term paper about child abuse

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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

4 Consequences of Child Abuse and Neglect

Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods—the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions.

• CASCADING CONSEQUENCES

Newborns are almost fully dependent upon parents to help them regulate physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as “co-regulators” of behavior and physiology ( Hertsgaard et al., 1995 ; Hofer, 1994 , 2006 ). Over time, children raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers.

For some children, parents cannot fill these roles as buffer and co-regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences.

Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulating behavior and physiology ( Moriceau et al., 2010 ). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an extended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children's health and social, psychological, cognitive, and brain development.

Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., problems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defiant disorder, conduct disorder, aggression), and posttraumatic stress disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity.

This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and neglect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic outcomes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that distinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6 , the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course.

Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of a child's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child's development. Therefore, the most rigorous research on this topic attempts to account for the many factors that may be confounded with abuse or neglect.

Ecological Framework

Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect ( Belsky, 1993 ; Cicchetti and Lynch, 1993 ; Cicchetti and Toth, 1998 ). Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by characteristics of the individual, parents and family, and neighborhood and/or community and their interactions.

In examining the role of contextual factors in the onset of consequences due to child abuse and neglect, Cicchetti and Lynch's (1993) ecological/transactional model is particularly useful because it successfully incorporates multiple etiological frameworks ( Lynch and Cicchetti, 1998 ). This model is based on Belsky's (1980 , 1993 ) ecological model and Cicchetti and Rizley's (1981) transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The ecological/transactional model describes four interrelated, mutually embedded categories that contribute to abuse and neglect and the potential associated consequences:

• Ontogenic development—Reflects factors within the individual that influence the achievement of competence and adaptation.
• Microsystem—Defined as the “immediate context” (i.e., the family) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child interactions directly or indirectly.
• Exosystem—The exo- and macrosystemic levels reflect social or cultural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning.
• Macrosystem—Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a “larger cultural fabric,” that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children).

The model is based on the fact that a child's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes. Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children.

At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment. These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur.

The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect.

Types of Evidence

Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible.

Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006 ; Suomi, 1997 ). One salient human study involved random assignment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) ( Nelson, 2007 ). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were extensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013 ; Nelson et al., 2007a , b ; Zeanah et al., 2003 ). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature.

The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999) , which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999 , 2000 ), Noll and colleagues (2007) , and Jonson-Reidz and colleagues (2012) . Retrospective designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases ( Briere, 1992 ; Offer et al., 2000 ; Ross, 1989 ; Widom, 1988 ). Results of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment ( Widom et al., 2007a ). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting ( Gilbert et al., 2009a ).

The federal government has supported an effort, launched since the 1993 NRC report was issued—the National Survey of Child and Adolescent Well-Being (NSCAW)—to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5 .

This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor.

Despite recent methodological advances, researchers face many challenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect (e.g., physical abuse, sexual abuse, neglect from caregivers) for child functioning and development. One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a number of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others ( Dubowitz et al., 1987 ; Lyons et al., 2005 ; McCurdy, 2005 ). These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children's functioning, but need to be disentangled from the specific effects of abuse and neglect ( Widom et al., 2007a ). Controlling for other relevant variables becomes vital, since failure to take such family variables into account may result in reporting spurious relationships ( Widom et al., 2007a ). Some studies consider and covary other risk factors, and some do not. Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues (2012) found that the number of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains.

Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning. These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect.

• NEUROBIOLOGICAL OUTCOMES

An adequate caregiver is needed to support developing brain architecture and the developing ability to regulate behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise development. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discussion begins, however, with a brief overview of brain development.

Overview of Neurobiological Development

The construction of the brain.

Brain development begins just a few weeks after conception, starting with the construction of the neural tube. This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter , whereas most of the rest of the brain is referred to as grey matter .

Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development—is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience ( Nelson et al., 2011 ).

Neural Plasticity and Sensitive Periods

Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experiences occur), development can go awry. This leads to the concept that plasticity “cuts both ways,” meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experiences or inadequate input, the brain may suffer ( Nelson et al., 2011 ). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation.

The Time Course of Development

In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion regulation—have a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive period for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1 .

The time course of key aspects of brain development. SOURCE: Thompson and Nelson, 2001 (reprinted with the permission of American Psychologist ).

These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience considerable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., neglect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed.

Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation

There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect (e.g., Bruce et al., 2009 ; Gunnar and Vazquez, 2001 ; Levine et al., 1993 ; Shonkoff et al., 2012 ). Glucocorticoids (cortisol in humans, corticosterone in rodents) are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintaining a diurnal rhythm. A cascade of events is designed to promote survival behavior by directing energy to processes that are critical to immediate survival (e.g., metabolism of glucose) and away from processes that are less critical to immediate survival, such as immune functioning, growth, digestion, and reproduction ( Gunnar and Cheatham, 2003 ).

Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation ( Gunnar and Cheatham, 2003 ). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime ( Gunnar and Donzella, 2002 ). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work ( Larson et al., 1991 ; Watamura et al., 2002 ). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children ( Bernard et al., 2010 ; Bruce et al., 2009 ; Dozier et al., 2006 ; Fisher et al., 2007 ; Gunnar and Vazquez, 2001 ). Similar flattened diurnal rhythms have been found in institutionalized children ( Bruce et al., 2000 ; Carlson and Earls, 1997 ). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation ( Carpenter et al., 2009 ; Fries et al., 2005 ).

Cicchetti and colleagues ( Cicchetti and Rogosch, 2001a , b ) examined changes across the day among abused and neglected children attending summer camp. The time points included when children first arrived at camp (at about 9 AM) and before they left camp for the day (at about 4 PM), likely tapping diurnal change within a challenging environment. The authors report complex findings regarding cortisol in this setting. Differences were found in some studies related to subtype and/or psychopathology and/or aggression ( Cicchetti and Rogosch, 2001b ; Murray-Close et al., 2008 ).

Animal models have been used to study experimentally the effects of neglect and abuse on HPA functioning (e.g., Levine et al., 1993 ). Experiences of abuse or neglect, depending on age of pup/infant, duration, chronicity, and subsequent response of dam/mother differentially affect short- and long-term effects on the HPA axis ( Sanchez, 2006 ). Under naturally occurring conditions (about 10 percent of rhesus monkeys abuse their infants), a 1-year-old rhesus monkey that was abused (primarily in the first month of life) showed higher cortisol levels under basal and stress conditions than a 1-year-old that had not been abused. These effects were not seen at older ages. (The age translation from rhesus to human is about 1 to 4, so a 1-year-old rhesus is developmentally similar to about a 4-year-old human child.) In other studies that have manipulated rearing conditions (such as isolation rearing), differences between conditions of abuse or neglect have been inconsistent. In some studies, higher cortisol values were observed in basal and/or stress conditions; in some, lower basal and/or stress conditions; and in some, no differences between the monkeys that had undergone deprivation and those that had not ( Champoux et al., 1989 ; Clarke, 1993 ; Higley et al., 1992 ; Shannon et al., 1998 ).

Disrupted HPA axis regulation may have negative effects on a number of other biological systems. High levels of circulating cortisol resulting from early life stress may cause damage to developing brain regions ( Teicher et al., 2003 ; Twardosz and Lutzker, 2010 ). Several brain regions, including limbic regions such as the amygdala and hippocampus and prefrontal regions, may be particularly susceptible to the effects of high levels of circulating cortisol because of the high number of glucocorticoid receptors in these areas ( Brake et al., 2000 ; Schatzberg and Lindley, 2008 ; Wellman, 2001 ).

High levels of circulating cortisol may affect telomere length as well. Telomeres are the repeated sequences of DNA that cap the ends of chromosomes. Telomeres shorten each time cells divide, a process generally associated with aging, but also with stress ( Epel et al., 2004 ). If telomeres become too short, the cell may become senescent (grow old) or may become malfunctional, for example, triggering inflammation or tumor development. Children who have been exposed to neglect show shortened telomeres ( Asok et al., 2013 ; Drury et al., 2011 ). Drury and colleagues (2011) found shorter telomeres among children in institutional care. Similarly, Asok and colleagues (2013) found that children living in highly challenging environments showed shorter telomeres than comparison children, but that mothers could buffer children from the environment challenge. When mothers of neglected children were sensitive to challenging environments, their children's telomeres were as long as those of low-risk children, but when mothers were insensitive, children's telomeres were shorter. Clearly, then, sensitive caregiving serves as a protective factor even under difficult conditions of adversity.

There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to affect brain development adversely, leaving these arguments speculative. Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems ( McEwen, 1998 ; Yehuda et al., 2002 ).

Studies (e.g., McGowan et al., 2008 , 2009 , 2011 ; Meaney and Szyf, 2005 ; Weaver et al., 2004 ) have found that the effects of abuse on the stress response are mediated by epigenetic programming of glucocorticoid receptor expression. Differential methylation of the glucocorticoid receptor gene promoter in the hippocampus was found to be associated with different rearing conditions in rodents, and was reversed by changes in caregiving conditions ( McGowan et al., 2008 ). Paralleling these findings among rodents are nonexperimental findings among humans examined in postmortem analyses ( McGowan et al., 2009 ; Szyf and Bick, 2013 ). Adult suicide victims who had experienced abuse as children differed in glucocorticoid receptor mRNA from adult suicide victims who had not experienced abuse as children and from controls. These findings are consistent with the experimental rodent findings, and suggest that methylation of receptor sites mediates the association between early care and stress responsiveness.

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity (e.g., Chareyron et al., 2012 ). Relative to low-risk children, abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity ( Ellis et al., 2004 ; Kaplow and Widom, 2007 ; Tottenham et al., 2009 ; van Ijzendoorn and Juffer, 2006 ; Zeanah et al., 2009 ) and deficits in emotional processing ( Dalgeish et al., 2001 ; Pollak et al., 2000 ; Vorria et al., 2006 ). Figure 4-2 illustrates structures in the medial temporal lobe critically involved in emotion (amygdala) and learning and memory (hippocampus).

Illustration of brain structures.

Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect ( De Bellis et al., 2001b ; Tottenham and Sheridan, 2010 ; Woon and Hedges, 2008 ). However, Tottenham and colleagues (2010) and Mehta and colleagues (2009) found that amygdala volume was enlarged among children following institutionalized care, although this finding was not replicated by Sheridan and colleagues (2012) among a similar population. Importantly, both the Mehta et al. and Sheridan et al. studies did find a dramatic reduction in total brain volume, meaning that these children had physically smaller brains.

Functional magnetic resonance imaging (fMRI) studies have shown that early adversity leads to a sensitized amygdala. Relative to comparison children, previously institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces ( Tottenham et al., 2011 ). Similarly, Maheu and colleagues (2010) found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces.

Hippocampus, Learning, and Memory

The hippocampus (see Figure 4-2 ) plays an important role in learning and memory ( Andersen et al., 2007 ; Ghetti et al., 2010 ; Otto and Eichenbaum, 1992 ) and, like the amygdala, matures rapidly over the first months and years of life ( Lavenex et al., 2007 ). The hippocampus appears to be particularly susceptible to stress early in life ( Gould and Tanapat, 1999 ; Sapolsky et al., 1990 ) and plays a role in modulating the response of the HPA axis to stressors, as binding of cortisol to hippocampal receptors serves to turn off the HPA axis response ( Kim and Yoon, 1998 ). Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation ( de Quervain et al., 1998 ; Sheridan et al., 2012 ).

Most studies have found no evidence of hippocampal volume deficits among abused children compared with healthy, nonabused control children ( De Bellis et al., 1999 , 2001a , 2002 ). Among adults, however, decreased hippocampal volume has been linked with the experience of childhood physical and sexual abuse ( Andersen and Teicher, 2004 ; Andersen et al., 2008 ; Schmahl et al., 2003 ; Woon and Hedges, 2008 ). Nonetheless, relatively smaller hippocampal volumes in abused adults may be specific to PTSD rather than abuse itself ( Kitayama et al., 2005 ).

Prefrontal Cortex and Executive Functions

The prefrontal cortex (see Figure 4-2 ) is responsible for a variety of higher-order “executive” functions ( Miller and Cohen, 2001 ). The development of the prefrontal cortex is protracted, extending from birth into the third decade of life ( Gogtay et al., 2004 ; Rubia et al., 2006 ; Sowell et al., 2003 ). Prefrontal systems are especially sensitive to experiences of early adversity ( Hart and Rubia, 2012 ; McLaughlin et al., 2010 ).

Evidence is mixed with regard to structural changes in the prefrontal cortex following abuse and neglect, with some studies showing smaller volumes of the right orbitofrontal cortex, right ventral-medial prefrontal cortex, and dorsolateral prefrontal cortex ( Hanson et al., 2010 ); some showing decreased grey matter volume in the prefrontal cortex in children with interpersonal trauma and PTSD symptoms ( Carrion et al., 2008 ); some showing the opposite effect ( Carrion et al., 2009 ; Richert et al., 2006 ); and still others showing no effect after controlling for total brain volume ( De Bellis et al., 2002 ). Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and related brain regions. In particular, children with trauma experiences show patterns of neural activation during tasks requiring executive function that are similar to patterns observed in children with attention-deficit hyperactivity disorder (ADHD) (e.g., Carrion et al., 2008 ).

Consistent with these findings among abused and neglected children, previously institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues (2010) found that children with a history of neglect or institutional care showed greater activation in several regions of the prefrontal cortex (e.g., left inferior frontal cortex, anterior cingulate cortex) during response inhibition trials of a go/no-go task compared with children without a history of neglect. Similar findings have been reported by McDermott and colleagues (2012) and Loman and colleagues (2009) among currently and previously institutionalized children.

Corpus Callosum

The corpus callosum facilitates communication between the two hemispheres of the brain ( Giedd et al., 1996a , b ; Kitterle, 1995 ). The white matter fibers composing the corpus callosum are myelinated throughout childhood and adulthood ( Giedd et al., 1996a ; Teicher et al., 2004 ), which allows faster, more efficient transmission ( Bloom and Hynd, 2005 ). Myelinated regions such as the corpus callosum are susceptible to the impacts of early exposure to high levels of cortisol, which suppress the glial cell division critical for myelination.

Retrospective/cross-sectional studies have found abuse and neglect to be associated with structural changes in the corpus callosum. Teicher and colleagues (2004) compared corpus callosum volume in adults with different abuse and neglect experiences. The total corpus callosum area of the abused children was smaller than that of both healthy control children and children with psychiatric disorders and no abuse or neglect. Other findings suggest that gender may moderate these effects, with the effects being more pronounced among males than females ( De Bellis and Keshavan, 2003 ; De Bellis et al., 1999 , 2002 ; Teicher et al., 1997). Sheridan and colleagues (2012) performed structural MRIs on children enrolled in the Bucharest Early Intervention Project, described previously in this chapter. In a follow-up of 8- to 11-year-olds, Sheridan and colleagues (2012) found smaller total white and gray matter volume and smaller posterior corpus callosum volume among children who had been institutionalized relative to those who had never been institutionalized. By middle childhood, however, there were no significant differences in total white matter volume or posterior corpus callosum volume between the never-institutionalized (community) children and the foster care children. These early differences in corpus callosum may be associated with less efficient cognitive functioning among children who experience early adversity.

Influence of Early Profound Neglect on Brain Electrical Activity

The influence of profound neglect early in life has been examined using electroencephalography (EEG) and event-related potentials (ERPs).

Electroencephalography

EEG measurements of the brain's electrical activity can serve as a coarse metric for brain development. Most work on EEG in the context of neglect has been performed on children with a history of institutional care. The most extensive study of brain electrical activity among children with a history of institutional care was conducted with the children enrolled in the prospective, longitudinal Bucharest Early Intervention Project. At baseline (mean age 20 months), prior to random assignment to continued institutional care or foster care, institutionalized children showed higher levels of theta power (low-frequency brain activity) and lower levels of alpha and beta power (high-frequency activity) compared with children who were not institutionalized ( Marshall et al., 2004 ). The pattern of activity observed in institutionalized children suggests a maturational delay or deficit in cortical development associated with an extreme form of neglect ( Marshall et al., 2004 ). The profiles are similar to patterns found among children with ADHD ( Barry et al., 2003 ; Harmony et al., 1990 ).

At follow-up, as a group, children assigned to foster care did not differ from the care-as-usual group ( Marshall et al., 2008 ). However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely resembled that of the never-institutionalized group than the care-as-usual group. Overall, then, “institutionalization led to dramatic reductions in brain activity (as reflected in the EEG), whereas placement in foster care before 2 years of age led to a more normal pattern of EEG activity” ( Nelson et al., 2011 , p. 139). This last finding was replicated when the children were 8 years old ( Vanderwert et al., 2010 ). Specifically, previously institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly assigned to institutional care.

Event-Related Potentials

ERPs measure changes in the brain's electrical activity in response to an internal or external stimulus or event. The components of the ERP (i.e., positive and negative deflections) can be quantified in terms of latency, amplitude, and location/distribution on the scalp. The P300 (i.e., positive deflection occurring approximately 300 ms after a stimulus) is associated with attention to emotionally evocative visual stimuli, such as emotional faces ( Eimer and Holmes, 2007 ; Olofsson et al., 2008 ). Whereas nonabused children show similar P300 activity across emotional expressions, abused children show larger P300s to angry target faces ( Pollak et al., 1997 , 2001 ), a finding consistent with behavioral evidence of enhanced attention to angry faces among abused children.

Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a number of factors and seen at some ages and not others. Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior. Finding: Abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional processing. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity leads to a sensitized amygdala. Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

• COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES

Cognitive Development

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement.

Executive Functioning and Attention

As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior ( Lewis-Morrarty et al., 2012 ). Included among executive functions are “holding information in working memory, inhibiting impulses, planning, sustaining attention amid distraction, and flexibly shifting attention to achieve goals” ( Lewis-Morrarty et al., 2012 , p. 2). Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop through at least the second decade of life.

Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a number of studies conducted by the Bucharest Early Intervention Project team ( McDermott et al., 2012 ). For example, McDermott and colleagues (2012) found that children who were randomly assigned to foster care showed better performance on an executive functioning task (i.e., a go/no-go task requiring inhibitory control) than children who were randomly assigned to treatment as usual. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children (with histories of institutionalization) have been reported (e.g., Loman et al., 2013 ). These findings suggest that extreme forms of neglect may interfere with the development of executive functioning.

Problems in regulating attention represent one of the most striking deficits seen among children who have experienced severe early deprivation in institutional settings ( Gunnar et al., 2007 ; Kreppner et al., 2001 ). Gunnar and colleagues (2007) found that problems with inattention or overactivity were more pronounced among children who had experienced early institutional care than among those who had been adopted internationally without early institutional care. Kreppner and colleagues (2007) found that many children who had been adopted following institutional care showed problems with inattention or overactivity, but that such problems were usually seen in combination with reactive attachment disorder, quasi-autistic behaviors, or severe cognitive impairment.

Using NSCAW data, Heneghan and colleagues (2013) examined mental health problems in teens older than age 12 who were the subject of a child welfare agency investigation. They found that 18.6 percent of abused and neglected teens scored positively for ADHD, compared with 5 percent of children and 2.5 percent of adults in the general U.S. population ( APA, 2013c ). Likewise, Briscoe-Smith and Hinshaw (2006) studied a sample of 228 girls with and without ADHD and with and without a history of abuse and neglect, finding that the girls with ADHD had a statistically significant heightened risk of having a documented history of abuse or neglect, as indicated by substantiated child protective services, parental, or school report. Some studies have found preliminary differences in the characteristics of ADHD displayed by children with and without a history of abuse or neglect ( Webb, 2013 ). For example, Becker-Blease and Freyd (2008) studied a small community sample of 8- to 11-year-old children in which ADHD and abuse history were assessed by parent report. They found that children with a history of abuse displayed more severe impulsivity and inattention than nonabused children with ADHD, but the groups did not differ on measures of hyperactivity ( Becker-Blease and Freyd, 2008 ).

