conclusions from research on child maltreatment have found that

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• Systematic Review
• Published: 25 September 2020

Social determinants of health and child maltreatment: a systematic review

• Amy A. Hunter 1 , 2 , 3 &
• Glenn Flores 3 , 4  

Pediatric Research volume  89 ,  pages 269–274 ( 2021 ) Cite this article

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Child maltreatment causes substantial numbers of injuries and deaths, but not enough is known about social determinants of health (SDH) as risk factors. The aim of this study was to conduct a systematic review of the association of SDH with child maltreatment.

Five data sources (PubMed, Web of Science Core Collection, SCOPUS, JSTORE, and the Social Intervention Research and Evaluation Network Evidence Library) were searched for studies examining the following SDH: poverty, parental educational attainment, housing instability, food insecurity, uninsurance, access to healthcare, and transportation. Studies were selected and coded using the PICOS statement.

The search identified 3441 studies; 33 were included in the final database. All SDH categories were significantly associated with child maltreatment, except that there were no studies on transportation or healthcare. The greatest number of studies were found for poverty ( n  = 29), followed by housing instability (13), parental educational attainment (8), food insecurity (1), and uninsurance (1).

Conclusions

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism.

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment.

No prior published systematic review, to our knowledge, has examined the spectrum of SDH with respect to their associations with child maltreatment.

These findings suggest an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism

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Child maltreatment is a pervasive public health problem in the United States (US). 1 Comprised of acts of commission and omission by a parent or other caregiver (e.g., physical abuse, sexual abuse, and various forms of neglect), 2 child maltreatment is a substantial cause of pediatric injury and death. In 2018, nearly 700,000 childhood victims of nonfatal maltreatment were identified, and an estimated 1770 children died. 1 The combined human and institutional cost attributed to maltreatment morbidity and mortality in the US is estimated to be $124 billion annually. 3

The World Health Organization defines social determinants of health (SDH) as “the conditions in which people are born, grown, work, live, and age, and the wider set of forces and systems shaping the conditions of life.” 4 These conditions are shaped by the distribution of resources, and connect facets of the physical, social, and built environment associated with health outcomes. 5 Among the most commonly recognized SDH (economic stability, education, neighborhood and built environment, health and healthcare, and social and community context), 6 poverty is a major and often overarching factor. Poverty also has been identified as a known risk factor for child maltreatment. 7 Thus, identifying how poverty and other SDH are associated with child maltreatment is a necessary step to develop effective interventions for maltreatment prevention and treatment, and mitigating the risk of associated physical and psychological injury.

Not enough is known about the association of SDH with child maltreatment. Four published systematic reviews have included analyses that examined the relationship between a single or two SDH and maltreatment. Two included socioeconomic status, 8 , 9 one included socioeconomic status and parental educational attainment, 10 and the fourth included immigration status. 11 No published systematic reviews (to our knowledge), however, have examined the spectrum of SDH with respect to their associations with child maltreatment. Therefore, the aim of this study was to conduct a systematic review of the associations of SDH (including poverty, housing insecurity, food insecurity, uninsurance, healthcare access, and transportation) with child maltreatment.

Inclusion criteria

Studies were selected using the PICOS approach for inclusion and exclusion. 12 , 13 The a priori inclusion criteria for studies were as follows: (1) English-language studies, (2) children 0–18 years old living in the US, (3) peer-reviewed, (4) observational and experimental designs, (5) outcome measures reported for at least one form of maltreatment, and 6) exposure measures for at least one SDH. The exclusion criteria were: (1) specific SDH could not be identified, and (2) conference presentations (e.g., abstracts, posters, or oral presentations).

The outcome of interest was child maltreatment, defined by the Child Abuse Prevention and Treatment Reauthorization Act of 2010 as “at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” 2 Included studies were assessed for the associations of selected SDH—including poverty, food insecurity, housing instability, parental educational attainment, child uninsurance, transportation barriers, and access barriers to healthcare—with child maltreatment. These SDH were chosen because they are domains hypothesized to be most likely associated with child maltreatment and were addressed in a recently published SDH screening instrument used for testing interventions effective in reducing SDH and improving child and caregiver health. 14 Immigration status was not included because of the recent publication of a systematic review examining the association of this SDH with child maltreatment. 11

Data sources

Five data sources were searched through March 2020: (1) PubMed, (2) Web of Science Core Collection, (3) SCOPUS, (4) JSTORE, and (5) the Social Intervention Research and Evaluation Network Evidence Library. All searches contained the following terms: (“Child Abuse”[Mesh] OR “child abuse”[tw] OR “child maltreatment”[tw] OR “child mistreatment”[tw] OR “child neglect”[tw]) AND (“Social Determinants of Health”[Mesh] OR “social determinants of health”[tw] OR “social class”). Searches for terms related to specific SDH varied. A sample search strategy (SCOPUS) can be found in Supplementary Table S 1 (online) .

An effort-to-yield measure of search precision, number needed to read (NNR) was calculated by taking the inverse of the precision of the searches. Precision was calculated by dividing the number of included studies by the number of screened studies, after removal of duplicates. NNR quantifies the number of articles that would be needed to be read before finding one that meets the established inclusion criteria. Dependent on the subject and inclusion criteria, this number provides insights into the time and resources needed for replication, or to conduct a similar study.

Selection of studies

All studies were stored on a Microsoft Excel document detailing the reasons for inclusion or exclusion.

Data abstraction

A codebook was developed using Microsoft Excel. Variables included study characteristics (year of publication, study design and population size, duration, data sources, and level[s] of analysis), sociodemographic characteristics of the study population (child age, racial composition, and sex), SDH under investigation, child maltreatment type (sexual, physical, psychological, neglect, multiple forms, and other), and measures of study quality.

Study quality

A modified version of the Downs and Black checklist was used to assess study quality (Supplementary Table S 2 ). 15 Each item was scored as no (0) or yes (1). The sum of all items ranged from 1 to 8, with higher scores representing a lower risk of bias.

Data synthesis

The criteria for SDH and definitions of child maltreatment varied by study. Therefore, we were unable to combine endpoints in a meta-analysis. Data synthesis at the level of the individual, family, and community were used to analyze included studies.

Study registration

The study protocol was registered with PROSPERO (CRD42020166969).

Study characteristics

Our initial search yielded 3441 studies. After screening by titles and abstracts, 118 met the initial inclusion criteria. Following a full review of 118 studies, 33 were included in the final analysis. The process for selecting included studies is presented in Fig.  1 . Search precision was 0.0096 and the NNR was 104. The characteristics of included studies are presented in Table  1 . Included studies were published from 1978 to 2020. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 Nine studies used national data, 16 , 23 , 27 , 30 , 36 , 38 , 42 , 43 , 47 and the remaining studies used data from individual states, including 14 from the Midwest, 17 , 18 , 19 , 20 , 25 , 26 , 28 , 29 , 31 , 33 , 39 , 40 , 41 , 45 four from the South, 21 , 22 , 32 , 37 four from the Northeast, 34 , 35 , 46 , 48 one from the West (California), 24 and one from the Pacific (Alaska). 44 Of these studies, 5 conducted chart reviews, 7 used cohort study designs, 7 used a cross-sectional design, and 14 conducted ecological analyses. Included studies assessed the relationship between SDH and child maltreatment at the levels of the individual, zip code, county, and census tracts.

a Studies may have been excluded for multiple reasons.

Study outcomes

Twenty-nine studies explored the association of poverty with child maltreatment. 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 47 Poverty was found to be consistently and strongly associated with maltreatment, with all but three studies identifying a significant association between either familial or community-level poverty and child maltreatment. 16 , 18 , 21 Across studies, poverty was defined by county, 45 neighborhood, 41 familial/household income, 17 , 18 , 19 , 20 , 23 , 28 , 41 , 42 , 43 socioeconomic status, 44 poverty rate, 21 , 27 , 35 , 40 unemployment, 16 , 17 , 21 , 31 , 32 , 34 , 36 , 40 percentage of families living below the federal poverty level, 24 , 28 , 31 , 32 , 33 , 36 , 37 , 38 , 39 children living in poverty, 17 , 47 receipt of public assistance, 19 , 25 , 31 , 40 composite impoverishment scores, 26 and self-reported acute financial challenges. 22

In some studies, the relationship between poverty and maltreatment differed by abuse type. For example, one study found that neighborhood poverty was associated with all three forms of child maltreatment, but to different degrees. 38 Another study indicated that financial problems were strongly associated with neglect and abandonment, but the association was less pronounced for sexual abuse. 21

Associations between poverty and maltreatment varied by race/ethnicity. A study comparing predominantly white and black neighborhoods found that the association between poverty and child maltreatment was strongest in whites. 25 Research linking multiple sources of data showed that black children living in poverty were twice as likely to be reported for needs-based neglect than their white counterparts. 26 A recent study showed that when income was held constant, white race was strongly associated with both sexual abuse and neglect, and black race was associated with physical abuse. 27

Housing instability

Thirteen studies examined the relationship between housing instability and child maltreatment. 16 , 18 , 20 , 21 , 23 , 26 , 28 , 29 , 32 , 33 , 34 , 40 , 46 Most studies revealed that housing instability is associated with child maltreatment. Among these studies, the definition of housing stability varied, and included percent vacancy, 21 , 26 , 32 , 33 , 40 rates of foreclosure and delinquency, 16 , 18 , 34 hazardous living conditions, 29 and instability/mobility (>1 move per year). 20 , 23 , 28 Only one study examined homelessness, performing an analysis of hospital and pediatric ambulatory records of children <18 years old. 46 After matching families on income, homeless children were found to have higher rates of maltreatment-related emergency-department (ED) visits and child maltreatment than their nonhomeless counterparts. One study found that displacement due to foreclosure, eviction, or mortgage delinquency was associated with maltreatment investigations. 34 Two studies documented that housing instability/mobility (>1 move per year) was associated with child protective service (CPS) reports and maltreatment risk. 20 , 23

Two studies found no association between housing insecurity and child maltreatment. 18 , 28 In the first, housing instability consisted of an aggregate measure of material hardship, including difficulty paying rent, eviction, or having experienced any utility shutoff in the previous year. 18 In the second, housing instability was measured by residential mobility. 28

Several studies reported differences in the association between housing stability and child maltreatment type. Two identified an association between the percent of vacant housing in communities and sexual abuse. 21 , 32 Another study found that hazardous housing conditions were associated with neglect, but not physical abuse; a history of housing instability increased the strength of this association. 29 One study found that mortgage delinquency was associated with traumatic brain injury and other forms of physical abuse. 20

Food insecurity

Just one study examined the relationship between food insecurity and child maltreatment. 30 An analysis of a national sample from the Fragile Families and Childhood Wellbeing Study revealed that, compared with food-secure households, food-insecure households experienced increased rates of total parental aggression (7% vs. 20%, respectively). Controlling for maternal characteristics did not attenuate this association.

