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Description of the MUSP Cohort

Inclusion criteria for original research publications, quality of supporting literature, predictors: maltreatment types, ethical approval, prevalence and co-occurrence of maltreatment subtypes, cognition and education outcomes, psychological and mental health outcomes, addiction and substance use outcomes, sexual health outcomes, physical health, magnitude of effects, abuse, neglect, and cognitive development, psychological maltreatment: emotional abuse and/or neglect, sexual abuse, physical abuse, limitations, conclusions, long-term cognitive, psychological, and health outcomes associated with child abuse and neglect.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Lane Strathearn , Michele Giannotti , Ryan Mills , Steve Kisely , Jake Najman , Amanuel Abajobir; Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect. Pediatrics October 2020; 146 (4): e20200438. 10.1542/peds.2020-0438

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Video Abstract

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.

Child maltreatment is a major public health issue worldwide, with serious and often debilitating long-term consequences for psychosocial development as well as physical and mental health. 1   In the United States alone, 3.5 million children are reported for suspected maltreatment each year, with an annual substantiated maltreatment rate of 9.1 per 1000 children. 2   Some of the long-term adverse outcomes associated with maltreatment include cognitive disability, anxiety and depression, psychosis, teen-aged pregnancy, addiction disorders, obesity, and cardiovascular disease. 3   Understanding the distinctive impact of differing types of maltreatment may help medical professionals provide more wholistic care and treatment recommendations as well as identify more specific public health targets for primary prevention.

Unfortunately, however, little is known about the long-term effects of differing types of child maltreatment, which include sexual abuse, physical abuse, emotional abuse, and neglect. 4   According to a meta-analysis review, 5   research on child maltreatment has predominantly been focused on sexual abuse, with far less attention paid to psychological maltreatment (emotional abuse and/or neglect) and the co-occurrence of different types of maltreatment. In addition, most of the current evidence is derived from cross-sectional studies, which may be subject to recall bias, 6 – 8   in which an outcome status (such as depression) may influence recall of the exposure (ie, previous maltreatment). Few previous studies have adequately controlled for confounding variables, such as perinatal risk, socioeconomic adversity, parental psychopathology, and impaired early childhood development, which may predispose to both child maltreatment and later adverse health outcomes.

Longitudinal studies offer evidence that is more robust, but these studies are relatively few in number and have generally been limited to certain sociodemographic groups 9   or to specific types of child maltreatment, such as sexual abuse. 1 , 10   Other longitudinal studies have relied on retrospective recall of maltreatment rather than prospectively collected agency-reported data. 11 – 13   In studies in which prospective data have been collected, 7 , 13 – 17   only a few have compared different types of child maltreatment. 7 , 16 , 17  

In this special article, we review findings from the Mater-University of Queensland Study of Pregnancy (MUSP), a now 40-year longitudinal prenatal cohort study from Brisbane, Australia, involving >7000 women and their children. 18   Unique features of the MUSP include its use of a population-based sample, its use of prospectively substantiated child maltreatment reports, and its consideration of different subtypes of maltreatment. In addition, the study design controlled for a wide range of confounders and covariates, including both maternal and child sociodemographic and mental health variables. This combined body of work, which includes numerous publications over the past decade, has documented a broad range of adverse outcomes associated with child maltreatment, including deficits in cognitive and educational outcomes 19 – 21   ; mental health problems, such as anxiety, depression, posttraumatic stress disorder (PTSD), psychosis, delinquency, and intimate partner violence (IPV) 22 – 25   ; substance abuse and addiction 26 – 30   ; sexual health problems 31   ; physical growth and health deficits 32 – 35   ; and overall decreased quality of life. 36  

Our purpose for this special article is to compare the effects of 4 differing types of maltreatment on long-term cognitive, psychological, addiction, and health outcomes assessed in the offspring at ∼14 and/or 21 years of age. Rather than providing a systematic review or meta-analysis of the current literature, which would include diverse study designs and purposes, we report and compare the findings of individual articles that used a common data set and standard methodology to study a broad array of outcomes. We particularly highlight the long-term impact of emotional abuse and neglect, which has received far less attention in the literature.

Between 1981 and 1983, 8556 consecutive pregnant women who attended their first prenatal clinic visit at the Mater Mothers’ Hospital in Brisbane, Australia, agreed to participate ( Fig 1 ). After excluding mothers who did not deliver a singleton infant at the Mater Mothers’ Hospital or withdrew consent, the MUSP birth cohort consisted of 7223 mother-infant dyads, who were followed over 2 decades: at 3 to 5 days, 6 months, 5 years, 14 years and 21 years. Midway through the study, this rich data set was anonymously linked to state reports of child abuse and neglect, which identified some form of suspected maltreatment in >10% of cases. 37   Notified cases, which had been referred from the community or by general medical practitioners, were investigated by the Queensland government child protection agency. Substantiated maltreatment was determined after a formal investigation when there was “reasonable cause to believe that the child had been, was being, or was likely to be abused or neglected.” 38   Substantiated maltreatment occurred when a notified case was confirmed for (1) sexual abuse, “exposing a child to or involving a child in inappropriate sexual activities”; (2) physical abuse, “any non-accidental physical injury inflicted by a person who had care of the child”; (3) emotional abuse, “any act resulting in a child suffering any kind of emotional deprivation or trauma”; or (4) neglect, “failure to provide conditions that were essential for the healthy physical and emotional development of a child,” which encompassed physical, emotional and medical neglect. 37  

Overview of the MUSP enrollment and testing.

We searched PubMed from inception to April 2020 for published MUSP articles in which agency-reported child maltreatment was evaluated as the predictor of a range of outcomes. Studies needed to meet the following criteria for inclusion in the review: (1) notified or substantiated abuse and neglect was listed as a main predictor variable and (2) outcomes included standardized measurements of cognitive, psychological, behavioral, or health functioning. From ∼340 published MUSP studies, we identified 24 articles dealing with child maltreatment, of which 21 included state-reported maltreatment versus self-reported maltreatment data ( n = 3). Nineteen of the 21 articles met all inclusion criteria and were evaluated in this review ( Fig 2 ). One study was excluded because it only examined outcomes associated with sexual abuse. 8   Another article was excluded because its outcome measures were similar to another included study. 29  

Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios ± 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N , number of offspring in sample; N (Mal) , number of offspring who experienced maltreatment. a In different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1 ); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. b Adjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. c Cases of notified (rather than substantiated) maltreatment. In the study by Mills et al, 26   a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. d Medium effect size, based on magnitude of the adjusted odds ratio (2 ≤ odds ratio ≤ 4). e Large effect size, based on magnitude of the adjusted odds ratio (odds ratio > 4).

