2001) and the United States (Briere et al. 1996). Researchers have also found that children born to substance abusers are more likely to experience neglect and injury compared to children of non-substance abusers (Bijur et al. 1992). Concerning family factors, children of neglect were most often from families living in poverty, families without a father present (Ferguson 2001; Polansky et al. 1981) or with an unemployed male adult (Hawkins and Dunkin 1985), families with four or more children ( Juvenile Justice Bulletin 1999), and families in which the interaction between the children and adults was primarily negative (Wiehe 1996). All of these factors often lead to a parent's inability to adequately parent, resulting in neglect of one form or another.

Perpetrators and Families in which Physical Abuse Occurs

Researchers have identified a number of factors associated with the physical abuse of a child, such as the characteristics of individuals who abuse and the characteristics of families in which child abuse occurs. In the United States less than 10 percent of child abuse is committed by non-family members ( Juvenile Justice Bulletin 1999). Obviously, the non-family abuse rate may be higher in countries such as Sri Lanka where conscription into the military and child prostitution are greater problems (de Silva 2001). In addition, in the United States only 3 percent of child maltreatment occurs at day care facilities or other institutions (Prevent Child Abuse America 1997). This rate may be higher in countries such as Romania (Muntean and Roth 2001) and Russia where institutional abuse of children has been identified as a serious problem (Berrien, Safonova, and Tsimbal 2001).

In general, there are a number of individual perpetrator differences that predict abuse in the West. For instance, individuals who were abused as children are believed to be more at risk to become abusers as adults (Straus, Gelles, and Steinmetz 1980). Physical abuse is also more likely to occur in family situations in which parental knowledge of parenting skills is inadequate, when high levels of stress are present, when parents are very young, when parental expectations are too high regarding a child's behaviors, when substance abuse is present, and/or when adults in the family have low levels of empathy towards a child (Kolko 1996). Abuse is found more often in families with female children (Sedlack and Broadhurst 1996) and in families with four or more children ( Juvenile Justice Bulletin 1999). Finally factors such as economic distress, lack of social support, and cultural or religious values have been linked to incidences of physical abuse in most countries that have addressed this problem (Schwartz-Kenney, McCauley, and Epstein 2001).

Effects of Abuse and Neglect: Long-Term and Short-Term Effects

There is little cross-cultural data on differences in harm to victims of child neglect and abuse in different countries. However, when one looks at studies from different countries there are a number of similarities. In general, empirical studies indicate that various forms of child maltreatment negatively affect the victim's development physically, intellectually, and psychosocially (Kempe and Kempe 1978; Mullen et al. 1993). Child victims of neglect and/or abuse are 1.75 times more likely to experience posttraumatic stress disorder as adults compared to individuals who did not experience neglect and/or abuse (Widom 1999). In addition, child victims are more likely to experience depression, attachment difficulties, and low self-esteem (Kolko 1996). A Canadian study found that a history of child abuse was one of the leading predictors of psychological problems in adulthood (Mian, Bala, and MacMillan 2001). Many studies also indicate the long-term effects of maltreatment given the carry-over from one generation to the next (Zuravin et al. 1996).

Furthermore, there are particular risks and harm associated with certain types of abuse, which are more prevalent in certain countries. For example, in addition to the negative outcomes discussed above, conscription into the military carries with it the risk of physical injury or death. Being forced to work as a prostitute significantly increases the chance of becoming infected with HIV or other sexually transmitted diseases. In India, which has a very high rate of child labor, children are often forced to work in dangerous conditions at exhausting hours (Segal 2001).

Finally, in addition to the harm of neglect and abuse to the individual child, there is also a broader harm or cost to society as a whole. Researchers have established a link between experiencing neglect and abuse as a child and engaging in illegal and delinquent behaviors as a teenager and adult (Widom 2001).

Cultural Differences

One must take into account the vast cross-cultural differences that exist when defining any type of child maltreatment. By examining comparative data from a diverse group of cultures, perhaps cultural factors and social structures can be identified to help us gain a better understanding of factors that contribute to abuse and factors that might assist in effectively preventing abuse. Simple definitions of child abuse and neglect do not exist, although there are a number of similarities in definitions even across cultures. Regardless of the differences in how abuse is defined, the number of reports of abuse has risen dramatically in the last decade without the needed growth in staff to respond to this increase in reports. This clearly indicates the need for greater prevention, resources dedicated to staffing, and effective treatment of this worldwide social problem.

See also:Child Abuse: Psychological Maltreatment; Child Abuse: Sexual Abuse; Childhood; Children of Alcoholics; Children's Rights; Conduct Disorder; Depression: Children and Adolescents; Discipline; Failure to Thrive; Infanticide; Juvenile Delinquency; Munchausen Syndrome by Proxy; Parenting Styles; Posttraumatic Stress Disorder (PTSD); Power: Family Relationships; Runaway Youths; Spanking; Substance Abuse

Bibliography

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beth m. schwartz-kenneymichelle mccauley

PSYCHOLOGICAL MALTREATMENT

Children should be protected against all forms of child maltreatment, including physical or mental violence, injury, abuse, or neglect. Children who have been maltreated should be given all necessary support to achieve recovery. These principles now have nearly universal acceptance by virtue of the standards of Articles 3, 19, 34, and 39 of the United Nations Convention on the Rights of the Child (United Nations General Assembly 1989), a treaty ratified by 191 of the 193 recognized nations of the world.

There are two major types of child maltreatment: physical and psychological. Sexual abuse, generally a combination of the two major types, is primarily psychological in the nature of its acts and consequences. Psychological maltreatment is understood to occur alone as psychological abuse or neglect, to occur in association with other forms of abuse and neglect, and to be the embedded psychological context and meanings of other forms of abuse and neglect.

The present empirical and theoretical knowledge base for child maltreatment supports the view considering psychological maltreatment to be the unifying concept embodying many of the most significant components of child abuse and neglect (Binggeli, Hart, and Brassard 2001). Essential aspects of this knowledge base are presented in this entry.

Definition

The lack of an adequate definition of psychological maltreatment was a major obstacle to making progress dealing with the issue during the first decades of serious societal consideration of child maltreatment (1960–1990). Since the early 1980s recognizable advances have been made in articulating rationally defensible definitions of psychological maltreatment that have substantial professional and public support.

The first U.S. law on child abuse—Public Law 93–247, originally passed in 1974—included attention to psychological maltreatment under the category of "mental injury." Early attempts to elaborate this ambiguous category in national policy and state law were not adequate and resulted in a confusing diversity of terms and standards. Significant progress toward a useful definition occurred through the processes and outcomes of the International Conference on Psychological Abuse of the Child (Office for the Study of the Psychological Rights of the Child 1983); through conceptual and empirical research (Baily and Baily 1986; Brassard, Germain, and Hart 1987; Garbarino, Guttman, and Seely 1986; Hart and Brassard 1989–1991); and through the development of related standards by the American Professional Society on the Abuse of Children (APSAC) (1995). Concern about psychological maltreatment internationally is displayed in the laws of Sweden prohibiting emotional psychological abuse of children, and in the expansion of child protection law in Singapore to include "emotional injury" in the definition of when a child or young person needs care and protection (Children and Young Persons [Amendment] Act 2001; source: Ministry for Community Development and Sports, Singapore).

The term psychological maltreatment has come to be preferred to other labels (e.g., emotional abuse and neglect, mental abuse or injury). It includes both the cognitive and affective (psychological) meanings of maltreatment as well as perpetrator maltreatment acts of both commission and omission.

The strongest expert-supported definition of psychological maltreatment is presently in the APSAC Guidelines for Psychosocial Evaluation of Suspected Psychological Maltreatment of Children and Adolescents (1995). These guidelines include the following conceptual statement and psychological maltreatment categories:

• Psychological maltreatment means a repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs (p. 2).
• Psychological maltreatment includes: (1) spurning (i.e., hostile rejecting/degrading verbal and nonverbal caregiver acts that reject and degrade a child); (2) terrorizing (i.e., caregiver behavior that threatens or is likely to physically hurt, kill, abandon, or place the child or child's loved ones or objects in recognizably dangerous situations); (3) isolating (i.e., caregiver acts that consistently deny the child opportunities to meet needs for interacting or communicating with peers or adults inside or outside the home); (4) exploiting/corrupting (i.e., modeling, permitting, or encouraging antisocial behavior); (5) denying emotional responsiveness (i.e., caregiver acts that ignore the child's attempts and needs to interact and show no emotion in interactions with the child); and (6) mental health, medical, and educational neglect (i.e., ignoring the need for, failing, or refusing to allow or provide treatment for serious emotional/behavioral, physical health, or educational problems or needs of the child).

These six categories of psychological maltreatment are further delineated through detailed subcategories that clarify their meanings (APSAC 1995). Empirical and conceptual support for these categories and definitions will be found in child-study research (Rohner and Rohner 1980; Claussen and Crittenden 1991; Egeland and Erickson 1987; Binggeli, Hart, and Brassard 2001); and in expert- and public-opinion research (Burnett 1993; Portwood 1999).

Incidence and Prevalence

Incidence of maltreatment generally refers to the number of new cases coming to the attention of authorities within a given year. Prevalence represents the total number of people in a sample who have ever experienced the maltreatment.