Parental educational attainment

Eight studies considered the relationship between parental educational attainment and child maltreatment. 17 , 18 , 20 , 24 , 25 , 32 , 41 , 42 The results of most studies indicate that low parental educational attainment is associated with child maltreatment. Parental educational attainment was defined as high-school completion in six studies, 17 , 18 , 20 , 32 , 41 , 42 maternal education level in one, 25 and completion of postsecondary education in the last. 24 Two studies found no association. 18 , 24 Notably, one of these studied failed to report victim and perpetrator demographic characteristics (age, sex, or race/ethnicity), 18 and the other relied on self-reported data. 24

Uninsurance

One study was identified that examined the association of the child lacking health insurance with child maltreatment. 48 This study reported that a higher proportion of preadolescent children seen in the ED with suspected sexual child abuse were uninsured, compared with a control group of children seen in the ED with upper-limb fractures, at 52% vs. 1%, respectively. No statistical analyses, however, were conducted, nor is it clear whether there was matching of cases and controls by age, sex, or other relevant characteristics.

The search did not reveal any studies that examined the associations of transportation or access to healthcare with child maltreatment.

Multiple studies document that SDH, including poverty, housing instability, food insecurity, low parental educational attainment, and child uninsurance, are significantly associated with child maltreatment. A recent systematic review also concluded that although the immigrant parental status is associated with a lower likelihood of overall child maltreatment, it may be associated with a higher risk of child neglect and neglectful supervision. 11 Taken together, these findings suggest that an urgent priority, therefore, should be to routinely screen families for SDH in inpatient and outpatient settings and in CPS, and to address identified SDH with referrals to appropriate services. This screening and referral process could have the potential to not only prevent child maltreatment by reducing or eliminating the SDH before they result in maltreatment, but might also decrease the risk of maltreatment recidivism in families in which maltreatment already has occurred. The American Academy of Pediatrics, American Academy of Family Physicians, and the National Academy of Sciences, Engineering, and Medicine all have endorsed SDH screening and service referral. 49 , 50 , 51 Several studies document that patients and caregivers are comfortable with completing SDH screening. 52 , 53 , 54 , 55 , 56 Addressing SDH by referral to such services as case managers, social workers, housing vouchers, medical–legal partnerships, and parent mentors, already has been shown to reduce hospitalizations, improve housing quality and stability, enhance economic security, improve healthcare outcomes, insure more uninsured children, increase the quality of care, empower parents, and save money for society, 57 thereby holding great promise as interventions that may prove effective in ultimately reducing or preventing child maltreatment.

Poverty was the SDH for which the greatest number of studies documented an association with child maltreatment. Although few studies have investigated the temporal relationship between poverty and child maltreatment, 8 there is evidence that families living in poverty are more likely to be reported to CPS for neglect. 58 Poverty sequelae, such as inability to feed, clothe, or house a child, overlap with the definition of child neglect, so it is important to distinguish intentional neglect from family challenges related to living in poverty. Differential or alternative response is one CPS approach that addresses maltreatment reports by attending to unmet family needs. 59 An analysis of the effectiveness of this form of intervention has shown that families living in poverty benefit most from this approach. 60 To date, this response has been implemented at the individual and family levels. Extending differential or alternative response to the community level may be an effective strategy for families living in impoverished neighborhoods, where racial biases in child maltreatment reports and investigations have been identified.

The study results underscore several unanswered questions regarding the association between SDH and child maltreatment. First, it is unclear whether transportation barriers or impaired access to healthcare are associated with child maltreatment, given that no studies were identified on these SDH. Second, because the definitions for each SDH varied considerably within and across studies (especially for poverty), it is unclear whether more consistent SDH definitions would yield different findings. Third, because males as caregivers and heads of household were under-represented and often excluded from some study populations, 20 , 23 , 25 , 33 an unanswered question is whether there are associations of paternal educational attainment and other male-caregiver SDHs with child maltreatment. Although single mothers have been identified as an at-risk population for maltreatment perpetration, it is equally important to examine the role that men play in maltreatment. In a previous analysis, the first author identified men as the predominant perpetrator in 58% of cases of fatal maltreatment in the US. 61 Results of our study emphasize the need for research inclusive of male caregivers, to identify and mitigate risk factors before they escalate to maltreatment fatalities. Fourth, most studies focusing on sexual abuse were primarily limited to female populations, 32 despite evidence that male children also are victims of sexual abuse. There is an urgent need to investigate how SDH perpetuate or protect against sexual abuse in male children, so that prevention efforts can be tailored by sex. Finally, because most studies combined maltreatment into one aggregate category, an unanswered question is what are the associations of SDH with specific maltreatment categories. It has been posited that each maltreatment type has a unique etiology, and lumping these types into one category likely attenuates the ability to identify meaningful associations. Although few studies in this systematic review disaggregated by maltreatment categories, those that did found significant differences in maltreatment risk according to the SDH examined.

Based on the study findings, a research agenda is proposed to address key issues regarding the association of SDH with child maltreatment. Research is needed to address the aforementioned identified research gaps, including studies on transportation barriers, impaired access to healthcare, consistently defined SDH, SDH for male caregivers, and the associations of SDH with specific maltreatment categories and male victims of sexual abuse. Studies are needed to determine whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk. Research is urgently needed to determine whether SDH screening and referral to appropriate services result in SDH reduction and elimination as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

Limitations and strengths

Certain study limitations should be noted. First, as with all systematic reviews, the quality of this analysis is limited by the scientific rigor of included studies. Second, studies were selected based on the search criteria. It is possible that relevant literature was missed because of the heterogeneity of terms used to describe the various SDH and child maltreatment. Third, many included studies were cross-sectional or ecological, preventing the ability to draw conclusions about the temporal relationship between SDH and child maltreatment. Fourth, many data sources for the included studies used administrative data derived from CPS. In most instances, these records only included reports of maltreatment that were screened in and accepted for either an investigation or alternative response. As a result, these data sources likely exclude many cases of maltreatment, given evidence demonstrating equivalent risk of incidence and recurrence between maltreatment reports and substantiations. 28 , 38

SDH, including poverty, parental educational attainment, housing instability, food insecurity, and uninsurance, are associated with child maltreatment. These findings suggest that an urgent priority should be routinely screening families for SDH, with referrals to appropriate services, a process that could have the potential to prevent both child maltreatment and subsequent recidivism. Unanswered questions include whether SDH are associated with specific maltreatment categories and male victims of sexual abuse, and whether transportation barriers, impaired access to healthcare, consistently defined SDH, and SDH for male caregivers are associated with child maltreatment. A proposed research agenda includes addressing these unanswered questions; determining whether there is a direct association between the number of SDH and the risk of maltreatment, and whether the presence of multiple SDH can synergistically increase maltreatment risk; and investigations on whether SDH screening and referral to appropriate services result in SDH reduction and elimination, as well as decreases in or the prevention of child maltreatment and maltreatment recidivism.

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We thank Marissa Gauthier for her assistance with the initial citation search.

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Hunter, A.A., Flores, G. Social determinants of health and child maltreatment: a systematic review. Pediatr Res 89 , 269–274 (2021). https://doi.org/10.1038/s41390-020-01175-x

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Child maltreatment, cognitive functions and the mediating role of mental health problems among maltreated children and adolescents in Uganda

• Herbert E. Ainamani   ORCID: orcid.org/0000-0001-7290-7232 1 , 2 ,
• Godfrey Z. Rukundo 3 ,
• Timothy Nduhukire 4 ,
• Eunice Ndyareba 5 &
• Tobias Hecker 6  

Child and Adolescent Psychiatry and Mental Health volume  15 , Article number:  22 ( 2021 ) Cite this article

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Child maltreatment poses high risks to the mental health and cognitive functioning of children not only in childhood but also in later life. However, it remains unclear whether child maltreatment is directly associated with impaired cognitive functioning or whether this link is mediated by mental health problems. Our study aimed at examining this research question among children and adolescents in Uganda.