Each of the reviewed articles followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the conduct of cohort studies. 41   The quality of the studies was also evaluated by using a modified version of the Newcastle-Ottawa Scale, which is used to assess the following domains: sample representativeness and size, comparability between respondents and nonrespondents, ascertainment of outcomes, and statistical quality. 42   On the basis of this assessment, all of the MUSP studies were determined to be of low risk of bias, with a score of 4 out of 5 points ( Supplemental Information ).

In all but 2 studies (which used notified maltreatment 21 , 26   ) events were dichotomized and coded as substantiated maltreatment versus no substantiated maltreatment. According to a validated classification of maltreatment types, 43   specific categories and co-occurring forms of childhood maltreatment 44   were used to predict outcomes. In 2 studies, 19 , 20   all types of abuse were combined into 1 category and compared to neglect, whereas in another study, sexual abuse was compared to any combination of nonsexual maltreatment. 21   In 2 other studies, 26 , 40   emotional abuse and neglect (examples of psychological maltreatment) were combined, partly because of overlapping definitional constructs from the government child protection agency (emotional abuse included “emotional deprivation,” and neglect included the failure to provide for “healthy…emotional development”). In all but 2 of the included articles, 25 , 33   co-occurrence of different types of maltreatment was considered, either by examining specific combinations of maltreatment types (in exclusive or nonexclusive overlapping categories) or by statistically adjusting for all remaining types of maltreatment ( Fig 2 ).

All of the odds ratios, mean differences, or coefficients were adjusted for potential confounding variables ( Fig 3 ). All articles adjusted for a variety of sociodemographic variables, such as age, race, education, income, and marital status. Perinatal and/or childhood factors, such as birth weight, gestational age, and breastfeeding status, were used as covariates, particularly in articles in which cognitive and educational outcomes were examined. Psychological and mental health variables (such as internalizing and externalizing behavior problems, maternal depression, chronic stress, or exposure to violence) were primarily included as covariates in mental health outcome studies, especially for psychosis. Addiction studies adjusted for youth and maternal alcohol or tobacco use, among other covariates, and physical health outcome studies adjusted for relevant covariates (such as BMI in a study of dietary fat intake and parental height when studying offspring height). In selected articles, maltreatment subtypes were also statistically adjusted for the other types of maltreatment to determine independent effects.

Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21-year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES-D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence. Covariates used in published articles from the MUSP to adjust for possible confounding.

A total of 46 outcomes were assessed at 14 years ( n = 5200) and/or 21 years ( n = 3778) ( Fig 1 ) and were grouped into 5 domains ( Fig 2 ):

Cognition and education outcomes included reading ability and perceptual reasoning measured in adolescence, and, at age 21, receptive verbal intelligence and failure to complete high school or be either enrolled in school or employed; attention problems were measured at both time points.

Psychological and mental health outcomes at 21 years included internalizing and externalizing behavior problems (which were also assessed at 14 years), lifetime anxiety disorder, depressive disorder and symptoms, PTSD, lifetime psychosis diagnosis, psychotic symptoms (such as delusional experience or visual and/or auditory hallucinations), delinquency, experience of IPV or harassment, and overall quality of life.

Addiction and substance use, measured at both time points, included alcohol and cigarette use at 14 and 21 years, and cannabis abuse and/or dependence (including early onset) and injecting-drug use at the 21-year follow-up.

Sexual health was investigated at age 21 in terms of early initiation of sexual experience, having multiple sexual partners, youth pregnancy, and miscarriage or termination.

Physical health outcomes measured at 21 years included symptoms of asthma, high dietary fat intake, poor sleep quality, and height deficits.

The 14-year assessments included a youth questionnaire ( n = 5172) and in-person cognitive testing ( n = 3796). The 21-year visit included an in-person assessment of mental health diagnoses in a subset of the cohort ( n = 2531) with the World Health Organization Composite International Diagnostic Interview (CIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria 45   ( Fig 1 ). All of the questionnaire and interview measures were validated, except for reported frequencies of specific events (ie, pregnancy, number of cigarettes, etc).

Associations were described by using either adjusted odds ratios or mean differences and coefficients, along with the corresponding 95% confidence intervals, and were plotted to visualize and compare the statistical significance of each association across specific outcome categories and types of maltreatment ( Figs 4 – 8 ).

Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio ± 95% confidence interval. B, Adjusted coefficients ± 95% confidence interval. * P < .05.

The MUSP was approved by the Human Ethics Review Committee of The University of Queensland and the Mater Misericordiae Children’s Hospital. Ethical approval was obtained separately from the Human Ethics Review Committee of The University of Queensland for linking substantiated child maltreatment data to the 21-year follow-up data.

In this cohort of 7214 children ( Fig 1 ), 7.1% ( n = 511 children) experienced at least 1 episode of substantiated maltreatment. Substantiated sexual abuse was reported in 2.0% ( n = 147), physical abuse in 4.0% ( n = 287), emotional abuse in 3.7% ( n = 267), and neglect in 3.7% of cases ( n = 269) ( Table 1 ). Almost 60% of the children with substantiated maltreatment had multiple substantiated episodes (293 children; range: 2–14 episodes per child; median: 3 episodes per child 37   ). Of the 3778 young adults included in the 21-year follow-up, 4.5% ( n = 171) had a history of substantiated maltreatment, 39   including sexual abuse ( n = 53), physical abuse ( n = 60), emotional abuse ( n = 71), and neglect ( n = 89).

More than half of the children who experienced substantiated maltreatment were reported for ≥2 co-occurring maltreatment types ( Table 1 ). Of the substantiated sexual abuse cases, 57.1% of the children experienced ≥1 additional maltreatment types (84 of 147); for physical abuse, this proportion was 79.1% (227 of 287); for emotional abuse, 83.5% (223 of 267); and for neglect, 73.6% (198 of 269). In particular, emotional abuse and neglect co-occurred, with or without other types of maltreatment, in ∼59% of cases. 46  

Nonexclusive and Exclusive Categorization of Child Maltreatment Subtypes (Single and in Combination) Within the MUSP Cohort

Abuse (a combined category) and neglect were both associated with significantly lower cognitive scores at both 14 and 21 years, as well as with negative long-term educational and employment outcomes in young adulthood. 19 , 20   This was after adjusting for factors such as the child’s race, sex, birth weight, breastfeeding exposure, and age; family income; and maternal education and alcohol and/or tobacco use ( Fig 3 ). Specifically, proxy measures of IQ, such as reading ability and perceptual reasoning, at age 14 years were adversely associated with both substantiated abuse and neglect. 19   Sexual abuse was associated with attention problems in adolescence, whereas nonsexual maltreatment was associated with attention problems at both time points. 21   Young adults who experienced substantiated child maltreatment had reduced scores on the Peabody Vocabulary Test at 21 years. In terms of educational outcomes in young adulthood, both abuse and neglect manifested a threefold to fourfold increase in odds of failing to complete high school and a twofold to threefold increase in the likelihood of being unemployed at age 21 years 20   ( Figs 2 and 4 ).