A number of studies have found evidence that children who experience abuse and neglect show deficits in executive functioning and attention ( Arseneault et al., 2011 ; De Bellis et al., 2009 ; Fisher et al., 2011 ; Lewis et al., 2007 ; Spann et al., 2012 ). Pears and colleagues (2008) found that abuse and neglect were associated with generally lower cognitive functioning among preschoolers. Lewis and colleagues (2007) found that 4-year-old children who had experienced abuse or neglect and were in foster care showed poorer inhibitory control on a Stroop-like task relative to comparison children, despite similar levels of performance on a control task. Spann and colleagues (2012) found that physical abuse and neglect were associated with diminished cognitive flexibility on the Wisconsin Card Sorting Task among adolescents.

Academic Achievement

Abuse and neglect increase children's risk for experiencing academic problems. Several studies suggest that abuse versus neglect matters, with neglect being especially predictive of academic underachievement ( Briere et al., 1996 ; Jonson-Reid et al., 2004 ; Nikulina et al., 2011 ). Other studies failed to find differences between abuse and neglect, with both predicting achievement problems (e.g., Barnett et al., 1996 ; Crozier and Barth, 2005 ; Eckenrode et al., 1993 ; Jaffee and Gallop, 2007 ; Kurtz et al., 1993 ; Leiter and Johnsen, 1997 ). On balance, the evidence suggests that both abuse and neglect are predictive of academic problems. Perez and Widom (1994) found that child abuse and neglect had a significant impact on reading ability, IQ scores, and academic achievement. For example, 42 percent of abused and neglected children completed high school, compared with two-thirds of the matched comparison group without histories of abuse and neglect. The average IQ score for the abused and neglected children was about one standard deviation below the average for the control group; this association was significant after controlling for age, race, gender, and social class ( Perez and Widom, 1994 ). Using NSCAW data, Jaffee and Maikovich-Fong (2011) found that chronically abused or neglected children had lower IQ scores than situationally abused or neglected children. The effect of chronic abuse or neglect on IQ scores remained significant after controlling for the effects of caregiver educational level on IQ. Leiter and Johnsen (1997) found that effects of abuse and neglect on school performance were cumulative, with more episodes of abuse and neglect being associated with poorer outcomes. Abuse and neglect predicted entry into special education after controlling for early medical conditions ( Jonson-Reid et al., 2004 ). Jonson-Reid and colleagues (2004) found that 24 percent of the abused and neglected children entered special education, compared with 14 percent of those with no record of abuse or neglect. Further, every additional report of abuse or neglect before the age of 8 led to an increase of 7 percent in entry into special education. Thompson and colleagues (2012) found that expectations of future academic success were adversely affected by previous experiences of abuse and neglect, with these expectations having powerful self-fulfilling possibilities ( Ross and Hill, 2002 ).

Psychosocial and Behavioral Outcomes

Given that child abuse and neglect are social experiences that undermine the ability to trust in caregivers, either because caregivers are frightening (as in cases of abuse) or because they fail to protect or provide care (as in cases of neglect), it makes sense that children who experience abuse and neglect are at risk for interpersonal problems. At the most proximal level, problems are seen in children's ability to form trusting attachments to their parents. But not surprisingly, the effects also are seen in such areas as children's processing of emotion (e.g., overly vigilant of angry faces), their attributions of others' intent (e.g., assuming that intentions are malevolent when they are ambiguous), and difficulties with peers (e.g., being the victim or perpetrator of bullying or violence). Problems also are seen in internalizing symptoms, such as anxiety and depression, and externalizing symptoms, such as conduct disorder and substance use.

Children develop secure attachments to parents who are responsive to them when they are distressed ( Ainsworth, 1978 ). Children typically develop insecure (avoidant or resistant) attachments when parents are unresponsive or inconsistent in responsiveness, but not frightening or bizarre (e.g., Lyons-Ruth et al., 1993 ; Schuengel et al., 1998 ). Secure, avoidant, and resistant attachments are referred to as organized attachment strategies because they are organized around the caregiver's availability and provide a child a template for dealing with distress. On the other hand, disorganized attachment represents a breakdown in or a lack of strategy for dealing with distress when in the parent's presence ( Main and Solomon, 1990 ). Disorganized attachments are the most problematic in terms of outcomes for children. Relative to organized attachment, disorganized attachment is most predictive of long-term problems, especially externalizing symptoms ( Fearon et al., 2010 ). Fearon and colleagues (2010) found strong evidence for a link between disorganized attachment and later externalizing symptoms through a meta-analysis of 34 studies involving 3,778 participants.

Child abuse and neglect are predictive of disorganized attachment, as well as insecure attachment more generally. A meta-analysis conducted by Cyr and colleagues (2010) included the 10 studies that have examined attachment quality with samples of children who have experienced abuse and neglect. The effect size was large for both disorganized and insecure attachment. Although abuse was more strongly related to disorganized attachment and neglect to insecure attachment, both abuse and neglect were associated with both types of attachment. These results are consistent with theory and with other empirical findings suggesting that when parents are either frightening or unavailable, children fail to develop a secure attachment to them. Nonetheless, the effects of having more than five socioeconomic risk factors were comparable to those of child abuse and neglect, indicating that multiple challenges to parental functioning had significant effects on attachment regardless of whether these effects were seen in child abuse and neglect.

In early childhood, abused or neglected children may develop attachment disorders resulting from and following pathogenic care that inhibits a young child's ability to form selective attachments ( Hornor, 2008 ). Childhood attachment disorders are phenomena distinct from insecure, disorganized, or nonexistent attachment types; they have been redefined in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-V) to include two distinct disorders: reactive attachment disorder and disinhibited social engagement disorder ( APA, 2013a , b ). Reactive attachment disorder involves inhibited or emotionally withdrawn behavior, including rarely seeking and responding to comforting; it results from a lack of or incompletely formed selective attachments to adult caregivers ( APA, 2013a ). Disinhibited social engagement disorder is marked by a pattern of overly familiar behavior with strangers; it may occur even in children with established or secure attachments. Previously, each attachment disorder was considered the inhibited or disinhibited type of reactive attachment disorder, respectively.

Zeanah and colleagues (2004) studied the prevalence of attachment disorders among 94 toddlers in foster care whose abuse or neglect cases had been substantiated and who were enrolled in an intervention program; they found that the prevalence of attachment disorders reached 38-40 percent. Lyons-Ruth and colleagues (2009) examined socially indiscriminate attachment behavior in a sample of mother-child dyads that included pairs referred to a clinical service because of problematic caregiving and comparison pairs matched on socioeconomic status. They found that 18-month-olds displayed socially indiscriminate attachment behavior only if they had a history of abuse or neglect, or their mother had a history of psychiatric hospitalizations. Both disorders also have been identified in children exposed to neglectful institutional care in Romania who were later adopted into middle-class families in the United Kingdom ( Smyke et al., 2002 ; Zeanah et al., 2002 ), although the disinhibited type of reactive attachment disorder (as defined in DSM-IV) has been found to be much more prevalent than the inhibited type ( O'Connor et al., 2003 ). Furthermore, findings from the Bucharest Early Intervention Project study indicate that the inhibited type of reactive attachment disorder declined significantly once institutionalized children were placed in foster care, but the disinhibited type proved more persistent ( Smyke et al., 2002 ; Zeanah and Gleason, 2010 ).

Emotion Regulation

Infants have limited capacities to regulate their own emotions and are dependent on caregivers to help them deal effectively with distress ( Tronick, 1989 ). Indeed, infants and young children are highly attuned and responsive to their parents' emotions and use parental emotional signals to guide their behavior ( Klinnert et al., 1983 ; Malatesta and Izard, 1984 ). The scaffolding important for the development of emotion regulation is challenged in abusing or neglecting families. When children feel upset or distressed, parents' availability and soothing presence can help them feel that they can cope with the strong negative affect, such that they are able to develop autonomous and effective means of regulating emotions over time. When children regulate their emotions well, they react to challenge with flexible and socially acceptable responses ( Cole et al., 1994 ; Kim and Cicchetti, 2010 ). Abused and neglected children, however, may not have such scaffolding experiences. It is likely that abused and neglected children experience not only a lack of modeling and support and an absence of positive affect but also harsh, inconsistent, and insensitive parenting ( Shipman and Zeman, 2001 ). In the case of abuse, parents often respond in threatening or unpredictable ways to children's distress ( Milner, 2000 ). In the case of neglect, parents may be unresponsive or nonempathic. As a result of either response, children are at risk of failing to develop effective strategies for regulating emotions ( Cicchetti et al., 1995 ; Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ).

An initial, key task in regulating emotions is processing of cues. Studies have examined differences among children who have experienced abuse and neglect in how readily they identify angry, sad, and happy faces ( Pollak and Sinha, 2002 ; Pollak and Tolley-Schell, 2003 ; Pollak et al., 2000 ; Shackman et al., 2007 ). Pollak and Sinha (2002) found that the threshold for detecting anger in the face was lower among abused than nonabused children; there were no differences in processing happy faces. Thus, these children appear to have a bias toward angry faces rather than a general deficit in processing faces. Pollak and Sinha (2002) point out that it is useful to identify emotions in others based on less than full information. Abused children's bias toward attributing angry or sad affect may be adaptive when living with parents whose anger may be an important threat cue ( Belsky et al., 2012 ); nonetheless, it comes at the cost of assuming hostile intent too readily under benign conditions, leading to aggressive responses that would not have been evoked had attributions been different ( Dodge et al., 1995 ). Neglected children, on the other hand, generally are not as good as nonneglected children at identifying facial expressions, showing a general deficit ( Pollak et al., 2000 ).

Emotion regulation can be seen as key to a number of the constructs considered in this chapter. Problems in regulating emotion are associated with externalizing behaviors, such as aggression and behavior problems ( Eisenberg et al., 2001 ; Kim and Cicchetti, 2010 ); internalizing behaviors, such as depression ( Cole et al., 2008 ; Maughan and Cicchetti, 2002 ); and challenges in peer relations ( Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ). Emotion regulation can be seen, then, to have effects both on children's own affect and on their behavioral reactions, which then have implications for their relationships with others.

Peer Relations

Children's relationships with their peers are critical to their sense of well-being. Abused and neglected children have problematic peer relations at disproportionately high rates ( Kim and Cicchetti, 2010 ), as do children with a history of institutional care ( Almas et al., 2012 ). Chronicity of child abuse and neglect predict peer relations, as reported by teachers, at age 8 ( Graham et al., 2010 ). Problematic emotion regulation ( Shields and Cicchetti, 2001 ) and higher levels of aggression and withdrawal ( Rogosch et al., 1995 ) found in abused and neglected children can become apparent to peers when frustrations and challenges arise in school and playground environments.

Externalizing Problems

Externalizing behavior refers to problem behaviors that are manifested externally (rather than internally, as in the case of depression and anxiety). Findings from several studies indicate that children who have experienced abuse and neglect are at greater risk for a number of externalizing behaviors, including conduct disorders, aggression, and delinquency ( Lansford et al., 2002 , 2009 ; Lynch and Cicchetti, 1998 ; Stouthamer-Loeber et al., 2001 ; Thornberry et al., 2010 ).

Oppositional defiant disorder and conduct disorder Studies have reported significant associations between a history of childhood abuse or neglect and various conduct problems, including those classified as oppositional defiant disorder or conduct disorder. Oppositional defiant disorder is indicated by a frequent or persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness ( APA, 2013a ). Its symptoms usually first appear during early childhood, and it often precedes conduct disorder, anxiety disorders, or major depressive disorder. Conduct disorder is indicated by a repetitive or persistent pattern of behavior that violates the basic rights of others or major societal norms or rules, including aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules ( APA, 2013a ). Conduct disorder can begin in childhood or adolescence; however, childhood-onset conduct disorder is more often preceded by oppositional defiant disorder, more persistent into adulthood, and more likely to include aggressive behavior than adolescence-onset conduct disorder. Both disorders also frequently co-occur with ADHD.

In a study using a community sample, Dodge and colleagues (1995) found that children who were physically abused before age 5 were 4 times more likely than nonabused children to display externalizing conduct problems in grade 3 and 4. Likewise, Kaplan and colleagues (1998) found that adolescents (aged 12-18) with substantiated cases of physical abuse were more likely to display conduct disorder or oppositional defiant disorder at the time of the study (odds ratio = 5.98) than the matched nonabused comparison group. Fergusson and colleagues (2008) found that childhood sexual abuse was associated with higher rates of conduct disorder in young adulthood. Furthermore, they found that childhood physical abuse was not associated with conduct disorder when sexual abuse was included in the model. Additional environmental and individual factors that interact with abuse or neglect to increase the likelihood of conduct disorder or oppositional defiant disorder include exposure to parental divorce ( Afifi et al., 2009 ), interparental violence ( Boden et al., 2010 ), and community violence ( McCabe et al., 2005 ), as well as gender, with males more likely to display conduct disorder ( Boden et al., 2010 ).

Aggression Manly and colleagues (2001) found that children who had experienced severe emotional abuse only as infants or severe physical abuse only as toddlers were more aggressive and showed more externalizing symptoms as school-aged children than children without a history of abuse or neglect. The severity of abuse experienced predicted aggressiveness and externalizing symptoms in middle childhood. Although abuse experienced only in early childhood had lasting effects, abuse experienced beyond early childhood also had effects on aggression and externalizing symptoms, and the most problematic effects were seen for children subjected to chronic, severe abuse ( Manly et al., 2001 ). Rogosch and colleagues (1995) found that physically abused children showed both aggressive behaviors and social withdrawal during peer interactions. Along these lines, abused and neglected children were disproportionately likely to be both bullies and victims of aggression, effects that were mediated by emotion dysregulation ( Shields and Cicchetti, 2001 ). At odds with these findings, Kotch and colleagues (2008) found that children who experienced neglect in their first 2 years of life showed more aggression toward peers at ages 4, 6, and 8 relative to children without a history of abuse or neglect. Indeed, in that study, other subgroups (children who were abused or who were neglected at older ages) did not show an increased likelihood of aggression.

Hostile attributional bias refers to the tendency to assume that someone intended harm when circumstances were ambiguous but a negative outcome was experienced. For example, if a peer spilled milk on a child, the child could assume that the action was benign (unintentional) or intentional, with the latter representing a hostile attributional bias. When children assume that such an action was intentional, they are likely to act aggressively in response ( Dodge et al., 1995 ). Physically abused children are more likely than other children to show such attributional biases ( Dodge et al., 1995 ). Price and Glad (2003) found that these effects were seen in boys only and were associated with frequency of abuse. Such biases can lead to a self-fulfilling prophecy whereby children anticipate that someone intends them harm and react in a hostile way, which then elicits a hostile response ( Dodge et al., 1995 ).

Internalizing Problems

Internalizing problems—problems that are manifested internally—include symptoms of depression and anxiety. Child abuse and neglect have been found to put children at increased risk of internalizing symptoms from early childhood through adolescence and adulthood ( Dubowitz et al., 2002 ; Thornberry et al., 2001 ; Widom et al., 2007a ).

Dubowitz and colleagues (2002) found that neglect was associated with internalizing problems for 3- and 5-year-old children. Swanston and colleagues (1997) found that sexually abused children had a significantly higher average score on depression measures than a control group just 5 years after the abuse occurred, after adjusting for individual differences in age and sex, as well as contextual factors such as socioeconomic status, family functioning, mother's mental health, and number of negative life events. Trickett and colleagues (2001) found that a sample of sexually abused girls had significantly higher rates of self-reported depression than a comparison group of nonabused females. At follow-up, approximately 7 years later, rates of depression were found to be significantly higher among the sexually abused group, excluding a subset whose experience of abuse was characterized chiefly by multiple perpetrators and a relatively short duration.

The heightened risk of depression extends beyond childhood to adolescence and adulthood. Multiple studies have found clear links between child abuse and neglect and depression in adolescence (e.g., Fergusson et al., 2008 ; Heneghan et al., 2013 ; Lansford et al., 2002 ). Brown and colleagues (1999) found that child abuse and neglect were associated with a nearly threefold increase in the rate of depression in adolescence, although this risk was diminished after controlling for other adverse conditions. Gilbert and colleagues (2009b) cite a body of studies reporting adjusted odds ratios ranging from 1.3 to 2.4 for depression after childhood among those subjected to abuse and neglect as children. Among adults, Brown and colleagues (1999) found that the increased risk of depression associated with child abuse and neglect remained when other factors were covaried, consistent with findings that more than one-third of abused or neglected children show symptoms of major depressive disorder by their late 20s ( Gilbert et al., 2009b ). Likewise, Widom and colleagues (2007a) followed a group of individuals who had experienced abuse and/or neglect in childhood and a matched comparison group into young adulthood and found that experiencing childhood physical abuse and multiple types of abuse increased the lifetime risk for a diagnosis of major depressive disorder.

A growing body of research examines whether different types and combinations of abuse or neglect in childhood result in different levels of risk for the development of depressive symptoms. The results in this domain are mixed, with strong evidence that sexual and physical abuse in childhood are associated with depression later in life (e.g., Heneghan et al., 2013 ), but mixed evidence that neglect increases risk for depression independent of contextual factors. Many studies have found child sexual abuse to have large and independent effects on risk for depression later in life. For example, Fergusson and colleagues (2008) found that young adults who reported a history of childhood sexual abuse had mental health disorders, including depression, at a rate 2.4 times higher than that among those not exposed to such abuse. By contrast, Widom and colleagues (2007a) found that child sexual abuse was not associated with an elevated risk of major depressive disorder relative to matched controls, although physical abuse or multiple kinds of abuse did increase the risk for lifetime major depressive disorder. Additional studies have found that physical abuse increased the risk for adult depression (e.g., Brown et al., 1999 ). Some studies have found that neglect did not increase the risk for depression when statistical models included contextual factors ( Nikulina et al., 2011 ), although Widom and colleagues (2007a) found that neglect increased risk for current major depressive disorder relative to matched controls in adulthood.

As discussed in the section on individual differences later in this chapter, researchers also have examined how the timing ( Dunn et al., 2013 ; Thornberry et al., 2001 ) and severity ( Fergusson et al., 2008 ) of abuse and neglect affect the risk of developing depression. Other factors throughout the life course, such as the presence or absence of social support ( Sperry and Widom, 2013 ) and exposure to multiple traumas ( Banyard et al., 2001 ) or stressful life events in adulthood ( Power et al., 2013 ), have been found to interact with childhood experiences of abuse and neglect to influence the risk of developing depression later in life.

Dissociation

Dissociation is defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including—but not limited to—memory, identity, consciousness, perception, and motor control” ( Spiegel et al., 2011 , p. 19). Dissociation can be measured reliably and validly in children, adolescents, and adults ( Briere et al., 2001 ; Keck Seeley et al., 2004 ; Lanktree et al., 2008 ; van Ijzendoorn and Schuengel, 1996 ; Wherry et al., 2009 ).

Child abuse and neglect have been associated with dissociation among both preschool-aged and elementary-aged children ( Hulette et al., 2008 , 2011 ; Macfie et al., 2001 ), as well as among adults ( van Ikzendoorn and Schuengel, 1996 ). The existence of a subgroup of PTSD patients with high levels of dissociation has been demonstrated in clinical ( Lanius et al., 2013 ; Putnam, 1997 ), psychophysiological ( Griffin et al., 1997 ), neuroimaging ( Lanius et al., 2013 ), and epidemiological ( Stein et al., 2013 ) research. As a result, DSM-V is adding a dissociative subtype to the PTSD diagnosis ( Spiegel et al., 2011 a) (see the discussion of PTSD on p. 139).

High scores on dissociation measures have proven to be a predictor of externalizing behavior in children ( Kisiel and Lyons, 2001 ; Shapiro et al., 2012 ; Yates et al., 2008 ). In adults, high levels of dissociation are associated with refractoriness to standard treatments for a number of psychiatric conditions, as well as increased comorbidity ( Jans et al., 2008 ; Kleindienst et al., 2011 ; Wolf et al., 2012 ; Zanarini et al., 2011 ).