A sample of 232 school-going children and adolescents with a mean age of 14.03 ( SD  = 3.25) was assessed on multiple forms of maltreatment using the Maltreatment and Abuse Chronology Exposure—Pediatric Version (pediMACE). Executive functions were assessed by the Tower of London task and working memory by the Corsi Block Tapping task, while mental health problems were assessed using the Child PTSD Symptom Scale for PTSD and the Center for Epidemiological Studies Depression Scale for Children (CES-DC).

In total, 232 (100%) of the participant reported to have experienced at least one type of maltreatment in their lifetime including emotional, physical, and sexual violence as well as neglect. We found a negative association between child maltreatment and executive functions (β = − 0.487, p  < 0.001) and working memory (β = − 0.242, p  = 0.001). Mental health problems did not mediate this relationship.

Conclusions

Child maltreatment seems to be related to lower working memory and executive functioning of affected children and adolescents even after controlling for potential cofounders. Our study indicates that child maltreatment the affects children’s cognitive functionality beyond health and well-being.

Child maltreatment which is defined as any act of abuse or neglect by a parent, caregiver or a community member that results in harm, potential harm, or threat of harm to a child has been remarked as one of the greatest global public health concerns [ 1 ]. Child maltreatment may include, emotional, physical, and sexual violence as well as neglect [ 1 , 2 , 3 ]. Estimates on the prevalence of violence against children in low- and middle-income countries (LMICs) show that a minimum of 50% of children in Asia and Africa between the ages of 2 and17 experience violence in their upbringing [ 4 ]. Various studies in Africa have shown that there is high level of child abuse in varying samples of children and adults [ 5 ]. Child maltreatment, has also been documented in East-African families, e.g., in Tanzania more than 90% of the children reported to have experienced violent discipline by parents [ 6 ] and different forms of maltreatments by teachers [ 7 ].While in Kenya, severe forms of child sexual abuse was reported [ 8 ] with key perpetrators being relatives (29%).

Similarly, studies in Uganda have reported that children and adolescents experienced violence very frequently [ 9 , 10 , 11 ]. For example, physical and emotional violence have been experienced by 98% of children, sexual violence by 76% and economic violence by 74% [ 10 ].

Child maltreatment does not only inflict physical pain on the affected children but also poses a major risk to cognitive impairment in both childhood and adulthood [ 12 , 13 , 14 ]. In support of the above findings, the toxic stress theory implicates exposure to early childhood adversity for altering the neuro-endocrinal immune system, which renders individual vulnerability to all forms of functional impairments and disease [ 15 ]. A systematic review of cognitive function after childhood trauma concluded that cognitive abnormalities may be linked to neuro-psychological and neurological impacts [ 16 ]. Studies with both animals and humans show that exposure to adverse experiences in early life affects brain regulation and endocrine responses to stress [ 17 , 18 , 19 ]. In fact, a number of studies on neuropsychological impairments have observed a significant disruption in prefrontal cortex that plays an important role in executive functioning following exposure to trauma and subsequent PTSD diagnosis [ 20 , 21 , 22 , 23 , 24 , 25 ]. Moreover, previous studies have documented how exposure to continuous stress affects hippocampal volume resulting from constant increase in glucocorticoid hormone which is released as the brain seeks to mitigate negative effects of stress. Stress in turn seems to affect the functionality of human memory and learning [ 18 , 26 , 27 , 28 ].

Therefore, it is not surprising that a systematic review on the impact of child maltreatment on later cognitive functions reported that children with experiences of child maltreatment performed poorly on tasks of working memory, attention, episodic memory and executive functions [ 29 ]. In line with these findings, other studies mostly from high income countries showed that as a consequence of adverse childhood experiences many affected children and adolescents suffer from cognitive deficiencies [ 25 , 30 , 31 ]. For example, child abuse was found to be associated with delayed language development, cognitive development, and a lower intelligence quotient [ 12 , 32 ]. A systematic review indicated that maltreated children performed poorly on tasks requiring executive functions, working memory and attention [ 33 ].

In addition to the high risk of cognitive impairment associated with child maltreatment, studies in high income countries have also found a strong association between maltreatment and mental health problems [ 34 , 35 , 36 ]. Others have repeatedly found links between maltreatment, PTSD, depression, impairments of prefrontal cortex functioning and dysregulation of HPA [ 37 , 38 , 39 , 40 ]. Furthermore, a negative effect of PTSD symptoms severity on cognitive functions but not trauma, has been frequently reported [ 24 , 41 , 42 ].

The described association between maltreatment and impaired cognitive functioning, maltreatment and mental health problems, as well as mental health problems and impaired cognitive functioning raise the question whether the association between child maltreatment and cognitive functions may be mediated by mental health problems [ 12 , 43 ]. A review of maltreatment studies recommended further studies that control for the mediation effect of psychiatric co-morbidities [ 32 ]. In line with this recommendation and other previous findings, it remains unclear whether child maltreatment is directly associated with impaired cognitive functioning or whether this link is mediated by mental health problems. Moreover, most of the studies testing this link have been conducted in high income-countries. Only one study in Tanzania showed that the relation between child maltreatment and cognitive functioning was mediated by internalizing mental health problems. The other existing studies in low- and middle-income countries, in which violence against and maltreatment of children is much more common, have either examined cognitive impairment among people living with HIV [ 44 , 45 , 46 ], refugees [ 41 ] and the elderly [ 47 ] but not among children and adolescents with a history of maltreatment.

To close this gap, our study sought to examine the relationship between child maltreatment and cognitive functioning (working memory and executive functions) and the mediating role of mental health problems (PTSD symptom severity and depressive symptoms) among maltreated children and adolescents in Southwestern Uganda. We hypothesized that child maltreatment would be negatively correlated with (a) working memory and (b) executive functions, and (c) that these relations would be mediated by mental health problems.

Participants

In total, 232 children and adolescents (52% male) with a mean age of 15 years ( SD  = 2.95) participated in our study. Overall, boys were older than girls and the majority ( n  = 145, 63%) attended primary school (Table 1 ). In total, 101 (44%) participants were living with their mothers as primary caregivers, 40 (17%) were under the primary care of their grandparents, 21 (9%) were primarily cared for by their fathers and 21(9%) were cared for by their siblings, while 30 (13%) indicated other relatives as their main primary caregivers. Only 19 (8%) participants were cared for by another person. Overall, 103 (44%) participants reported to have lived in more than two families in their lifetime.

Study setting and design

This was a cross-sectional study in which 232 children and adolescents between the ages of 8 to 18 studying at two primary schools and one secondary school located in the districts of Mbarara and Rubanda in Southwestern Uganda. The three schools were chosen because they were mainly supported by nonprofit organizations and were expected to have enrolled at-risk children in terms of maltreatment experiences. On average, the enrollment per each school was at 300 (n = 900) children with a total number of 305 children recorded as the most at risk of child maltreatment. Southwestern Uganda is mainly inhabited by Bantu and Nile Hamites ethnic groups. Most residents live in rural areas, where the local economy is primarily characterized by subsistence economy with high levels of food and water insecurity [ 48 , 49 ].

Recruitment and sampling procedure

Data were collected between June 2018 and May 2019. The social workers within the schools helped to locate children and adolescents with a known history of maltreatment in their schools. Only children below the ages of 18 were recruited. We interviewed all children that were identified by the school social workers until there were no more potential participants. Two counsellors and one psychologist conducted the interviews.

The interviewers went through 1-week training in the psychological assessment and practiced the assessment in joint interviews to accomplish high inter-rater reliability. Generally, each interview took 45–60 min in a private setting within the school premises.

Ethical considerations

Ethical clearance was obtained from the Mbarara University of Science and Technology Research Ethics Committee (MUST-REC) under approval number 07/02-18 and the Uganda National Council for Science and Technology (UNSCT) under approval number SS 4928.

Additionally, we sought permission from the school Head Teachers who introduced us to the school social workers. Before the interviews, information on the content, procedures, risks, the right to withdraw, and confidentiality were explained to the participants. Written informed consent (signature or fingerprints) of the legal guardian were obtained. In addition, children and adolescents provided their assent before participating in the study. Each family received two bars of soap as a token of appreciation for taking part in the study. Children with severe symptoms of mental health problems were referred to the nearest health facilities for specialized psychological treatment.

All instruments were translated into Runyankole-Rukiga and back translated to English in a blind written form to ensure the original meaning was not lost. Face to face interviews included socio-demographic information, such as age, gender, educational level and having stayed in two or more homes.

• Child maltreatment

Child maltreatment and other adversities encountered at home were assessed using the Maltreatment and Abuse Chronology of Exposure—Pediatric Version (pediMACE). This tool was the child-appropriate version of the Maltreatment and Abuse Chronology of Exposure [ 50 ]. The pediMACE consists of 45 dichotomous (yes/no) questions, measuring witnessed or self-experienced forms of childhood maltreatment throughout one’s lifetime. We summed up all the questions to a total child maltreatment score (possible range: 0 to 45) that was subsequently used in the analysis.

Exposure to traumatic events

Exposure to traumatic events was assessed using a 15-item checklist on the revised version of the Child PTSD Symptoms Scale for DSM-5—Self-Report (CPSS-VSR) [ 51 ]. With response to yes or no, children were assessed on their exposure to severe natural disasters, severe accidents, being robbed or threatened, being slapped or knifed, seeing relative being beaten or slapped and many others. The scale provides the participants with an opportunity to mention any other traumatizing event that could have been experienced. We summed up all the 15 items to come with a total score that was subsequently used in the analysis.