During adolescence, physical abuse, emotional abuse, and neglect were all significantly associated with both internalizing and externalizing behavior problems, although this was not the case for physical abuse notifications without co-occurring emotional abuse or neglect. 22   After adjustment for relevant sociodemographic variables, the associations with emotional abuse and neglect remained significant at 21 years. 39   No statistically significant association was found between sexual abuse and these behavior problems at either time point.

Psychological maltreatment in childhood was associated with all of the other 15 psychological and mental health outcomes in young adulthood, except for delinquency in women. This was true after adjustment for sociodemographic variables and psychological and mental health problems (such as attention-deficit/hyperactivity disorder, aggressive behavior problems, and maternal depression or adverse life events, in the case of psychosis and/or IPV exposure outcomes) ( Fig 3 ). Specifically, both emotional abuse and neglect were significantly associated at 21 years with all of the following outcomes: anxiety, depression, PTSD, psychosis (with some exceptions), delinquency in men, and experiencing IPV and harassment (except for neglect). 22 – 25 , 39   Emotional abuse and neglect were the only maltreatment subtypes associated with a significant decrease in quality-of-life scores. 36  

The only mental health outcomes associated with sexual abuse were clinical depression, lifetime PTSD, and experiencing physical IPV. 8 , 25 , 39   Physical abuse was associated with externalizing behavior problems and delinquency (in men), internalizing behavior problems and depressive symptoms, experience of IPV, and PTSD 22 , 24 , 25 , 39   ( Figs 2 and 5 ).

Overall, emotional abuse and/or neglect were associated with all categories of substance use and addiction at both 14 and 21 years, whereas physical and sexual abuse were associated with surprisingly few substance abuse outcomes. Specifically, childhood emotional abuse and neglect were associated with adolescent substance use at age 14, including alcohol use and smoking. 26   This was after adjustment for sociodemographic factors and youth and maternal drug use. The association with cigarette and alcohol use persisted from adolescence to adulthood. The category of "any cigarette use" was the only addiction outcome associated with all 4 types of maltreatment. 40   At 21 years, emotional abuse and neglect were both associated with the early onset of cannabis abuse after adjustment for maternal stress and cigarette use. Additionally, physical abuse, emotional abuse, and neglect all revealed increased odds of cannabis dependence at age 21, with early onset associated with physical abuse and neglect. 28   In contrast, only emotional abuse significantly predicted injecting-drug use in young adult men, after adjustment for maternal alcohol use and depression, whereas all types of substantiated childhood maltreatment were associated with injecting-drug use in women. 27   Sexual abuse was not associated with any addiction or substance use outcome except for cigarette use at 21 years ( Figs 2 and 6 ).

All forms of maltreatment were significantly associated, at 21 years, with early onset of sexual activity and subsequent youth pregnancy. This was after adjustment for factors such as gestational age, youth psychopathology, and drug use. Neglect was the only type of maltreatment associated with having multiple sexual partners and was the maltreatment type most strongly associated with most other sexual health outcomes, especially youth pregnancy. Pregnancy miscarriage was modestly associated with emotional abuse, whereas termination of pregnancy was not associated with any maltreatment subtype 31   ( Figs 2 and 7 ).

Reduced adult height at 21 years, adjusted for parental height, was associated with all maltreatment subtypes except sexual abuse (which was not associated with any of the physical health outcomes). At 21 years, physical abuse was also associated with high dietary fat intake, a risk factor for obesity (adjusted for BMI), and poor sleep quality in men (adjusted for psychopathology and drug use). Asthma at 21 years revealed a modest association with emotional abuse. The combined category of any maltreatment was also associated with high dietary fat intake ( Figs 2 and 8 ).

To estimate the magnitude of potential effects of child maltreatment on long-term outcomes, other studies have used a number of statistical techniques. In one Australian study that used the MUSP and other data sets, the population attributable risk of child maltreatment causing anxiety disorders in men and women, was estimated to be 21% and 31%, respectively, and 16% and 23% for depressive disorders. 46   Similarly, in the MUSP study on cognitive and educational outcomes of maltreated youth, the population attributable risk of child maltreatment leading to “failure to complete high school” was 13%, and 14% for “failure to be in either education or employment at 21 years.” 20  

Based on one published metric of effect size using the magnitude of the adjusted odds ratio, 47   77% of the statistically significant associations in this review were considered to have a medium to large effect size (odds ratio ≥2), including 10% with a large effect size (odds ratio >4) ( Fig 2 ).

In summary, over the past decade, the MUSP has revealed that child maltreatment is associated with a broad array of adverse outcomes during adolescence and young adulthood, including the following:

deficits in cognitive development, attention, educational attainment, and employment;

serious mental health problems, including anxiety, depression, PTSD, and psychosis, as well as delinquency and the experience of IPV;

substance use and addiction problems;

sexual health problems; and

physical health limitations and risk.

These results were seen after adjustment for a broad range of relevant sociodemographic, perinatal, psychological, and other risk factors ( Fig 3 ). Many of the studies also adjusted for the other subtypes of child maltreatment and demonstrated that specific maltreatment types were closely associated with particular outcomes.

Significant cognitive delays and educational failure were seen for both abuse and neglect across adolescence and adulthood. In another study, the authors concluded that preexisting cognitive impairments at 3 or 5 years may explain this association, rather than maltreatment per se. 16   However, other research has revealed that children neglected over the first 4 years of life show a progressive decline in cognitive functioning, which is associated with a significantly reduced head circumference at 2 and 4 years of age. 48   In rodent models, contingent maternal behavior is linked with infant cognitive development, and possible mechanisms include increases in synaptic connections within the hippocampus 49   and reduced apoptotic cell loss. 50   Prolonged maternal separation, in contrast, is associated with impaired cognitive development in rodent and primate models. 51 , 52  

One of the most striking conclusions from this review was the broad association between emotional abuse and/or neglect and adverse outcomes in almost all areas of assessment ( Fig 2 ). In stark contrast, physical abuse and sexual abuse were associated with far fewer adverse outcomes. Overall, quality of life was lower for those who had experienced emotional abuse and neglect but not for those who had experienced physical or sexual abuse. Although emotional abuse and neglect often co-occur with other types of maltreatment, 46   the associated outcomes were generally robust even after statistical adjustment or separation into differing maltreatment categories ( Fig 2 ).