The true incidence of psychological maltreatment is unknown. The best available estimates of the incidence of psychological maltreatment come from findings of the National Incidence Study and research on verbal aggression. The National Incidence Study of the Federal Office on Child Abuse and Neglect (Sedlak and Broadhurst 1996) applies both an existing Harm Standard and a projected Endangerment Standard in gathering data from local social service, health and law enforcement professionals, and child welfare agencies. Data for 1993 supported estimates of more than 1.5 million children abused or neglected under the Harm Standard and three million under the Endangerment Standard, with approximately 532,000 of these children emotionally abused and 585,100 emotionally neglected. High annual levels of verbal/symbolic aggression (defined as "communication intended to cause psychological pain to another person, or a communication perceived as having that intent," [Vissing et al. 1991, p. 224]) were found in a telephone survey of the tactics used by a national sample of 3,458 parents to deal with conflicts in relations with their children. Over 11 percent if the children were reported to have experienced an average of more than two such incidents per month, whereas 63 percent experienced at least one such incident per year (Vissing et al. 1991).

Prevalence estimates can be made from data collected in studies of the childhood-experience histories of adults, retrospectively surveyed, using definitions similar to those in the APSAC Guidelines (1995). Nelson Binggeli, Stuart Hart, and Marla Brassard (2001) concluded, from reviews of such studies, that over one-third of the adult population has had significant psychological maltreatment experiences and that 10 to 15 percent of the adult population has suffered chronic or severe psychological maltreatment. Confidence in these estimates is further supported by the facts that the definitions used in these studies were fairly conservative, the types were considered appropriate by both researchers and community representatives, and it is more likely that the subjects minimized rather than exaggerated their maltreatment histories.

Evidence of Impact

Evidence that psychological maltreatment is a threat and destructive to the well-being and development of children is vital to producing the societal concern and interventions necessary to combat it. Until recently, however, the relationship between psychological maltreatment and negative developmental consequences for victims have had to be accepted as somewhat speculative because the construct was not well defined.

The existence of the broadly supported definitions for spurning, terrorizing, isolating, corrupting/exploiting, and denying emotional responsiveness has made it possible to carry out more rigorous reviews of related research literature. The available knowledge base indicates that psychological maltreatment probably has the most severe, longest lasting, and broadest range of negative developmental consequences of any form of child abuse or neglect (with the exception of the killing of a child), and that it is the core component in child abuse (Hart, Brassard, and Binggeli 1998).

Longitudinal and cross-cultural research has identified psychological maltreatment as a significant contributor to the following conditions: children who become angry, assaultive, or aggressive; delinquent, criminal, and/or substance abusers; persons who feel unloved and inadequate; and persons who develop negative feelings and perspectives about the purposes and possibilities for enjoyment of life, including having a happy marriage and being a good parent (Egeland and Erickson 1987; Rohner and Rohner 1980). Studies comparing the effects of various forms of child maltreatment have documented that (a) combinations of verbal abuse and emotional neglect tend to produce the most powerfully negative outcomes; (b) psychological maltreatment is a better predictor of detrimental developmental outcomes for young children than is the severity of physical injury experienced by children; (c) psychological maltreatment is the indicator most related to behavior problems for children and adolescents, and is more strongly related to physical aggression, delinquency, or interpersonal problems than parental physical aggression; (d) psychological abuse is a stronger predictor than physical abuse of both depression and low self-esteem and, in particular, is strongly related to anxiety, depression, interpersonal sensitivity, dissociation (disruption in usually integrated functions of consciousness, identity, or perception of the environment), and low self-esteem; and (e) psychologically unavailable caretaking is the most devastating of all maltreatment forms (Briere and Runtz 1990; Claussen and Crittenden 1991; Egeland and Erickson 1987; Vissing et al. 1991).

Numerous studies have identified the possible effects of psychological maltreatment within families. This evidence found through these studies fits nicely within the conceptual framework used by the nation's schools to guide identification of child "emotional disturbance" (federal Individuals with Disabilities Act Law 94–142). Findings indicate relationships between psychological maltreatment and problems with intrapersonal thoughts, feelings, and behaviors (e.g., anxiety, depression, low self-esteem, negative life views, post-traumatic symptoms and fears, and suicidal thinking ); emotional problem symptoms (e.g., emotional instability, impulse control problems, unresponsiveness, substance abuse, and eating disorders); social competency problems and anti-social functioning (e.g., attachment problems, self-isolating behavior, low social competency, low empathy, noncompliance, dependency, sexual maladjustment, aggression and violent behavior, and delinquency or criminality); learning problems (e.g., decline in mental competence, lower measured intelligence, non-compliance, lack of impulse control, impaired learning, academic problems and lower achievement test results, and impaired development of moral reasoning); and physical health problems (e.g., allergies, asthma and other respiratory ailments, hypertension, somatic complaints, physical growth failure, physical and behavioral delay, brain damage, and high mortality rates) (Hart, Brassard, and Binggeli 1998).

Theoretical Perspectives

Psychological maltreatment is an interpersonal experience. The essential role of interpersonal relations in human development and need fulfillment establishes an inherent vulnerability to psychological maltreatment. Many of the major theories in psychology contain constructs that are related to psychological maltreatment, particularly in the way they describe critical factors of the developmental process susceptible to the influences of various kinds of interpersonal experiences. Human needs theory, psychosocial stage theory, attachment theory, parental acceptance-rejection theory, the coercion model and the prisoner of war model each have value for psychological maltreatment research and interventions. They clarify the ways in which psychological maltreatment interferes with need fulfillment and development processes and produce retardation and/or distortions in growth and behavior (Binggeli, Hart, and Brassard 2001).

Psychological Maltreatment and the Law

In general, psychological maltreatment has not led to coercive or punitive governmental intervention, unless it accompanied other forms of maltreatment. Judicial precedents on psychological maltreatment are, for most part, unavailable to courts because there have been few reported appellate court decisions on stand-alone psychological maltreatment. Child protection officials and judges must largely be guided by the relevant language in state laws. Current state laws indicates that the federal "mental injury" principle has proven difficult for many legislatures to define.

Some states have simply used the term mental injury—or some similar term—without further explanation. Other states have incorporated one or more of the following standards or requirements:

• The child has experienced serious psychological or mental injury caused by recognizable acts;
• Injuries must be observable, substantial, sustained, and identifiable impairments of the child's intellectual or psychological capacity or emotional stability;
• A child displays substantially diminished psychological or intellectual functioning;
• Failure to provide for a child's "mental or emotional needs";
• Application of a list of problem-related symptoms (see earlier lists of impact);
• Failure to provide needed health services;
• Expert witness opinion (e.g., a licensed physician or qualified mental health professional);
• Specific recognition of certain forms of psychological maltreatment (e.g., isolation through use of mechanical devices to physically restrain).

The psychological maltreatment experienced by children due to exposure to domestic violence in the home is an emerging area of concern. Evidence of negative child-impact from observed domestic violence is growing (Hughes and Graham-Bermann 1998). California (Domestic Violence Unit 1999) has taken deliberate efforts to work toward identifying and serving domestic violence–exposed children as abused.

Despite the myriad of potential statutory variations for legal intervention where psychological harm has been inflicted upon children by their parents, it should be possible for judicial and CPS agency efforts to be applied to psychological maltreatment cases. For this to occur, it will require a change from the status quo: child welfare agency personnel, attorneys, and juvenile court judges will need to be educated on psychological maltreatment (Hart et al. 2001).

Interventions for Psychological Maltreatment

Substantial progress has been made in guiding assessments in cases of suspected psychological maltreatment of children, whereas only small beginnings have been made in developing effective correction and prevention strategies. The APSAC Guidelines (1995) provides the best available framework for professionals in evaluations of suspected psychological maltreatment. The guidelines were designed to assist in case planning, legal decision making, and treatment planning for psychological maltreatment that occurs as a powerful single instance or continual pattern, and maltreatment that occurs in isolation from as well as in conjunction with other forms of abuse and neglect. The Guidelines assist in making determinations of the nature and severity of psychological maltreatment, including extant or predicted developmental impact, through direct observation, interviews, review of records and collateral reports, and consultation. The Guidelines also help professionals apply ethical standards, weigh cultural factors, and report findings.

In general, the development of effective strategies for prevention and treatment of child maltreatment has been elusive, and psychological maltreatment has received relatively little direct attention in this regard. Intervention models applied to perpetrators and families that have shown improved outcomes have devoted resources (e.g., reduced client load, highly trained and well-supervised therapists, and many client contact hours) well beyond those usually available to child protective services or contracted private agencies. Although the development and study of specific treatments for children has genuine potential, according to existing research findings, it remains uncommon. Available research does indicate that children generally experience greater treatment gains than adults and provides unquestionable evidence of intergenerational transmission of child maltreatment.

It appears wise to give prevention the top intervention priority for child maltreatment, and particularly for psychological maltreatment because it is such a pervading, insidious, and powerfully destructive force. Studies of resilience have identified affiliation and self-efficacy (i.e., realistic confidence in one's competence to deal effectively with life's challenges and opportunities) as necessary to support healthy development under difficult conditions. Prevention and correction are well served by programs supporting development of secure attachment to adult caretakers through sensitive, responsive parenting and pre-school and elementary school teacher-student relations; through modeling and promoting appropriate childcare and interpersonal skills for parents and children; and through helping children develop a genuine sense of practical competence in school and community play and work, including problem solving and conflict resolution. Progress can be made if high quality intervention research and effective programs are supported through societal commitment and funding.