Mental health problems

We used the CPSS-VSR also to assess the PTSD symptoms severity [ 51 ]. This is a 20-item scale that assesses the occurrence and frequency of PTSD symptoms in relation to the most distressing event experienced by an individual. Participants were asked to rate the frequencies of listed symptoms during the previous 2 weeks on a 5-point Likert scale from 0 (not at all/only once) to 4 (almost every week). A total sum score was calculated. A cut off score of 31 indicated a probable PTSD diagnosis [ 52 ]. This scale has good psychometric measures and showed good psychometric properties, e.g. a Cronbach alpha of 0.92 and test retest reliability of r = 0.93 [ 53 ]. In the current study the Cronbach alpha was 0.86.

Furthermore, we assessed for depressive symptoms using the Center for Epidemiological Studies Depression Scale for Children (CES-DC) [ 54 ]. This is a 20-item self-report depression inventory with total scores ranging from 0 to 60. Each response to an item is scored as: 0 = “Not at All” 1 = “A Little” 2 = “Some” 3 = “A Lot”. Items 4, 8, 12, and 16 are phrased positively, and thus were inverted prior to the calculation of the total score. Higher CES-DC scores indicate higher levels of depression. Scores above 15 have been suggested to indicate significant depressive symptoms in children and adolescents [ 55 ]. However, in this study, we used an adopted cut-off score [ 56 ]. Owing to the cultural context in East Africa, the authors set the cut-off point of probable depression at > 30 [ 53 ]. In the Rwandan study, CES-DC was validated and showed good psychometric properties: Cronbach alpha of 0.86 and test–retest reliability of r = 0.85. In the current study, the Cronbach alpha was 0.87.

Working memory capacity

Corsi-block tapping (CBT) task was used to assess working memory. This neuropsychological test, which has been widely used as a measure of spatial memory in both clinical and experimental contexts for several decades and comes with good psychometric properties shown in validation studies [ 57 , 58 ]. It has also been successfully used in studies within the Great Lakes Region in Central Africa [ 7 , 41 ].The task requires participants to reproduce block-tapping sequences of increasing length in the same or in the reversed order and provides an index of working memory capacity. The Corsi apparatus consisted of nine 2.25 cm 3 black, wooden blocks fixed to a 27.5 cm × 22.8 cm grey, wooden board. The blocks were placed as described in the original test developed by Corsi [ 58 , 59 ]. Each cube was numbered on one side so that the numbers were visible to the interviewer but not to the participant. The participant was seated in front of the interviewer, who subsequently tapped the blocks starting with a sequence of three blocks. Three trials were given per block sequence of the same length. The blocks were touched with the index finger at a rate of approximately one block per second with no pauses between the individual blocks. In the first application of the test after the first half of the interview, the participant had to tap the block sequences in the same order immediately after the interviewer was finished. In the second application at the end of the interview, the participants had to tap the block sequence in reversed order. We computed a total score for both applications (same order and reversed order) by adding the number of correctly repeated sequences until the test was discontinued (i.e., the number of correct trials). The total score ranged from 0 to 21. High performance implied higher working memory capacity.

Executive functions

The Tower of London (TOL) assessed executive functions. The TOL is a classic neuropsychological test for the assessment of executive functions that include planning and problem-solving skills, which has been widely used in diverse cultures [ 41 , 60 , 61 ].

The validation study revealed sound psychometric properties [ 61 ]. The TOL consisted of three wooden pegs, which were fixed on a block of wood and three wooden balls of different colors (black, grey and white) that were placed on the pegs and moved from one peg to another. The participants were shown 12 pictures which depicted the TOL with the balls being placed in different positions on the pegs and were asked to arrange the balls to match the positions on the picture. Each trial started from the same starting positions and varied in difficulty due to the number of moves that were allowed to arrange the balls to match the picture (from two to five). Three attempts were granted for each problem. For each problem up to three points could be earned (if successful in the first attempt). The total sum scores ranged from 0 to 36. Higher grades would mean better performance.

Data analysis

Data were analyzed using SPSS version 23 for Mac. Descriptive statistics were used to compute demographic variables for participants. We z-standardized the two sum scores of PTSD and depressive symptoms severity to compute a mental health problem composite score. Linear regression models were used to test for the association between maltreatment (predictor variable) and the outcome variables of working memory and executive functions. Furthermore, we conducted a simple mediation analysis within the set mediation assumptions that (a) the independent variable would be significantly associated with the dependent variable, (b) the independent variable would be significantly associated with the mediator, and (c) the mediator would be significantly associated with the dependent variable while controlling for the independent variable [ 62 ]. These procedures were followed through the analysis process to estimate the mediating role of mental health problems (mediator variable) on the relationship between child maltreatment and the cognitive domains of working memory and executive functions while controlling for age, years of education and trauma load. As test statistic for the mediating role, we used the Sobel test and non-parametric approach of 5000 bootstraps [ 63 ]. All models fulfilled the necessary quality criteria for linear regression analysis. The residuals did not deviate significantly from normality, linearity or homoscedasticity and no univariate outliers could be identified. The maximum variance inflation factor did not exceed 1.52. Hence, we did not need to take multicollinearity into consideration.

Table 1 displays the descriptive statistics for the main study variables. Overall, 232 (100%) of the participant reported to have experienced at least one type of maltreatment in their lifetime. Female participants experienced more maltreatment types than their male counterparts (see Table 1 ). For example, the majority of participants endorsed having been intentionally pushed by an authority figure (89.7%, n = 208), 89.2% (n = 207) reported having felt that their feelings were not understood by family members. In total, 37.5% of the girls (n = 45,) and 5.4% of the boys (n = 6) indicated that they had been touched in a sexual way (see Additional file 1 : Table S1 for more details). The prevalence of PTSD and depression within our sample was 60% (n = 140) and 39% (n = 91), respectively.

Associations between maltreatment, mental health problems, and executive functions

In a regression model with maltreatment as an explanatory variable and executive functions as the outcome variable while controlling for participant’s age, education in years and trauma load, we found a significant association between maltreatment and executive functions (see Table 2 and Fig.  1 ). The regression model explained 20% of the variability in executive functions. In addition, trauma load and maltreatment significantly correlated with mental health problems (see Table 2 and Fig.  1 ). This model explained 26% of the variance of mental health problems. To investigate whether the association between maltreatment and executive functions was mediated by mental health problems, we conducted a simple mediation analysis with maltreatment as an independent variable and executive functions as dependent variable (Fig.  1 ). When the composite score of mental health problems was added as a mediator variable, the indirect effect of child maltreatment via mental health problems was not significant (see Table 2 , Bootstrap results: B = 0.011, SE = 0.023, 95% CI − 0.036, 0.059).

Mediated regression model ( N  = 232) exploring the mediating influence of mental health problems on the relation between child maltreatment and executive functions. This model indicates that the mental health problems did not mediate the association between child maltreatment and executive functions

Associations between maltreatment, mental health, and working memory

After controlling for age, years of education, and trauma load, maltreatment was significantly associated with working memory (Table 3 and Fig. 2 ). The regression model explained 4% of the variability in working memory. Furthermore, maltreatment and trauma load were significantly associated with mental health problems (Table 3 and Fig. 2 ). The regression model explained 26% of the variations of mental health problems. To investigate whether the association between maltreatment and working memory is mediated by mental health problems, we conducted a simple mediation analysis with maltreatment as independent variable, working memory as dependent variable (Fig. 2 ). When the mental health composite score was added as a mediator variable, the indirect effect of child maltreatment via mental health problems was not significant (see Table 3 , Bootstrap results: B = 0.005, SE = 0.008, 95% CI − 0.010, 0.021).

Mediated regression model ( N  = 232) exploring the mediating influence of mental health problems on the relation between child maltreatment and working memory. This model indicates that mental health problems did not mediate the association between child maltreatment and working memory

In this study, we aimed at examining the association between child maltreatment and the cognitive domains of executive functions and working memory as well as the mediating role of mental health problems in a sample of maltreated children and adolescents in Southwestern Uganda. In line with our hypothesis (a) and (b), we found a negative relationship between child maltreatment and both domains of cognitive functioning after controlling for potential influences, such as age, education, and trauma load. However, in contrast to our hypothesis (c), we did not find an indirect effect via mental health problems.

The finding that child maltreatment was negatively associated with executive functions is in line with previous studies suggesting impairments in executive functions among individuals exposed to child maltreatment [ 29 , 64 , 65 , 66 ]. Furthermore, we found a negative association between child maltreatment and working memory. This observation is also in line with previous findings that found a negative association between child maltreatment and executive functions [ 13 , 67 , 68 , 69 ]. A possible explanation for these negative associations could be the toxic stress theory that implicates exposure to early childhood adversity in altering the neuro-endocrinal immune system, which renders individuals vulnerable to all forms of functional impairments and disease [ 15 , 18 ]. For example, children who have experienced harsh punishments and other forms of maltreatment performed poorly on indicators of self-regulation and other cognitive domains [ 7 , 70 , 71 ]. Differences between maltreated children and non-maltreated children can also be seen in children’s physiology, stress response pathways and cortisol levels [ 72 , 73 ]. With exposure to high levels of maltreatment in our sample, high levels of stress may have negatively impacted hippocampus and the prefrontal cortex functioning. Dense concentration of cortisol receptors in specific brain areas are a possible explanation of cognitive dysfunctioining e.g., in the domains of working memory and executive functions [ 18 , 19 , 74 ]. Based on our own findings and the existing evidence base, including a systematic review [ 29 ], we may conclude that children and adolescents exposed to child maltreatment have a higher likelihood of performing poorly on tasks assessing working memory and executive functions. Our findings therefore lend further support to previous research that children exposed to maltreatment risk impairment in cognitive functions [ 14 , 29 ]. However, it is important to note that most studies on cognitive impairment in individuals exposed to maltreatment are based on cross-sectional data [ 12 , 69 , 75 , 76 ]. Therefore, it remains unclear in literature whether maltreatment leads to poor cognitive functions, whether it co-occurs or whether poor functions increase the risk for maltreatment. Future research should focus on longitudinal, prospective, and experimental studies. For example, randomized controlled studies that implement preventative intervention approaches that reduce maltreatment would offer a unique opportunity to test for causal relations [ 6 ].