Emotional abuse and neglect in early childhood may lead to psychopathology via insecure attachment, 53 , 54   which has been associated with externalizing behavior problems 55   and impaired social competence. 56 , 57   Emotional neglect, in particular, may lead to deficits in emotion recognition and regulation, as well as insensitivity to reward, 3   potentially influencing social and emotional development. Neglected children are less able to discriminate facial expressions and emotions, 58   whereas youth who have been emotionally neglected show blunted development of the brain’s reward area, the ventral striatum. 59   Reduced reward activation may predict risk for depression, 59   addiction, 60   and other psychopathologies. 61  

Neglect was also associated with the early onset of sexual activity, multiple sexual partners, and youth pregnancy, even after adjustment for other maltreatment subtypes. This suggests that neglect may result in compensatory efforts to obtain sexual intimacy, consistent with other studies revealing higher rates of unprotected sex 62   and adolescent pregnancy in neglected children. 63   In the animal literature, female rodents that experience maternal deprivation tend to have an earlier onset of puberty and increased sexual receptivity, leading to elevated reproductive activity to help offset an environment of higher offspring risk. 64 , 65  

As observed elsewhere, 66   sexual abuse was associated with early sexual experimentation and youth pregnancy as well as symptoms of PTSD and depression. Risky sexual behaviors were independent of other types of maltreatment but were not specific for sexual abuse. An additional MUSP study comparing self-reported and agency-notified child sexual abuse revealed consistent associations with major depressive disorder, anxiety disorders, and PTSD. 8   The absence of associations with other adverse outcomes, however, may be, in part, due to the lower prevalence of substantiated sexual abuse, especially at the 21-year follow-up.

Outcomes associated with physical abuse differed from those associated with sexual abuse, with increased odds of externalizing behavior problems, and delinquency in men. Jaffee 3   suggests that physical abuse, in particular, may lead to a hypervigilance response to threat, including negative attentional bias, disproportionate to relatively mild threat cues. Studies have revealed that physically abused children show selective attention to anger cues, 67   have difficulty disengaging from them, 58 , 68   and are more likely to misinterpret facial cues as being angry or fearful. 69  

Although these studies demonstrated significant associations between maltreatment and a range of long-term outcomes, association does not equal causality. The causal mechanisms proposed above are tentative and may relate to multiple types of maltreatment.

Other limitations should also be considered. Firstly, selective attrition of socioeconomically disadvantaged and maltreated young people was evident in the MUSP cohort ( Supplemental Information ). However, based on multiple imputation calculations and inverse probability weighting of MUSP data, 18 , 70   differences in the rate of loss to follow-up, for both dependent and independent variables, made little difference to either the estimates or their precision, mirroring findings from other longitudinal studies. 71   In addition, the findings were mostly unchanged when using propensity analysis, which is used to assess the effects of nonrandom sampling variation by analyzing the probability of assignment to a particular category within an observational study given the observed covariates. 72   Specifically, the sample was weighted so that it better resembled sociodemographic characteristics at baseline to minimize bias from differential attrition in those with greater socioeconomic disadvantage.

Secondly, differences in the prevalence of specific maltreatment subtypes might have influenced the statistical power to detect true effects, particularly regarding sexual abuse ( Table 1 ).

Finally, the co-occurrence of different types of maltreatment may have impacted the ability to accurately predict the associations between specific types of maltreatment and outcomes. Other studies have revealed that emotional abuse and neglect, in particular, are more likely to co-occur with each other and with other types of maltreatment. 73   However, even in those articles that statistically adjusted for other co-occurring maltreatment subtypes, the associated outcomes linked with emotional abuse and/or neglect were generally robust. In articles that did not adjust for these co-occurrences, some of the strongest associations were still observed for emotional abuse and/or neglect.

Child maltreatment, particularly psychological maltreatment, is associated with a broad range of negative long-term health and developmental outcomes extending into adolescence and young adulthood. Although these data do not establish causality, neurodevelopmental pathways are likely influenced by stress and early social experience through epigenetic mechanisms, which may affect gene expression and regulation and, ultimately, behavior and development. 3 , 74  

Understanding the developmental roots of these adverse outcomes may motivate physicians to more systematically inquire about early-life trauma and refer patients to more appropriate treatment services. 75 , 76   Even more importantly, early intervention and prevention programs, such as prenatal and infancy nurse home visiting, 77   have demonstrated, in randomized clinical trials, diminished rates of child abuse and neglect. 78 , 79   Long-term benefits to the offspring include decreased childhood internalizing problems, 80   reduced antisocial behavior and substance abuse in adolescence, 81   and improved cognitive skills extending into young adulthood. 80 , 82   Supporting at-risk parents and young children should thus be an urgent priority.

Dr Strathearn conceptualized and designed the original study linking the Mater-University of Queensland Study of Pregnancy data set with substantiated reports of child maltreatment, drafted the special article, and reviewed and revised the manuscript; Dr Giannotti assisted in drafting the manuscript and prepared all tables and figures; Drs Mills, Kisely, and Abajobir conceptualized and wrote the original research articles summarized in this article; Dr Najman was the original principal investigator of the Mater-University of Queensland Study of Pregnancy; and all authors critically reviewed the manuscript for important intellectual content and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Partially supported by the US National Institute on Drug Abuse (R01DA026437). The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute or the National Institutes of Health. Funded by the National Institutes of Health (NIH).

Composite International Diagnostic Interview

intimate partner violence

Mater-University of Queensland Study of Pregnancy

posttraumatic stress disorder

Competing Interests

Supplementary data.

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Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported 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 long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

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

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, 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.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental 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. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

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, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. 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. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families 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. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. 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 mal-

treatment 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.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or 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 merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. 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.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

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.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

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

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

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.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

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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Child physical abuse: factors influencing the associations between self-reported exposure and self-reported health problems: a cross-sectional study

• Eva-Maria Annerbäck 1 , 2 ,
• Carl Göran Svedin 3 &
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Child and Adolescent Psychiatry and Mental Health volume  12 , Article number:  38 ( 2018 ) Cite this article

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Child physical abuse (CPA) is an extensive public health problem because of its associations with poor health outcomes. The aim of this study was to examine which of the background factors of CPA committed by a parent or other caregiver relates to self-reported poor health among girls and boys (13; 15 and 17 years old): perpetrator, last year exposure; severity and frequency; socioeconomic load and foreign background.

In a cross-sectional study in a Swedish county (n = 8024) a path analysis was performed to evaluate a model where all background variables were put as predictors of three health-status variables: mental; physical and general health problems. In a second step a log linear analysis was performed to examine how the distribution over the health-status categories was different for different combinations of background factors.

Children exposed to CPA reported poor health to a much higher extent than those who were not exposed. In the path analysis it was found that frequency and severity of abuse (boys only) and having experienced CPA during the last year, was significantly associated with poor health as well as socioeconomic load in the families. Foreign background was significantly negatively associated with all three health indicators especially for girls. Neither mother nor father as perpetrator remained significant in the path analysis, while the results from the log linear analyses showed that mother-abuse did in fact relate to poor general health and mental as well as physical health problems among boys and girls. Father-abuse was associated with poor mental health if severe abuse was reported. Poor mental health was also associated with mild father-abuse if exposure during the last year was reported.