A meta-analysis of 55 studies ( Cyr et al., 2010 ) links abuse with disorganized attachment. Grienenberger and colleagues (2005) found that mothers who engaged in disrupted affective communication with their infants at 4 months (as measured using the AMBIANCE scale) were more likely to have toddlers who were classified as disorganized at 14 months. In turn, disorganized attachment at 14 months predicted high dissociation scores at age 20 years ( Lyons-Ruth, 2008 ). Disorganized attachment assessed during the child's second year predicted elevated levels of self-reported dissociation in mid-adolescence (age 16 years) ( Carlson, 1998 ) and early adulthood (age 19) ( Ogawa et al., 1997 ).

Based on findings from the Minnesota Mother-Child Project, Egeland and Susman-Stillman (1996) propose that dissociation may act as a mediator of child abuse across generations. In a longitudinal study of sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, a tentative generational loop can be hypothesized in which harsh and abusive parenting increases the risk for higher levels of dissociation in childhood and adolescence, which in turn increases the risk for impulsive behavior and harsh parenting of offspring. Further research, especially with a longitudinal design, is warranted to determine whether this hypothesized generational pattern of transmission represents an early opportunity for prevention of abuse in the next generation.

Posttraumatic Stress Disorder

In DSM-V, PTSD is classified as a trauma- and stressor-related disorder, a change from its previous classification as an anxiety disorder. PTSD develops following “exposure to actual or threatened death, serious injury, or sexual violation,” including directly experiencing the traumatic event, witnessing the event firsthand, learning that an actual or threatened violent or accidental death occurred to a family member or close friend, and experiencing repeated or extreme firsthand exposure to the details of the traumatic event ( APA, 2013c ). Behavioral symptoms of PTSD are divided into four categories: intrusion or reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity ( National Center for PTSD, 2013 ). Experiences of child abuse and neglect involve traumatic events that are often violent, invasive, and coercive ( Kearney et al., 2010 ). Furthermore, secondary trauma may result from experiences of child abuse and neglect, including separation from family or homelessness, which may also trigger a PTSD response ( Wechsler-Zimring et al., 2012 ).

A number of prospective and retrospective studies have found elevated rates of PTSD among individuals with a history of abuse and neglect ( Chen et al., 2010 ; Kearney et al., 2010 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Numerous studies have found that PTSD was preceded by abuse and neglect; links with sexual abuse were especially strong ( Chen et al., 2010 ; Gregg and Parks, 1995 ; Kendall-Tackett et al., 1993 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Kearney and colleagues (2010) report PTSD rates of 20-50 percent among youth who had been sexually abused, 50 percent among youth who had been physically abused, and 33-50 percent among youth who had experienced neglect combined with exposure to domestic violence. Kolko (2010) found that nearly 20 percent of youth in out-of-home care showed posttraumatic symptoms. Widom (1999) found increased risk for PTSD among adults who had experienced abuse and neglect as children, with 23 percent of those who had been sexually abused, 19 percent of those who had been physically abused, and 17 percent of those who had been neglected meeting criteria for PTSD at age 29, compared with 10 percent of the comparison group.

Some evidence indicates that PTSD may mediate the association between childhood abuse and neglect and later adverse outcomes. Wolfe and colleagues (2004) found that boys who had been abused or neglected in childhood and displayed a greater number of PTSD symptoms were at higher risk of perpetrating emotional abuse in a dating relationship compared with abused or neglected boys who displayed fewer trauma symptoms. Weierich and Nock (2008) found that the specific PTSD symptoms of reexperiencing, avoidance, and numbing mediated the relationship between childhood experiences of abuse and neglect and nonsuicidal self-injury. In a study of adult women survivors of childhood sexual abuse, Ginzburg and colleagues (2006) found that severe childhood maltreatment, including sexual abuse as well as other types of abuse or neglect, was significantly associated with experiencing high levels of dissociation in conjunction with PTSD, while less severe childhood maltreatment was not significantly associated with the dissociative subtype. Avery and colleagues (2000) examined PTSD and key areas of functioning based on interviews with sexually abused children and their nonoffending parents. Compared with sexually abused girls with low scores on the Child Posttraumatic Stress Reaction Index, sexually abused girls with higher scores expressed more worries; reported increased problems with sleep, appetite, headaches, and stomachaches; reported increased depression and suicidal ideation; displayed more problems in school functioning; and had higher levels of family disruption.

Personality Disorders

Evidence links child abuse and neglect with personality disorders. Johnson and colleagues (1999) found that adults with a history of abuse and neglect (as indicated by records and/or self-report) had a fourfold increase in personality disorders relative to those without a history of abuse or neglect. Physical abuse was associated with elevated antisocial and depressive personality disorder symptoms; sexual abuse was associated with elevated borderline personality disorder symptoms; and neglect was associated with elevated symptoms of antisocial, avoidant, borderline, narcissistic, and passive-aggressive personality disorders, as well as with attachment difficulties and other interpersonal and psychological problems. Widom (1998) reports an increase in risk for antisocial personality disorder for both males and females with a history of abuse and neglect. In a subsequent study, Widom and colleagues (2009) report an increase in risk for borderline personality disorder in males only, suggesting that there may be sex differences in the consequences of abuse and neglect. Natsuaki and colleagues (2009) found that personality problems, although not diagnosed personality disorders, worsened as adolescence progressed.

Finding: Abuse and neglect have profound effects on selected aspects of children's cognitive development. Although many attempts have been made to disentangle the effects of abuse and neglect, the balance of findings suggests that severe neglect may interfere with the development of executive functioning, and both neglect and abuse increase the risk for attention regulation problems and ADHD, lower IQ, and poorer school performance. Finding: As a result of abusive or neglectful responses from caregivers, children have a difficult time developing organized and secure attachments. As a result, abused and neglected children are at higher risk for the development of attachment disorders, particularly disinhibited social engagement disorder. Finding: Abused and neglected children often fail to develop effective strategies for emotion regulation, partly as a result of differences in processing of emotional cues. Difficulties with emotion regulation can lead to further problems, including externalizing and internalizing problems and challenges in peer relations. Finding: Children who experience abuse or neglect have been found to be at higher risk for the development of externalizing behavior problems, including oppositional defiant disorder, conduct disorder, and aggressive behaviors. Abused and neglected children also have been found to be at increased risk for internalizing problems, particularly depression, in childhood, adolescence, and adulthood. Finding: Among preschool- and elementary school–aged children, as well as adults, a history of childhood abuse and neglect has been associated with dissociation, which increases the risk for externalizing behavior in childhood and resistance to treatment for psychiatric conditions later in life. It has been suggested that dissociation may act as a mediator of harsh or abusive parenting across generations, although this hypothesis requires further research. Finding: A number of studies have found elevated rates of PTSD among individuals with a history of abuse and neglect. PTSD has been associated with physical, cognitive, psychological, social, and behavioral problems among youth who were abused or neglected in childhood.

• HEALTH OUTCOMES

Child abuse and neglect have effects on a number of health outcomes, from growth to illness to obesity. Connections have been found between problematic neurobiological outcomes of child abuse and neglect and health. One plausible mechanism for these effects relates to the purported frequent or chronic activation of the HPA axis. As discussed previously, the HPA axis is designed for responding in crises.

Growth and Motor Development

In their most extreme forms, abuse and neglect are associated with stunted growth. Children living in institutional environments ( Johnson et al., 2010 ) or adopted from highly neglecting institutional environments ( Johnson and Gunnar, 2011 ) sometimes show very delayed growth in height and head circumference. Olivan (2003) found that children placed in foster care between ages 24 and 48 months were significantly below normal for height, weight, and head circumference. Similarly, Chernoff and colleagues (1994) found that most children entering foster care had an abnormal physical screen involving at least one body system, and on average weighed less and were shorter than comparison children.

Gross motor development often is delayed among children with a history of institutional care who have then been adopted internationally ( Dobrova-Krol et al., 2008 ; Roeber et al., 2012 ). Roeber and colleagues (2012) found that children adopted from institutional settings showed motor system delays, with greater balance delays being predicted by length of time institutionalized and bilateral coordination delays being predicted by severity of deprivation. Rapid gains are seen after placement in adoptive homes, however ( Pomerleau et al., 2005 ). Although somewhat canalized (less responsive to genetic or environmental variations), the development of these gross motor abilities is dependent upon opportunities to engage in motor activities. Note that these findings regarding motor delays may be limited in their application to extreme cases of neglect in which young children are left alone in their cribs or otherwise neglected for extended periods of time.

Child abuse and neglect have been linked to various forms of physical illness as well as various indicators of physical health problems. Adolescents with a history of childhood abuse or neglect report a lower rating of their own health compared with low-risk peers ( Bonomi et al., 2008 ; Hussey et al., 2006 ). Likewise, more gastrointestinal symptoms were reported by adults who reported having been abused or neglected as children ( Walker et al., 1999 ). To examine whether this association resulted from shared method variance, van Tilburg and colleagues (2010) used data collected from multiple informants among a sample of 845 children enrolled in the longitudinal, prospective Longitudinal Studies of Child Abuse and Neglect. Across informants, youth who had experienced abuse or neglect had an increased likelihood of gastrointestinal symptoms, which often followed or coincided with sexual abuse.

In a longitudinal prospective study, childhood abuse and neglect predicted health indices among middle-aged adults ( Widom et al., 2012 ). Both physical abuse and neglect predicted hemoglobin A1C (a biomarker for diabetes) and albumin (a biomarker for liver and kidney function); physical abuse uniquely predicted malnutrition and blood urea nitrogen (a marker for kidney function); neglect uniquely predicted poor peak airflow; and sexual abuse uniquely predicted hepatitis C ( Widom et al., 2012 ).

Findings from the Adverse Childhood Experiences study indicate a heightened risk for liver disease, lung cancer, and ischemic heart disease among adults who report multiple adverse experiences in childhood ( Brown et al., 2010 ; Dong et al., 2003 , 2004 ). The adverse experiences measured in the study include emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, as well as indicators of household dysfunction, such as domestic violence, parental divorce or separation, household member mental illness, household member substance abuse, and household member incarceration. Dong and colleagues (2003) found that the adjusted odds ratio for ever having liver disease ranged from 1.4 to 1.6 for different types of abuse and neglect; among individuals with more than 6 adverse childhood experiences, the adjusted odds ratio was 2.6. Notably, the risk of liver disease was substantially mediated by risk behaviors for liver disease, such as alcohol and drug use and various sexual behaviors. Brown and colleagues (2010) found an association between adverse childhood experiences and an increased risk of lung cancer, which was partially mediated by smoking behavior. In particular, exposure to a large number of adverse childhood experiences was strongly associated with premature death from lung cancer; among individuals who died from lung cancer, those with 6 or more adverse childhood experiences died an average of 13 years earlier than those with no adverse childhood experiences. Likewise, Dong and colleagues (2004) found that adverse childhood experiences increased the likelihood of ischemic heart disease. The association was substantially mediated by both traditional (diabetes, hypertension, physical inactivity, smoking, and obesity) and psychological (anger and depressed affect) risk factors, but the psychological risk factors of anger (adjusted odds ratio of 2.1) and depression (adjusted odds ratio of 2.5) had stronger associations with heart disease than the traditional risk factors.

In various studies, different forms of child abuse and neglect have been linked with increased body mass index and higher rates of obesity in childhood, adolescence, and adulthood. Some studies link neglect but not abuse to obesity (e.g., Johnson et al., 2002 ; Lissau and Sorensen, 1994 ), and some link physical abuse but not neglect ( Bentley and Widom, 2009 ). These differences may be the result of differences in the time points at which obesity is assessed, in sample characteristics, or in the adequacy of controls, or other factors. Knutson and colleagues (2010) found that specific types of neglect (supervisory versus care) predicted obesity at different ages. Care neglect, defined as inattention to such things as provision of adequate food and clothing, predicted body mass index at younger ages, whereas supervisory neglect, defined as parental lack of availability, predicted body mass index at older ages.

Finding: Experiences of child abuse and neglect have effects on many health outcomes, including risks for long-term chronic and debilitating diseases and, in extreme cases, stunted growth.

• ADOLESCENT AND ADULT OUTCOMES

While a number of the consequences of child abuse and neglect discussed previously in this chapter can be present across childhood, adolescence, and adulthood, this section focuses on behavioral outcomes that manifest specifically in either adolescence or adulthood.

Delinquency and Violence

Maxfield and Widom (1996) found that abuse and neglect experienced in childhood predicted violence and arrests in early adulthood. Adults with a history of abuse and neglect were more likely than adults without such a history to have committed nontraffic offenses (49 percent versus 38 percent) and violent crimes (18 percent versus 14 percent). Victims of childhood physical abuse and neglect were more likely to be arrested for violence (odds ratios 1.9 and 1.6, respectively) after controlling for age, race, and sex. These authors also found that abused and neglected girls were at increased risk for being arrested for violence relative to girls who had not been abused and neglected, with an odds ratio of 1.9. Smith and colleagues (2005) also found that abuse and neglect increase the risk of violent offending in late adolescence and early adulthood. Jonson-Reid and colleagues (2012) found a powerful effect for the number of child abuse reports predicting violent delinquency, with the association being linear for up to three reports. Two of these prospective longitudinal studies also found that sexual abuse increased the risk for general offending, but not violent offending ( Smith et al., 2005 ). Physical abuse appears to be strongly related to violence in girls, as demonstrated in a meta-analysis ( Hubbard and Pratt, 2002 ).

There is evidence that childhood abuse increases the risk for crime and delinquency. A number of large prospective investigations in different parts of the United States have documented a relationship between childhood abuse and neglect and juvenile and/or young adult crime ( English et al., 2002 ; Lansford et al., 2007 ; Maxfield and Widom, 1996 ; Smith and Thornberry, 1995 ; Stouthamer-Loeber et al., 2001 ; Widom, 1989 ; Widom and Maxfield, 2001 ; Zingraff et al., 1993 ). Despite differences in geographic region, time period, youths' age and sex, definition of child maltreatment, and assessment technique, these prospective investigations provide evidence that childhood maltreatment increases later risk for delinquency and violence. Replication of this relationship across a number of well-designed studies supports the generalizability of and increases confidence in the results.

Alcohol and Substance Use

As adolescents and adults, those with a history of abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect ( Gilbert et al., 2009b ; Jonson-Reid et al., 2012 ). The effects tend to be stronger for women, being seen even when other factors are covaried ( Simpson and Miller, 2002 ; Widom et al., 1995 ). For example, Widom and colleagues (1995) found no association between a history of abuse and neglect and alcohol use by young men, but found an association for women even after controlling for parental substance use and other correlated variables. A similar pattern of results emerged in a follow-up with these participants about 10 years later, when they were approximately 40 years old. Women with a documented history of child abuse and/or neglect were more likely to drink excessively in middle adulthood than those without such a history ( Widom et al., 2007b ); again, this difference was not seen in men. Girls with a history of physical abuse tend to start using substances (including alcohol, marijuana, tobacco, etc.) at younger ages than youth without such a history ( Lansford et al., 2010 ). Work by Lansford and colleagues (2010) suggests that this early initiation serves as the mechanism for later substance use in adulthood.

Evidence linking abuse and neglect to substance abuse in adulthood is mixed ( Gilbert et al., 2009b ; Widom et al., 1999 ), with retrospective and prospective findings differing. For example, Widom and colleagues (1999) describe findings based on defining child abuse and neglect prospectively and retrospectively using self-reports (i.e., following their sample forward and asking adults whether they had been abused or neglected as children). The findings based on these two types of data differed dramatically. The prospective data showed no increase in risk of substance abuse at age 29, whereas the retrospective data showed significant differences. Interestingly, a later follow-up with this sample ( Widom et al., 2006 ) found that in middle adulthood, abused and neglected individuals compared with controls were about 1.5 times more likely to report using any illicit drug (in particular, marijuana) during the past year, and reported use of a greater number of illicit drugs and more substance use–related problems. Findings such as these provide support for the importance of longitudinal studies because without the subsequent follow-up, there would have appeared to be no increase in risk for adults who had experienced childhood abuse or neglect; these findings also illustrate the importance of contextual factors in understanding consequences.

Suicide Attempts

Experiences of abuse and neglect in childhood have a large effect on suicide attempts in adolescence and adulthood ( Brown et al., 1999 ; Fergusson et al., 2008 ; Gilbert et al., 2009b ; Widom, 1998 ). Among adults in their late 20s, Widom (1998) found that 19 percent of those with a history of abuse or neglect had made at least one suicide attempt, as compared with 8 percent of a matched community sample. Fergusson and colleagues (2008) found high rates of suicide among a New Zealand sample as well. These effects are seen for physical and sexual abuse even after accounting for other associated risk factors ( Fergusson et al., 2008 ). Trickett and colleagues (2011) found, through a prospective design, more incidents of self-harm and suicidal behaviors among women who had been sexually abused than among a control group of women who had not been sexually abused.

Sexual Behavior

Studies have investigated the association between child abuse and neglect and several aspects of sexual behavior, including early sexual initiation and sexual risk behavior, teen pregnancy, and prostitution and the risk for commercial sexual exploitation of children and adults.

Early Sexual Initiation and Sexual Risk Behavior

Children who experience abuse and neglect may initiate sexual activity at earlier ages than other children ( Lodico and DiClemente, 1994 ; Noll et al., 2003 ; Springs and Friedrich, 1992 ; Wilson and Widom, 2008 ). In addition, there is limited evidence of an association between child abuse and neglect and increased risky sexual behaviors ( Jones et al., 2010 ; Senn et al., 2008 ). This association has been studied most frequently for sexual abuse; however, Jones and colleagues (2010) found that physical and emotional abuse, but not neglect, contributed to risky behaviors over and above the effects of sexual abuse. Trickett and colleagues (2011) undertook one of the most extensive longitudinal studies of developmental outcomes for female victims of sexual abuse. The majority had experienced severe sexual abuse, defined by the type of abuse (with vaginal and anal penetrative abuse seen as most severe), the length of time over which the abuse occurred, and the relationship of the abuser to the victim. In addition to earlier initiation of sexual activity among women who had been sexually abused in childhood, the authors found less use of birth control ( Noll et al., 2003 ). For both abused and nonabused women, having a large number of male peers in childhood networks was associated with a lack of birth control use in adolescence ( Trickett et al., 2011 ). For abused females, however, having high-quality relationships with male peers and nonpeers in childhood was associated with greater birth control use in adolescence; in the comparison group, this association was not found.

Teen Pregnancy

Evidence linking childhood sexual abuse and increased risk for teen pregnancy has been mixed. Trickett and colleagues (2011) found that severely sexually abused females reported significantly higher rates of teen pregnancy and teen motherhood than nonabused females (abused = 39 percent, nonabused = 15 percent). In a meta-analysis of previously published studies of sequelae of child sexual abuse, Noll and colleagues (2009) found an increased risk for early pregnancy among girls who had been sexually abused. In contrast, using a prospective cohort design that followed children with documented cases of abuse and neglect into young adulthood, Widom and Kuhns (1996) found no evidence that childhood sexual abuse was a significant risk factor for multiple early sexual partners or teenage pregnancy.

Prostitution and Risk for Commercial Sexual Exploitation of Children and Adults

In a prospective study, Widom and Kuhns (1996) found that sexual abuse and neglect, but not physical abuse, were associated with later prostitution. In a subsequent study, Wilson and Widom (2010) examined the role of problem behaviors as a pathway to adult prostitution and found that adult victims who had experienced child abuse and neglect were more likely than nonvictims to report having been involved in prostitution as adults or prostituted as juveniles ( Wilson and Widom, 2008 ). Stoltz and colleagues (2007) found a significant relationship between child abuse and neglect (sexual, physical, and emotional) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada.

While an important topic, evidence that child abuse and neglect increase the risk for commercial sexual exploitation of children is very limited and comes primarily from retrospective studies of sexually exploited youth. Some older studies have reported that experiences of childhood sexual abuse influenced the decision of young women to become involved in commercial sex work ( Bagley and Young, 1987 ; Silbert and Pines, 1983 ). A comprehensive look at those issues will be presented in a forthcoming Institute of Medicine report from the Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States.