Contrary to our hypothesis, we did not find an indirect effect of child maltreatment via mental health problems on cognitive functions. Although our results are partially in line with one study that also did not find an indirect effect of child maltreatment via PTSD on cognitive functions [ 12 ], most studies in high income countries compared individuals with and without mental health problems after trauma exposure [ 77 , 78 ], while others especially in Africa examined the direct association between mental health problems and cognitive functions [ 7 , 41 ]. Overall, the current evidence suggests that mental health problems seem to be linked with poor performance in cognitive functioning [ 79 ]. In our sample, we could not replicate this finding. Our findings, on the other hand, suggest that it is not the mental health problems but the exposure to maltreatment that is linked to poor performance. As most of the above-mentioned studies did not include maltreatment in their analysis, the question remains whether the found associations would hold when including maltreatment in their analysis. However, it is important to consider that our sample was composed of children and adolescents exposed to severe child maltreatment and the found associations may be specific for severely maltreated children. For example, potential effects on the stress response axis may have played a more prominent role [ 31 , 74 ]. Due to the limitation of our cross sectional design further research in Africa and Uganda examining the interplay between child maltreatment, mental health problems, and cognitive functions is needed to fully understand the causal mechanisms that lead to cognitive impairments.

Strength and limitations

Our study examined the relationship between child maltreatment and cognitive functioning and the mediating role of mental health problems among maltreated children and adolescents in Southwestern Uganda. To our knowledge, this is one of the few studies in Africa and other LAMICs that has assessed the mediating role of mental health on child maltreatment and cognitive functions among a sample of maltreated children. Despite our study’s strength, some limitations should be noted: first, the convenience sample does not allow generalizing our findings beyond our specific sample. Secondly, the cross-sectional nature of our study design does not allow us to draw any conclusions about the directionality of our findings. We recommend prospective and experimental studies to shed light on the causal relations. Thirdly, our sample consists of at-risk children. This also limits the possibility to generalize our findings to the general population of children and adolescents. Lastly, it is important to note that biases such as social desirability can never be completely ruled out for subjective reports.

Our findings therefore provide further support to earlier findings, especially from high income countries, that child maltreatment is associated with poor cognitive functioning. Similarly, based on our findings, we advocate for preventive measures to protect children in Uganda and Africa from violence and maltreatment. Programs aimed at equipping parents, caregivers, and teachers with none violent competencies while interacting with children are highly needed in societies where violence against children is still socially accepted. Based on our findings, we advocate for preventing child maltreatment within schools and families to enable more children in Uganda to grow up in a secure environment and to ensure their healthy development. Future studies in Africa should investigate differential associations and consequences of different types of maltreatment on mental health and cognitive functions.

Availability of data and materials

The data sets used and analyzed during the current study are available from the corresponding author on request.

Abbreviations

Post traumatic stress disorder

Low- and middle-income countries

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Acknowledgements

We thank the children and caregivers who participated in this study; the administrators of New Times Nursery and Primary School, Kishanje Highlands High school and Murole Preparatory school. We are grateful to our motivated research assistants; Ninsiima Ainembabazi, Joseph Namanya and Eunice Atuheire for assisting with data collection. We also thank Mr. Chris Brett for proofreading this Manuscript.

HEA acknowledges partial funding from Bishop Stuart University Mbarara-Uganda.

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Herbert E. Ainamani

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Godfrey Z. Rukundo

Department of Pediatrics, Kabale University School of Medicine, Kabale, Uganda

Timothy Nduhukire

Department of Educational Psychology, Kabale University, Kabale, Uganda

Eunice Ndyareba

Department of Psychology, Bielefeld University, Bielefeld, Germany

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HEA participated in the conception and design of the study, collected the data, performed data analyses, interpreted the data, and drafted the manuscript. GZR participated in the conception of the study, supervised data collection and revised the manuscript. TN and EN participated in the conception of study and revised the manuscript. TH participated in the conception and design of the study, supervised data analysis and provided substantial revision of the manuscript. All authors read and approved the final manuscript.

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Additional file 1: table s1..

Endorsement of individual items on pediMACE stratified by gender.

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Ainamani, H.E., Rukundo, G.Z., Nduhukire, T. et al. Child maltreatment, cognitive functions and the mediating role of mental health problems among maltreated children and adolescents in Uganda. Child Adolesc Psychiatry Ment Health 15 , 22 (2021). https://doi.org/10.1186/s13034-021-00373-7

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• Cognitive functions
• Mental health
• East Africa

Child and Adolescent Psychiatry and Mental Health

ISSN: 1753-2000

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Children's Responses to Maltreatment: Key Conclusions From a Systematic Literature Review

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• 1 Bob Shapell School of Social Work, Tel Aviv University, Israel.
• PMID: 32116133
• DOI: 10.1177/1524838020908851

Child maltreatment (CM) has received much research attention in recent years, leading to the enormous development of services provided to children worldwide. However, although the literature in the field of trauma studies recognizes that responses to trauma are of central importance, for a variety of reasons, the research on this subject is sparse. The current systematic literature review was therefore designed to characterize and analyze the existing knowledge on children's responses to CM, while putting in focus all possible responses that will appear in the identified manuscripts. Key databases were explored using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and only six studies were identified as relevant to the focus of the current study. Utilizing thematic analysis, the results addressed four main themes: the studies' methodologies, the terminology and responses that were explored in these studies, the abuse-related factors and contexts that were taken into account, and the consequences for the children (of their responses to the maltreatment). A key conclusion from this review is that concepts in this area, as well as theory, are considerably lacking. Promoting the development of theory regarding children's responses to CM is urgently needed, as it will greatly impact clinical intervention, legal investigation, and the development of prevention programs.

Keywords: children; maltreatment; response.

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• Systematic Review
• Child Abuse*

Longterm Consequences of Child Maltreatment

• First Online: 21 November 2013

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• Cathy Spatz Widom 5  

Part of the book series: Child Maltreatment ((MALT,volume 2))

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Over the past three decades, considerable progress has been made in understanding the long-term consequences of childhood victimization. Using a schematic modified ecological model to organize this chapter, the first part reviews the literature on the “cascade of consequences of childhood maltreatment” across multiple domains of functioning, including cognitive and academic, social and behavioral, psychiatric and emotional, and physical health and neurobiological. Where possible, consequences for specific types of childhood maltreatment (physical abuse, sexual abuse, and neglect) are described. Because the negative effects of childhood maltreatment are not inevitable, the next section describes research on protective factors that may buffer maltreated children from succumbing to negative consequences. The next section discusses the important role that contextual factors play in influencing the development of children. Finally, there is a discussion of the challenges to the field and a brief section on gaps in knowledge and suggestions for future research.

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Widom, C.S. (2014). Longterm Consequences of Child Maltreatment. In: Korbin, J., Krugman, R. (eds) Handbook of Child Maltreatment. Child Maltreatment, vol 2. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-7208-3_12

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Childhood maltreatment responsible for up to 40 percent of mental health conditions

A study examining childhood maltreatment in Australia has revealed the shocking burden for Australians, estimating it causes up to 40 percent of common, life-long mental health conditions.

The mental health conditions examined were anxiety, depression, harmful alcohol and drug use, self-harm and suicide attempts. Childhood maltreatment is classified as physical, sexual and emotional abuse, and emotional or physical neglect before the age of 18.

Childhood maltreatment was found to account for 41 percent of suicide attempts in Australia, 35 percent for cases of self-harm and 21 percent for depression.

The analysis, published in JAMA Psychiatry is the first study to provide estimates of the proportion of mental health conditions in Australia that arise from childhood maltreatment.

The researchers said the results are a wakeup call for childhood abuse and neglect to be treated as a national public health priority.

"The results are devasting and are an urgent call to invest in prevention -- not just giving individual support to children and families, but wider policies to reduce stress experienced by families," said Dr Lucinda Grummitt, from the University of Sydney's Matilda Centre, who led the study.

"Investments to address childhood maltreatment have the potential to avert millions of cases of mental disorders in Australia."

The analysis also found that if childhood maltreatment was eradicated in Australia, more than 1.8 million cases of depression, anxiety and substance use disorders could be prevented.

The study also found elimination of childhood maltreatment in Australia would, in 2023, have prevented 66,143 years of life lost (death) and 118,493 years lived with disability, totaling 184,636 years of healthy life lost through mental health conditions.

Researchers examined data that included national surveys provided by the Australian Child Maltreatment Study in 2023 (8500 participants), the Australian National Study of Mental Health and Wellbeing 2020-2022 (15,893 participants) and the Australian Burden of Disease study 2023.

The study made use of analytical methods to investigate the link between child maltreatment and mental health, which isolated other influential factors such as genetics or social environments. This provides stronger evidence that childhood maltreatment causes some mental health conditions.

Mental health conditions are currently the leading cause of disease burden globally and affect 13 percent of the global population. In Australia, suicide is the leading cause of death for young people.