Despite the limitations that cross-sectional studies imply, this study provides new knowledge about factors associated with poor health among physically abused children. It describes details of CPA that have significant associations to different aspects of poor health and thus what needs to be addressed by professionals within mental health providers and social services. Understanding how different factors may contribute to different health outcomes for exposed children is important in future research and needs further studies.

Definitions

Child physical abuse (cpa).

Physical violence against a child executed by a parent or a caregiver.

A person who had parental responsibility for the child at the time of the abuse.

A person younger than 18 years.

CPA is an extensive public health problem because of its high prevalence and its associations with adverse health outcomes [ 1 , 2 ]. There is a great amount of research showing that there are strong enduring effects of physical abuse and other adverse childhood experiences on mental and/or physical health in adulthood [ 3 , 4 , 5 , 6 , 7 ]. In a previous study it was found that CPA was associated with health problems among boys and girls and that the associations were stronger among the children who reported repeated CPA [ 8 ]. The impact of child abuse on health cannot be explained by any single cause since health depends on a complex web of different factors [ 9 ]. Kiser et al. [ 10 ] emphasize that research is needed about the mechanisms of the traumatic experiences. They mention, for example, type of trauma, age of exposure, duration, frequency, severity, and the relationship to the perpetrator as examples of such details identified in the literature that promote a nuanced picture of CPA [ 10 ].

Perpetrator patterns

Betrayal trauma or trauma perpetrated by someone with whom a victim is close has been shown to be associated with young adults’ physical and mental health difficulties to a greater extent than other forms of trauma [ 11 ]. This is in good agreement with Attachment theory , that provides a universal explanation of implications of CPA and points to the difference between being exposed to violence by parents and to violence committed by other adults. If the person who should represent the Secure Base for a child is the same person who hurts the child, this seriously harms the vital relationship between child and parent and over time the health of the child [ 12 , 13 , 14 , 15 ].

In general, few studies have examined the relationship between health problems among physically abused children and gender of the perpetrator. Already, in 1993, Allen and Epperson [ 16 ] pointed out the lack of research on gender differences among the perpetrators of child maltreatment and argued that a differentiated knowledge would result in improved understanding of, among other things, the consequences of child abuse [ 16 ]. They proposed that there might have been different reasons for this lack of research such as (1) “a males-only perspective”; (2) “the mother-blaming perspective” or (3) the choice of study group, which all imply limitations. They considered that studies of registered cases distort results because men, for example, are overrepresented as perpetrators in police statistics (Allen and Epperson [ 16 ], p. 545–50). In a study of youth victimization in the U.S. [ 17 ], it was found that males were overrepresented as perpetrators and boys as victims in physical abuse by caregivers and that “Many violence types were more severe when perpetrated by males versus females as indicated by higher injury rates and greater victim fear” (Hamby et al. [ 17 ], p. 915). In a Swedish study from 2008 there were almost as many women as men among the perpetrators of CPA, even though there was a greater percentage of males who had exposed the children to repeated violence [ 18 ]. In a recent Swedish study, no differences in health outcomes were found whether the mother or the father was the perpetrator of the abuse [ 19 ].

Time point for the abuse/last year exposure

Previous studies have found an increase of reports of physical abuse with age [ 20 , 21 ]. In a study conducted in 2008, it was found that 13 year olds reported 12.1% “lifetime experience” of CPA; 15 year olds 18.6% and 17 year olds 16% [ 18 ]. The increase with age is important to examine further since there could be different explanations of this. The question is, if there really is an increase of exposure to CPA among teenagers or if these figures depend on different reporting patterns in different age groups? In the current study a question about experience of CPA during the last year thus was added in order to be able to test how this might influence associations with health-factors.

Frequency and type/severity of abuse

In a previous study it was found that there was a dose–response effect between frequency of CPA and self-reported ill health [ 8 ]. In Sweden where all corporal punishment has been considered a crime for almost 40 years, the use of physical violence in child rearing has become more unusual.

The immediate consequences of CPA are physical pain, acute stress and potential physical injuries. The most common injuries from physical abuse are marks from beatings and kicks. Bruises in unusual places or bruises of different ages might indicate abuse. But CPA also includes more severe violence and injuries which can cause life-long consequences or even be life-threatening [ 22 , 23 ]. In a Swedish school survey in 2011 (15–16 year olds), one-third of the children who reported CPA (in total 13.8%), reported that they had been exposed at some point to more severe types such as harder beatings with the hand/fist, kicked, scalded, squeezed on the throat or that they had been beaten with an object [ 24 ]. In a study of cases of CPA reported to the police in Sweden, the share of severe cases including striking the child with an object or against a surface, choking the child or beating up the child was 41% [ 25 ]. There are reasons to believe that the more severe forms have greater impact, since they are likely to be more painful, more frightening and thereby also more psychologically traumatizing. To the best of our knowledge, there are no studies on how different types/different severity of CPA influences the relations with poor self-reported health.

Socioeconomic load and foreign origin

Social and economic factors are seen to have great impact on health among youths as well as among adults. Social and economic inequality predicts health problems such as high body-mass index, psychological and physical problems as well as social problems among adolescents and is therefore an important factor to consider when studying poor health among youths [ 26 , 27 ]. According to studies of child poverty in Sweden carried out by Save the Children, the groups subjected to the strongest effects are immigrant families and single-parent families [ 28 ]. Children with foreign origin, meaning that both parents are born abroad have been seen to have an increased risk of being exposed to CPA in Sweden [ 18 , 24 ]. Widom et al. [ 7 ] discussed whether consequences of abuse differ for children of different racial and ethnic backgrounds. They describe varying and partly opposing theories: (1) the racial inference theory which predicts that effects of abuse would be about the same independent of origin, (2) the double jeopardy theory implying stronger associations with poor health for children of minority status and exposure for abuse, and (3) the theory of resilience which states that the effects are less for children of other origins due to the fact that they have grown up with other stressors in life and other cultural factors that can buffer the effects of abuse [ 7 ].

In summary, the above presented literature review shows that there is limited knowledge on how different factors interact with each other and how these contribute to poor health among children exposed to CPA. The current study aims to examine four different categories of such factors that have been seen to have potential influence: perpetrators, severity, frequency and time point of the abuse.