See also:Child Abuse: Physical Abuse and Neglect; Child Abuse: Sexual Abuse; Childhood; Children's Rights; Conduct Disorder; Depression: Children and Adolescents; Interparental Violence—Effects on Children; Munchausen Syndrome by Proxy; Parenting Styles; Power: Family Relationships; Runaway Youths; Spanking

Bibliography

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hart, s. n., and brassard, m. r. (1989–1991). final report(stages 1 and 2). developing and validating operationally defined measures of emotional maltreatment: a multimodal study of the relationship between caretaker behaviors and children characteristics across three developmental levels (grant no. dhhs90ca1216). washington, dc: department of health and human services and national center for child abuse and neglect.

hart, s. n.; brassard m. r.; binggeli, n. j.; and davidson,h. a. (2002). "psychological maltreatment." in the apsac handbook on child maltreatment, 2nd edition, ed. j. e. b., myers, l. berliner, j. briere, c. t. hendrix, c. jenny, and t. a. reid. thousand oaks, ca: sage publications.

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rohner, r. p., and rohner, e. c. (1980). "antecedents and consequences of parental rejection: a theory of emotional abuse." child abuse and neglect 4:189–198.

sedlak, a. j., and broadhurst, d. d. (1996). the third national incidence study of child abuse and neglect. washington, dc: u. s. department of health and human services, administration for children, youth, and families.

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vissing, y. m.; straus, m. a.; gelles, r. j.; and harrop,j. w. (1991). "verbal aggression by parents and psychosocial problems of children." child abuse and neglect 15:223–238.

stuart n. hartmarla r. brassardnelson j. binggelihoward a. davidson

SEXUAL ABUSE

Each year, thousands of boys and girls are sexually abused. The effects of this abuse can last a lifetime. The American Academy of Pediatrics (1991) defines sexual abuse as "engaging of a child in sexual activities that the child cannot comprehend, for which the child is developmentally unprepared and cannot give informed consent, and/or that violate the social and legal taboos of society" (p. 254).

Sexual abuse accounts for 12 percent of the one million substantiated cases of child abuse and neglect annually (Reece 2000). Approximately 20 percent of adult women, and 5 to 10 percent of men have been sexually abused as children. The peak age of vulnerability to sexual abuse is between seven and thirteen years of age, but children older or much younger have been abused (Finkelhor 1994). Girls are approximately three times more likely to be sexually abused than boys (Sedlak and Broadhurst 1996). The overwhelming majority of victims know their abusers. Girls are more likely to be abused by family members, and boys by friends of the family (Kendall-Tackett and Simon 1992).

The Effects of Sexual Abuse

The effects of sexual abuse are its most highly studied aspect—and its most political. Some claim sexual abuse is always harmful. Others maintain that some children actually benefit from these sexual experiences. And some children show no symptoms at all (Kendall-Tackett, Williams, and Finkelhor 1993). Allegations of abuse also raise legal and custody issues.

Short-term effects. Children experience a wide range of symptoms after they have been sexually abused. Some symptoms show up immediately, and others appear as delayed responses. Still others get better over time. Traumatic events, including sexual abuse, can alter the brains of children, and the effects may not be obvious for several years (Perry 2001).

Posttraumatic stress disorder (PTSD) is common, but not specific to sexual abuse. Sexualized behavior is the most characteristic symptom, but not one that every child manifests. It is also one of the more disturbing symptoms and includes public masturbation, sexual play with dolls, and asking other children and adults to participate in sexual activity.

Symptoms by age of child. The symptoms that children manifest also vary by age of the child. For example, preschool-age children are more likely to experience anxiety, nightmares, or sexual acting out. Common symptoms for school-age children include fear, aggression, school problems, hyperactivity, and regressive behaviors. Adolescents are more likely to be depressed, attempt suicide, abuse substances, or participate in illegal behaviors. Symptoms often change over time. For example, a preschooler who is sexually acting out may become an adolescent with multiple sexual partners (Kendall-Tackett et al. 1993).

Long-term effects. The effects of child sexual abuse can continue well into adulthood. Symptoms adult survivors manifest are often logical extensions of dysfunctional coping mechanisms developed during childhood. While these dysfunctional behaviors may have helped the child cope with on-going abuse, they have a negative impact on adult functioning. Long-term effects can be divided into seven categories (Briere and Elliot 1994; Kendall-Tackett and Marshall 1998):

• Posttraumatic stress disorder (PTSD). Post-traumatic stress disorder (PTSD) is a commonly occurring symptom among adult survivors of sexual abuse. According to John Briere and Diana Elliot (1994), 80 percent of abuse survivors have symptoms of PTSD, even if they do not meet the full diagnostic criteria. These reactions include hypervigilance, sleep disturbances, startle responses, intrusive thoughts, and flashbacks.
• Cognitive distortions. Sexual abuse survivors often learn to perceive the world as a dangerous place. These cognitive distortions make them more vulnerable to both re-victimization and depression because they believe they are powerless to change their lives.
• Emotional distress. Emotional distress is another common symptom among adult survivors. Sexual abuse survivors have a lifetime risk of depression that is four times higher than their nonabused counterparts. They may also experience mild-to-severe anxiety and anger on a regular basis.
• Impaired sense of self. Survivors may have difficulty separating their moods and emotional states from the reactions of others. If their partners are depressed or angry, survivors are too, without necessarily considering whether they really feel the same way. Impaired sense of self can also inhibit self-protection, increasing survivors' risk of re-victimization.
• Avoidance. Avoidance includes some of the more serious sequelae of past abuse. Survivors may experience dissociation, which includes feeling separated from their bodies, emotional numbing, amnesia for painful memories, and multiple personality disorder. Other types of avoidant behavior are substance abuse, suicidal ideation and attempts, and tension-reducing activities, including indiscriminate sexual behavior, bingeing and purging, and self-mutilation.
• Interpersonal difficulties. Adult survivors may have problems with interpersonal relationships. They may adopt an avoidant style, characterized by low interdependency, self-disclosure, and warmth. Or they may adopt an "intrusive" style, characterized by extremely high needs for closeness, excessive self-disclosure, and a demanding and controlling style. Both styles result in loneliness (Becker-Lausen and Mallon-Kraft 1997).
• Physical health problems. Adult survivors have substantially higher rates of health care use than their nonabused counterparts. Pain syndromes are the most common type of illness and include irritable bowel syndrome, fibromyalgia, headache, pelvic pain, and back pain. Adult survivors also had overall lower satisfaction with their physical health than their nonabused counterparts (Kendall-Tackett 2000).

Differences in Response to Sexual Abuse

Reactions to child sexual abuse can vary tremendously depending on the child, the family, whether it was reported to law enforcement, and the types of support that were available after disclosure. Responses can also vary by both characteristics of the abuse and ethnicity of the child.

Characteristics of the abuse. Characteristics of the abuse itself can also exert an influence on how people react. Some people are more seriously affected by abuse because their experiences were more severe. In general, abuse will be more harmful if the abuser is someone the child knows and trusts, and the abuse violates that trust. Abuse that includes penetration (oral, vaginal, or anal) often leads to more symptoms. Abuse that occurs often and lasts for years will typically be more harmful than abuse that happens only sporadically and over less time. The exception is the one-time violent assault (Berliner and Elliot 1996; Kendall-Tackett et al. 1993).

Differences among ethnic groups. Researchers have identified some specific ethnic-group differences in both characteristics of abuse and in reactions to it. Although no clear patterns have emerged, there are enough differences for professionals to understand the importance of ethnic group identity and meaning of sexual abuse in a culture.

Asian children tend to be older at the onset of victimization than non-Asians. African-American children tend to be younger at onset than either their Asian or Caucasian counterparts (Berliner and Elliot 1996). African-American victims have approximately the same rates of victimization as Caucasian children, but are more likely to experience penetration as part of their victimization experience (Wyatt 1985). The overall rates of sexual abuse are lowest for Asian women, but high for Hispanic women, when reported retrospectively (Russell 1984). In a sample of 582 Southwestern American Indians, rates of sexual abuse were high, especially among females. Forty-nine percent of females in the sample and 14 percent of males reported a history of sexual abuse. Seventy-eight percent reported intrafamilial abuse (Robin et al. 1997). Worldwide, rates of child sexual abuse have similar ranges (from low to high). According to the World Health Organization (1999), in studies from nineteen countries, including South Africa, Sweden, and the Dominican Republic, rates of sexual abuse range from 7 percent to 34 percent for girls, and from 3 percent to 29 percent for boys. Some of these differences in range are due to varying definitions of sexual abuse from country to country and the accuracy of the reporting system.

Culture and ethnicity also appear related to how symptomatic abuse survivors become in the wake of their abuse experiences. Ferol Mennen (1995) found that Latina girls whose abuse included penetration were more anxious and depressed than African-American or white girls who experienced penetration. The author explains these findings in part as due to the emphasis on purity and virginity in Latino communities. When virginity is lost, the trauma of sexual abuse is compounded because the Latina girls feel that they are no longer suitable marriage partners.

Another ethnic-group difference appeared in rates of re-victimization. In a sample drawn from a community college, black women who were sexually abused in childhood were more likely to be raped as adults than their white, Latina, or Asian counterparts (Urquiza and Goodlin-Jones 1994).

Gordon Nagayama Hall and Christy Barongan (1997) speculated that these differences in rates of sexual aggression might be due to characteristics of specific cultures. For example, cultures with a collectivist orientation, where the group is more important than the individual, tend to have lower rates of sexual aggression. Asian cultures often have a collectivist orientation. Crimes against a single person are perceived as crimes against the entire culture. Shame also keeps these behaviors in check. However, as Catherine Koverola and Subadra Panchandeswaran (in press) describe, shame may not keep the behaviors in check, but may keep people from acknowledging these crimes outside the community. Thus, it is at least possible that even in cultures where the rates appear low, abuse may simply be hidden from view.