Finding: Experiences of abuse and neglect in childhood have a large effect on delinquency, violence, and suicide attempts in adolescence and adulthood. Finding: Adolescents and adults with a history of child abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect, although this relationship has been found most frequently in women. Finding: Children who experience abuse and neglect may initiate sexual activity at earlier ages than comparison groups. Childhood sexual abuse also has been found to be associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors. Finding: Studies seeking an association between child abuse and neglect and teen pregnancy or adult prostitution have reported mixed results.

• INDIVIDUAL DIFFERENCES IN OUTCOMES

This chapter has presented extensive evidence that children who are abused or neglected, as a group, are at increased risk for a variety of problematic outcomes. However, not all children who experience abuse or neglect experience these negative consequences. Not surprisingly (given what is known about typical development), children vary in the outcomes they experience even when exposed to the same type of abuse or neglect, with outcomes ranging from the most problematic to functioning well across domains. As discussed earlier in this chapter, an ecological-transactional model is helpful for understanding outcomes related to abuse and neglect as influenced by the interplay of risk and protective factors that occur at multiple levels of a child's ecology. Through examination of compensatory resources in children and their environment, an ecological-transactional framework can aid in understanding children who exhibit resilient outcomes despite having been abused or neglected ( Cicchetti and Toth, 2009 ; Luthar et al., 2000 ). Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. However, neither a child's individual strengths nor the surrounding environment alone can predict resilient outcomes. As noted by Jaffee and colleagues (2007 , p. 233), “the fit between the child and the environment is the best predictor of children's psychological well-being.” The following sections describe research examining explanatory factors for differences in outcomes related to child abuse and neglect.

Characteristics of Abuse or Neglect Experiences

Characteristics of a child's exposure to abuse or neglect have been shown to influence the risk for problematic outcomes. Such characteristics include the point within the course of a child's development at which an experience of abuse or neglect occurs; the chronicity of abuse or neglect experiences, taking into account their duration and frequency; the severity of the experiences; and the type of abuse or neglect ( Bulik et al., 2001 ; Collishaw et al., 2007 ; Keiley et al., 2001 ; Manly et al., 2001 ).

Among a sample of adult female twins, Bulik and colleagues (2001) found an association between characteristics of the abuse experience (e.g., a high level of severity of child sexual abuse, such as attempted or completed intercourse and the use of force or threats) and certain psychiatric disorders. In examining the effect of timing on outcomes related to child physical abuse, Keiley and colleagues (2001) found that children who experienced such abuse while under the age of 5 were at higher risk for negative outcomes than those who experienced the same type of abuse at age 5 or older. Jonson-Reid and colleagues (2012) found that nearly all children who experienced chronic, persisting abusing or neglect showed adverse outcomes in adulthood: 91.9 percent of children showed at least one negative outcome if they had 12 or more reports of abuse or neglect ( Jonson-Reid et al., 2012 ).

The concept of resilience serves as a useful lens for evaluating the differing outcomes of children exposed to abuse and neglect. By examining factors that contribute to whether children experience maladaptive outcomes in response to abuse or neglect, researchers can gain a better understanding of how better to prevent and treat these consequences. While resilience has been defined in various ways, it can be understood as “a good outcome in spite of high risk, sustained competence under stress, and recovery from trauma” ( McGloin and Widom, 2001 , p. 1022).

The study of resilience in the context of child abuse and neglect must take into account several factors. First, as shown throughout this chapter, consequences of child abuse and neglect can manifest in multiple domains of functioning. Therefore, a child's subsequent adaptation or maladaptation following abuse or neglect must be assessed in terms of multiple outcomes rather than a single indicator, such as depression ( Afifi and Macmillan, 2011 ; McGloin and Widom, 2001 ). Second, resilience is not a static construct, meaning that a child can exhibit resilient outcomes at a certain point in the course of development but may still experience problematic outcomes at a later time. It follows that analysis of resilience in abused and neglected children should include a temporal component ( McGloin and Widom, 2001 ). Third, many factors believed to promote resilience in response to child abuse and neglect can also serve to promote positive adaptation more generally in response to other childhood stressors, making it imperative for studies to include a comparison group that has not been abused or neglected ( Collishaw et al., 2007 ). Finally, resilience might usefully be considered from the perspective of allostatic load ( Danese and McEwen, 2012 ). That is, some children who experience abuse or neglect do not show problematic outcomes, but as abuse, neglect, and other adverse childhood experiences accumulate, they challenge children's ability to cope with the negotiation of life tasks.

Results from a study of adults who were the subjects of substantiated cases of child abuse or neglect as children indicate that 22 percent of abused and neglected individuals met the criteria for resilience, which required successful functioning in 6 of 8 domains ( McGloin and Widom, 2001 ). A study by Collishaw and colleagues (2007) examined resilience to adult psychopathology within a representative community sample, finding that 44 percent of adults who reported abuse during childhood reported no psychiatric problems in adulthood and demonstrated positive adaptation in other domains.

Protective factors supporting resilience have been examined at the levels of the individual, family, and social environment, with resilience being measured in childhood, adolescence, and early adulthood. In a review of protective factors for resilience following child abuse and neglect, Afifi and Macmillan (2011) identify three protective factors that are best supported by findings from longitudinal and cross-sectional studies: a stable family environment, supportive familial relationships, and personality traits that support social skills.

Individual-level protective factors identified among those displaying resilience following child abuse and neglect include personality traits (e.g., high ego control, high self-esteem, internal locus of control, external attributions of blame, and attribution of success to own efforts); gender (females more resilient than males); and relationship capabilities ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee and Gallop, 2007 ; Jaffee et al., 2007 ). There is some evidence that intelligence or cognitive ability functions as a protective factor ( Masten and Tellegen, 2012 ), but it has not always been found to be significant in supporting resilience ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ). Jaffee and colleagues (2007) found that children with protective individual-level characteristics were likely to be resilient in low-stress environments (59 percent), but children with the same protective individual-level characteristics were less likely to be resilient in highly challenging environments.

Family-level protective factors include a caring and safe home environment; positive changes in family structure (e.g., intervention, cessation of visiting rights, or removal to foster care); and supportive familial relationships at the time of abuse ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee et al., 2007 ). In a sample of sexually abused girls in foster care, family support was not found to be a protective factor, but peer influences, school plan certainty, and positive future orientation were ( Edmond et al., 2006 ). Other social-level protective factors include supportive relationships with non-family members, such as teachers or camp counselors, and supportive relationships with peers in adolescence ( Flores et al., 2005 ; Jaffee et al., 2007 ).

Gene x Environment Interactions

Historically, those working in the field of child abuse and neglect were unable to examine whether such adverse experiences interacted with biological risk or protective factors (e.g., so-called risk or protective genes)—specifically, whether experience interacted with underlying genetics. This situation has changed over the past 20 years as advances in molecular genetics have enabled a search for gene x environment (GxE) interactions. A number of such interactions have been studied in the last several decades in relation to early adversity generally and child abuse and neglect in particular. Critics of these approaches charge, among other things, that examining single gene and single environment combinations in interactions capitalizes on chance. In addition, some experts in genetics argue that the action of any single gene is likely to be very small, and to detect its effects will likely require very large sample sizes. Nonetheless, some GxE findings have emerged as robust and apparently replicable.

The 5-HTT gene is perhaps at the top of this list. This gene regulates reuptake of serotonin (a neurotransmitter that has various functions, including regulation of mood and sleep and some cognitive functions, such as memory and learning) at the synaptic cleft. The gene has long and short allelic variants that confer differential reuptake efficiency. Rodent, nonhuman primate, and human studies (e.g., Caspi et al., 2003 ) have shown that two alleles confer advantage among animals raised in stressful environments. Caspi and colleagues (2003) found that adults who had experienced stressful life events as children were more likely to have a major depressive disorder if they had one or two short alleles. Those who had two long alleles were no more likely to develop depression than individuals who had not experienced stressful life events.

A second genetic polymorphism that has received much attention is a functional polymorphism in the promoter region of the monoamine oxidase A (MAOA) gene. MAOA encodes the MAOA enzyme and selectively degrades serotonin, norepinephrine, and dopamine. Abused and neglected boys with the genotype conferring low levels of MAOA expression were found to be more likely to develop a range of externalizing behaviors, including conduct disorder, antisocial personality disorder, and violent criminality ( Caspi et al., 2002 ). However, subsequent studies have failed to replicate these findings or have demonstrated only partial replications ( Huizinga et al., 2006 ; Widom and Brzustowicz, 2006 ). For a recent review of the GxE literature concerned with child depression and abuse, see Dunn and colleagues (2011) .

Finding: Not all children who experience abuse or neglect show problematic outcomes. Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. These factors, along with risks and stressors at each level, interact with one another to predict resilient outcomes. Finding: There is a positive association between the number of risk factors for abuse and neglect to which a child is exposed and the likelihood of experiencing adverse outcomes. Finding: The timing, chronicity, and severity of child abuse and neglect, as well as the context in which they occur, have been shown to impact the associated outcomes.

• ECONOMIC BURDEN

Although the total costs of child abuse and neglect are difficult to gauge because much abuse is unreported ( Waters et al., 2004 ), a number of studies over the last few decades have attempted to document the economic burden of child abuse and neglect on society ( Corso and Fertig, 2010 ; Fang et al., 2012 ; Wang and Holton, 2007 ; Waters et al., 2004 ). Economic burden or economic impact analyses typically quantify burden by aggregating the direct medical expenditures resulting from a condition, the direct nonmedical expenditures associated with a condition, and the subsequent indirect losses in productivity potential for society. These analyses often are called cost of illness/injury analyses .

Examples of direct medical expenditures include inpatient and outpatient hospital care, mental health care, medical transport required in the event of an emergency, medications and medical devices, and the medical treatment of chronic conditions resulting from the abuse. Multiple studies since the 1993 NRC report was issued have assessed the direct medical costs associated with child abuse and neglect ( Brown et al., 2011 ), particularly the inpatient costs associated with severe abuse ( Courtney, 1999 ; Evasovich et al., 1998 ; Irazuzta et al., 1997 ; Libby et al., 2003 ; New and Berliner, 2000 ; Rovi et al., 2004 ).

Direct nonmedical expenditures include use of the child welfare system, law enforcement, and the criminal justice system. Studies have included nonmedical costs in their assessment of the economic burden of child abuse and neglect ( Staudt, 2003 ; Zagar et al., 2009 ).

Productivity losses include the child's missing school or performing at subpar levels in school because of the abuse, parents missing work or performing at subpar levels at work because of the abuse situation or having to deal with child welfare and criminal justice services, and permanent losses in lifetime productivity potential because of premature death. Productivity losses and economic well-being have been incorporated into a number of analyses of the economic burden of child abuse and neglect ( Brown et al., 2011 ; Corso and Fertig, 2010 ; Corso et al., 2011 ; Currie and Widom, 2010 ; Fang et al., 2012 ).

Gelles and Perlman (2012) estimate that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion each year—$33.3 billion in direct costs and $46.9 billion in indirect costs. 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 lost 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.

Currie and Widom (2010) found that adults who had experienced abuse and neglect in childhood had lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect. A higher percentage of adults who had been abused or neglected as children worked in menial, semiskilled positions at age 29 compared with adults who had not been abused or neglected—62 versus 45 percent, respectively. More of the abused and neglected group has been unemployed at some point during the previous 5 years (41 versus 58 percent, respectively). And fewer of those from the abused or neglected group were currently employed or had a bank account, owned a car, or owned their home. Larger effects were seen for women than for men.

Analyses of the economic burden of child abuse and neglect could be strengthened by greater transparency in the study methods, including a full accounting of all cost categories that may be impacted by abuse and neglect and transparency in the unit cost estimates for each cost category, as well as a methodologically sound choice of study design for estimating economic burden ( Corso and Fertig, 2010 ; Corso and Lutzker, 2006 ; Fang et al., 2012 ). Several approaches could be taken to estimate economic burden, each of which has advantages and disadvantages that could potentially result in overestimating or underestimating the true economic cost of child abuse and neglect. Options include using cross-sectional data to compare the medical costs for an abused/neglected population compared with a nonabused/nonneglected population, including only those health care costs that can be explicitly linked to diagnosis-specific health care utilization (and costs) through the use of diagnosis and external cause codes used in inpatient settings, and supplementing either of these two approaches by including the costs of the fraction of other health conditions attributed to child abuse and neglect.

Finding: Although the total costs of child abuse and neglect are difficult to gauge, a number of studies have attempted to document the economic burden of child abuse and neglect on society, including such measures as direct medical and nonmedical expenditures and productivity losses. One study estimates that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion annually ( Gelles and Perlman, 2012 ). Finding: Some studies have shown that adults who experienced abuse and neglect in childhood have lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect.

• CONCLUSIONS

Child abuse and neglect appear to influence the course of development by altering many elements of biological, cognitive, psychosocial, and behavioral development; in other words, child abuse and neglect “get under the skin” ( Hertzman and Boyce, 2010 ) to have a profound and often lasting impact on development. Brain development is affected, as is the ability to make decisions as carefully as one's peers, or executive functioning; the ability to regulate physiology, behavior, and emotions is impaired; and the trajectory toward more problematic outcomes is impacted. Effects are seen across domains, with the interplay across brain and behavioral systems being particularly striking.

Risk and protective factors across multiple levels of a child's ecology interact to influence outcomes related to child abuse and neglect. Factors that influence resilience across these domains are important to an understanding of how to protect children from the adverse outcomes discussed in this chapter. Evidence suggests that the timing, chronicity, and severity of the abuse or neglect matter in terms of outcomes. The more times children experience abuse or neglect, the worse are the outcomes ( Jonson-Reid et al., 2012 ). As Jonson-Reid and colleagues (2012) point out, it is not enough to know whether an event happened; one must also know how ongoing the problem is. The committee sees as hopeful the evidence that changing environments can change brain development, health, and behavioral outcomes. There is a window of opportunity, with developmental tasks becoming increasingly more challenging to negotiate with continued abuse and neglect over time.

Future research in this area needs to focus on disentangling the effects of child abuse and neglect from those of other conditions. There is a need to explore beneath the surface to understand the behavioral, neurobiological, social, and environmental mechanisms that mediate the association between exposure to abuse and neglect and their behavioral and neurobiological sequelae.

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• 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. 4, Consequences of Child Abuse and Neglect.
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Understanding Child Abuse and Neglect (1993)

Chapter: summary.

Child maltreatment is a devastating social problem in American society. In 1990, case reports involving over 2 million children were made to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive dimensions of child abuse and neglect. Reports of child maltreatment reveal little about the interactions among individuals, families, communities, and society that lead to such incidents. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, cost more than $500 million annually, according to estimates by the General Accounting Office (1991).

No specific theories about the causes of child abuse and neglect have been substantially replicated across studies, yet significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment. Furthermore, research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, social welfare, and criminal violence.

In part, this underdevelopment is influenced by a lack of funds as well as the methodological difficulties of research on topics with a complex

etiology. But in part it is underinvestment due to bias, prejudice, and the lack of a clear political constituency for children in general, and disadvantaged children in particular, in the competition for scarce research funds. Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can lead to the prevention of maltreatment and also improve the quality of social services and public policy decisions affecting the health and welfare of abused and neglected children and their families. Long-term research and collaborative ventures are necessary to develop knowledge that can improve understanding of, and response to, child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central focus of more comprehensive research activity.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families (ACYF) in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.

A Developmental And Ecological Perspective

Over the past several decades, a growing number of state and federal funding programs, government reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment. The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual

framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Collaborative efforts are also needed to facilitate the integration and application of research on child maltreatment with related areas such as child development, spousal violence, substance abuse, and juvenile delinquency.

In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom maltreatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

The panel has adopted an ecological developmental perspective to examine factors in the child, family, and society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors in the cycle of child development merit attention in shaping a research agenda on child maltreatment. The panel's ecological perspective recognizes that dysfunctional families are often part of a dysfunctional environment. This report extends beyond what is—to what could be, if children and families were supported to attain healthy development. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

Identification And Definitions

Four categories of child maltreatment are now generally distinguished: (1) physical abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own

typology and framework of reference terms. As a result, we know very little about the extent to which different types of child abuse and neglect share common risk factors or the ways in which they respond to different types of interventions.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent and the specific causes, consequences, prevention, and treatment of selected types of child abuse and neglect is relatively unknown. Inconsistencies in definitions often preclude comparative analyses of clinical studies.

The complexity of studies on child maltreatment also reflects the fragmentation of services and responses by which our society addresses specific cases. Furthermore, the duration, source, intensity, timing, and situational context of incidents of child victimization are important. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment.

Despite vigorous debate over the last two decades, little progress has been made in constructing clear, reliable, valid, and useful definitions of child abuse and neglect. The difficulties in constructing definitions include such factors as lack of social consensus over what forms of parenting are dangerous or unacceptable; uncertainty about whether to define maltreatment based on adult characteristics, adult behavior, child outcome, environmental context, or some combination; conflict over whether standards of endangerment or harm should be used in constructing definitions; and confusion as to whether similar definitions should be used for scientific, legal, and clinical purposes.

Standardization of definitions is difficult and carries with it dangers of oversimplification. However, consistent definitions are necessary for better measurement and instrumentation in the field. Attempts to reach consensus on clear operational measures must be made to overcome existing limitations and to develop more refined measures. The formulation of research definitions of child maltreatment should be guided by four key principles: consideration of the specific objectives the definition must serve; division into homogeneous subtypes; conceptual clarity; and feasibility in practice.

Scope Of The Problem

From 1976, when the first national figures for child maltreatment were generated, to 1990, the most recent year covered by the National Child Abuse and Neglect Data System, reports of maltreatment have grown from 416,033 per year (affecting 669,000 children) to 1,700,000 per year (affecting 2,712,917 children). This alarming rise in the number of reported cases

of child maltreatment has promoted the view that there is an epidemic of child maltreatment in the United States.

The panel's review of national prevalence and incidence child maltreatment studies has revealed important methodological problems that greatly affect the usefulness of these data for drawing conclusions about both the scope and origins of the problem. These methodological problems include definitional issues, confusion of prevalence and incidence, the source of maltreatment data, sampling and design considerations, a paucity of reliable and valid measurement instruments, the problem of retrospective bias, the impact of mandatory reporting requirements on the reliability of survey respondents' reports, and scarce funding for methodological work (specifically instrument development). The paucity of rigorous epidemiological investigations has retarded progress in this field. However, the available evidence suggests that child abuse and neglect is an important, prevalent problem in the United States, with conservative estimates placing the annual number of children affected by this problem at more than 1 million, following an analysis of substantiated rates of reported cases. Child abuse and neglect are particularly important compared with other critical childhood problems because they are often directly associated with adverse physical and mental health consequences in children and families. Furthermore, given the prevalence of childhood maltreatment, the level of federal funds expended in this research area is extremely small when compared with the resources allocated for less prevalent childhood mental disorders, such as autism and childhood schizophrenia.

Specifically, the panel concludes:

Overview Of Etiological Models

Most forms of maltreatment are part of a pattern of maladaptive behavior that emerges over time, but research evidence regarding the origins and

maintenance of this pattern is not clear. Investigators disagree about whether child maltreatment is a continuum of behaviors (ranging from mild physical discipline to severe forms of physical or sexual abuse) or a set of unique behavioral problems with distinctive etiologies.

Since no single risk factor has been identified that provides a necessary or sufficient cause of child maltreatment, etiological models of child maltreatment have evolved from isolated cause-and-effect models to approaches that consider the combination of individual, familial, environmental, and social or cultural risk factors that may contribute to child maltreatment. The phenomenon of child abuse and neglect has thus been moved away from a theoretical framework of an individual disorder or psychological disturbance, toward a focus on extreme disturbances of childrearing, often part of a context of other serious family problems, such as substance abuse or mental illness.

Interactive models suggest that child maltreatment occurs when multiple risk factors outweigh protective, compensatory, and buffering factors. The role of particular risk or protective factors may increase or decrease during different developmental and historical periods, as individuals, their life circumstances, and the society in which they live change. These models show promise and suggest issues that need to be addressed in research on the etiology of child maltreatment.