Previous research (independent to the University of Sydney study) found over half (53.8 percent) of Australians experienced maltreatment during their childhood.

Dr Grummitt said there are effective interventions, such as programs to support children experiencing maltreatment or parent education programs, but the most sustainable solution to prevent child maltreatment is policy-driven prevention.

"Policies to alleviate stress experienced by families, such as paid parental leave, affordable childcare, income support like Jobseeker, and making sure parents have access to treatment and support for their own mental health could make a world of difference for Australian children.

"Addressing the societal and economic conditions that give rise to child maltreatment can play a large part in preventing mental disorders at a national level," Dr Grummitt said.

The researchers cite an example in the United States where the introduction of state paid parental leave policies and timely access to subsidised childcare were strongly linked to reduced rates of child maltreatment.

• Mental Health Research
• Chronic Illness
• Children's Health
• Mental Health
• Child Psychology
• Public Health
• Poverty and Learning
• STEM Education
• Child abuse
• Public health
• Environmental impact assessment
• Epidemiology
• Early childhood education
• Substance abuse
• Political science

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Journal Reference :

• Lucinda Grummitt, Jessie R. Baldwin, Johanna Lafoa’i, Katherine M. Keyes, Emma L. Barrett. Burden of Mental Disorders and Suicide Attributable to Childhood Maltreatment . JAMA Psychiatry , 2024; DOI: 10.1001/jamapsychiatry.2024.0804

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Up to 40% of mental health conditions can be linked back to childhood maltreatment

by Freya Lucas

Nearly half of all common mental health conditions have their roots in child abuse and neglect, a study from the University of Sydney has found , leaving researchers to call for childhood maltreatment to be treated as a public health priority.

The mental health conditions examined were anxiety, depression, harmful alcohol and drug use, self-harm and suicide attempts, and childhood maltreatment, in the context of the study, was classified as physical, sexual and emotional abuse, and emotional or physical neglect occuring before the age of 18 years.

Childhood maltreatment was found to account for 41 percent of suicide attempts in Australia, 35 percent for cases of self-harm and 21 percent for depression.

Published in JAMA Psychiatry the study is the first to provide estimates of the proportion of mental health conditions in Australia that arise from childhood maltreatment.  

“The results are devastating and are an urgent call to invest in prevention – not just giving individual support to children and families, but wider policies to reduce stress experienced by families,” study lead Dr Lucinda Grummitt said. 

If it were possible to eradicate childhood maltreatment in Australia, the researchers noted, more than 1.8 million cases of depression, anxiety and substance use disorders could be prevented.

In 2023 alone, the elimination of childhood maltreatment in Australia would have prevented 66,143 years of life lost (death) and 118,493 years lived with disability, totaling 184,636 years of healthy life lost through mental health conditions.

To reach their findings researchers examined data that included national surveys provided by the Australian Child Maltreatment Study in 2023 (8500 participants), the Australian National Study of Mental Health and Wellbeing 2020-2022 (15,893 participants) and the Australian Burden of Disease study 2023.

The study made use of analytical methods to investigate the link between child maltreatment and mental health, which isolated other influential factors such as genetics or social environments. This provides stronger evidence that childhood maltreatment causes some mental health conditions.

Mental health conditions are currently the leading cause of disease burden globally and affect 13 percent of the global population. In Australia, suicide is the leading cause of death for young people.

Dr Grummitt said there are effective interventions, such as programs to support children experiencing maltreatment or parent education programs, but the most sustainable solution to prevent child maltreatment is policy-driven prevention.

“Policies to alleviate stress experienced by families, such as paid parental leave, affordable childcare, income support like Jobseeker, and making sure parents have access to treatment and support for their own mental health could make a world of difference for Australian children,” she explained.

“Addressing the societal and economic conditions that give rise to child maltreatment can play a large part in preventing mental disorders at a national level.” 

There is an international precedent supporting the impact of the introduction of state paid parental leave policies and timely access to subsidised care which were strongly linked to reduced rates of child maltreatment.

Read the study in full here . 

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Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25.

New Directions in Child Abuse and Neglect Research.

• Hardcopy Version at National Academies Press

1 Introduction

The 1993 National Research Council (NRC) report Understanding Child Abuse and Neglect notes that “Child maltreatment is a devastating social problem in American society” ( NRC, 1993 , p. 1). The committee responsible for the present report, armed with research findings gleaned during the past 20 years, regards child abuse and neglect not just as a social problem but as a serious public health issue. Researchers have found that child abuse and neglect affects not only children but also the adults they become. Its effects cascade throughout the life course, with costly consequences for individuals, families, and society. These effects are seen in all aspects of human functioning, including physical and mental health, as well as important areas such as education, work, and social relationships. Furthermore, rigorous examinations of risk and protective factors for child abuse and neglect at the individual, contextual, and macrosystem levels have led to more effective strategies for prevention and treatment.

This public health problem requires swift and effective action. The committee's deliberations led to recommendations for responding to the problem of child abuse and neglect while remaining realistic about the nature of feasible actions in these challenging political and economic times. The intent is to capitalize on existing opportunities whenever possible while advocating for new actions when they are needed.

The committee also believes that the existing body of research creates enormous opportunities for research going forward; the nation is poised to take full advantage of a developing science of child abuse and neglect. In particular, the results of studies of the consequences of child abuse and neglect, integrating biological with behavioral and social context research, as well as studies and controlled prevention trials that integrate basic findings with services research, now provide a solid base for moving forward with more sophisticated and systematic research designs to address important unanswered questions. New knowledge and better research tools can yield a better understanding of the causes of child abuse and neglect, as well as the most effective ways to prevent and treat it.

At the same time, however, the existing research and service system infrastructures are inadequate for taking full advantage of this new knowledge. The committee hopes that this gap will narrow as researchers in diverse domains collaborate to elucidate the underlying causes and consequences of child abuse and neglect, as those implementing promising interventions learn how best to take evidence-based models to scale with fidelity, and as policies are examined more rigorously for their ability to improve outcomes and create a coordinated and efficient system of care.

• THE 1993 REPORT

Two decades ago, the Administration on Children, Youth and Families (ACYF) within the U.S. Department of Health and Human Services asked the National Academy of Sciences to conduct a study of research needs in the area of child abuse and neglect. That study resulted in the 1993 NRC report, which synthesizes the research on child abuse and neglect and, adopting a child-oriented developmental and ecological perspective, outlines 17 research priorities in an agenda that addresses 4 objectives:

clarify the nature and scope of child maltreatment;

provide an understanding of the origins and consequences of child maltreatment to improve the quality of future policy and program efforts;

provide empirical information about the strengths and limitations of existing interventions while guiding the development of more effective interventions; and

develop a science policy for child maltreatment research that recognizes the importance of national leadership, human and financial resources, instrumentation, and appropriate institutional arrangements.

• TRENDS SINCE 1993

Since the 1993 report, research on child abuse and neglect has expanded, and understanding of the consequences and other aspects of child abuse and neglect for the children involved, their families, and society has advanced significantly. During that same period, rates of reported physical and sexual abuse (but not neglect) have declined substantially, for reasons not fully understood. On the other hand, reports of psychological and emotional abuse have risen.

Child abuse and neglect nonetheless remains a pervasive, persistent, and pernicious problem in the United States. Each year more than 3 million referrals for child abuse and neglect are received that involve around 6 million children, although most of these reports are not substantiated. In fiscal year 2011, the latest year for which data are available, state child protective services agencies encountered 676,569 children, or about 9.1 of every 1,000 children, who were found to be victims of child abuse and neglect, including physical abuse, sexual abuse, psychological abuse, and medical and other types of neglect. More than one-quarter had been victimized previously. Of these 676,569 children, 1,545 died as a result of the abuse or neglect they suffered—most younger than 4 years old ( ACF, 2012 ). Yet these figures are underestimates because of underreporting ( GAO, 2011 ). For example, the estimate of the rate of child abuse and neglect by caretakers in 2005-2006 derived from the most recent National Incidence Study of Child Abuse and Neglect, a sample survey, was 17.1 of every 1,000 children (totaling more than 1.25 million children), and many more were determined to be at risk ( Sedlak et al., 2010 ). This uncertainty as to the extent of child abuse and neglect hampers understanding of its causes and consequences, as well as effective prevention and treatment interventions.

Research conducted since 1993 has made clear that child abuse and neglect has much broader and longer-lasting effects than bruises and broken bones or other acute physical and psychological trauma. As noted above, child abuse and neglect can have long-term impacts on its victims, their families, and society. Children's experiences of these long-term consequences vary significantly, depending on the severity, chronicity, and timing of abuse or neglect, as well as the protective factors present in their lives. Nevertheless, abused and neglected children are more prone to experience mental health conditions such as posttraumatic stress disorder and depression, alcoholism and drug abuse, behavioral problems, criminal behavior and violence, certain chronic diseases, and diminished economic well-being.

Society is also affected. Each year, cases of abuse or neglect may impose a cumulative cost to society of $80.3 billion—$33.3 billion in direct costs (e.g., hospitalization, childhood mental health care costs, child welfare system costs, law enforcement costs) and $46.9 billion in indirect costs (e.g., special education, early intervention, adult homelessness, adult mental and physical health care, juvenile and adult criminal justice costs, lost work productivity) ( Gelles and Perlman, 2012 ). An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to loss of productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012 ). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity. These costs are comparable to those of other major health problems, such as stroke and type 2 diabetes, issues that garner far more research funding and public attention.