How Sexual Abuse Compares with Other Types of Child Maltreatment

Although researchers have focused predominantly on sexual abuse, it is not the most common type of maltreatment. In the Third National Incidence Study of Child Abuse and Neglect, the rate of sexual abuse per 1,000 children was 4.9 for females and 1.6 for males. For physical abuse the rate was 5.6 per 1,000 for females and 5.8 for males. For neglect, the rate was 12.9 per 1,000 for females and 13.3 for males. Physical abuse and neglect are much more common for both boys and for girls. Girls and boys have approximately the same rates of fatal injuries (.01/1000 and .04/1000 for females and males respectively). Sexual abuse can certainly be harmful, but the plight of the physically abused or neglected child also deserves the attention of professionals (Sedlak and Broadhurst 1996).

Conclusion

Abuse experiences vary in their severity, as do reactions of those who are sexually abused. Even when the experience is severe, however, there is hope for healing. In one study, survivors reported that good came from the tragedy of their abuse (McMillen, Zuravin, and Rideout 1995). They described how their abusive pasts made them more sensitive to the needs of others. Many felt compelled to help others who had suffered similar experiences.

See also:Child Abuse: Physical Abuse and Neglect; Child Abuse: Psychological Maltreatment; Childhood; Children's Rights; Conduct Disorder; Depression: Children and Adolescents; Incest; Incest/Inbreeding Taboos; Munchausen Syndrome by Proxy; Parenting Styles; Posttraumatic Stress Disorder (PTSD); Power: Family Relationships; Rape; Runaway Youths; Substance Abuse

Bibliography

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becker-lausen, e., and mallon-kraft, s. (1997). "pandemicoutcomes: the intimacy variable." in out of darkness: current perspectives on family violence, ed. g. k. kantor and j. s. jasinski. newbury park, ca: sage.

berliner, l. and elliot, d. (1996). "sexual abuse of children." in the apsac handbook on child maltreatment, ed. j. briere, l. berliner, j. a. bulkley, c. jenny, and t. reid. newbury park, ca: sage.

briere, j. n., and elliot, d. m. (1994). "immediate andlong-term impacts of child sexual abuse." the future of children 4:54–69.

finkelhor, d. (1994). "current information on the scope and nature of child sexual abuse." the future of children 4:31–53.

kendall-tackett, k. a. (2000). "the long-term health effects of victimization." joining forces 5(1):1–4.

kendall-tackett, k. a., and marshall, r. (1998). "sexualvictimization of children: incest and child sexual abuse." in issues in intimate violence, ed. r. k. bergen. newbury park, ca: sage.

kendall-tackett, k. a., and simon, a. f. (1992). "a comparison of the abuse experiences of male and female adults molested as children." journal of family violence 7:57–62.

kendall-tackett, k. a.; williams, l. m.; and finkelhor, d.(1993). "the effects of sexual abuse on children: a review and synthesis of recent empirical studies." psychological bulletin 113:164–180.

mcmillen, c.; zuravin, s.; and rideout, g. (1995). "perceived benefit from child sexual abuse." journal of consulting and clinical psychology 63:1037–1043.

mennen, f. e. (1995). "the relationship of race/ethnicity to symptoms of childhood sexual abuse." child abuse and neglect 19:115–124.

nagayama hall, g. c., and barongan, c. (1997). "prevention of sexual aggression: sociocultural risk and protective factors." american psychologist 52:5–14.

perry, b. d. (2001). "the neuroarcheology of childhoodmaltreatment: the neurodevelopmental costs of adverse childhood events." in the cost of child maltreatment: who pays? we all do, ed. k. franey, r. geffner, and r. falconer. san diego, ca: family violence and sexual assault institute.

reece, r. m. (2000). treatment of child abuse: commonground for mental health, medical, and legal practitioners. baltimore, md: the johns hopkins university press.

robin, r. w.; chester, b.; rasmussen, j. k.; jaranson,j. m.; and goldman, d. (1997). "prevalence, characteristics, and impact of childhood sexual abuse in a southwestern american indian tribe." child abuse and neglect 21:769–787.

russell, d. e. h. (1984). "the prevalence and seriousness of incestuous abuse: stepfathers vs. biological fathers." child abuse and neglect. 8:15–22.

sedlak, a., and broadhurst, d. d. (1996). third nationalincidence study of child abuse and neglect. final report. washington, dc: u.s. department of health and human services.

urquiza, a. j., and goodlin-jones, b. l. (1994). "child sexual abuse and adult revictimization with women of color." violence and victims 9:223–232.

wyatt, g. e. (1985). "the sexual abuse of afro-american and white-american women in childhood." child abuse and neglect 9:507–519.

other resource

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kathleen kendall-tackett

Child Abuse

Definition

Child abuse is the blanket term to describe four types of child mistreatment: physical abuse, sexual abuse, emotional abuse, and neglect. In many cases children are the victims of more than one type of abuse. The abusers can be parents or other family members, caretakers such as teachers and babysitters, acquaintances (including other children), and (in rare instances) strangers.

Description

Prevalence of abuse

Child abuse was once viewed as a minor social problem affecting only a handful of United States children. However, it has begun to closer attention from the media, law enforcement, and the helping professions. With increased public and professional awareness has come a sharp rise in the number of reported cases. But because abuse often is hidden from view and its victims too young or fearful to speak out, experts suggest that its true prevalence is possibly much greater than the official data indicate. In 1996, more than three million victims of alleged abuse were reported to child protective services (CPS) agencies in the United States, and the reports were substantiated in more than one million cases. Put another way, 1.5% of the country's children were confirmed victims of abuse in 1996. Parents were the abusers in 77% of the confirmed cases, other relatives in 11%. Sexual abuse was more likely to be committed by males, whereas females were responsible for the majority of neglect cases. More than 1,000 United States children died from abuse in 1996. A 2004 report said that nearly 17% of adult women and 8% of adult men had been abused as children. The United Nations Children's Fund (UNICEF) reported in early 2004 that nearly 3,500 children younger than age 15 die every year from physical abuse and neglect in the 27 richest nations in the world.

Although experts are quick to point out that abuse occurs among all social, ethnic, and income groups, reported cases usually involve poor families with little education. Young mothers, single-parent families, and parental alcohol or drug abuse also are common in reported cases. Charles F. Johnson remarks, "More than 90% of abusing parents have neither psychotic nor criminal personalities. Rather they tend to be lonely, unhappy, angry, young, and single parents who do not plan their pregnancies, have little or no knowledge of child development, and have unrealistic expectations for child behavior." About 10%, or perhaps as many as 40%, of abusive parents were themselves physically abused as children, but most abused children do not grow up to be abusive parents.

Types of abuse

PHYSICAL ABUSE. Physical abuse is the nonaccidental infliction of physical injury to a child. The abuser is usually a family member or other caretaker, and is more likely to be male. In 1996, 24% of the confirmed cases of United States child abuse involved physical abuse.

A rare form of physical abuse is Munchausen syndrome by proxy, in which a caretaker (most often the mother) seeks attention by making the child sick or appear to be sick.

SEXUAL ABUSE. Charles F. Johnson defines child sexual abuse as "any activity with a child, before the age of legal consent, that is for the sexual gratification of an adult or a significantly older child." It includes, among other things, sexual touching and penetration, persuading a child to expose his or her sexual organs, and allowing a child to view pornography. In most cases the child is related to or knows the abuser, and about one in five abusers are themselves underage. Sexual abuse was present in 12% of the confirmed 1996 abuse cases. An estimated 20-25% of females and 10-15% of males report that they were sexually abused by age 18.

The 1990s and early 2000s were rocked by reports of sexual abuse of children committed by Catholic priests. Most of the abuse appeared to have occurred during the 1970s and a prominent report released early in 2004 stated that as many as 10,667 children were sexually abused by more than 4,300 priests. Increases also have been seen in recent years in child pornography cases, where children are the subjects of pornography, particularly on the Internet.

EMOTIONAL ABUSE. Emotional abuse, according to Richard D. Krugman, "has been defined as the rejection, ignoring, criticizing, isolation, or terrorizing of children, all of which have the effect of eroding their self-esteem." Emotional abuse usually expresses itself in verbal attacks involving rejection, scapegoating, belittlement, and so forth. Because it often accompanies other types of abuse and is difficult to prove, it is rarely reported, and accounted for only 6% of the confirmed 1996 cases.

NEGLECT. Neglect—failure to satisfy a child's basic needs—can assume many forms. Physical neglect is the failure (beyond the constraints imposed by poverty) to provide adequate food, clothing, shelter, or supervision. Emotional neglect is the failure to satisfy a child's normal emotional needs, or behavior that damages a child's normal emotional and psychological development (such as permitting drug abuse in the home). Failing to see that a child receives proper schooling or medical care is also considered neglect. In 1996 neglect was the finding in 52% of the confirmed abuse cases.

Causes and symptoms

Physical abuse

The usual physical abuse scenario involves a parent who loses control and lashes out at a child. The trigger may be normal child behavior such as crying or dirtying a diaper. Unlike nonabusive parents, who may become angry at or upset with their children from time to time but are genuinely loving, abusive parents tend to harbor deep-rooted negative feelings toward their children.

Unexplained or suspicious bruises or other marks on the skin are typical signs of physical abuse, as are burns. Skull and other bone fractures are often seen in young abused children, and in fact, head injuries are the leading cause of death from abuse. Children less than one year old are particularly vulnerable to injury from shaking. This is called shaken baby syndrome or shaken impact syndrome. Not surprisingly, physical abuse also causes a wide variety of behavioral changes in children.