Individual Ontogenic Factors

A parent's personality influences child development primarily through the interactive process of parenting. Disrupted parenting can occur in a variety of ways, especially when a parent's personality attributes (such as anger or anxiety) are compounded by additional stresses such as marital conflict, absence of the spouse, poverty, unemployment, and having a difficult child. Individual factors that have sometimes been associated with child maltreatment include adult attitudes, attributions, and cognitive factors; the intergenerational transmission of abusive parenting; the use of alcohol and drugs; characteristics of the child (such as temperament); and demographic factors such as maternal age, marital status, and household density. Research on the role of these individual factors in stimulating or maintaining neglectful or abusive behaviors has been contradictory and inconclusive, suggesting that no single factor, in isolation, can explain with satisfaction the origins of child maltreatment. For example, although alcohol often is cited as a principal risk factor in the etiology of child maltreatment, its relationship to child abuse and neglect remains uncertain. More needs to be known about the unique and immediate effects of alcohol, its co-occurrence with other problem behaviors such as antisocial personality disorder and substance abuse, the circumstances under which different types

of drinking situations lead to or sustain violence against children, and cultural factors that mitigate or exacerbate connections between substance use or abuse and aggression.

Family Factors

Dysfunctions in all aspects of family relations, not just parent-child interactions, are often present in the families of maltreated children, and research is needed to examine whether such dysfunctions contribute to or are consequences of child maltreatment. Anger, conflict, and social isolation are pervasive features of maltreating families. In many cases of maltreatment, there often is not a single maltreated child, but multiple victims. Thus, maltreated children may be exposed to considerable violence involving other family members as well as violence directed toward themselves.

A distinctive feature associated with chronically neglecting families is the chaotic and unpredictable character of the family system. The effect on children of repeated acts of violence or constant fluctuations in the makeup of their household, in addition to child neglect, has not been examined in the research literature, although such factors may contribute to unrelatedness and detachment.

An important gap in the literature on child maltreatment is the lack of comparative analysis of the effects of parenting styles and dysfunctional parenting patterns (including abuse and neglect) on children in different social, ethnic, and cultural groups. The relationships among physical discipline, stress, and parental and family dysfunctions that give rise to the emergence of child maltreatment also need to be clarified.

Although a parent's own history of victimization during childhood is thought to predict child maltreatment, this association is based on retrospective studies that are sometimes methodologically suspect. The relationship between physical discipline and child maltreatment is also largely unknown, particularly in the context of cultural differences and practices. Finally, stressful life events are thought to play an important role on parental abilities, but relations between stress and poor parenting are complex and poorly understood at this time.

Environmental and Community Factors

Family functioning occurs within the context of various social institutions and external forces that influence family and parent-child behaviors. Research on environmental factors has concentrated on neighborhood and community environments, but other factors may affect individual and family functioning as well, including the workplace, the media, the school, church, and peer groups.

Discussion of the relationship of poverty to child maltreatment has persisted since publications of the early professional papers on child abuse in the 1960s. Although child maltreatment is reported across the socioeconomic spectrum, it is disproportionately reported among poor families. Furthermore, child maltreatment—especially child neglect—is not simply concentrated among the poor, but among the poorest of the poor. Whether this association results from greater stress due to poverty-related conditions that precipitate abuse, or from greater scrutiny by public agencies that results in overreporting, or whether maltreatment is but one characteristic of the pattern of disruption among the poorest of the poor continues to be debated. The link between unemployment and maltreatment is significant in understanding the relationship between poverty and maltreatment. Families reported for abuse often have multiple problems, and the abuse may simply be a part—or a consequence—of a broader continuum of social dysfunctions.

Although it occurs in all social levels, violent behavior toward children, particularly severe violence, is more likely in poor families. Despite the fact that the evidence on maternal age as a risk factor for child maltreatment is mixed, mothers with young children living below the poverty line have the greatest risk of behaving violently toward children.

Although neighborhoods are recognized as important in the ecology of child maltreatment, more insight is needed into the processes by which neighborhood conditions and factors affect maltreatment. Poor neighborhoods differ in their social and physical conditions and in their ability to influence specific risks posed to children by poverty, unemployment, and community violence. Socioeconomic conditions have predictive value for explaining child maltreatment rates, yet some neighborhoods have higher or lower child abuse rates than would be expected based on socioeconomic conditions alone.

Social isolation has been identified as an important etiological risk factor in child maltreatment, but its role as a consequence or cause of maltreatment is uncertain. The influence of family ties and organizational affiliations (including employment and education) are poorly understood but increasingly recognized as powerful forces in shaping parenting styles and family functioning. Financial stability, employment, and neighborhoods can create a context that either supports a family during periods of stress or enhances the potential for abuse.

Social and Cultural Factors

Family practices and policies that reflect social and cultural values can foster or mitigate stress in family life. Although the relationship of cultural factors is not well understood, some American societal values may contribute to child maltreatment and they have achieved new importance in emerg-

ing theoretical models of child maltreatment. Racism, for example, can lead to an inequitable distribution of resources, education, and employment that undermine many ethnic minority families' abilities to support their children (financially and emotionally) and to provide parental care. The term societal neglect has been suggested to characterize American tolerance for a situation in which one-fifth of all preschool children live below the poverty line, with a substantially higher rate among ethnic minorities. Societal fascination with violence, including violence toward children, has been suggested as a risk factor for child maltreatment, as has the lack of coherent family leave and family support policies, particularly the absence of preventive health care for infants, children, and adolescents at risk for maltreatment.

Conclusions

Many factors have been identified as contributing to the occurrence of child maltreatment, but single-factor theories of child maltreatment have not been able to identify specific mechanisms that influence the etiology of child maltreatment. Such environmental factors as poverty and unemployment and such individual characteristics as a prior history of abuse, social isolation, and low self-esteem have been significantly associated with child maltreatment offenders, but the relationships among such factors are not well understood in determining the origins of child maltreatment. The panel believes that the etiology of maltreatment involves complex clusters of variables that interact along various dimensions of a child's ecological/transactional system. Factors that increase risk for maltreatment and factors that decrease the likelihood for maltreatment are found at all ecological levels and interact to produce child maltreatment. Although theoretical models that describe the etiological complexity of maltreatment have been developed, they have not been subjected to testing and adequate research. Our recommendations seek to address these limitations.

In the past, the risk factor literature for child maltreatment has been dominated by an orientation that emphasizes correction of perceived weaknesses or problem behaviors and ignores protective factors that may influence outcomes. In recent years, some researchers have begun to examine variables that foster healthy relationships and reduce risk for child maltreatment. The reduction of multiple vulnerabilities as well as the development of compensatory behaviors should be a goal for future prevention research.

Risk Factors and Pathways to Prevention

Until recently, the primary focus in designing preventive interventions was the identification and modification of problematic or damaging parental practices associated with child maltreatment, such as physical discipline, failure to provide children with basic necessities and care, and mismatches between a parent's expectations and a child's ability.

This singular focus on parental roles was altered with the recognition of the prevalence of sexual abuse in the late 1970s. Research on victims of child sexual abuse suggested that risk factors with respect to perpetrator characteristics, victim characteristics, and sociodemographic variables are far more heterogeneous than they are for physical abuse or neglect victims. As a result, prevention advocates focused on ways to strengthen potential victims of sexual abuse through classroom-based instruction for children of all ages.

In recent years, schools have placed a new emphasis on violence prevention programs, designed to equip students to develop nonviolent methods of conflict resolution. Although the generalizability of these programs to the field of child maltreatment has not been systematically assessed, such programs represent a promising direction for future research.

Parental Enhancement Programs

Parental practices in families with young children are a major focus of research on prevention strategies for child maltreatment. Prevention strategies have built on individual, familial, and community-level risk and protective factors that contribute directly to both parental practices and to child well-being. This research foundation has provided the basis for identifying vulnerable families that are at high risk for maladaptive parental practices. Increasingly, at-risk communities are becoming the target of early intervention programs.

Four major types of prevention strategies have been developed for families with young children (defined as the prenatal period through age 8): (1) comprehensive programs, often including home visitor services that vary widely in both scope and content, (2) center-based programs that include a family support component, parent information services, and early childhood education services, (3) community-based interventions that offer a range of family support services, and (4) hospital-based interventions.

Although some well-designed, randomized control, clinical trials exist (such as the Olds study [1986a,b] in upstate New York), many early intervention services lack a theoretical framework and their mission is not always well defined. Some interventions demonstrate that knowledge about child development can be transferred to parents in a relatively brief period of time (i.e., 6-12 weeks), but a time commitment of six months or more is

needed to change attitudes and strengthen parenting and interpersonal skills. Prevention programs need to focus directly on families at most risk for maltreatment, to accommodate families with differing needs and experiences, and to adapt to changing family situations.

Community-Based Prevention Programs

The large majority of existing community-based programs focus on prevention of physical and sexual abuse. Child maltreatment prevention programs that are found in the schools are primarily child sexual abuse prevention programs designed for children in elementary and high schools. In addition to major efforts in child sexual abuse prevention, the panel reviewed two other efforts that may have implications for the prevention of child abuse and neglect. These are community-based antipoverty programs, some of which involve vocational or educational assistance, and the violence prevention programs in the schools designed to educate children, primarily adolescents, about conflict resolution skills. Such programs may be important in helping improve the welfare of many families and peer relations, but they have not been systematically evaluated in terms of their outcomes for child abuse and neglect.

Although sexual abuse prevention education programs have generally achieved the goals of teaching prevention knowledge and skill acquisition, it is not clear that these gains are retained over time or are useful to a child under assault, especially if the offender is a relative or trusted adult. Less is known about the efficacy of child sexual abuse prevention programs compared with prevention efforts directed primarily at the physical abuse and neglect of children. There is disagreement in the child safety field about the theories that should guide child sexual abuse prevention programs. At this juncture, it seems critical for child sexual assault prevention programs to evaluate the contributions of extensive parent and teacher training components. Research efforts should be expanded to include extended after-school programs and in-depth discussion programs for certain high-risk groups (e.g., former victims, teen-age parents).

Since poverty has consistently been associated with child maltreatment, particularly child neglect, programs designed to improve the income of poor families could become a major source of prevention of child neglect. At a time when education has become an important requirement for better-paying jobs, programs designed to increase the career options of young parents through educational and vocational training efforts are commonly viewed as part of the preventive spectrum for child maltreatment.

Day care providers, teachers, principals, and others who have ongoing and long-term contact with children are in a position to identify suspected victims of maltreatment and report them to child protective services. Such

interventions can be a source of reduced incidence for the recurrence or the prevention of child maltreatment. However, the low percentage of suspected cases identified by educators and other personnel in the school system that are eventually reported to child protection agencies may be a cause for concern. Day care providers, educators, and other youth service personnel require training in the identification of child abuse and neglect, guidance in reporting suspected cases, and methods for supporting maltreatment victims and their families, including referrals to relevant treatment services and peer support groups for victims.

Since many families who are reported for child maltreatment are characterized by other forms of violence (including spouse abuse and involvement in criminal assaults), interrupting the cycle of violence in one area of life may have spillover effects on others, but this assumption needs to be tested empirically. School-based interventions have several advantages, including accessibility to a broad youth population, mandated attendance, ease in scheduling, and cost effectiveness. Although school-based violence prevention programs are a promising development, no firm conclusions can be drawn at this time regarding their effectiveness or generalizability for the prevention of child abuse, and it is not known if participants will be less likely to be perpetrators of family violence.

Media representatives can become important participants in public education about prevention in child abuse and neglect. Media efforts to prevent child maltreatment may benefit from lessons derived from the role of the media in addressing public health issues. Similarly, media programs could be developed to promote community support for appropriate parental practices, especially in the use of physical discipline, and to improve the response of bystanders who witness acts of child maltreatment in public places.

Community-based prevention efforts show promise, especially in the design of multisystem approaches that can build on family-school-media-community approaches. Many avenues can be considered in designing prevention programs, but well-designed program evaluations are critical for developing a knowledge base to guide future efforts. The community mental health approach and community-based interventions designed to reduce smoking and heart disease represent much promise, but such efforts have not yet been developed or tested in the area of child maltreatment.

The Role of Cultural and Social Values in Prevention

Prevention programs increasingly focus on ways to foster cultural changes that could lead to regulatory and voluntary approaches to reinforce health messages at other system levels. Several areas that have relevance for prevention research on child maltreatment include attitudes toward the use

of corporal punishment, the effects of criminal sanctions on the maltreatment of children, and the use of violence as a means of resolving conflict. Reliance on corporal punishment by parents has been identified by some researchers as an important risk factor for physical abuse, but corporal punishment is usually not dealt with in programs to prevent physical abuse. Research is needed on whether the inclusion of alternatives to spanking in such programs reduces physical abuse.

In considering the effectiveness of criminal sanctions in the area of child maltreatment, associated problems of abusive and neglectful families need to be recognized. Many of these families are already involved with the legal system because of other behaviors, including substance abuse, juvenile delinquency, and other crimes. Assessment of the impact of criminal sanctions solely in the area of child maltreatment is challenging, since the perpetrators may be removed from the home in a variety of other ways involving the court system.

Evaluations of home visitation programs, school-based programs for the prevention of sexual abuse and violence, and other community-based child maltreatment prevention programs are quite limited. Many evaluations are compromised by serious methodological problems, and many promising preventive interventions do not systematically include child maltreatment as a program outcome. Children and families who are most at risk for child maltreatment may not participate in the interventions, and those that do may not be sufficiently motivated to change or will have difficulty in implementing skills in their social context, especially if they live in violent neighborhoods.

The panel's primary conclusion is that comprehensive and intensive prevention programs that incorporate a theoretical framework, identifying critical pathways to child maltreatment, offer the greatest potential for future programmatic efforts. New theoretical models that incorporate ecological and developmental perspectives have complicated the development of prevention research, but these models hold much promise, for they suggest multiple opportunities for prevention. Prevention research needs to be guided by rigorous evaluation that can provide knowledge about the importance of different combinations of risk and protective factors, the developmental course of various forms of maltreatment, and the importance of replacing or supplementing risk behaviors with compensatory skills. In the face of uncertainty as to whether etiologies of the various forms of child maltreatment are similar or different, a diverse range of approaches to prevention research should be encouraged.

Consequences

For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive, and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attention problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations to extraordinarily violent behaviors. Thus, the victims of abusive treatment and the society in which they live pay an enormous price for the results of child maltreatment.

Yet empirical studies of child maltreatment have identified important complexities that challenge our understanding of factors and relationships that exacerbate or modify the consequences of abusive experiences. The majority of children who are abused do not show signs of extreme disturbance. Research has suggested a relationship between child maltreatment and a variety of short- and long-term consequences, but considerable uncertainty and debate remain about the effects of child victimization on children, adolescents, and adults.

The scientific study of child maltreatment and its consequences is in its infancy. Until recently, research on the consequences of physical and sexual child abuse and neglect has been limited by delays between the child's experience and official identification of maltreatment. Maltreatment often occurs in the presence of multiple problems within a family or social environment, including poverty, violence, substance abuse, and unemployment. Distinguishing consequences that are associated directly with the experience of child maltreatment itself rather than other social problems is a daunting task for the research investigator.

As a result, we do not yet understand the consequences on children of particular types or multiple forms of abuse. Nor do we yet know the importance of the particular timing, intensity, and context of abuse on the outcome. Factors such as age, gender, developmental status, family relationships, and placement experiences of the child may influence the outcomes of maltreatment experiences. Disordered patterns of adaptation may lie dormant, only to appear during times of stress or in conjunction with particular circumstances. Furthermore, certain intrinsic strengths and vulnerabilities within a child and the child's environment may affect the extent to which abuse will have adverse consequences.

Victims of child abuse and neglect are at increased risk for delinquency and running away, but the majority of childhood victims do not manifest these problem behaviors. Significantly less is known about connections between childhood victimization and other problem behaviors, such as teen-

age pregnancy, use of alcohol and illicit drugs, and self-destructive behavior. Alcohol and illicit drug use are both illegal for teenagers, creating a natural confounding of alcohol and substance use with delinquency. Diagnoses of alcoholism are complicated by the presence of antisocial personality disorder, which in turn may include components of criminal behavior and sexual promiscuity. Engaging in any one of these behaviors, then, might increase the likelihood of involvement in other high-risk behaviors.

Issues of Stigma, Bias, and Discrimination

Problem behaviors may result from the chain of events occurring subsequent to the victimization rather then the victimization experience per se. For example, being separated from one's biological parents, subsequent to the abuse and neglect incident(s), and placed in foster care can be associated with deleterious effects. Furthermore, children can encounter discrimination against their race, color, language, life and family styles, and religious and cultural beliefs that affect their self-esteem and magnify the initial and lasting effects of both types of victimization. The observed relationship between early childhood victimization and later problem behaviors may also be affected by practices of the juvenile justice system that disproportionately label and treat maltreatment victims as juvenile offenders.

Protective Factors

Not all abused and neglected children grow up to become dysfunctional adults. A broad range of protective factors, such as temperamental attributes, environmental conditions, and positive events, can mitigate the effects of early negative experiences. The consequences of childhood maltreatment vary by demographic, background, and clinical variables—such as the child's gender, the family's socioeconomic status, and the level of marital and family violence.

Individual characteristics, such as high intelligence, certain kinds of temperament, the cognitive appraisal of victimization experiences, a relationship with a significant person, and out-of-home placement experiences protect some childhood victims. But conflicting or indirect evidence about most of these characteristics and experiences results in a major gap in knowledge about what factors make a difference in the lives of abused and neglected children. Research is needed to determine the role of protective factors and mediating individual characteristics, particularly how they operate to increase or decrease vulnerability for problem behaviors.

Placement outside the home may act to protect abused and neglected children from serious long-term consequences, but such an action is controversial. Foster care placements may pose additional risks for the abused or

neglected child, and the trauma of separation from one's biological family can also be damaging. Although some out-of-home placements may exacerbate stress in children from abusive and neglectful households, such placements may not always be deterimental. However, abused and neglected children in foster care and other out-of-home placement experiences, who typically come from multi-problem families, are a particularly vulnerable group because they have experienced both a disturbed family situation and separation from their natural parents.

Knowledge of the long-term consequences of childhood maltreatment into adulthood is extremely limited, with sparse information on intellectual and academic outcomes and medical and physiological consequences. Some research has addressed parenting behaviors (particularly the intergenerational effects of abuse), but the vast majority of existing research has focused on psychosocial outcomes and, in particular, psychopathology.

Childhood victimization often occurs in the context of multiproblem homes. Other family variables, such as poverty, unemployment, parental alcoholism or drug problems, and other factors that affect social and family functioning, need to be disentangled from the specific effects of childhood abuse and neglect. Few studies have assessed the long-term consequences on the development of abused and neglected children, beyond adolescence and into adulthood. Control groups matched on socioeconomic status and other relevant variables become necessary and vital components of this research, in order to determine the effect of childhood victimization on later behavior, in the context of family and demographic characteristics.

Interventions And Treatment

Research on interventions in child maltreatment is complicated by ethical, legal, and logistical problems, as well as difficulties in isolating factors specifically associated with child abuse and neglect in programs that often include families with multiple problems. Interventions include the assessment and investigation of child abuse reports by state child protection agencies, clinical treatment of physical injuries, legal action against the perpetrator, family and individual counseling, self-help services, and informal provision of goods and services (e.g., homemaker and respite care). Multiple agencies determine policies that guide interventions in child abuse and neglect and coordinate human and financial resources to fulfill these objectives. Researchers in this area have limited resources to collect compatible data, the results of project evaluations are rarely published in the profes-

sional literature, and issues of service delivery and accessibility are difficult to document.

The fragmentary nature of research in this area inhibited the panel's ability to evaluate the strengths and limitations of the intervention process. Furthermore, we did not have sufficient time to evaluate the full spectrum of administrative and legal procedures associated with reports of child maltreatment. The panel has thus focused its attention on those areas in which significant theory and empirical evidence exist.