This study aims to investigate potential factors by which CPA perpetrated by caregivers might be associated with self-reported poor health. We hypothesized that (1) parental physical abuse; (2) severity and frequency of CPA and (3) time point—exposure to CPA within the last year, negatively influence the health of children exposed to CPA. More specifically, the first aim was to examine which of the factors: relation to the perpetrator (mother, father, stepparent), last year exposure, type of abuse, frequency of abuse, socioeconomic load and foreign origin, relates to poor self-reported general health, physical health and/or mental health problems among girls and boys exposed to CPA. The second aim was to examine if, and if so in what way, background factors such as mother-abuse, father-abuse (both with stepparent-abuse as baseline), gender, last-year exposure, socio-economic load and foreign origin are associated with health-status (poor self-reported general health, physical health problems and mental health problems).

Data collection

All pupils in grade seven and nine in compulsory school and grade two in upper secondary school (13, 15 and 17 years old) in Södermanland County, Sweden, were invited to participate in a population-based study in 2011 (n = 9600). The Centre for Public Health conducted the study in collaboration with the Centre for Clinical Research at Södermanland county council. School employees managed questionnaire distribution and collection. The questionnaires were completed in classrooms during school hours. All answers were anonymous and were returned in sealed envelopes. The children were informed orally and in writing about the purpose of the study, and that they could discontinue or refuse to participate in the study. They were also told that the collected information would remain confidential. The schools informed parents of pupils in grade seven about the survey and that they could prevent their children from participating by informing the school about this. The parents of pupils in grade nine and grade two were not informed since children > 15 years of age in Sweden are considered to have the right to make their own decisions in such matters.

Study sample

Response rates were 86% in grade seven (13 years old), 84% in grade nine (15 years old) and 77% in grade two (17 years old). The drop-outs consisted mainly of children absent from school on the days the survey was given out. These children were probably absent because of illness or truancy. A second chance was given to the non-respondents. The final sample consisted of 8024 respondents. The internal data loss on individual questions used in this study was less than 2% apart from parental employment, which was 9%. The total numbers of individuals included in different analyses vary because of internal dropout for some of the questions. For further information on children included in different analysis see flow chart (Fig.  1 ).

Flow chart showing eligible children and study groups

The questionnaires

The main purpose of the survey was to collect data on young people’s health and the children were asked about health, lifestyle and life experiences. The same kind of survey had been conducted previously on three occasions. Material from the survey in 2008 has been used in previous studies on CPA [ 8 , 18 ]. This paper focuses on CPA and related questions from the 2011 survey [ 29 ], which was conducted in a new sample. In the 2011 questionnaire two new questions were added. The first new question was about the type/severity of CPA with answer options in a modified version of Conflict Tactic Scale (CTS), Parent–Child Version. CTS is an instrument for identifying child abuse and distinguishes physical abuse in two subscales; Corporal punishment (mild abuse) and Severe Physical Assault [ 30 ]. The second new question was whether abuse occurred during the last year or not. The questions had multiple answer options except for the question about time point for the abuse, which had two answer options (Table  1 ).

Variables of CPA are described in Table  1 .

Health indicators

Poor general health was designated when the child answered “bad” or “very bad” to the question “How is your health in general?”. Physical health problems were indicated if the child answered “Yes, almost every day” to at least one of the alternatives in the question “How often during the last 3 months have you had the following complaints: headache, migraine, stomach-ache (not menstrual pain), ringing in the ears/tinnitus, and pain in back/hips/shoulders?” Mental health problems were indicated if the child answered “Yes, almost every day” to at least one of the alternatives in the question “How often during the last 3 months have you had the following complaints: insomnia, anxiety and worry, depression?”

Background indicators

Socioeconomic load was measured by two questions. “What is your mother/father doing?” (with answer options: working, studying, unemployed, on sick leave, other) and “How do you live?” (with answer options of different types of accommodations: rented apartment, condominium, own townhouse or villa which defined the question). Socioeconomic load was designated if the child reported that one or both parents were unemployed/on sick leave and that the family lived in rented accommodation. (In Sweden, those who live in rented accommodation have lower average incomes than those who own their home [ 31 ].

Origin was dichotomized as (1) At least one parent born in Sweden ( Swedish origin ) (2) Both parents born abroad ( Foreign origin ).

Statistical analyses

Descriptive statistics were calculated using standard methods: frequencies and cross-tabulations.

The first aim, to investigate potential factors by which CPA perpetrated by caregivers might be associated with self-reported poor health, was examined by path analysis starting with a model where all background variables—frequency of abuse, severity of abuse, last-year exposure, socioeconomic load and foreign origin—were put as predictors of each health-status variable—poor general health, physical health problems, and mental health problems. Thereafter a stepwise procedure was conducted where the least significant path was removed, until only significant ( p  < 0.05) predictors remained. The final model represents the theoretical model, where background variables are assumed to cause health status, which best fits with the data. This was done separately for all participants, for girls, and for boys. To take account of the categorical character of data, the models were estimated using the mean and variance adjusted weighted least squares (WLSMV) estimator in the Mplus statistical modeling program. The model was evaluated using several different fit indices [ 32 ] provided by the Mplus output: Chi square statistics, Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), Tucker-Lewis Index [TLI, also known as the Non-normed fit index (NNFI)] and the Weighted Root Mean Square Residual (WRMR). The model was judged as having good fit when the overall picture of fit indices indicated good fit and excellent if all of them indicated good fit: RMSEA ≤ 0.05, CFI and TLI ≥ 0.95, and WRMR < 0.90 (see e.g. [ 33 ]).

The second aim, to examine if, and if so in what way, health-status (poor self-reported general health, physical health problems, mental health problems) are associated with abuse [mother-abuse and father-abuse (both with stepparent-abuse as baseline)] and in possible interactions with gender, last-year exposure, socioeconomic load and foreign origin, was examined by log linear analysis and Chi square tests of homogeneity. Combinations of variables included:

at least one of the health status variables—poor general health, physical health problems, mental health problems.

any of mother-abuse, father-abuse, gender, last-year exposure, socioeconomic load or foreign origin.

The procedure tests the highest-order interaction and if non-significant, it is excluded. Thereafter, the next highest-order interactions are tested, and so on. In case of a significant interaction a split of the data is made based on one of the variables and the interactions among the remaining variables are tested for in the split datasets. 2-way interactions were examined by Chi square statistics using Cramer’s V as a measure of effect size and using standardized residuals less than − 2 (indicating unexpectedly low frequencies) or larger than 2 (indicating unexpectedly high frequencies) to describe what cells (combination of variable values) explain the significance. Analyses required expected frequencies ≥ 1 for all cells and < 5 for at most 20% of the included cells. Therefore 5-way interactions were tested, followed by all lower-level interactions that were not already included in any higher-order interaction that fulfilled the required criteria.

The path analysis was performed using Mplus Version 7.4 [ 34 ] and the log linear analysis was performed using IBM Statistical Package for the Social Sciences (SPSS) version 22.0.