Sexual abuse

John M. Leventhal observes, "The two prerequisites for this form of maltreatment include sexual arousal to children and the willingness to act on this arousal. Factors that may contribute to this willingness include alcohol or drug abuse, poor impulse control, and a belief that the sexual behaviors are acceptable and not harmful to the child." The chances of abuse are higher if the child is developmentally handicapped or vulnerable in some other way.

Genital or anal injuries or abnormalities (including the presence of sexually transmitted diseases ) can be signs of sexual abuse, but often there is no physical evidence for a doctor to find. In fact, physical examinations of children in cases of suspected sexual abuse supply grounds for further suspicion only 15-20% of the time. Anxiety, poor academic performance, and suicidal conduct are some of the behavioral signs of sexual abuse, but are also found in children suffering other kinds of stress. Excessive masturbation and other unusually sexualized kinds of behavior are more closely associated with sexual abuse itself.

Emotional abuse

Emotional abuse can happen in many settings: at home, at school, on sports teams, and so on. Some of the possible symptoms include loss of self-esteem, sleep disturbances, headaches or stomach aches, school avoidance, and running away from home.

Child Abuse: Signs And Symptoms

Although these signs do not necessarily indicate that a child has been abused, they may help adults recognize that something is wrong. The possiblity of abuse should be investigated if a child shows a number of these symptoms, or any of them to a marked degree:

Sexual Abuse

  Being overly affectionate or knowledgeable in a sexual way inappropriate to the child's age

  Medical problems such as chronic itching, pain in the genitals, venereal diseases

  Other extreme reactions, such as depression, self-mutilation, suicide attempts, running away, overdoses, anorexia

  Personality changes such as becoming insecure or clinging

  Regressing to younger behavior patterns such as thumb sucking or bringing out discarded cuddly toys

  Sudden loss of appetite or compulsive eating

  Being isolated or withdrawn

  Inability to concentrate

  Lack of trust or fear someone they know well, such as not wanting to be alone with a babysitter

  Starting to wet bed again, day or night/nightmares

  Become worried about clothing being removed

  Suddenly drawing sexually explicit pictures

  Trying to be "ultra-good" or perfect; overreacting to criticism

Physical Abuse

  Unexplained recurrent injuries or burns

  Improbable excuses or refusal to explain injuries

  Wearing clothes to cover injuries, even in hot weather

  Refusal to undress for gym

  Bald patches

  Chronic running away

  Fear of medical help or examination

  Self-destructive tendencies

  Aggression towards others

  Fear of physical contact—shrinking back if touched

  Admitting that they are punished, but the punishment is excessive (such as a child being beaten every night to "make him/her study")

  Fear of suspected abuser being contacted

Emotional Abuse

  Physical, mental, and emotional development lags

  Sudden speech disorders

  Continual self-depreciation ("I'm stupid, ugly, worthless, etc.")

  Overreaction to mistakes

  Extreme fear of any new situation

  Inappropriate response to pain ("I deserve this")

  Neurotic behavior (rocking, hair twisting, self-mutilation)

  Extremes of passivity or aggression

Neglect

  Constant hunger

  Poor personal hygiene

  No social relationships

  Constant tiredness

  Poor state of clothing

  Compulsive scavenging Emaciation

  Untreated medical problems

  Destructive tendencies

A child may be subjected to a combination of different kinds of abuse. It is also possible that a child may show no outward signs and hide what is happening from everyone.

Neglect

Many cases of neglect occur because the parent experiences strong negative feelings toward the child. At other times, the parent may truly care about the child, but lack the ability or strength to adequately provide for the child's needs because he or she is handicapped by depression, drug abuse, mental retardation, or some other problem.

Neglected children often do not receive adequate nourishment or emotional and mental stimulation. As a result, their physical, social, emotional, and mental development is hindered. They may, for instance, be underweight, develop language skills less quickly than other children, and seem emotionally needy.

Diagnosis

Doctors and many other professionals who work with children are required by law to report suspected abuse to their state's Child Protective Services (CPS) agency. Abuse investigations often are a group effort involving medical personnel, social workers, police officers, and others. Some hospitals and communities maintain child protection teams that respond to cases of possible abuse. Careful questioning of the parents is crucial, as is interviewing the child (if he or she is capable of being interviewed). The investigators must ensure, however, that their questioning does not further traumatize the child. A physical examination for signs of abuse or neglect is, of course, always necessary, and may include x rays, blood tests, and other procedures.

Treatment

Notification of the appropriate authorities, treatment of the child's injuries, and protecting the child from further harm are the immediate priorities in abuse cases. If the child does not require hospital treatment, protection often involves placing him or her with relatives or in foster care. Once the immediate concerns are dealt with, it becomes essential to determine how the child's long-term medical, psychological, educational, and other needs can best be met, a process that involves evaluating not only the child's needs but also the family's (such as for drug abuse counseling or parental skills training). If the child has brothers or sisters, the authorities must determine whether they have been abused as well. On investigation, signs of physical abuse are discovered in about 20% of the brothers and sisters of abused children.

Prognosis

Child abuse can have lifelong consequences. Research shows that abused children and adolescents are more likely, for instance, to do poorly in school, suffer emotional problems, develop an antisocial personality, become promiscuous, abuse drugs and alcohol, and attempt suicide. As adults they often have trouble establishing intimate relationships. Whether professional treatment is able to moderate the long-term psychological effects of abuse is a question that remains unanswered.

Prevention

Government efforts to prevent abuse include home-visitor programs aimed at high-risk families and school-based efforts to teach children how to respond to attempted sexual abuse. Emotional abuse prevention has been promoted through the media.

When children reach age three, parents should begin teaching them about "bad touches" and about confiding in a suitable adult if they are touched or treated in a way that makes them uneasy. Parents also need to exercise caution in hiring babysitters and other caretakers. Anyone who suspects abuse should immediately report those suspicions to the police or his or her local CPS agency, which will usually be listed in the blue pages of the telephone book under Rehabilitative Services or Child and Family Services, or in the yellow pages. Round-the-clock crisis counseling for children and adults is offered by the Childhelp USA/IOF Foresters National Child Abuse Hotline. The National Committee to Prevent Child Abuse is an excellent source of information on the many support groups and other organizations that help abused and at-risk children and their families. One of these organizations, National Parents Anonymous, sponsors 2,100 local self-help groups throughout the United States, Canada, and Europe. Telephone numbers for its local groups are listed in the white pages of the telephone book under Parents Anonymous or can be obtained by calling the national headquarters.

Resources

PERIODICALS

Jellinek, Michael S. "Making the Call: Identifying Child Sexual Abuse." Pediatric News March 2004: 26.

Plante, Thomas G. "Another Aftershock: What Have We Learned from the John Jay Report?" America March 22, 2004: 10.

"UNICEF Report on Child Abuse in Developed Nations." Public Health Reports March-April 2004: 220-224.

ORGANIZATIONS

Childhelp USA/IOF Foresters National Child Abuse Hotline. (800) 422-4453.

National Clearinghouse on Child Abuse and Neglect Information. P.O. Box 1182, Washington, DC 20013-1182. (800) 394-3366. 〈http://www.calib.com/nccanch〉.

National Committee to Prevent Child Abuse. 200 S. Michigan Ave., 17th Floor, Chicago, IL 60604. (312) 663-3520. 〈http://www.childabuse.org〉.

National Parents Anonymous. 675 W. Foothill Blvd., Suite 220, Claremont, CA 91711. (909) 621-6184.

Child Abuse

Child abuse, as a historical subject, is deeply problematic, since the concept of abuse is inevitably relative and can be only very tentatively applied across cultures and across centuries. Parental conduct that would be considered battering abuse in contemporary America might be practiced as routine parental discipline in other parts of the world, and would certainly have been regarded thus in past centuries in America itself. Furthermore, by today's Scandinavian standards even limited corporal punishment, as practiced in some American families, might seem abusive, and there is debate about the acceptability of such punishment within the American medical establishment. Without doubt, judging across cultures, Americans would consider as abusive the female circumcision practiced in parts of the contemporary Islamic world or the foot binding that was once practiced in China. The history and sociology of child abuse thus inevitably involve a recognition of relativism in identifying and describing the practice of abuse, inasmuch as abuse can be best understood within a particular social and cultural context.

Defining Abuse in Historical Context

The watershed in the history of child abuse must be dated as recently as 1962, when child abuse received its modern formulation by the American medical establishment as the battered-child syndrome. The mistreatment of children was certainly common in earlier centuries, indeed timelessly imprinted upon European folklore as recorded, for instance, in the tales of the brothers Grimm. Yet that very prevalence ruled out any consensus about what constituted an abusive divergence from the social norm. The article "The Battered-Child Syndrome," by C. Henry Kempe, Frederic N. Silverman, and colleagues thus marked the end of the ancien régime in the history of child abuse, separating the epochs before and after 1962. Thereafter it was the medical establishment, with its scientific credentials, that defined child abuse according to the evidence of medical examination, including the evidence of radiology, revealing the battered bones of young children. At the same time, the scientific conclusions of "The Battered-Child Syndrome" further implied a set of sociological revelations: first, the general prevalence of abuse in a supposedly enlightened society, and second, the hitherto unacknowledgable circumstance that abuse was not usually the work of evil strangers, or even evil step-parents, but was largely practiced by natural parents upon their own children.

Crucial for the theoretical understanding of the history of child abuse was the history of childhood itself. In 1960 the French historian Philippe AriÈs proposed the controversial theses that the concept of childhood varied and developed in different historical contexts and that modern childhood was, in some sense, "discovered" in the Renaissance; only then, according to Ariès, did European culture and society become fully attuned to the distinctive character of childhood, to its fundamental difference from adulthood. The notion of fundamental difference between childhood and adulthood is essential for understanding child abuse, since the concept of child abuse assumes that there is a distinctive standard for the treatment of children and the violation of that standard defines abuse.