Treatment of Child Victims

Despite the large literature on the detrimental effects of child maltreatment, the majority of treatment programs do not provide services directed at the psychosocial problems of the abused child. Children's involvement in treatment programs has generally occurred in the context of family-based services in which some children have received direct programmatic attention but others have not. Treatment interventions for child victims of abuse and neglect draw extensively from approaches for treating other childhood and adolescent problems with similar symptom profiles, but the psychological effects of abuse have not been well formulated in terms of theoretical constructs that can provide a basis for intervention.

Treatment of Adult Survivors

The treatment of adult survivors of childhood sexual victimization is a newly emerging field; the first programs appeared in the late 1970s. Many adult survivors of child abuse do not identify themselves as such, and most treatment programs or studies for adult survivors focus on child sexual abuse rather than other forms of child maltreatment. Research on the treatment of adult survivors is submerged in the literature on adult psychological disorders such as addiction, eating disorders, borderline personality disorders, and sexual dysfunction.

Treatment for Adult and Adolescent Sex Offenders

The treatment of child molesters is a controversial issue. Treatment programs are frequently offered to adult and adolescent offenders as part of plea bargaining negotiations in criminal prosecutions. The traditional assumption has been that children and society are better protected by offender treatment than by traditional prosecution and incarceration if the treatment service is effective. However, there is currently considerable debate about whether child molesters can be effectively treated. Until recently, adolescent sexual offenders have been neglected in clinical and research literature.

Empirically tested models to explain why adolescents commit sexual crimes or develop deviant sexual interest patterns are lacking.

The most common approaches to treating child molesters are comprehensive treatment programs aimed at simultaneously treating multiple aspects of deviant sexual behavior. Although many different approaches to the treatment of sexual offenders have been tried (including group therapy, family systems treatment, chemical interventions, and relapse prevention), scientific data indicating sustained reductions in recidivism are not available. Most studies follow offenders for only one year after treatment, and the effectiveness of the treatments in eliminating molestation behavior beyond that period is not known. Preliminary outcome data on the treatment of juvenile sex offenders show positive outcomes, although there is a lack of substantive research in the field and a lack of consensus regarding basic principles of treatment.

Family-Oriented Interventions

Most treatment interventions for physical abuse, child neglect, and emotional abuse seek to change parenting practices or the home environment. Only recently have treatment services incorporated empirical findings that examine the interactions of family members, abusive parents' perceptions of their children, behavioral characteristics that may restrict parenting abilities, and emotional reactions to stressful childrearing situations.

A lack of consensus exists regarding the effectiveness of a wide range of treatment services for maltreating families, including parental enhancement programs, family systems treatment, home-based services, and family support programs. Outcome studies have indicated positive behavioral and attitudinal changes as a result of family or parent treatment, but few studies have examined the effects of such interventions on subsequent reports of child abuse and neglect beyond one year. Definitive conclusions about the generalizability of the findings from studies of family-oriented programs in reducing subsequent child maltreatment are difficult to develop because the participants in these programs often present varied types of parental dysfunction.

Family Income and Supplemental Benefits

Government programs designed to alleviate or mitigate the effects of poverty on children are often part of a comprehensive set of services for low-income, maltreating families. Such programs include Social Security supplemental income programs, Aid to Families with Dependent Children, Women with Infants and Children food supplement program, Head Start, rent-subsidy programs, and school lunch programs, among others. While

national and local child welfare programs designed to improve the well-being of all poor families may provide food, shelter, and other necessary resources for children in households characterized by neglect or abuse, the relationship between income support, material assistance, and the subsequent reduction of maltreatment has not been systematically addressed.

Community-Based Interventions

Family-oriented interventions often exist within a context of a broad range of diverse services provided by community agencies. Understanding these responses to child maltreatment is important in understanding the experiences of children and families following reports of maltreatment. Yet little is known about the efficacy of these community-based interventions.

A few treatment programs have been developed at the community level to provide services to families, such as counseling and educational services for the parents, supervised day care, and specialized referrals for community services, including mental health care, housing, and substance addiction treatment. Although such neighborhood-focused programs may assist children who are victims of abuse or neglect, program evaluations usually do not consider outcomes in terms of maltreatment subpopulations.

Medical Treatment of Child Abuse

Health professionals in private practice, community health clinics, and hospitals are often the first point of contact for abused children and their families when physical injuries are sustained. Little is known about treatments recommended for abused children in medical settings, and even less is known about specific treatment outcomes. Studies suggest, however, that many health professionals may not be sufficiently trained to detect or validate signs of abuse or to deal with the emotional, technical, and legal aspects of evaluating maltreated children, particularly sexually abused children.

Child Protective Services

Child protection agencies receive and screen initial reports of child abuse and neglect from educators, health personnel, police, members of the public (e.g., neighbors, family friends), relatives (including siblings and parents), and others to determine whether investigation is required. The processes that determine their responses to children and families have not attracted much research attention, although a few studies have attempted to document and characterize various stages of the process and their effects on children and families. Evaluations of operations of child protective services

are complicated by the emergency situation in which most investigations occur, the confidential nature of the process, limited budgets, staff turnover, variations in definitions of child maltreatment and the absence of clear objectives, procedures, and standards of evaluation. The lack of systematic record-keeping and compatible data, and political sensitivity also inhibit the observation and analysis of decisions made by child protective services workers.

Research on the nature and effectiveness of risk assessment and referral decisions involving maltreating families is difficult, and we know little about factors that influence the assessment, investigation, and substantiation of specific cases; the operation of the referral system and follow-up services; the character of cases that are likely to receive services; the nature, intensity, and length of the services provided; and outcomes resulting from intervention services for different types of child maltreatment. Many factors can affect referral decisions, including availability of services, costs to clients and sponsors, ease of access, client attitudes, perceived need, and organizational relations. Recent clinical reports of child abuse cases suggest that many cases are closed immediately after services have been initiated and, in some instances, even prior to actual service delivery.

Child Welfare Services

The decision to allow a maltreated child to remain with family members or relatives during treatment is a critical and controversial aspect of the case management process. In some cases, temporary or permanent foster care is provided to children on the premise that protection of the child from physical harm is paramount.

Research on services provided to children in foster or kinship care is difficult. Information about children in foster care is often dispersed among biological parents, foster parents, relatives, and caseworkers, and cooperation among agencies providing services is frequently hampered by issues of confidentiality, funding and eligibility requirements, budgetary restrictions, and the specialized nature of professional services, that tend to focus on isolated problems.

Legal Intervention in Child Maltreatment

A small proportion of child maltreatment cases that are reported to child protection agencies become involved with juvenile courts, family courts, and criminal courts. Areas of convergence and conflict between the goals of service providers and the legal system in the treatment of child abuse and neglect have been documented, but much uncertainty remains in this area. Legal interventions in child maltreatment are complicated by many factors,

such as the absence of physical evidence, difficulties in obtaining consistent and reliable testimony from children, emotional trauma that might be incurred in forcing a child victim to testify against a parent or other adult who may have harmed him or her, and inconclusive scientific evidence regarding the effectiveness of treatment in halting abusive and neglectful behavior. Even though relatively low numbers of sexually abused children are involved in court proceedings, the legal treatment of child sexual abuse cases has attracted significant research attention. Almost nothing is known about the quality of court experiences for children or adults who are affected by physical abuse, neglect, and emotional maltreatment.

Social and Cultural Interventions

National policies, professional services, and institutional programs sometimes reveal inconsistent policies and fundamental value conflicts. Values that strongly influence the current American social context for responding to reported or suspected child maltreatment include respect for child safety and family preservation. The rights of individual privacy, confidentiality, and other liberties that are often constitutionally guaranteed also influence both the provision of social and professional interventions as well as evaluations of their effectiveness.

The conditions under which child, parental, or community rights should supersede all other rights and obligations, and the criteria that should be considered in balancing long-term dangers against immediate threats, are unclear. Research defining the ''best interests of the child" is becoming a significant issue in determining the outcomes of assignment of visitation and custodial rights in court decisions.

Medical, psychological, social, and legal interventions in child maltreatment cases seek to reduce the negative physical, behavioral, and emotional consequences of child abuse and neglect, foster attitudes and behaviors that improve the quality of parent-child interactions, and limit or eradicate recurrences of maltreatment. Interventions have been developed in response to public, professional, legal, and budgetary pressures that often have competing and sometimes contradictory policies and objectives. Some interventions focus on protecting the child or protecting the community; others focus on providing individual treatment for the child or the offender; others emphasize developing family coping strategies and improving skills in parent-child interactions. Assumptions about the severity of selected risk factors, the adequacy of caretaking behaviors, the impact of abuse, and the steps necessary to prevent abuse or neglect from recurring may vary.

Little is known about the quality of existing interventions in treating different forms of child maltreatment. No comprehensive inventory of treatment interventions currently exists, and we lack basic descriptive and evaluative information regarding key factors that influence the delivery and results of treatment for victims and offenders at different developmental stages and in different environmental contexts. A coherent base of research information on the nature and the effectiveness of treatment is not available at this time to guide the decisions of case workers, probation officers, health professionals, family counselors, and judges.

Investigations of child maltreatment reports often influence the development and availability of other professional services, including medical examinations, counseling, evaluation of risk factors, and substantiation of complaints. Research on various federal, state, and private agency involvement and interactions in treatment interventions has not been systematically organized. Although the panel acknowledges the challenges of performing research in this area, future study designs require adequate sample sizes, well-characterized and well-designed samples, and validated and comparable measures.

Human Resources, Instrumentation, And Research Infrastructure

Child maltreatment research in the 1990s will require a diverse mix of professional skills and collaborative efforts. The development of human resources, measurement tools, and research infrastructure in this field is complicated by the absence of support for problem-oriented research efforts in academic centers; the legal and ethical complexities associated with this kind of research; the lack of a shared research paradigm that can integrate interdisciplinary efforts across types of maltreatment; problems in gaining access to relevant data and study populations; the absence of data and report archives; and funding inconsistencies associated with shifting research priorities.

The Research Community

A variety of disciplines and subject areas contributes to studies of child maltreatment, including medicine (especially pediatrics and psychiatry), psychology, social work, criminal justice, law, sociology, public health, nursing, anthropology, demography, statistics, and education. Few systematic efforts have been made to integrate research on child maltreatment with the knowledge that has evolved from recent studies of normal child development, family systems, adult and child sexual behavior, family violence, community violence, substance abuse, poverty, and injuries.

Academic training for professionals who must work in the area of child maltreatment has not kept pace with the demands for expertise. About a dozen child maltreatment research programs exist at various universities, medical centers, and child advocacy organizations, but the depth and quality of these centers as well as the skills and affiliations of their research staff are generally unknown. Consequently, considerable effort is needed to deepen and broaden the human resources, instrumentation, and research infrastructure available for addressing the key research questions.

The number of doctorates and other advanced degrees that involve dissertations on child maltreatment studies has been increasing over the past decade, reflecting a growing interest in research in this field. Although many universities offer graduate courses in child abuse and neglect, less than half a dozen universities now sponsor graduate or postgraduate training programs in this field. Graduate training programs have achieved consensus regarding the general body of information necessary in the field of child maltreatment, but considerable variability exists in the length of the programs, student eligibility requirements, time requirements for classroom instruction and practical experience, and the availability of financial support.

Methodological Issues

The absence of support for methodological research has impeded scientific progress in child maltreatment studies. The development of adequate research tools is essential to move a research field beyond theoretical or design problems toward the collection and analysis of empirical data.

Methodology and instrumentation issues present one of the most significant barriers to the development of child maltreatment research. A number of issues deserve particular attention:

In many cases research instruments may simply be unavailable. Measures have been developed to assess "normal" child behavior or other problems in samples of unabused children, but they may not be adequate to assess child maltreatment issues and they may not be standardized on diverse cultural or ethnic populations. Furthermore, available research instruments adapted from other fields may not provide significant information for the practitioner. Difficulties in the use of instruments may result from training—researchers have often come from disciplines that give inadequate

attention to the importance of valid and reliable measures and empirical results. Overall, the use of standard measures of family characteristics and social environmental characteristics seems to be less frequent in child maltreatment research than in child development and family research in general.

The development and use of standardized measures in child maltreatment research is complicated by an additional set of pragmatic and professional factors, including the lack of budgetary support for instrumentation research projects, publication policies that discourage discussions of psychometric work in reporting research results, and research sponsors' preference for substantive rather than methodological topics.

Although some useful resources can be identified, the field of child maltreatment studies has not successfully developed a comprehensive information service designed to integrate research publications from diverse professional and private sources in an easily accessible format. In contrast to effective dissemination programs focused on criminal justice research, limited efforts exist to summarize and disseminate maltreatment research findings from the fields of psychology, social work, medicine, and other relevant disciplines.

Federal Funding for Research

Federal support for child maltreatment research is currently divided among 28 separate offices in 5 federal departments—the departments of Health and Human Services, Justice, Education, Defense, and Transportation. The forms of federal research support are diverse, including large research center program awards, individual research awards, data collection efforts, individual training grants, and evaluations of demonstration projects. With the exception of the National Center for Child Abuse and Neglect, which has a research program focused explicitly on studies of child maltreatment, most federal agencies support child maltreatment research in the context of other scientific objectives and program responsibilities, such as research on violence, maternal and child health care, family support, mental health, and criminal justice. As a result, federally supported research activities that may advance scientific knowledge of the identification, causes, consequences, treatment, and prevention of child abuse and neglect are often embedded within other research studies that have multiple objectives. No central repository exists to maintain an ongoing index of federally supported research on child maltreatment.

A 1992 forum sponsored by the Federal Interagency Task Force on Child Abuse and Neglect indicated that the total federal research budget for studies directly related to child maltreatment research is in the $15-20 million range. It is important to note that these figures reflect only research that is "primarily relevant" to child abuse and neglect studies. Additional

research efforts related to child maltreatment are also sponsored by federal agencies, although the level of investment in these secondary research efforts depends on the perceived significance of studies about parent-child interactions, substance abuse, family violence, and juvenile delinquency to child maltreatment.

The relevance of child maltreatment research to the central mission of each federal department appears to be idiosyncratic and uneven. Adopting a comprehensive view of research on child maltreatment presents certain difficulties of identification, organization, and taxonomy. Efforts to prevent child abuse and neglect and improve child welfare are dispersed among a wide range of federal programs within the U.S. Department of Health and Human Services alone. However, most of these efforts are not "child abuse" in name, and no systematic effort has been made to evaluate the lessons for child maltreatment learned from them. Various direct services for abused children and their families, demonstration projects, and educational and information dissemination activities are scattered throughout other federal program efforts as well.

Clearly, not all research on children, families, poverty, and violence is relevant to studies of child maltreatment. However, the fragmented and specialized character of the current federal research portfolio in these issues can hamper systematic efforts to organize and build on advances in research. The specialized roles of federal programs that have relevance for studies of child maltreatment continue to inhibit the development of this field. Research investigators and program officers in separate agencies are often unaware of previous studies or active projects related to their research interests. Researchers funded by separate agencies to conduct studies on aspects of child maltreatment often work with separate theoretical paradigms, use different sample populations, develop project-specific methodologies, draw on separate research databases, and present their results in a wide variety of journals and professional meetings. The absence of a central tracking and documentation resource center and the diffuse organization of the federal research portfolio, as well as the fragmented bureaucratic and legislative requirements that are associated with child maltreatment, inhibit the development of a dynamic and interdisciplinary research field.

State Roles in Research on Child Maltreatment

No comprehensive inventory of state research programs exists for studies on child maltreatment issues, but it is unlikely that the total amount of research funds available from individual state agencies is significant (i.e., greater than $1 million per year). However, individual scientists reported to the panel that they have received occasional research support from various state agencies, including the maternal and child health departments and

family services offices in the states of Hawaii, Illinois, and Minnesota, the children's trust funds administered by the states, and other offices. The decentralized and sporadic nature of state-funded research efforts discourages efforts to build collaborative interdisciplinary research teams or long-term studies focused on complex research topics.

States are a potential source of future support for specific training and data collection programs in areas such as the criminal justice, education, and public health systems that need to be integrated into comprehensive studies of outcomes and consequences of child abuse and neglect. It is useful to think of the state agencies as important partners in building an expanded research base for studies of child maltreatment.

State science programs are expected to assume a larger role in sponsoring and using research related to domestic health, social, and environmental issues in the decades ahead. The 1992 report of the Carnegie Commission on Science, Technology and Government, for example, concluded that new scientific and technological advisory organizations will be needed to foster better communication between and within the states. These organizations will need to improve the gathering of scientific knowledge, of identifying best practices, and of suggesting research priorities in national science and technology forums. Studies on child maltreatment should be viewed as an important opportunity for building collaborative state and federal research organizations directed toward long-term improvements in social service programs in areas such as child protection, child welfare, family counseling, and foster care.

Private Foundations

In addition to research funding from governmental agencies, at least eight private foundations have selected child abuse and neglect as a priority funding area. Despite this interest, the amount of funds provided by private foundations for studies on child maltreatment is quite limited.

The nongovernmental sector may be an important source of potential funding for dissertation and graduate student support in funding studies on the relationships among child maltreatment, child development, family welfare, poverty, and others. It is most important, therefore, to see the private sector as a collaborator in strengthening the research foundation for studies on child maltreatment.

Support for child maltreatment research has developed in a haphazard, piecemeal fashion, reflecting the absence of a national plan for providing research, educational, and professional support for studies of child abuse and neglect. Governmental roles in this area have been complicated by

poor leadership, the absence of sufficient funds to support a robust research program, uncertainties about the most promising research directions to pursue, tensions between the role of the federal and state governments in sponsoring projects in such areas as child maltreatment and child and family welfare, and conflicting social values about the proper interventions to develop in response to child maltreatment incidents. Tensions also exist in the allocation of funds between professional and social services for maltreated children and their families and research projects that seem to provide no immediate benefits for these groups.

Given the current status and evolution of child maltreatment studies, a broad diversity of parallel efforts should be maintained. Top-down or centralized approaches should be avoided that may discourage or fail to recognize the significance of emerging theoretical paradigms, instrumentation research, and other approaches that seek to extend the boundaries of current knowledge about the origins, scope, and consequences of child abuse and neglect. In particular, attention to cultural and ethnic issues that affect our understanding of childhood needs, child development, and family life require a breadth of effort that currently does not exist in the research community.

While diversity of effort is important to maintain, the panel concludes that better national leadership is needed to organize the research base. Such leadership requires more informed documentation of research efforts so that scientific findings, instrumentation, theory, and data can be better recorded, integrated, and disseminated to researchers and practitioners. There is also a pressing need to connect education, research, and practice so that individuals who become caseworkers, family counselors, administrators, legal officials, and future scientists have a richer understanding of the complexities of child maltreatment. Finally, the development of both young and mature scientists needs attention to build a foundation for future explorations of the intricate scientific questions that lie ahead.

Ethical And Legal Issues

Ethical and legal issues for studies of child maltreatment will gain increasing prominence with the growth of research activities on child maltreatment, especially as researchers acquire the ability and resources to conduct long-term prospective studies of nonclinical samples involving large numbers of children and families.

Human Subjects Research Issues

Many ethical issues arise in the course of human subjects research, some of which have special relevance for studies of child maltreatment.

Five issues that deserve special attention are: (1) the recruitment of research subjects; (2) informed consent and deception; (3) assignment of subjects to experimental or control programs; (4) issues of privacy, confidentiality, and autonomy; and (5) debriefing or desensitizing of research subjects following research on matters that may involve deception or significant stress.

Issues Derived from Research on Children and Families

The validity of scientific research takes on special relevance in studies of children and other vulnerable populations, when research results are likely to influence social policy and public perceptions of the problem under study. Information that scientists disseminate about child victimization is often socially and politically sensitive and can affect both parental and professional behavior as well as public policy. Scientific information, communicated through the popular media, can influence the manner in which abusive parents view abuse, and the ways in which victims view themselves. High-quality research is needed to provide information that has a factual, scientific basis, rather than information based on conjecture or opinion.