The results show that 962 (12.0%) of the 8024 children reported that they had been exposed to CPA committed by a parent or other caregiver and that 30% of these reported that they had been abused during the last year. Perpetrators were usually biological parents (92.6%) while stepparents accounted for 7.4% of perpetrators. Descriptives of CPA variables within the total group are presented in Table  2 . Eight percent of all exposed children (n = 962) had told an authority (school personnel, social services, police and similar) about the abuse. Mental health problems were reported by 11.3% of the not exposed (n = 7062) and of 31.6% of the CPA group (p < 0.001). Physical health problems were reported by 10.9% of the not exposed and 22.5% of the CPA group (p < 0.001). Poor general health was reported by 2.3% of the children not exposed to CPA compared with 10.5% among the exposed (p < 0.001). In the total study sample, the children of foreign origin reported CPA more often (19.0%) than children with Swedish origin (11.0%), Children of foreign origin reported mental health problems more often (16.6%) than those with Swedish origin (13.8%), Physical poor health was reported less often by children of foreign origin (11.0%) than of those with Swedish origin (13.8%) and poor general health to about the same extent in both groups.

In the path and loglinear analyses cases with missing values were excluded, resulting in a slightly smaller sample (n = 664). Drop-outs (n = 298) reported slightly more exposure (examined by cross-tabulations), meaning that, if anything, associations and relations from these analyses are slightly under-estimated.

Health status with different background variables

Stepwise deletion of non-significant variables—mother-abuse, father-abuse (stepparent as baseline), last-year exposure; and the other background variables—resulted in different models with good fit for all, for boys and for girls (Figs.  2 , 3 , 4 ). Notably, perpetrator (mother-abuse and/or father-abuse, with stepparent-abuse as baseline) did not remain significant in any of the models, while last year exposure showed a significant association with poor general health, mainly for boys.

Girls and boys; path analysis for the association between background variables and health problems. NB all coefficients are standardized and significant at p < 0.05. MentProb = mental health problems (0 = no, 1 = yes); PhysProb = physiological health problems (0 = no, 1 = yes); PGenH = poor general health (0 = no, 1 = yes); Frequency = frequency of abuse; LastYear = last year exposure (0 = no, 1 = yes); SocEc = socio-economic load (0 = no, 1 = yes); ForeignBG = foreign background (0 = no, 1 = yes)

Girls; path analysis for the association between background variables and health problems. NB all coefficients are standardized and significant at p < 0.05. MentProb = mental health problems (0 = no, 1 = yes); PhysProb = physiological health problems (0 = no, 1 = yes); Frequency = frequency of abuse; SocEc = socio-economic load (0 = no, 1 = yes); ForeignBG = foreign background (0 = no, 1 = yes)

Boys; path analysis for the association between background variables and health problems. NB all coefficients are standardized and significant at p < 0.05. MentProb = mental health problems (0 = no, 1 = yes); PhysProb = physiological health problems (0 = no, 1 = yes); PGenH = poor general health (0 = no, 1 = yes); Frequency = frequency of abuse (0 = not more than twice, 1 = more than twice); Type = type of abuse (0 = minor, 1 = severe); LastYear = last year exposure (0 = no, 1 = yes); SocEc = socio-economic load (0 = no, 1 = yes)

Mental health problems were related with higher frequency of abuse, for boys as well as for girls (Figs.  2 , 3 , 4 ).

Physical health problems were associated with higher frequency of abuse, with socioeconomic load and negatively with foreign origin (Fig.  2 ). These associations were also present when girls were examined separately (Fig.  3 ). For boys there was a significant association with severe type of abuse (Fig.  4 ).

Poor general health was associated with last year exposure, socioeconomic load and negatively with foreign origin (Fig.  2 ), although origin did not remain significant for boys (Fig.  4 ) and there was no significant relation with poor general health in the gender-specific analyses (Figs.  3 , 4 ).

The pairwise associations between the variables are presented in Table  3 .

Health status and associations with background variables

The higher-order interactions (3-way and higher) are presented and explored in Table  4 .

Mental health problems

Mental health problems were differently distributed over mother-abuse and last-year exposure for those with and for those without foreign origin p = 0.011. For those with no foreign origin the distribution of reported mental health problems depending on reported mother-abuse differed between those with and those without last-year experience, p = 0.041. Those (with no foreign origin) without last-year exposure had higher odds (OR = 1.63; 95% CI 1.01, 2.63) of mental health problems if reporting mother-abuse, p = 0.043. For those (with no foreign origin) with last-year experience there was lower odds (OR = 0.71; 95% CI 0.37, 1.35) of mental health problems if reporting mother-abuse (although not significant). For those with foreign origin, the distribution of reported mental health problems depending on reported mother-abuse also differed between those with and those without last-year experience, p = 0.043, but in the opposite direction compared to those with no foreign origin. Among those (with foreign origin) without last-year experience, there was lower odds (OR = 0.45; 95% CI 0.17, 1.18) of mental health problems if reporting mother-abuse, and although non-significant this was different from those (still with foreign origin) with last-year experience where there was higher odds (OR = 1.52; 95% CI 0.26, 8.77) of mental health problems if reporting mother-abuse (also non-significant).

Mental health problems were also related to father-abuse; mental health problems were differently distributed over father-abuse and last-year exposure for those with experience of mild and for those with experience of severe abuse, p = 0.042. For those experiencing mild abuse, the distribution of mental health problems depending on father-abuse differed between those reporting last-year experience and those who did not, p = 0.003. For those (experiencing mild abuse) without last-year experience there was a lower odds (OR = 0.63; 95% CI 0.40, 0.98) of mental health problems if reporting father-abuse, p = 0.040, while those (experiencing mild abuse) with no last-year experience showed a higher odds (OR = 2.27; 95% CI 1.09, 4.73) of mental health problems if reporting father-abuse, p = 0.027. For those experiencing severe abuse these distributions were not significant, p = 0.494, nor were there any differences in distributions of mental health problems depending on last-year-experience (for those who experienced severe abuse), p = 0.559.

Physical health problems

Physical health problems were differently distributed over type of abuse for boys and girls, p < 0.001. For boys there was a significant association between physical health problems and type of abuse (OR = 5.54; 95% CI 2.68, 11.45), i.e. more physical health problems with severe abuse, p < 0.001, while there was no such significant association for girls (OR = 1.16; 95% CI 0.67, 2.00).

The distribution of physical health problems was differently distributed over mother-abuse for those without, compared to those with, last-year experience, p < 0.001. In cases of no last-year experience mother-abuse showed a significant association with physical health problems (OR = 1.67; 95% CI 1.04, 2.67), p = 0.032, but in cases of no last-year experience, the association was in the opposite direction (OR = 0.44; 95% CI 0.24, 0.82), p = 0.009.