The relevance of the battered-child syndrome for the centuries before 1962 concerns not only the prevalence and intensity of corporal punishment but also the changing norms of punishment that might have made beating seem excessive to contemporaries. Historians such as Lawrence Stone and Philip Greven have described a culture of corporal punishment in early modern England and colonial America that is extreme by modern standards but seemingly normal in the contemporary contexts. Beatings at school constituted routine pedagogical discipline in early modern Europe, England, and the United States, and this continued into modern times, while the punishment of children during the Reformation and Counter-Reformation was prescribed according to differing religious perspectives on the fundamental innocence or sinfulness of children. The well-known principle of not sparing the rod for fear of spoiling the child was not evidence of widespread abuse, but indicated rather that beating was considered an appropriate measure in the rearing of children. In fact, the Protestant culture of corporal punishment still flourished in America in the late twentieth century, prescribed in such fundamentalist publications as God, the Rod, and Your Child's Bod: The Art of Loving Correction for Christian Parents

(1981).

While social practice in early modern families generally involved some degree of corporal punishment and some variation in judging the appropriate degree of intensity, landmark ideological developments in the writings of such philosophers as John Locke and Jean-Jacques Rousseau began to transform the earlier religious controversy concerning children's sinfulness and the application of the rod. Locke, in Some Thoughts Concerning Education (1693), advocated less beating and preferred a penal strategy of inducing shame, while Rousseau, who celebrated the innocence of humanity in the state of nature, was correspondingly convinced of the innocence of children. "Love childhood," he enjoined his readers, in Émile in 1762, outlining a new pedagogy so sensitive to the child's supposed nature that conventional education appeared almost in itself to be something abusive. Rousseau believed that childhood could be violated by inappropriate treatment, and that the child could be accordingly robbed of childhood; such ideas were essential to the formulation of a modern concept of abuse. Stone argues that a whole new culture of child rearing emerged in eighteenth-century England, a culture of coddling, based on indulgence of children and childhood. The controversy surrounding swaddling was characteristic of the century, for Rousseau declared this conventional practice to be cruel and oppressive, in some sense abusive of the child's freedom of the limbs; therefore he called for liberation from swaddling and enlightened parents heeded his appeal.

Locke's preference for shame over corporal punishment eventually pointed the way toward a modern conception of punishment for children in which excessive beating would appear as abusive. Yet considering the twentieth-century French philosopher Michel Foucault's argument on the historical transition from the exemplary punishment of criminals to a social system of discipline and surveillance, one might conclude that children too were subject to the pressures of more comprehensive discipline even when they were ultimately spared the rod. In this sense the crystallization of the concept of child abuse would have occurred at the historical crossroads when beating was no longer regarded as the most efficacious method of pedagogy or discipline.

Innocence and Abuse

The secular standard of children's innocence, dating from the late eighteenth century, suggested whole new arenas for reconsidering what was appropriate treatment of children. The attribution of innocence implied the possibility of violation, and the necessity of protection. The British Parliament passed legislation to protect chimney sweeps in 1788, and in 1789 the poet William Blake conjured their condition in his Songs of Innocence. During the nineteenth century child labor laws were enacted in England, America, France, and Germany, with rhetorical emphasis on the need to protect children from exploitation. That concept of exploitation implicitly suggested the notion of child abuse.

Innocence also implied the need for sexual protection, and beginning in the late eighteenth century, according to the research of historian Georges Vigarello, the prosecution of rape in France began to reflect a new and particular disapproval of the rape of children. Though in the eighteenth century Casanova had sex with girls as young as eleven and cheerfully boasted about it in his memoirs, by the late eighteenth century in Casanova's Venice, sexual relations between adult men and prepubescent girls could also be formulated with emphatic disapproval as the violation of innocence. Nevertheless there was neither a legal nor a sociological framework for identifying such conduct as sexual abuse.

A public breakthrough occurred in the late nineteenth century when the London journalist W. T. Stead exposed the prevalence of child prostitution in the Maiden Tribute scandal of 1885, publishing his revelations, for instance, under the headline, "A Child of Thirteen Bought for Five Pounds." In response to this scandal, the age of sexual consent in England was raised from thirteen to sixteen. Public horror at child prostitution pointed toward the eventual public recognition of sexual abuse, and, in the late nineteenth century, psychiatry further focused on the issue by diagnosing the perpetrators. The nineteenth-century German psychiatrist Richard von Krafft-Ebing, in his Psychopathia Sexualis described the "psycho-sexual perversion, which may at present be named erotic paedophilia (love of children)," which he defined, according to German and Austrian law, as the "violation of individuals under the age of fourteen" (p.371).

The recognition of sexual abuse in its domestic context was almost achieved by Sigmund Freud when he arrived at the "seduction theory" in 1895, ascribing hysteria to the sexual victimization of children by adults, especially their fathers. In 1897 Freud reconsidered this theory, and decided that his patients suffered only from fantasies of sexual violation as children. This conclusion suggests how difficult it was for even the most intellectually adventurous Victorians to confront the concept of child abuse as a common sociological syndrome. In 1919, when Freud wrote the article "A Child is Being Beaten," he discussed this scenario entirely as a matter of fantasy.

Yet in the late nineteenth century, there were established philanthropic societies for intervention on behalf of children neglected or mistreated by their parents. The model, ironically, was the Society for the Prevention of Cruelty to Animals, founded in America in 1866 and followed afterwards by Societies for the Prevention of Cruelty tohildren in America and England in the 1870s and 1880s. A "Children's Charter" in England, in 1889, attempted to formulate the rights of children. Inevitably, the philanthropic societies became the agents of Victorian middle-class intervention in the family life of the poorer classes, for the mistreatment of children was more readily attributed to the poor.

Throughout the Victorian age, dating from the first serial installments of Charles Dickens's Oliver Twist in 1837, at the very beginning of Victoria's reign, the figure of the menaced and mistreated child became a sentimental totem, and the brutalization of childhood's innocence exercised an almost prurient fascination upon the Victorian public. The preservation of innocence became such an obsession in nineteenth-century society that the consequences were often oppressive to the children themselves, and indeed abusive by the modern standard. The most striking instance was the medical preoccupation, all over Europe, with the prevention of masturbation, as parents were encouraged to employ with their children painful precautions, contraptions, and punishments. In 1855 a French governess, Celestine Doudet, was discovered to be torturing five English sisters, with the approval of their father, in order to prevent them from masturbating. She was tried and imprisoned when one of the children died. Similarly, in Vienna in 1899, sensational cases of battering abuse came before the public only when mistreatment actually brought about the children's deaths.

The crucial technological development that brought about the twentieth-century revolution in the recognition of battering abuse was the X ray. Radiology played a pioneering role in exploring the hidden presence of abuse in American families, beginning in 1946 with an article by John Caffey entitled "Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma." With such crucial discoveries being made in the medical profession, it was, eventually, in the field of pediatrics that the evidence of radiology was synthesized and assimilated, culminating in the publication of "The Battered-Child Syndrome" in 1962. Recognition of the prevalence of a child abuse was a challenge both for the medical profession and for society at large. The authors of "The Battered-Child Syndrome" remarked, "There is reluctance on the part of many physicians to accept the radiologic signs as indications of repetitive trauma and possible abuse. This reluctance stems from the emotional unwillingness of the physician to consider abuse as the cause of the child's difficulty" (pp. 18–19). Yet, by the end of the decade, child abuse laws were adopted in all fifty states, and departments of social services all over America were receiving reports and making interventions in domestic scenarios for the protection of children. In the 1970s the national incidence of child abuse was estimated at 500 cases annually for every million Americans. In 1977 an International Society for the Prevention of Child Abuse and Neglect was established, with backing from the United Nations Children's Fund (UNICEF) and the World Health Organization, for promoting and coordinating awareness of these issues all over the world.

Preventing and Prosecuting Child Abuse

Recognizing the problem has not led to automatic or simple solutions. The most emphatic interventions–that is, the removal of children from the parents' home and sometimes even the complete termination of parental rights–may have disastrous consequences for the child. Depriving the child of parents, even violent and abusive parents, can only be vindicated by the provision of compassionate foster care, which is always, inevitably, in short supply. Indeed, institutional foster care sometimes exposes abused children to new forms of abuse. In December 2002 the New York Times interviewed an adult who had been victimized as a child: "He spent six months with his mother, months when he was abused and beaten again, he said, before being sent to another foster home…. He said he was sexually and physically abused inseveral foster homes."

Even the mandated reporting of suspected abuse has turned out to be an unreliable instrument. Especially the category of neglect, which, according to one pediatric account, encompasses "lack of supervision" and "chaotic life styles," encourges social workers to make rather subjective judgments, especially concerning poor families (Cantwell, p.183). Child abuse in the middle classes, however, remains more easily concealed and less readily suspected. In 1987, New York City, and most of America, was rocked by the sensational coverage of the savage abuse, resulting in death, of Lisa Steinberg, age seven, the daughter of Joel Steinberg, a lawyer, and Hedda Nussbaum, an editor.