• THE CURRENT STUDY

In 2012, ACYF requested that the National Academies update the 1993 NRC report. ACYF asked that the updated report “provide recommendations for allocating existing research funds and also suggest funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.” Box 1-1 contains the complete statement of task for this study.

Statement of Task. Building on Phase 1, an ad hoc committee will conduct a full study that will culminate in an updated version of the 1993 NRC publication entitled Understanding Child Abuse and Neglect . Similar to the 1993 report, the updated report (more...)

• STUDY APPROACH

The Institute of Medicine of the National Academies appointed a committee with expertise in relevant areas—child development and pediatrics, psychology and psychiatry, social work and implementation science, sociology, and policy and legal studies—to conduct this study. The chair and one committee member had been the chair and a member, respectively, of the 1993 study committee, which provided for continuity. The committee commissioned a number of background papers that reviewed research results and research infrastructure needs in key areas of child abuse and neglect research. It held four face-to-face meetings, including two public sessions, as well as many whole-committee and subcommittee conference calls, to review the literature; discuss current understanding of the extent, causes, and consequences of child abuse and neglect, the effectiveness of intervention programs, and the impact of public policies; and discuss the draft report chapters and reach consensus on findings, conclusions, and recommendations.

In constructing the evidence base for this report, the committee looked back nearly 20 years to assess the state of research on child abuse and neglect. Doing so involved a conscious decision to privilege the peer-reviewed literature across a variety of disciplines (e.g., social-cultural science, developmental science, neuroscience, prevention and intervention science, epidemiology) and multiple dimensions of child abuse and neglect, including etiology, consequences, prevention, and intervention, as well as ethics, service delivery, and policy. The committee considered the most rigorous evidence drawn from a variety of study designs and methods, including mixed-methods, experimental, observational, prospective, retrospective, descriptive, longitudinal, epidemiological, meta-analysis, and cost-effectiveness studies.

The committee built on a literature review conducted as part of a workshop exploring major research advances since publication of the 1993 report ( IOM and NRC, 2012 ). That initial literature review yielded a brief updated summary of selected research literature, reports, and grey literature on the topics covered in the original report ( NRC, 1993 ). Relevant studies were selected through a search of several scientific databases and were augmented by additional research conducted by other agencies and organizations (see IOM and NRC, 2012 , for more detailed information).

The committee expanded on the 2012 literature review and critically examined publications derived from a literature database search, supplemented by the committee's knowledge of relevant work in the field. The review strategy began with a keyword search of electronic citation databases, followed by a review of the literature gleaned from published research syntheses, academic books, and peer-reviewed journals (i.e., Child Abuse and Neglect, Child Maltreatment, Children and Youth Services Review, Child Welfare, Protecting Children ); websites of research, nonprofit, and policy organizations (including evidence-based clearinghouses); professional conference proceedings; and other grey literature. Literature on child abuse and neglect in the United States was the primary focus; however, the committee also considered key studies from other countries. While the committee's approach did not represent a systematic review of the evidence, it did provide a body of research well suited to guide an understanding of critical issues and formulation of the recommendations presented in this report.

Definitions

As described in Chapter 2 , definitions of child abuse and neglect can vary considerably as legal definitions differ across states, and researchers apply diverse standards in determining whether abuse or neglect has occurred. A basic yet important definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA) 1 :

At a minimum, any recent act or set of acts or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act, which presents an imminent risk of serious harm.

While this federal definition sets a minimum standard for legal definitions, each state has developed its own definitions of child abuse and neglect. Child abuse and neglect are usually represented by four major categories: physical abuse, neglect, sexual abuse, and emotional (or psychological) abuse. Table 1-1 presents examples of acts that are considered to represent each of these four types of abuse and neglect, as compiled by the Child Welfare Information Gateway.

Examples of Acts of Child Abuse and Neglect.

The examples listed in Table 1-1 are drawn from state definitions of child abuse and neglect; however, they are not representative of any specific state. There is considerable variation across jurisdictions with regard to statutory descriptions of which acts constitute abuse or neglect. In addition, child abuse and neglect are defined in many contexts outside of legal and child protection system venues, research being the most notably germane to this report. Many studies identify cases of abuse and neglect through the use of survey instruments. Across these studies is found much variation in the types of questions asked of respondents and the types of responses that indicate instances of abuse or neglect. While some standards have been developed, definitions of child abuse and neglect in this context are often tailored to the needs of specific studies.

Given this definitional landscape, which is discussed further in Chapter 2 , the committee made two significant determinations with regard to definitions of child abuse and neglect for the purposes of this report. First, the scope of the discussion in this report is limited to actions (or inaction) of parents or caretakers, to the exclusion of extrafamilial abuse. This scope is reflective of the minimum definitional standard prescribed by CAPTA. Although individual jurisdictions may expand their definitions of abuse to include actions by extrafamilial parties, the CAPTA minimum standard is the most universally relevant to legal and child protection systems across the United States, as well as the data drawn from such sources for research purposes. Restricting the scope of this report to parent or caregiver actors also allowed the committee to conduct a more focused evaluation of the causes and consequences of abuse and neglect, as well as the delivery of prevention and treatment services, within the context of family and home. It is important to note that while this scope applies to the organization and content of the report, some of the studies discussed in the following chapters draw samples from jurisdictions that include instances of extrafamilial abuse in their definitions.

Second, the report does not specify a particular set of circumstances that would define whether or not an instance of child abuse or neglect has occurred. In addition to the need to review many studies that incorporate samples based on differing characterizations of acts of child abuse and neglect, there is insufficient evidence with which to determine the single most reliable, effective, and appropriate definitional approach. As studies are presented throughout the report, methodological limitations identified by the committee are described where applicable.

• RESEARCH ADVANCES IN CHILD ABUSE AND NEGLECT

As noted above, research conducted in the past 20 years has revealed child abuse and neglect to be a serious public health problem, but it has also revealed that rates of physical and sexual abuse of children (although not neglect) appear to have declined. Credited with the possible declines are some policy and practice reforms that include more aggressive prosecution of offenders, especially in the area of child sexual abuse; more effective treatment programs for victims of child abuse and neglect; and increased investments in prevention programs, especially for new parents. Yet contradictions and inconsistencies in the data demand more analysis.

Publications on child abuse and neglect increased more than threefold over the past two decades. Among the key areas seeing significant advances are (1) research on the consequences of child abuse and neglect, demonstrating that its effects are severe, long-lasting, and cumulative over adulthood; (2) research demonstrating effects on the brain and other biological systems, as well as on behavior and psychosocial outcomes; and (3) rigorous treatment and prevention research demonstrating the effectiveness of interventions.

Despite these advances, however, the research evidence also underscores how much remains unknown. More specific research designs and incorporation of core questions into studies examining factors that impact parental capacity and child development are needed to enable greater understanding and more effective prevention of child abuse and neglect. Also needed is a better understanding of the remarkable declines in reported child abuse, why children have differential sensitivity to abuse of similar severity, and how different types of abuse impact a child's developmental trajectory.

Needed as well are improved theories and research that can make it possible to disentangle the multiple causes and consequences of child abuse and neglect. The complexity of child abuse and neglect requires a systems approach, employing integrated, cross-disciplinary thinking, and research methods that can support better-specified model testing. Among specific improvements needed are refined theoretical models and research designs representing the relevant disciplines and ecological levels with appropriate specification of effects; multiple measures and methods for tracking core constructs, including neurological and other biological measures such as genetic and epigenetic factors; longitudinal research designs with which to assess the sequences of events that lead to abusive and neglectful behaviors and to identify treatment and prevention interventions that can protect against the intergenerational transfer of abuse and neglect; appropriate statistical analyses that differentiate effects at various ecological levels; appropriate statistical control to create more rigorous experimental opportunities when randomized controlled trials are infeasible for evaluating interventions; and designs that account for overlapping variance due to children's being nested within multiple layers of systems. Simpler designs and analyses can still play a role, especially when descriptive studies are needed to generate hypotheses. And essential for any study is clarity of the question being examined, preferably with a hypothesis that can be tested; the appropriate research design and statistical analysis can then be identified.

While some longitudinal studies on child abuse and neglect do exist, including the Longitudinal Studies in Child Abuse (LONGSCAN) and National Survey of Child and Adolescent Well-Being (NSCAW), additional longitudinal, prospective studies are needed. An example of the kind of study required is the Fragile Families and Child Wellbeing Study, which is following a cohort of nearly 5,000 children born in large U.S. cities between 1998 and 2000, with an oversample of 75 percent children born to unmarried parents (for further information, see www.fragilefamilies.princeton.edu ). This longitudinal study (now producing the sixth wave of data on children and their families 15 years after the original data collection) has examined many questions related to the nature of the sample, including child abuse and neglect (e.g., Guterman et al., 2009 ; Lee et al., 2008 ; Whitaker et al., 2007 ). The study employs embedded variables, such as children and parents within families, including all the variations that currently occur in families, and many types of data, from neighborhood characteristics to biological measures.

Importantly, this study serves as an example for the rigor of data analysis. A recent working paper by McLanahan and colleagues (2012) carefully reviews the literature on the causal effects of father absence to examine how study design impacts findings. The authors conclude that studies with more rigorous designs have found negative effects of father absence on child well-being, but with smaller effect sizes than have been found with standard cross-sectional designs. These conclusions demonstrate the importance of designing rigorous studies to examine complex questions such as those relating to child abuse and neglect. The Fragile Families study can provide a great deal of information on child abuse and neglect, and a similarly rigorous study designed to examine the many important questions concerning child abuse and neglect could do much more.