Because validity is so important but hard to achieve in research on children and families, factors that affect validity are receiving increased attention. These factors include the definitions of child maltreatment, instrumentation and research methods, selection of subject samples, collection of data, interpretation of findings, and safeguards for ensuring privacy, confidentiality, and reliability in the research study.

Research on Socially Sensitive Topics

Scientific studies of child maltreatment require extraordinary care and confidentiality in eliciting, safeguarding, and disclosing information from respondents because of the socially sensitive nature of the research subject. Family disciplinary practices, the use of violence between family members, and expressions of anger or rage are difficult to detect, observe, and record. Research on children's sexual development is one of the most unexamined areas in all of social science, impeded by a variety of social taboos, political sensitivities, and ethical ambiguities in general and discussions of sexual behavior with children in particular.

Researchers who seek to foster valid and creative research projects must address fundamental ethical issues in the recruitment of research subjects; the process of obtaining informed consent; the assignment of subjects; debriefing, dehoaxing, and desensitizing subjects when deception or stress-

ful research is involved; and in providing referrals for children and family members in distress.

Research Priorities

Despite the clear significance of child maltreatment, the panel concludes that research in this area is in an early stage of development. Although much insight has been gained over the past three decades, the field has not yet developed an integrated and organized base of knowledge or ongoing data collection efforts that can inform practice, guide the development of programs and policies relevant to child maltreatment, and shape the formation and testing of major hypotheses in this field. As a result, research is needed in diverse areas to explore promising directions. At the same time, research on child maltreatment requires guidance, coordination, and leadership to organize the research base and cultivate future generations of researchers who are well trained and informed about the complex research questions in this field.

The panel concludes that a research agenda for child maltreatment studies should address four separate objectives. We need knowledge that can:

Each chapter in this report includes key research recommendations within the topic under review. In the final chapter of the report (Chapter 10) the panel uses the four headings listed above as a framework for organizing the research priorities that it selected as the most important to address in the decade ahead. Details regarding each priority area appear in the individual chapters of the report.

Under each general heading below, the panel has organized the research priorities in order of their importance, with the most important recommendation listed first within each section.

The Nature and Scope of Child Maltreatment

Research definitions of child maltreatment are inconsistent, and the breadth and quality of instrumentation for child maltreatment studies are seriously incomplete. The variation in existing definitions and inadequate instrumentation impedes high-quality research, inhibits the comparison of studies of related phenomena, and restrains the development of good evaluations of intervention efforts. Improved definitions and instrumentation will facilitate the development of small- and large-scale epidemiologic investigations. These investigations would provide solid information on the occurrence of these important problems as well as on key etiologic agents.

Research Priority 1. A consensus on research definitions needs to be established for each form of child abuse and neglect. The development of consensus requires a major federal and professional commitment to a dynamic, evolutionary process, guided by a series of expert multidisciplinary panels and developed in conjunction with existing agencies, that could review existing work on research definitions.

Research Priority 2: Reliable and valid clinical-diagnostic and research instruments for the measurement of child maltreatment are needed to operationalize the definitions discussed under Research Priority 1. The absence of appropriate instrumentation and methodology is a second serious barrier to the development of good child maltreatment research. The reliability and validity of these instruments must be established by sound methodology, including testing their relevance and usefulness for economically and culturally diverse populations.

Research Priority 3: Epidemiologic studies on the incidence and prevalence of child abuse and neglect should be encouraged, as well as the inclusion of research questions about child maltreatment in other national surveys. After considerable work on instrumentation, including investigations into effective questioning strategies, the panel recommends funding several epidemiologic studies of different size and scope (including different age groups and ethnic groups) to address several different questions relating to child maltreatment (for example, the extent of the hidden nature of abuse).

Understanding the Origins and Consequences of Child Maltreatment

Research Priority 4: Research that examines the processes by which individual, family, community, and social factors interact will improve understanding of the causes of child maltreatment and should be supported. Theoretical models that integrate a variety of risk and protective factors are a promising development in research on the origins of child maltreatment and deserve further research attention. Rather than endorsing

a single approach, the panel recommends that diverse models be tested using a variety of research strategies so that researchers can test theory and generate hypotheses about mechanisms that activate or protect against individual child maltreatment.

Research Priority 5: Research that clarifies the common and divergent pathways in the etiologies of different forms of child maltreatment for diverse populations is essential to improve the quality of future prevention and intervention efforts. Studies that compare the etiologies of different types of maltreatment, and the patterns of risk and protective factors among populations that vary by ethnicity, cultural, and economic status, should be supported. It is particularly important at this time to uncover key pathways for child victimization that may be amenable to prevention or other forms of intervention.

Research Priority 6: Research that assesses the outcomes of specific and combined types of maltreatment should be supported. Research is needed that assesses direct and indirect consequences of child maltreatment across different domains of life, such as health, cognitive and intellectual skills, and social behavior in a variety of cultural contexts.

Research Priority 7: Research is needed to clarify the effects of multiple forms of child victimization that often occur in the social context of child maltreatment. The consequences of child maltreatment may be significantly influenced by a combination of risk factors that have not been well described or understood. The presence or absence of certain characteristics and other adverse events may influence a child's response to childhood victimization, and in some cases the combined effects of two stresses (such as family environment and poor caretaking) may be greater than the sum of the two considered separately. The social context is particularly important, since the effects of abuse or neglect often cannot be separated from other problems confronting families experiencing a variety of problems. It is not yet known whether a syndrome of problem behaviors or combined risks have common origins or whether discrete behaviors have different etiologies. These contrasting pathways have different implications for intervention strategies.

Research Priority 8: Studies of similarities and differences in the etiologies and consequences of various forms of maltreatment across various cultural and ethnic groups are necessary. The effects of risk potentiating and protective factors on child maltreatment in diverse cultural and ethnic groups have not been adequately explored.

Improving Treatment and Preventive Interventions

At present, we have limited knowledge about the range or nature of treatment and preventive services for child maltreatment or the context in

which these services are available to children and their families. Research evaluations in this area therefore must seek to broaden understanding of what currently exists as well as documenting what services appear to work for which individuals or groups, under what circumstances. Research on service interventions must also seek to identify factors and mechanisms that facilitate, or impede, the transfer of knowledge between researchers who study the origins, nature, scope, and outcomes of child maltreatment and those who develop and implement policies and programs for child and family services in the public sector.

Research Priority 9: High-quality evaluation studies of existing program and service interventions are needed to develop criteria and instrumentation that can help identify promising developments in the delivery of treatment and prevention services. Independent scientific evaluations are needed to clarify the outcomes to be assessed for service delivery programs in the area of child maltreatment. Such evaluations should identify the outcomes to be assessed, clarify the instrumentation and measures that can provide effective indicators of child and family well-being or dysfunction, and develop the criteria that should be considered in evaluating the effectiveness of a specific program or service. Evaluation studies currently rely heavily on reported incidents of child maltreatment as a measure of program effectiveness. Given the uncertainties associated with official detection of child maltreatment, such outcomes may have limited value in measuring the achievements or limitations of a selected program intervention.

Rigorous evaluation studies should be an essential part of all major demonstration projects in the area of child maltreatment, and funds should also be available for investigator-initiated evaluation studies of smaller program efforts. Smaller programs should be encouraged to use similar assessment instruments, so that results can be compared across studies. Scientific program evaluations, published in the professional literature, are an important means of transferring the knowledge and experience gained in the service sector into the research community. Such information exchange can improve the quality of studies on the origins, consequences, and other aspects of child maltreatment, ultimately leading to improved services and programs.

Evaluation research is particularly important in the following areas:

Research Priority 10: Research on the operation of the existing child protection and child welfare systems is urgently needed. Factors that influence different aspects of case handling decisions and the delivery and use of individual and family services require attention. The strengths and limitations of alternatives to existing institutional arrangements need to be described and evaluated. We have very poor information about the methods and mechanisms used to identify and confirm cases of child maltreatment, to evaluate the severity of child and family dysfunction, to assess personal and social resources, family strengths, and extrafamilial influences, and to match clients to appropriate treatments based on these formulations. An analysis is needed of interactions among different agencies involved in intervention and treatment and the degree to which decisions made by one agency affect outcomes in others. A research framework that provides standardized classifications and descriptions of child maltreatment investigations, adjudications, and treatment services should be developed. Comparative studies are needed to describe the agencies involved in the system, the types of interventions available for selected forms of maltreatment, the costs of investigating and responding to reports of child maltreatment, and the outcomes of case reports. Such studies should also consider the development of alternatives to existing institutional arrangements to improve the quality of service delivery systems.

Research Priority 11: Service system research on existing state data systems should be conducted to improve the quality of child maltreatment research information as well as to foster improved service interventions. Variations in state definitions of child abuse and neglect as well as differences in verification procedures result in significant unevenness in the quality of research data on child maltreatment reports.

Research Priority 12: The role of the media in reinforcing or questioning social norms relevant to child maltreatment needs further study. Important lessons can be learned from the role of the media in fostering healthy or unhealthy behaviors in areas such as the use of alcohol, smoking, drug use, and condom use. Research is needed that can identify the significant pathways by which key factors and behaviors affect child maltreatment, such as parenting styles, the use of corporal punishment, the use of violence and time-out periods in stress management and conflict resolution, and young children's relationships with strangers and abusive caretakers.

A Science Policy for Research on Child Maltreatment

The complexity of the problem of child maltreatment requires a sustained commitment to high-quality research, national leadership, human resources, and adequate funds. Scientific knowledge can contribute to our understanding of the nature, scope, origins, and consequences of child maltreatment, but such knowledge cannot be developed in a haphazard manner. Thus the panel has formulated priorities for science policy and the research infrastructure that supports child maltreatment studies in order to highlight key strengths and existing deficiencies in the research system.

Research Priority 13: Federal agencies concerned with child maltreatment research need to formulate a national research plan and provide leadership for child maltreatment research. Existing fragmentation in the federal research effort focused on child maltreatment requires immediate attention. National leadership is necessary to develop a long-term plan that would implement the child maltreatment research priorities identified by the panel, help coordinate the field, and focus it on key research questions. The panel believes that Congress, federal agency directors, and the research community should weigh the strengths and limitations of alternative federal research management approaches presented in this report in considering how to implement a national research plan for child maltreatment. Once a course of action has been formulated, current and proposed agency research activities need to be examined so that areas of strength, duplication of effort, and gaps in current efforts can be identified.

Research Priority 14: Governmental leadership is needed to sustain and improve the capabilities of the available pool of researchers who can contribute to studies of child maltreatment. National leadership is also required to foster the integration of research from related fields that offer significant insights into the causes, consequences, treatment, and prevention of child maltreatment.

Research Priority 15: Recognizing that fiscal pressures and budgetary deficits diminish prospects for significant increases in research budgets generally, special efforts are required to find new funds for

research on child abuse and neglect and to encourage research collaboration and data collection in related fields. The federal government spent about $15 million in fiscal year 1992 on research directly related to child maltreatment. As a first step in strengthening the research portfolio, the panel recommends that the research budgets of the National Center on Child Abuse and Neglect, the National Institute of Mental Health, the National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, and the Department of Justice that are relevant to child maltreatment studies be doubled over the next three years. Second, the panel recommends that the National Center on Child Abuse and Neglect convene a consortium of government agencies, private foundations, and research scientists to develop a task force to identify ways in which research on programs relevant to child maltreatment (such as substance abuse, spousal violence and child abuse, child homicides, juvenile delinquency, and so forth) can be more systematically integrated into the research infrastructure for child abuse and neglect.

Research Priority 16: Research is needed to identify organizational innovations that can improve the process by which child maltreatment findings are disseminated to practitioners and policy makers. The role of state agencies in supporting, disseminating, and utilizing empirical research deserves particular attention. Research on the information dissemination process can strengthen the ways in which science is used to inform and advise legislative and judicial decision makers. Such research can also contribute to the effective partnerships among scientists, practitioners, clinicians, and governmental officials to encourage the use of sound research results in formulating policies, programs, and services that affect the lives of thousands of children and their families.

State agencies have an important role in developing and disseminating knowledge about factors that affect the identification, treatment, and prevention of child maltreatment. The National Center on Child Abuse and Neglect should encourage the development of a state consortium that can serve as a documentation and research support center, allowing the states to collaborate in sponsoring child maltreatment studies and facilitating the dissemination of significant research findings to state officials.

Research Priority 17: Researchers should design methods, procedures, and resources that can resolve ethical problems associated with recruitment of research subjects; informed consent; privacy, confidentiality, and autonomy; assignment of experimental and control research participants; and debriefings. Research is needed to clarify the nature of individual and group interests in the course of research, to develop clinical advice and experience that can resolve such conflicts among such interests, and to identify methods by which such guidance could be communicated to researchers, institutional review boards, research administrators, research subjects, and others.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

Olds, D.L., C.R. Henderson, R. Chamberlin, and R. Tatelbaum 1986a Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics 78:65-78.

Olds, D.L., C.R. Henderson, R. Tatelbaum, and R. Chamberlin 1986b Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77:16-28.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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The uprising in child abuse cases in America is forcing the country to open its eyes and investigate the underlying issue. Psychologist, social workers, law enforcement and researcher are all working hand and hand to combat the dilemma, yet all face the puzzling question “Why does this continue happen? And “Where does the issue stem from?”. These are two question that once solved could substantially decrease cases of child abuse. Erik Erikson in 1963 was one the first to divulge […]

Child Abuse is Happening

Child abuse is happening all over the world.The major abuse in are society is child abuse more than 80 percent has child abuse in are world.America has to stop child abuse in are country.Nearly more than a thousand plus more children was victims of child abuse or neglect.Child abuse has ruined the worlds of little children,More parents are abusing children and hurting their lives with abusing them. Child abuse can be prevented. People can prevent child abuse by training parents,getting […]

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Child abuse, neglect, or maltreatment and even intimate partner violence are all considered to be factors with negative effects for children. Neglect or maltreatment leads to many forms of abuse. Some of these are domestic violence, sexual abuse, and emotional abuse. These could impact a child's overall health if not treated early. More so, if children are not treated with therapy at an early stage, serious mental health issues could develop when children become adolescents. It has been stated that […]

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The topic of the research paper is the child abuse and neglect and negative physical health. Both of these topics are very important to look into and research. One reason would be to find out consequences, because the consequences of child abuse and neglect can be very extensive and may not only affect the victim's mental health, like it is known to do, but also possibly their physical health which may often be overlooked because it can take longer to […]

Child Abuse Means a Physical Maltreatment

Child abuse means a physical maltreatment or sexual molestation of a child. When a child is starting to experience abuse, they change. They suddenly don't show affect for a certain relative or they don't want to go over to that relative's house. They get an attitude or change their behavior. Most people just see this as they are growing up and rebelling. When children start making sexual remarks or start displaying sexual behaviors with other young children, those are signs […]

Catherine Roerva: a Complex Figure in the Narrative of Child Abuse

Catherine Roerva, a name that has become synonymous with the heart-wrenching narrative of child abuse in Dave Pelzer's memoir "A Child Called 'It'," stands as a controversial and complex figure in the realm of autobiographical literature. Pelzer's portrayal of his mother as an abusive figure has sparked discussions and debates about the nature of abuse, the dynamics of family dysfunction, and the resilience of the human spirit in the face of adversity. This essay aims to explore the multifaceted character […]

Child Abuse by Maid: Unmasking a Hidden Threat

Every parent's nightmare? Trust someone with their child, only to discover that trust might've been misplaced. Now, imagine this breach of trust coming from someone right within your home — the maid or nanny you believed would care and nurture. A topic we often tiptoe around, preferring the comfort of ignorance, is child abuse by those entrusted to care for them. Let's shed light on this hushed matter, not to provoke fear but to arm ourselves with awareness and action […]

Adverse Childhood Experiences and their Effects on High School Graduation Rates

Introduction The startling effect adverse childhood experiences (ACEs) have on children and adults came to light in a groundbreaking study first published twenty years ago. Andra et al. reported a strong link between exposure to abuse, divorce, substance abuse, and more to several health risk factors in adults (1998). The Adverse Childhood Experiences (ACE) Study opened our eyes to the long-term impact of direct and indirect abuse and how child did not have to be abused themselves to suffer serious […]

Child Abuse in India: Unveiling the Harsh Realities

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How To Write an Essay About Child Abuse

Understanding child abuse.

Before writing an essay about child abuse, it's essential to understand its forms and implications. Child abuse refers to any emotional, physical, or sexual harm inflicted on a child by an adult or older adolescent. It can also include neglect, where a child's basic needs for safety, affection, and education are not met. Begin your essay by defining the different types of child abuse and their characteristics. Discuss the prevalence of child abuse and the various factors that contribute to it, such as family stress, substance abuse, and historical abuse within the family. Understanding the psychological, physical, and social impact of abuse on children is crucial for a comprehensive analysis of this topic.

Developing a Thesis Statement

A strong essay on child abuse should be centered around a clear, concise thesis statement. This statement should present a specific viewpoint or argument about child abuse. For instance, you might discuss the long-term psychological effects of child abuse, analyze the societal factors contributing to its prevalence, or argue the need for improved child protection policies and interventions. Your thesis will guide the direction of your essay and provide a structured approach to your analysis.

Gathering Supporting Evidence

To support your thesis, gather evidence from credible sources such as child welfare studies, psychological research, and statistics from child protection agencies. This might include data on the incidence of child abuse, findings from studies on the effects of abuse, or examples of successful intervention programs. Use this evidence to support your thesis and build a persuasive argument. Remember to consider different perspectives and address potential counterarguments to your thesis.

Analyzing the Effects and Responses to Child Abuse

Dedicate a section of your essay to analyzing the effects of child abuse and society’s response to it. Discuss the short-term and long-term impacts on a child's physical health, psychological well-being, and social development. Explore the role of child protective services, legal systems, and non-governmental organizations in responding to and preventing child abuse. Consider both the successes and challenges faced in addressing child abuse.

Concluding the Essay

Conclude your essay by summarizing the main points of your discussion and restating your thesis in light of the evidence provided. Your conclusion should tie together your analysis and emphasize the importance of addressing child abuse both as a societal and individual issue. You might also want to suggest areas for future research, policy development, or public education campaigns to prevent child abuse.

Reviewing and Refining Your Essay

After completing your essay, review and refine it for clarity and coherence. Ensure that your arguments are well-structured and supported by evidence. Check for grammatical accuracy and ensure that your essay flows logically from one point to the next. Consider seeking feedback from peers, educators, or professionals in the field of child welfare to further improve your essay. A well-written essay on child abuse will not only demonstrate your understanding of the issue but also your ability to engage with a sensitive and complex social problem.

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Prevention Strategies

Child abuse and neglect are serious problems that can have lasting harmful effects on victims. CDC’s goal is to stop child abuse and neglect from happening in the first place.

Child abuse and neglect are complex problems rooted in unhealthy relationships and environments. Preventing child abuse and neglect requires addressing risk and protective factors at the individual, relational, community, and societal levels.

CDC developed a resource, Child Abuse and Neglect Prevention Resource for Action [4 MB, 50 Pages]  to help states and communities use the best available evidence to prevent and reduce child abuse and neglect. This resource is available in English and Spanish [21 MB, 52 Pages, 508] and can impact individual behaviors and the relationship, family, school, community, and societal factors that influence risk and protective factors for violence. Effective prevention strategies focus on modifying policies, practices, and societal norms to create safe, stable, nurturing relationships and environments. The strategies and their corresponding approaches are presented in the table below.

See Child Abuse and Neglect Resources  for more publications, data sources, and other resources about preventing child abuse and neglect. 

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Child Abuse: Signs, Types, Impact

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Ann-Louise T. Lockhart, PsyD, ABPP, is a board-certified pediatric psychologist, parent coach, author, speaker, and owner of A New Day Pediatric Psychology, PLLC.

LumiNola / Getty Images

Indicators of Child Abuse

Types of child abuse, impact of child abuse, how to manage the effects of child abuse.