Because some of the categories of abuse are inevitably vague, and because American consciousness of abuse changed so rapidly in the course of a generation, it became more and more common in the 1980s for adults to define themselves as victims of abuse in their own childhoods. The category of emotional abuse was considered alongside physical abuse, and some spankings, in memory, seemed like batterings. Furthermore some therapists encouraged their patients to "recover" memories of abuse that had been forgotten or repressed. This was often sexual abuse, sometimes satanic sexual abuse, and in some therapy practices it turned out, implausibly, that 100 percent of patients had been victims of childhood abuse. Issues of sexual abuse also led to devastating legal tangles in the great day care scandals of the 1980s, at the McMartin Preschool in California and the Fells Acre Day Care Center in Massachusetts. At first these cases seemed to suggest hitherto unsuspected depths of child abuse hidden away in the world of institutional day care, but the questionable legal procedure surrounding the children's testimonies led to doubts about their reliability, resulting in mistrials and overturned convictions.

Following the rape and murder of seven-year-old Megan Kanka in New Jersey in 1994, and the subsequent revelation that the crime had been committed by a man who had previously been convicted, a national movement emerged to establish a registry of sex offenders. The determination to identify convicted sexual criminals in local communities, culminating in the passage of "Megan's Law" in New Jersey in 1996, reflected the anxiety in American society about child abuse. Though the abused child can sometimes be identified through bruises or burns by a doctor or a teacher, the abusive adult can rarely be distinguished from others in the community.

A full generation after "The Battered-Child Syndrome" was first published, there is general public recognition that various forms of child abuse are pervasive–but also an awareness that abuse may remain largely concealed within the domestic walls that protect family privacy. Furthermore, just as treatment of children in the historical past may appear abusive by current standards, so there is also a divergence of perspectives within contemporary society about what exactly constitutes abuse. For all these reasons, child abuse is a social problem that has been recognized but by no means resolved. This was emphatically demonstrated at the very beginning of the twenty-first century with the scandalous revelations ofa pedophile predation by Catholic priests in American parishes during the previous several decades. It was discovered that the church hierarchy had been willfully looking the other way, suppressing the scandal of abuse and reassigning pedophile priests who simply continued their abusive conduct in new communities. Public outrage, which eventually resulted in the resignation in December 2002 of Cardinal Bernard Law, the archbishop of Boston, marked a new level of American commitment to the prosecution of child abuse as an unmitigated social evil.

See also: Age of Consent; Child Labor in the West; Children's Rights; Incest; Megan's Law(s); Pedophilia; Recovered Memory; Violence Against Children .

bibliography

Ariès, Philippe. 1962. Centuries of Childhood: A Social History of Family Life. Trans. Robert Baldick. New York: Knopf.

Behlmer, George. 1982. Child Abuse and Moral Reform in England, 1870–1908. Stanford, CA: Stanford University Press.

Cunningham, Hugh. 1995. Children and Childhood in Western Society Since 1500. London: Longman.

DeMause, Lloyd, ed. 1974. The History of Childhood. New York: Psychohistory Press.

Greven, Philip. 1977. The Protestant Temperament: Patterns of Child-Rearing, Religious Experience, and the Self in Early America. New York: Knopf.

Greven, Philip. 1990. Spare the Child: The Religious Roots of Punishment and the Psychological Impact of Physical Abuse. New York: Knopf.

Kantwell, Hendrika. 1980. "Child Neglect." In The Battered Child, 3rd edition, ed. C. Henry Kempe and Ray Helfer. Chicago: University of Chicago Press.

Kempe, C. Henry, and Ray Helfer, eds. 1980. The Battered Child, 3rd ed. Chicago: University of Chicago Press.

Kempe, C. H., F. N. Silverman, B. F. Steele, W. Droegemueller, and H. K. Silver. 1962. "The Battered-Child Syndrome." Journal of the American Medical Association 181: 17–24.

Krafft-Ebing, Richard von. 1998. Psychopathia Sexualis. Trans. Franklin Klaf. New York: Arcade.

Masson, Jeffrey. 1984. The Assault on Truth: Freud's Suppression of the Seduction Theory. New York: Farrar, Straus, Giroux.

Miller, Alice. 1984. Thou Shalt Not Be Aware: Society's Betrayal of the Child. Trans. Hildegarde and Hunter Hannum. New York: Farrar, Straus, Giroux.

Shorter, Edward. 1975. The Making of the Modern Family. New York: Basic Books.

Sommerville, C. John. 1982. The Rise and Fall of Childhood. Beverly Hills, CA: Sage.

Stone, Lawrence. 1977. The Family, Sex, and Marriage in England, 1500–1800. New York: Harper and Row.

Vigarello, Georges. 2001. A History of Rape: Sexual Violence in France from the 16th to the 20th Century. Trans. Jean Birrell. Malden, MA: Polity Press.

Wolff, Larry. 1988. Postcards from the End of the World: Child Abuse in Freud's Vienna. New York: Atheneum.

Larry Wolff

CHILD ABUSE

The world in which many children live is punctuated by violent act after violent act. In many situations children become victims of this violence. Some children have been the direct targets of an act of violence, while other children have been indirectly affected through witnessing such acts; it is often difficult to distinguish between these two cases based on outward appearance alone. There are yet other children living in situations just as egregious where violence does not play a significant role. Theirs is merely an existence where their needs are not adequately met, including basic necessities of food and shelter, protection, structure, and supervision. Society labels these children as victims, when in fact they are the truest of survivors. What greater challenge can there be than having caretakers who cannot be trusted to provide adequate care? The common denominator of maltreatment is that those responsible for the child's well-being are either unable or unwilling to care for the child properly. Intervention from others is warranted to ensure that the needs and welfare of the child are fully considered.

Definitions of Child Maltreatment

The phrase "child abuse" often immediately brings to mind the image of a child beaten black and blue by an angry parent or caregiver. This is merely one scenario and perhaps the easiest to contrive because one can see what has been done to the child. It sparks people's emotions and a desire to take action against the offending adult. In reality there are many faces of child abuse and many more acts that leave scars "invisible" to the naked eye. There is a tendency to ignore children who display no physical or outward signs of abuse. A large number of these children go unrecognized, living in environments that hinder their potential and their development as secure, healthy individuals.

"Child maltreatment" is a term designed to draw attention away from the purely abuse-related acts or injuries that children suffer. It is an all-inclusive term to describe, in essence, when a caregiver does something or fails to do something that has harmed or threatens to harm a child in his or her care. Child abuse refers to acts of commission, which are done to a child and cause harm (or the threat of harm), whereas child neglect refers to acts of omission, acts that are not done to or for a child, which result in harm (or the threat of harm). In using the separate categories of child abuse and child neglect there are further distinctions that can be made. Abuse is often categorized into physical, sexual, psychological, and emotional abuse. Neglect is often categorized into physical, emotional, medical, and educational neglect. The most commonly reported statistics are those for physical abuse, sexual abuse, and overall child neglect.

How are child abuse and neglect manifested? Physical abuse involves harming the physical body with such acts as kicking, punching, stabbing, or beating a child with an object; whereas physical neglect involves not taking care of the needs of the physical body with food or shelter. A child's exposure to a harmful environment (such as one in which drug use is occurring) could also be construed as physical neglect because of the threat of harm to the child (i.e., if the child were capable of getting to the drugs himself, or if the drugs impaired the ability of the caretaker to adequately supervise the child). Similarly, emotional abuse might involve harming a child emotionally by yelling, threatening the child, or calling the child demeaning names, such as "stupid." Emotional neglect would be failing to provide emotional support for a child such as happens when a caretaker abandons a child or lacks any affection for a child. For many children, different forms of maltreatment occur at the same time.

While these definitions seem self-explanatory, there is much debate about what constitutes abuse and neglect in the United States. In other words, the practical application of these terms is not always easy. At the broad ends of the spectrum, there is usually little argument about whether abuse or neglect has occurred. If a parent takes an iron and intentionally burns his two-year-old child just because the child wet the bed at night, few would argue that this was child abuse. Yet, if a single parent working two jobs to support the family has no time at the end of the day to interact with his children, is this neglect? The larger issue is that having such definitions implies that there are certain standards for parenting or caring for children. With such a diverse and multicultural population, clear differences in parenting styles and standards exist. The task of deciding where abuse and neglect fall in that spectrum is challenging.

Another issue of debate in defining child maltreatment involves the societal response to child maltreatment. Social workers, medical professionals, and law enforcement personnel are most often involved in cases of child maltreatment. Each profession has its own criteria for identifying abuse and neglect. Law enforcement, for example, is concerned with proof of abuse or neglect and assigning culpability; in other words, who is to blame? The law requires respondents to look for and present "evidence" of maltreatment, when evidence may not be readily apparent. In many sexual abuse cases, for example, a child has made statements that indicate abuse, but the physical exam of the child is normal. Despite what the child has disclosed, it is rare for these cases to be brought to trial without physical evidence of abuse being present.

Incidence of Child Maltreatment

Annual data on the occurrence of child maltreatment in the United States are collected and analyzed by the National Child Abuse and Neglect Data System (NCANDS). This is a systematic, nationwide effort that was launched to collect data from state child protective service agencies, the primary state agency responsible for responding to child maltreatment. Each state reports the numbers of children reported for suspected maltreatment, investigated, and subsequently determined to be abused or neglected.

The NCANDS report for 1998 states that the estimated number of children reported for suspected maltreatment was more than 2.8 million. The estimated number of children abused or neglected in the United States during that year was 903,000. Of this number, more than half were victims of neglect, nearly one-quarter were physically abused, and approximately 12 percent were sexually abused. Approximately 25 percent of the children experienced multiple forms of abuse. These percentages are typical of the breakdown from year to year.