Both practice and policy research require similar improvements. Future research efforts need to address the impacts of service integration and the additive effects of conducting multiple interventions that simultaneously address the problem at the individual and community levels. While strengthening the response to child abuse and neglect will require continued rigorous prevention and treatment research on the efficacy of promising interventions, equally important is examining how such efforts can be replicated with quality and consistency. Finally, research is needed to understand the role and impacts of a more integrated, systemic response to child abuse and neglect with respect to participant outcomes and system performance. A better understanding also is needed of the utility and potential limitations of employing a singular focus on evidence-based decision making to guide policy and practice.

• A SYSTEMS FRAMEWORK FOR CHILD ABUSE AND NEGLECT

Research advances in child abuse and neglect make clear that attaining a better understanding of the problem and mounting an effective response will require a systems perspective (e.g., Senge and Sterman, 1992 ). The public health problem of child abuse and neglect encompasses many embedded systems that are engaged both positively and negatively in creating, sustaining, and responding to the problem. Such systems include individual development, family systems, social relationship systems, and service systems from the local to the national level, among others. All of these systems and factors within them involve complex interdependencies, such that efforts to solve one aspect of the problem may reveal or even create problems at other levels.

Systems thinking has been adopted in the child protection field both in the United States and globally (e.g., Wulczyn et al., 2010 ). As Wulczyn and colleagues note, the systems approach fits well with the major theoretical model in the field of child development—that of Bronfenbrenner (1979) . From any perspective, children can be considered in terms of the nested or embedded and interacting structures (e.g., families, communities) that affect them. Conversely, considering any child-related issue without taking such a perspective will be an incomplete exercise. From the perspective of the child protection system, all of the systems that work with children are highly entangled and must work in concert to achieve effective results ( Wulczyn et al., 2010 ). Figure 1-1 depicts the interplay among the actors, contexts, and components of child protection systems.

Child protection systems: actors, contexts, and components. SOURCE: Wulczyn et al., 2010 (reprinted with the permission of the paper authors).

Policy and program failures typically are considered to be system failures ( Petersen, 2006 ). They often involve a given system's establishing unsustainable ends or goals, or the use of approaches that fail to achieve the intended results and may have unintended consequences that may be worse than the initial problem. The common system failures (e.g., Senge and Sterman, 1992 ; Sterman, 2002 ) include misspecified ends, unintended consequences, drifting goals, underinvestment in capacity, and delays in delivering results.

An underlying problem that can contribute to all of these types of system failure is incomplete analysis of opportunities and challenges at the initial stage. To be effective, change efforts and the policies designed to sustain them must include a rigorous analysis of system dynamics. For example, the usefulness of systems analysis has been demonstrated in multiple successful applications to business challenges (e.g., Ford, 1990 ; Harris, 1999 ; Jones and Cooper, 1980 ), as well as in current efforts to apply systems analysis to the child protection system (e.g., Wulczyn et al., 2010 ). Systems analysis helps reveal mental models held by participants, including beliefs, assumptions, and presumed knowledge. This allows all participants in a change effort to recognize and take responsibility for their mental models and to account for them in the design of the change effort. In addition, systems analysis includes identification of potential barriers or challenges to implementation so that approaches to overcome them can be anticipated. Finally, the systems analysis approach views all solutions identified by the process as interim, systematically building feedback into the implementation of a change effort. By intentionally seeking, generating, and learning from feedback over time, participants in change efforts will improve their understanding of the system and efforts to improve it, and will see concomitant improvements in the efforts' results.

The complexity of child abuse and neglect makes the problem difficult to address in the absence of a full understanding of the diverse and multilevel systems that impact its incidence, consequences, and social response. By contrast, sustained and thoughtful systems thinking can lead to rigorous research designs that can advance knowledge and program or service implementation in meaningful ways. Such research can progress from addressing symptoms to focusing increasingly on core causes and solutions that draw more effectively on the strengths of multiple actors and domains.

Prevention of child abuse and neglect is a complex problem that can be solved only if many societal systems and the people within them cooperate to play positive roles ( Wulczyn et al., 2010 ). As with all complex societal problems, child abuse and neglect has no single cause; therefore, tackling the problem strategically at multiple levels is the only way to make a substantial impact on the problem.

• THE UNIQUE ROLE OF SOCIAL AND ECONOMIC STRATIFICATION

In the 1993 NRC report, issues concerning the influence of sociocultural factors on child abuse and neglect are addressed only marginally and, in truth, somewhat superficially. What is more, that report often implies that the racial and socioeconomic dimensions of abuse and neglect represent “cultural” effects. This misnomer distorts understanding of those social, economic, and cultural factors that influence the prevalence, mechanisms, processes, and outcomes of child abuse and neglect. The present report proposes several new conceptual and empirical directions for addressing these themes in future research on child abuse and neglect. Unfortunately, they are not well covered in existing research in the field, so the review of the literature presented herein generally is missing these perspectives.

The committee emphasizes the importance of adopting a critical stratification lens in considering and writing about the impact of social and economic factors on child abuse and neglect. Stratification involves the rank ordering of people based on their social and economic traits ( Keister and Southgate, 2012 ). Based on this rank ordering, people have unequal access to resources and are differentially exposed to certain behaviors, processes, and circumstances (e.g., discrimination) that influence the nature, power, vulnerability, privilege, and protection of children who are abused, those who abuse them, and those who are charged with preventing and intervening in abuse situations. This lens therefore makes it possible to consider the various domains of stratification—race, skin color, ethnicity, class (social and economic), gender, sexual orientation, immigration status—and how the inequalities that ensue because of rank ordering in these domains impact child abuse and neglect. In addition, this lens enables intersectionality to be infused into the discourse; thus, how the multiple strata occupied by an individual (e.g., a poor dark-skinned Latino female) collectively influence the lived experiences of child abuse and child neglect for all involved can be discussed and differentiated ( Burton et al., 2010 ; Dill and Zambrana, 2009 ). Finally, attention to stratification issues points to the need to consider how place matters relative to child abuse and neglect. Stratification processes create inequalities in physical and environmental locations that differentially shape certain behaviors and outcomes. Researchers in the field need to consider whether differences in the prevalence and nature of child abuse and neglect are observed in certain urban, suburban, rural, and regional areas of the United States and how those differences are related to population, institutional, and political inequalities.

Also important is avoiding the error of equating domains of stratification with the attributes and practices of culture. Culture is distinct from stratification. It is not necessarily circumscribed by the same mechanisms and processes as, for example, racial stratification; it encompasses but is larger than stratification issues. In Geertz's classic work The Interpretation of Culture , culture is defined as “an historically transmitted pattern of meanings embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men communicate, perpetuate, and develop their knowledge about and attitudes toward life” ( Geertz, 1973 , p. 89). And as Swidler notes, “seeing culture as meaning embodied in symbols focuses attention on such phenomena as beliefs, ritual practices, art forms, and ceremonies, and on informal cultural practices such as language gossip, stories, and rituals of daily life” ( Swidler, 2001 , p. 12). Thus, a fundamental component of culture is the social processes by which these symbols, attitudes, and modes of behavior are shared, reified, and sanctioned within families and communities. A focus on culture then directs attention to different types of questions, such as how certain religions and other collectives (not necessarily defined by race) value children, adopt harsh parenting styles, or execute certain moral codes/beliefs in the contexts in which they reside.

Attention to these issues will contribute to achieving the goal for research on child abuse and neglect of having sufficient specificity so that understanding of the problem's causes and consequences, as well as programs or services to address it, will be focused rather than overly general. Research conducted to date is informative about risk factors but not about how or why more risk factors lead to worse results, or which risk factors are more important than others and for which types of abuse or neglect. For example, poverty is a risk factor, yet many poor children are not abused or neglected. Which poor children are abused and why? The committee believes attention to these issues of social and economic stratification will yield increased understanding and more effective responses to the problem.

Significant progress has been made in efforts to understand child abuse and neglect; to document its devastating and lifelong impacts on both its victims and society; and to develop, test, and replicate evidence-based treatment and prevention strategies. Today, strong evidence demonstrates that child abuse and neglect is a public health issue in terms of both its immediate impact on child development and well-being and its impact on long-term productivity.

Research advances in child abuse and neglect underscore the importance of viewing the problem as a systemic challenge. The interdependency of myriad factors operating at multiple levels and in multiple domains complicates understanding of the causes and consequences of child abuse and neglect and challenges the ability to design, implement, and sustain effective responses. Building on the gains realized in the past 20 years will require a research paradigm and infrastructure capable of capturing this complexity.

• ORGANIZATION OF THE REPORT

This report is organized into nine chapters. Between this introductory chapter and the final chapter, which contains the committee's recommendations, are seven chapters that review the state of knowledge and contain the committee's findings and conclusions related to important aspects of child abuse and neglect research. In these chapters, major research findings are summarized at the end of major sections, and each chapter ends with overall conclusions. The aspects of child abuse and neglect addressed are the extent of the problem ( Chapter 2 ); research on its causes ( Chapter 3 ); research on its consequences ( Chapter 4 ); an overview of the child welfare system, which constitutes society's primary vehicle for identifying and responding to formal reports of child abuse and neglect ( Chapter 5 ); research on the implementation and impacts of prevention and treatment programs ( Chapter 6 ); an overview of the infrastructure for child abuse and neglect research ( Chapter 7 ); and research on relevant public policies ( Chapter 8 ). The recommendations presented in Chapter 9 are based on the findings and conclusions in these chapters, as well as the supporting discussion.

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42 U.S.C. § 5101 note.

• Cite this Page Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25. 1, Introduction.
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