Child abuse is the wrongful treatment of a child. It may be in the form of physical, emotional , or sexual abuse . This form of abuse may also be recognized as the exploitation of a child, as well as the failure to properly care for a child, otherwise known as neglect .

Children that are subjected to abuse usually experience harm to their health, welfare, and self-respect.

This article covers the many forms of child abuse, how each form impacts a child's mental and physical well-being, and discusses how childhood trauma can be treated.

If you are a victim of child abuse or know someone who might be, call or text the Childhelp National Child Abuse Hotline at 1-800-422-4453 to speak with a professional crisis counselor.

For more mental health resources, see our National Helpline Database .

When a child is experiencing ill-treatment from a caregiver or other person, there are signs that may indicate abuse. These include:

Signs of Physical Abuse

• Unexplained facial injuries
• Injuries on forearms
• Burn marks on the skin
• Bruises on the ears
• Oral and dental injuries
• Dislocations around the body
• Internal damage 
• Vomiting or breathing difficulties due to head trauma

Signs of Sexual Abuse

• Bruising around the genitals
• Painful urination or defecation
• Discharge around the genital or rectal areas
• Difficulty walking or sitting

Signs of Neglect

• Poor hygiene
• Improper clothing during the seasons
• Lack of access to medical care
• Worsening medical conditions
• Poorly-tended wounds
• Malnutrition

Behavioral Cues of Child Abuse

• Excessive crying in infants
• Poor concentration
• Development of phobias
• Eating issues
• Displays fear around parents/caregivers
• Speech difficulties
• Poor performance at school
• Substance abuse
• Discomfort while undressing
• Docile during physical exams
• Withdrawing when touched

Child abuse is committed in epidemic proportions in the United States. Every year, approximately one million children are deprived of a normal, harm-free childhood. Instead, they are subjected to the horrors of maltreatment in their formative stages.

The abuse of children may take different forms, listed below.

Physical Abuse

This form of abuse refers to the deliberate physical harm of a child by parents or caregivers. Physical abuse affects around 18% of maltreated children, and is a leading cause of child deaths—homicide falling in second for the loss of infant lives younger than one.

Physical abuse may involve hitting a child with hands or an object. Burning, biting, or physically restraining a child with the intent to do harm is also considered physical abuse.

Children of all races, ethnicities and economic groups may be subject to physical abuse. It is, however, more commonly observed in boys and infant children.

A child is also at a higher risk of physical abuse where they live with a disability or are under the care of an unmarried mother.

There is also an increased chance of violence where a child is raised in poverty, or in a home where domestic violence is rampant. The same goes in situations where a child grows up with an unrelated adult, or with more than two siblings at home.

Emotional Abuse

This form of abuse may not always have the immediately apparent signs of physical harm but is no less painful.

Emotional abuse occurs where a child is degraded, terrorized, isolated, or exploited by a parent/caregiver. This is seen where a child is constantly criticized, threatened, rejected, or given no support or love while growing up.

In 2010, The Federal Report of Child Maltreatment Statistics stated that 8% of all reported cases of child maltreatment involve emotional abuse. There is a chance that cases of emotional abuse may be even higher than those reported.

Sexual Abuse

Sexual abuse refers to the forceful participation of children in sexual acts. It may also involve forcing a child to engage in sexual acts that they do not fully understand.  This abuse may also force children to engage in sexual acts that they do not fully understand.

Sexual abuse includes sexual assault, rape, incest, fondling, oral sexual contact, the commercial sexual exploitation of children, or genital/anal penetration. Sexual abuse is a worryingly common form of child abuse. By adulthood, it is estimated that 26% of girls and 5% of boys will experience this maltreatment.

While sexual contact typically makes up sexual abuse, non-contact improper treatment may also come under the abuse classification. This includes the exposure of a child to sexual activity or taking inappropriate photographs of children.

This is the failure of a caregiver/parent to meet the most basic needs of a child. It is the most common form of child abuse where approximately two-thirds of reports to child protective services are made over concerns of child neglect.

Neglect takes many forms and can be observed where a child is not taken for regular doctor appointments, or is denied access to healthcare by a caregiver.

This form of abuse is also apparent where a child is not given the right nutritional care, or when children are exposed to harmful substances like drugs.

Abuse has far-reaching effects on every aspect of a child’s well-being.

Impact of Physical Abuse

Physically, children may suffer the pains of fractures, burns, facial or bodily disfigurement, and even seizures brought on by bodily maltreatment. The mental effects of this treatment may leave children with PTSD or even cognitive retardation.

Impact of Emotional Abuse

Emotional abuse may cause a disconnect in a child’s sense of self. This abuse could be responsible for negative disruptions in the brain, anxiety, depression, low self-esteem , hostile behaviors , and noticeable delinquent habits such as alcohol use in early adulthood.  

Impact of Sexual Abuse

The sexual abuse of children has both immediate and long-term effects on their well-being. Survivors of child sexual abuse may feel anger, guilt, and shame over the treatment they have endured.

Children who have experienced sexual abuse are also at a higher risk of developing anxiety, depression, and inappropriate sexual behaviors in life. In later years, these survivors may experience problems like alcoholism , drug dependency, marriage/family difficulties, and a  worrying preoccupation with suicide .

Impact of Neglect

A child left without the useful tools and care for proper development may perform poorly in school. This child is also likely to display emotional and behavioral problems as a result of their abandonment. 

Later difficulties in life like liver and heart disease may also be traceable to poor treatment received in childhood.

In suspected cases of child abuse at the hands of a parent or caregiver, this treatment should be reported to child protection services or other relevant law enforcement agencies. 

Children that have been physically abused should then be stabilized, with examinations carried out to determine the extent of the ill-treatment endured. 

Physical, emotional, and sexual abuse victims, as well as children that have lived through neglect, need appropriate care. These children may be protected using treatments like psychotherapy , medication, or a combination of both.

Therapy is useful for addressing the issues linked with abuse and neglect. It is also necessary to teach a child appropriate behaviors for adult-child relationships. Therapy can also provide a support system for poorly treated children.

Medication may be recommended for the PTSD, anxiety, depression, and other pains associated with abusive treatment.

Maltreatment is a painful thing to experience during development. The different forms of child abuse have far-reaching effects on welfare, but may be managed using the right methods.

A Word From Verywell

Child abuse is an alarmingly common form of abuse. With many different forms, children are exposed to multiple ripple effects from the maltreatment they've been subjected to. While recovery from a life punctuated by physical assault, sexual violence, or neglect can be difficult, healing is possible. Putting a child affected by abuse in therapy, or placing them on medication to manage adverse outcomes are effective ways to manage child abuse. To protect a child against abuse, it's important to report suspected cases of ill-treatment to the correct authorities.

Gonzalez D, Bethencourt Mirabal A, McCall JD. Child Abuse and Neglect .In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 

Stanford Medicine. Child abuse .

Mahoney J. Types of abuse . Nurs Clin North Am . 2011;46(4):385-v. doi:10.1016/j.cnur.2011.08.005

Brown CL, Yilanli M, Rabbitt AL. Child Physical Abuse And Neglect . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 

Shin SH, Lee S, Jeon SM, Wills TA. Childhood emotional abuse, negative emotion-driven impulsivity, and alcohol use in young adulthood . Child Abuse Negl . 2015;50:94-103. doi:10.1016/j.chiabu.2015.02.010

Murray LK, Nguyen A, Cohen JA. Child sexual abuse . Child Adolesc Psychiatr Clin N Am . 2014;23(2):321-337. doi:10.1016/j.chc.2014.01.003

Melmer MN, Gutovitz S. Child Sexual Abuse And Neglect . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. 

Dubowitz H. Neglect in children . Pediatr Ann . 2013;42(4):73-77. doi:10.3928/00904481-20130326-11

Childwelfare.gov. Anthony U., Cynthia W. Treatment for Abused and Neglected Children: Infancy to Age 18 .

Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons with Child Abuse and Neglect Issues . Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2000. (Treatment Improvement Protocol (TIP) Series, No. 36.) Chapter 3—Comprehensive Treatment for Adult Survivors of Child Abuse and Neglect. 

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Child Abuse and Neglect Essay

Introduction, events to strengthen the family.

Children are vulnerable individuals whose welfare is dependent on their parents or guardians. This exposes the children to the risk of suffering abuse and neglect from their caretakers. Hunt (2014) declares that the maltreatment of children occurs across all socio-economic, cultural and ethnic groups with negative consequences on the development of the child. Child abuse and neglect have deleterious effects on the future life of the child.

It is therefore necessary to take steps to tackle these issues and ensure the healthy emotional and physical development of the child. This paper will describe four events that can be implemented to strengthen the family and therefore reduce or eliminate incidents of child abuse and neglect.

Playgroup events can play a major role in strengthening the family on issues of child abuse and neglect is playgroups. Parents who come from the same neighborhood or those whose children attend the same school or daycare facility can form playgroups. The events provide a chance for families with similar interests and children of the same ages to connect with each other and share their experiences. Selph and Bougatsos (2013) reveal that the events are hugely beneficial to both the parents and their children.

The children are able to develop through play and interaction with their peers. The social skills and learning of the children is enhanced as they engage in play activities. Research indicates that play groups contribute to shaping family life and equipping parents with the tools necessary to engage in the challenging task of raising children (Hunt, 2014). Playgroup events provide an informal forum for parents to discuss their parenting issues and concern.

Nilsen (2010) confirms that parents are not only able to obtain important advice from their peers, but they also get to realize that other people are going through the same hurdles as they are. This is empowering especially to new parents who might feel overwhelmed by the difficulties of parenting.

These events also promote a feeling of community and each parent begins to take an interest in the wellbeing of the children of his/her friend. This makes it possible to identify incidents of abuse among children in the playgroup and take appropriate action in response.

A church/synagogue/mosque retreat activity for parents and they children can be beneficial in strengthening parents to deal with the issues of child abuse and neglect. Religion plays an important role in the lives of many individuals and they rely on their faith to inform their actions in many situations. The religious institute can therefore play a major role in promoting child safety in the community (Nilsen, 2010).

A retreat event can be planned for the parents in the congregation on a weekend. This retreat will be sponsored by the religious body, which will make it affordable to all the parents. An important advantage of faith-based events is that they possess significant resources since the congregation is made up of a variety of professionals including teachers, nurses, pediatricians, and social works. These professionals will be able to provide free advice on how to safeguard children during the retreat (Hunt, 2014).

Another benefit of the faith-based event is that it relies on the shared religious beliefs of the participants. The religious beliefs of the parents can therefore be used to exhort them to engage in good parenting practices. The religious-based family retreat will provide numerous opportunities for the families to socialize with each other.

There will be coffee breaks during which the parents and children will interact with each other and exchange contacts. Veteran parents will share their experiences and provide advice to the younger parents. The faith-based event will therefore serve as a good opportunity for the parents to establish social support systems.

Technological events can play a part in mitigating child abuse and neglect in the society. Specifically, parents can make use of online forums to learn about appropriate parenting practices and acquire skills for protecting their children against abuse. The online forum should be designed to attract parents who wish to improve the safety and wellbeing of their children. This technological tool can include a facilitator who will initiate discussion topics and moderate the discussions taking place on the website.

Online forums enable parents to express their concerns and issues in a safe environment. Through online forums, parents can be linked to numerous resources for strengthening families. Nilsen (2010) documents that there is a correlation between exposure to educational resources and a decrease in incidents of child abuse and neglect. Parents are also able to gain tangible benefits from the online events. Through the event, parents are made aware of the community resources available to them as they raise their child.

Nilsen (2010) asserts that information on available community resources is of great importance especially to parents who are at-risk of neglecting their children due to limited economic resources. A benefit of online events is that they are accessible to many parents at their convenience.

Parents do not need to adjust their schedules in order to participate in these events. This is an important factor since most parents might be overwhelmed by obligations that make it impossible for them to engage in events that require them to be physically present at venues outside their home or work setting.

Parents can enroll on home visitation programs to assist in the prevention of child abuse and neglect. The home visitation event should be voluntary and semi-formal in nature. An important feature of these events is that Nurses or Educators, who possess expert knowledge on childhood development, carry them out. These experts are able to convey to the parents professional information on subjects such as positive parenting practices.

Selph and Bougatsos (2013) reveal that such events can be of great service to pregnant women as well as families with young children. Through the home visitation, the parents are provided with information about their child’s development. The professionals can also help parents to gain a better understanding about age-appropriate behavior for their children. The home visitation events should be developed with cultural factors in mind.

Different cultures have varying values and customs that influence how the parents deal with their children. Nilsen (2010) asserts that the professionals engaging in the visitation must demonstrate sensitivity to cultures whose values and customs are different from their own. The strengths of the specific culture should be exploited to increase the safety of the child. In cultures were extended family bounds are strong, the visitation events can be scheduled to include some of the members of the extended family.

These members can be equipped to provide assistance to at-risk children and parents within their family. Parents who enroll in home visitation events are well equipped to engage in positive parenting and as a result, they engage in fewer acts of physical aggression towards their children (Promising Practices Network, 2010).

Child abuse and neglect have a lasting negative impact on the lives of children. This paper set out to discuss events that can be used to strengthen families and therefore mitigate or prevent these damaging issues from happening.

The paper has described playgroup events, faith-based activities, technological events, and home visitation programs that can be used to strengthen families. By implementing these events, the family will be equipped to prevent child abuse and neglect therefore ensuring the healthy psychological and physical wellbeing of the child.

Hunt, K. (2014). Safeguarding children – the need for vigilance. Practice Nurse, 44 (6), 18-22.

Nilsen, B. A. (2010). Week by Week: Plans for Documenting Children’s Development. NY: Cengage Learning.

Promising Practices Network. (2010). Promising Practices for Preventing Child Abuse and Neglect . NY: RAND Corporation.

Selph, S. & Bougatsos, C. (2013). Behavioral Interventions and Counseling to Prevent Child Abuse and Neglect: A Systematic Review to Update the U.S. Preventive Services Task Force Recommendation. Annals of Internal Medicine, 158 (3), 179-190.

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Guest Essay

What Happens When Abusive Parents Keep Their Children

By Naomi Schaefer Riley

Ms. Riley is a senior fellow at the American Enterprise Institute and the author of “No Way to Treat a Child.”

In February 2023, Phoenix Castro was born in San Jose, Calif., suffering from neonatal opioid withdrawal after being exposed to fentanyl and methamphetamine in her mother’s womb.

Her mother was sent to jail and then ended up at a drug treatment facility. But her father, who had multiple drug arrests, was allowed to take the newborn to his San Jose apartment, even though a social worker had warned that the baby would be at “very high” risk if she was sent home. The county’s child protection agency had already removed the couple’s two older children because of neglect.

Three months later, Phoenix was dead from an overdose of fentanyl and methamphetamine.

The ensuing uproar, chronicled in detail by The Mercury News, focused on new efforts by the county to keep at-risk families together. In the past, children often would be removed from unsafe homes and placed in foster care, and newborns like Phoenix in all likelihood would not have been sent home.

Those policy changes led to a “ significant ” drop in removals of children from troubled homes in the San Jose area, according to the state’s social services agency. They reflected a larger shift in child welfare thinking nationwide that has upended the foster care system. Reducing the number of children placed in foster care has been hailed as an achievement. But leaving children in families with histories of abuse and neglect to avoid the trauma of removing them has had tragic results.

We need to ask whether avoiding foster care, seemingly at all costs — especially for children in families mired in violence, addiction or mental illness — is too often compromising their safety and welfare.

The use of foster care has been in decline even as more children are dying from abuse and neglect in their homes. In recent years, the number of children in foster care fell by nearly 16 percent while the fatality rate from abuse and neglect rose by almost 18 percent. Many factors were and are at work, among them caseworker inexperience, a lack of resources and the high bars for removing children from their homes that have been erected by child welfare agencies, policymakers and judges.

What is clear from a sampling of states that release fatality reports in a timely fashion is that we are seeing deaths of children in cases in which they had been allowed to remain in homes with records of violence, drug use and neglect.

In Minnesota, a children’s advocacy group’s study of 88 child fatalities in the state from 2014 to 2022 found that “many of these deaths were preventable” and were the result of a “child welfare philosophy which gave such high priority to the interests of parents and other adults in households, as well as to the goals of family preservation and reunification, that child safety and well-being were regularly compromised.”

The prioritization of family preservation has been advanced by states and the federal government and by the nation’s largest foundation focused on reducing the need for foster care, Casey Family Programs.

Three ideas seem to have guided the effort: the child welfare system is plagued by systemic racial bias, adults should not be punished for drug addiction, and a majority of children in the system are simply in need of financial support and social services.

This effort was bolstered in 2018 with the passage by Congress of the Family First Prevention Services Act , which enables states to use federal funds “to provide enhanced support to children and families and prevent foster care placements through the provision of mental health and substance abuse prevention and treatment services” and other programs.

The push certainly has been well-intentioned. There was a sense that child welfare authorities had overreacted to concerns about a crack baby epidemic in the 1980s. Mothers were arrested and babies and children taken away. The number of children in foster care more than doubled between 1985 and 2000. There was also deep concern — concern that persists — that Black children in particular were bearing the brunt of being removed from their homes and sent to foster care, which can cause its own upheaval for children.

In some states, the reductions in the number of children in foster care were drastic. But there are limits to how much those numbers can be reduced without putting children in grave danger.

In Santa Clara County, Calif., where Phoenix Castro died, an inquiry the previous year by the California Department of Social Services into the county’s child protection agency found “multiple” instances of “children placed into protective custody by law enforcement,” only to have the county agency “immediately” place “the children back in the care of the unsafe parent.” (In what appears to be an about-face by the county, The Mercury News reported that in the last two months of 2023, the number of children removed from their homes was triple the two-month average for the previous months of that year.)

In an email to Santa Clara County’s Department of Family and Children’s Services staff in 2021, explaining the new emphasis on keeping families together, the director at the time described the move as part of the county’s strong commitment “to racial justice and to healing the historical wounds underlying disproportionate representation of children of color in the child welfare system.”

As much as racial disparities in foster care are deeply troubling — Black children are twice as likely as white children to spend time in foster care — Black children also suffer fatalities from abuse and neglect at three times the rate of white children. Which means that policies intended to reduce disproportionality by reducing foster care may actually be resulting in more deaths of Black children.

Foster care is not a panacea. The trauma children suffer from suddenly being removed from their home and their siblings, to be placed in a strange home with a caregiver they don’t know, is well documented. But the alternative, allowing a child to remain in a dangerous home, should never be an alternative.

Naomi Schaefer Riley is a senior fellow at the American Enterprise Institute and the author of “No Way to Treat a Child.”

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

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A Research Paper on Child Abuse and Its Effects on Children

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Published: Mar 18, 2021

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Know the warning signs of child abuse

D ERIDDER, La. (KPLC) - A Sulphur father and his girlfriend remain jailed on murder charges after his son was found unresponsive and died two days later.

KPLC’s investigative team filed several public records requests. Records show once the 4-year-old was brought to the hospital, doctors believed the bleeding on his brain and the bruising on his body showed a history of abuse as well as current abuse.

However, any previous abuse had not been reported to the State Department of Child and Family Services.

In instances of abuse, children could be suffering in silence, that’s why it’s important to know the warning signs.

“What people can look out for is a change in behavior. They can look for bruises, the child’s attendance record at school, eating patterns, sleeping patterns all those things can be indicators,” CASA West CENLA Executive Director Tommy Edwards said.

CASA West CENLA is an organization that advocates for a child’s best interest in situations of abuse and makes recommendations in court.

Edwards said reporting abuse is a must and could save a life.

“I think it’s really important that we find the strength, if it definitely looks like it, we need to find the strength to report it,” he said.

According to DCFS, there were nearly 52,0000 reports of child abuse in the state last year.

“We see a lot of neglect. We have a lot of children that are younger, that are under the age of 10, so a lot it is neglect,” Edwards said.

Edwards said it’s vital that we continue our efforts to help put a stop to child abuse.

“It is important that we all do we that can, that our children have the same opportunities we did as children, and it’s a whole community thing,” Edwards said.

If you suspect that a child is being abused, you can contact DCFS at 855-452-5437.