The rate of abuse and neglect for 1998 was 12.9 per 1,000 children less than eighteen years of age. This is actually a slight decrease from the previous year. Since records have been maintained by NCANDS, however, there has been an upward trend in the number of maltreated children. In 1974 the number of reports for suspected maltreatment was merely 60,000; in 1980, the number increased to greater than one million. Several factors contribute to this dramatic increase, including changes in child abuse reporting laws and an increased recognition of abuse and neglect as real societal problems. Early laws governing reporting of suspected child maltreatment required only professionals to report to the state child protective service agencies. By the late twentieth century, most states required anyone with a suspicion of maltreatment to make a report. There is also evidence that the level of violence in society has increased such that it has been declared a public health epidemic. Violence toward children and violence involving children (as witnesses) are both on the rise.

The numbers of maltreated children are impressive, but it is commonly accepted that these numbers are inaccurate. The cases reported to social services represent only the "tip of the iceberg" of all maltreated children. There are several ways researchers know this to be true. One indication that some children are missed comes from studies of child fatalities. Many children are killed as a result of abuse or neglect, but not all are identified as victims of abuse or neglect at the time of their death. Second, parent surveys and other periodic national surveys obtain higher rates of abuse and neglect than that counted by social services. In some cases the difference in rates is not trivial. For example, a nationwide telephone survey of parents found a nearly tenfold increase in rates of physical maltreatment compared to rates reported by social services.

Obtaining accurate numbers of maltreated children is difficult for other reasons. A fundamental reason is that simply defining what constitutes child maltreatment, as previously mentioned, is problematic. Maltreatment definitions also vary from state to state. The potential for missing abuse clearly exists when only two-thirds of reported cases are investigated, in part because of an overburdened social services system.

Consider also the process by which children are identified as being maltreated—someone has to make a report. This process relies on individuals recognizing abuse and taking action. Several studies have identified resilient kids—where abuse or neglect is occurring at home but the children find ways to cope. These children are less likely to be identified, as are very young children who cannot relate what has happened to them. Then there are biases (based on race, gender, and socioeconomic status) that make individuals more likely to suspect and report maltreatment. Poor families are notoriously suspect because of presumably higher financial stress and the frequently associated lack of education and resources. The opposite also happens: there are biases that prevent suspicion of abuse, leading to many maltreated children being missed. Girls are traditionally viewed as the only victims of sexual abuse, and young boys who act out are labeled as hyperactive but the question of sexual abuse is never entertained. Even if abuse is recognized and suspected, someone must take action, which is a well-known barrier to intervention. People are reluctant to become involved in family matters even if it means helping a child.

Developmental Perspectives of Child Maltreatment

It is very important to have an understanding of the relationship between child development and child maltreatment. Childhood is typically a time of rapid change and growth. Each stage of development brings new challenges and changes in the physical, cognitive, and behavioral makeup of a child. These changes are reflected in the epidemiology of maltreatment, which is the pattern of abuse and neglect that is commonly seen. Child development affects all of the following: the precipitating factors that lead to maltreatment; the susceptibility of a child to different types of maltreatment at different ages; the physical findings of abuse or neglect; the treatment options following maltreatment; and the likelihood of long-term sequelae (secondary effects) from abuse or neglect.

Infants are at the greatest risk for all types of maltreatment, including fatal maltreatment. This is relatively easy to understand from a developmental standpoint. Child neglect occurs commonly as infants are the most dependent on their caregivers to provide the basic necessities of life in a stable, secure environment. Parents who are overwhelmed by life stressors and have personal limitations, or have certain cognitive or medical conditions (such as mental retardation or depression) may become caregivers who cannot pick up on infant cues. In these situations there is a risk of poor attachment and emotional neglect. Parents can also be easily frustrated by an infant whose crying or temperament makes them difficult to handle, leading to the potential for physical abuse. This risk is dangerously high given that infants are already at higher risk for physical abuse because of their physical attributes, such as softer bones, small size, and the inability to resist physical harm or verbalize what happens to them. The "shaken baby syndrome" illustrates this principle. An infant has limited muscle tone, particularly in the neck, and an infant's head size is proportionately larger than other parts of its body. An infant that is forcibly shaken can get a form of whiplash, which creates forces that shear the delicate and developing brain. These infants suffer significant neurological damage and often die as a result of the brain injury and swelling.

The toddler and preschool years provide new challenges as children are growing and developing new physical skills. These physical skills enable children to run, climb, and openly explore in areas they previously could not, so caregiver supervision becomes increasingly important. A neglectful caregiver will not make the environment safe or provide appropriate boundaries. Verbal skills increase and children vocalize their emerging independence. A parent unprepared for the typical use of the word "no" may interpret this as defiant behavior and resort to harsh physical punishment that becomes abusive, not recognizing the appropriateness of the child's behavior for this developmental stage. Toilet training during these years is one of the more common parental stressors and precipitant of abuse.

School-age children and adolescents have a lower overall risk of maltreatment. They spend less time in the presence of caregivers because of school, after-school activities, and peer interactions. They are also less dependent as their physical and cognitive development allows them to do many things for themselves. Physically they are larger in size, stature, and strength, and it takes more force to cause injury. Sexual abuse, however, is more prevalent among school-age children and teens, particularly girls. The reason for this increase is related in part to the physical developmental changes that occur in both boys and girls as they enter puberty.

Treatment and System Responses

When it is determined that a child has been abused or neglected, the system will intervene. The primary state agency responsible for children is social services, but children are first identified in any number of ways: by neighbors, relatives, day-care staff, teachers, or medical professionals. Medical professionals and day-care staff often identify young children, because the doctor's office and the day-care center are common places for children to be seen on a regular basis. School personnel frequently identify older children when changes in behavior, attendance, or school performance are noticed. Suspicions of abuse or neglect are then referred to the appropriate social services agency for a more thorough investigation.

One of the first concerns for social services is the safety of the child. The agency's primary purpose is to ensure that no further harm comes to the child. If the perpetrator of maltreatment (the person suspected of abusing or neglecting the child) is to continue to have access to the child, this can be handled in several ways. What happens next will depend on the type and severity of abuse or neglect and the mandates of the state. The perpetrator will often contract with social services and agree not to maltreat the child. The person can agree to leave the home temporarily. The child can also be removed from the unsafe environment and placed in the care of a relative or foster family.

Many times children will require a medical evaluation to determine what harm has been done, document the extent of harm, and treat any new or existing medical conditions. The needs of the whole child should be addressed during a medical evaluation, although emergent needs are prioritized. In the case of shaken baby syndrome, for example, the majority of these children are brought in on an emergency basis when they stop breathing at home. Obviously these children require intensive care even before the determination of abuse is made. For other children, the medical evaluation may entail treating a broken bone, tending to lacerations, evaluating bruises, or examining for sexually transmitted diseases. It can also involve recommending a developmental evaluation for a child who is developmentally delayed or recommending medical and behavioral treatment for depression.

Further treatment usually involves obtaining mental health services or additional services for the family. The goals of these services are to assist the child and family in coping with the maltreatment and to restore family functioning. Mental health services can be directed to the child or to the child's caretakers, if the child is too young or unable to participate actively in treatment sessions on her own. Play therapy is very commonly employed in this setting. For the family, evaluating the home environment and the circumstances surrounding the abuse or neglect is critical to assisting the family and preventing maltreatment from reoccurring. There may be social services such as food stamps or parenting education that can assist the family and reduce family stressors. Parents and caregivers may also be prior victims of child maltreatment and/or violence in other forms and benefit from mental health, substance abuse, or domestic violence resources themselves.

Consequences of Maltreatment

The consequences of maltreatment for children who are abused or neglected vary a great deal. There are many factors that affect what happens after maltreatment, including: the developmental stage of the child at the time of the abuse or neglect, the type and chronicity of abuse or neglect, the relationship of the perpetrator to the child, and the child's temperament and natural ability (intelligence). There are also several different categories of consequences, including: medical or physical consequences; emotional, behavioral, or cognitive consequences; short-term versus long-term consequences; and consequences with or without intervention by social services or others.

One significant principle that appears in the child maltreatment literature repeatedly is that children suffering multiple types of abuse or neglect tend to have a poorer outcome than children who suffer only one type or incident of abuse or neglect. Studies that document the long-term effects of child abuse and neglect mirror these findings. These studies show that lifestyle choices and responses to stress may be altered, leading to greater risk for adult criminal behavior and significant health problems (such as heart disease) in adulthood.

Prevention of Maltreatment

Unfortunately, there is little data on how to prevent child maltreatment. Home visiting programs have shown the most promise in the primary prevention of maltreatment, which is preventing abuse or neglect before it occurs. Home visiting programs involve pairing new parents with someone trained or experienced in child development so that the new parents can learn how to care for and respond to the needs of their infants. The most widely modeled programs, when studied, have been successful in reducing the incidence of but have not entirely eliminated child maltreatment in the study populations. Issues of funding in many geographic regions have limited the availability of such services to those families considered at higher risk for maltreatment.

Efforts in the prevention of maltreatment primarily function on the level of secondary prevention. Intervention by social services or other professionals occurs when maltreatment has already taken place or when children are considered already at risk for abuse or neglect. In these situations the focus is on preventing further abuse or neglect, as well as treating and minimizing complications of the maltreatment that has occurred.

There is no doubt that prevention of child maltreatment is a complex issue. There are multiple factors involved when a child is abused or neglected, factors related to the individual child, the family structure, and other environmental stressors (such as poverty). The cycle of violence is a well-known phenomenon, where today's victims become tomorrow's perpetrators. In order to prevent child maltreatment, prevention itself must become a priority. This will require commitment and collaboration from many sources, including individuals, professionals, community groups, and government agencies. All of these sources must be willing to work together to make a difference for children.

See also:DOMESTIC VIOLENCE

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Adrea D.Theodore