General health problems

Distribution of general health problems was differently distributed over those without and those with reporting mother-abuse for those with last-year exposure compared to those with no last-year exposure, p = 0.035. In cases with no last-year experience there was a significant association between general health problems and mother-abuse (OR = 2.25; 95% CI 1.05, 4.81), p = 0.033, indicating higher odds of general health problems if experiencing mother-abuse, but in cases of last-year exposure, there was no such significant association (OR = 0.72; 95% CI 0.34, 1.52).

Mental health and physical health problems

Distribution of mental health problems, physical health problems and mother-abuse were different for boys and girls, p = 0.024. For boys, the association between mental and physical health problems were not significantly different between boys not experiencing and boys experiencing mother-abuse, p = 0.177, but there were nevertheless a significant association between mental health problems and Physical health problems (OR = 4.51; 95% CI 2.22, 1.52) indicating higher odds of mental health problems for boys reporting physical health problems, p < 0.001. For girls, the associations were similar, but unlike boys the three-way interaction between mental health problems, physical health problems and mother-abuse was significant, p = 0.038. There was a positive association between mental and physical health problems for girls with no experience of mother-abuse (OR = 2.01; 95% CI 0.98, 4.12), although non-significant, but that association was significantly stronger for girls being abused by the mother (OR = 5.40; 95% CI 2.96, 8.96), p < 0.001.

The present study aimed to contribute to the field of research on CPA by examining how different characteristics of abuse were associated with poor health in a group of children who reported that they had been exposed to physical abuse by a caregiver. The study shows that children exposed to CPA reported poor health to a higher extent than those who were not exposed. Associations between characteristics of the abuse and other background factors and poor health were examined in two different types of analysis: one path analysis and in addition in log linear analysis.

The hypothesis, that violence perpetrated by mothers and fathers (with stepparent as base-line), is associated with the worst outcomes of CPA was not supported by the results in the path analysis where all the prerequisite variables were put together in a base-model. Since the hypothesis might still be valid in groups with different characteristics of background variables, this issue was examined further. The results from the log linear analyses showed that mother-abuse did in fact relate to mental as well as physical and general health problems. For those experiencing mild father-abuse there was a positive association with mental health problems if the abuse had occurred during the last year otherwise there was a negative association. Mother-abuse is associated with poor self-reported health more often than father-abuse and does not seem to be affected by last year experience in the same way. Why CPA performed by mothers has more effect on health problems might be explained by attachment theory since mothers are often the most important attachment figures [ 12 , 15 ]. This is partly supported by the study of Nilsson et al. [ 19 ] where children abused by their mothers reported their mothers’ parenting as more negative when mothers only or both parents were perpetrators of the abuse compared to only fathers as perpetrators. Further studies are required, to more clearly elucidate the question of the impact of CPA performed by primary attachment figures in comparison with violence from other caregivers. Previous research has given conflicting results on this point [ 10 , 11 ].

Further, in the path analysis it was found that frequency and severity (boys only) of abuse and having experienced CPA during the last year (especially boys) was significantly associated with poor health as well as socioeconomic load in the families. The fact that higher frequency of abuse and socioeconomic problems are strongly associated with self-reported ill health among boys and girls is consistent with other studies [ 8 , 27 ].

Another demographic factor, foreign origin had a partial opposite influence on self-reported health. The exposed children with foreign origin reported significantly fewer health problems than the exposed children of Swedish origin, although the association was not significant in the separate analysis for boys. One possible explanation of this difference might be cultural differences connected to CPA. In Sweden, where all violence against children has been banned for almost 40 years, exposure to violence from a caregiver has come to be viewed as a deviant experience. For the Swedish children this experience may be perceived as exclusion in society and lead to marginalization for the abused children and thus result in poorer health [ 35 , 36 ]. The same behavior might not have the same impact if the internal family values are more permissive towards corporal punishment and is normalized in families or groups of children of foreign origin where corporal punishment is more prevalent [ 18 , 24 ]. These results thus seem to support the hypothesis of resilience in more disadvantaged groups due to the probability that these children have grown up with other stressors in life and other cultural factors that can buffer the effects of abuse, as described in Widom et al. [ 7 ]. Another assumption is that CPA is not associated with other family problems to the same extent in families of foreign origin as in families with Swedish origin, where all violence against children is considered to be abnormal and prohibited. Perhaps families of foreign origin can offer their children support in a way that is protective against poor health despite the violence.

Finally, the study shows that a relatively high proportion of older children in their teens report being abused during the last year, especially boys and that this contributes to poor self-perceived health. The finding of high proportion of last year experience of CPA corresponds with Finkelhor et al. who found that last year experience of abuse was frequently reported by 14–17 years old adolescents [ 20 ]. In the current study all the three age groups (13, 15 and 17 years old) reported that they had been abused in the last year, although the prevalence of last year exposure was more common at the younger ages. These results correspond with Radford et al. who found that last year experiences rise from ages 11–12, peak between ages 13–16 and then decline [ 21 ].

Limitations/methodological considerations

The present study has several possible limitations. First, the cross-sectional design implies lack of temporal ordering of incidents, which limits the possibility of addressing the question of causality [ 37 ]. Second, the data are based on self-reports of experiences in the past. Gilbert et al. [ 1 ] discussed the complexity of the phenomenon of child abuse and of research design in the field. They proposed that it would be desirable that research on consequences of child abuse consisted of prospective cohort studies, but in the same article they also discussed the problems such designs imply since official cases of abuse do not represent the population of all abused children. The retrospective nature of data also implies potential recall bias since children cannot report occasions that happened during their first years. In addition to this, another limitation of the study might be that we do not have data on the actual age of exposure, except if it occurred in the last year. Age of exposure might affect the outcome in health [ 10 ]. Third, this study focuses solely on physical abuse which might be another limitation since there are not adjustments for concurrent other types of abuse. Child abuse, however, is a complex phenomenon and is characterized by multifactorial patterns and it is a challenge to find adequate methods in this research-area. There are also difficulties in determining causality between the abuse experience and health problems in longitudinal studies because there are several unknown factors that might affect the outcomes. In a Swedish study of CPA-cases reported to the police, a 5-year follow-up revealed that much had happened in the children’s lives after the reports that were not directly linked to the abuse [ 38 ]. In addition, there are several other changes that occur naturally in young people’s lives. Overall, these circumstances may affect the health of young people as well as experiences of abuse do and could be regarded as a mutual limitation in different types of study design [ 39 ]. Fourth, another type of bias, dependent measurement bias, implies that false associations can occur due to problems in measurement [ 40 , 41 ]. One source of such bias in connection to questionnaire based studies, is that the stable personality traits of the participants in a study means that they tend to consistently report the most “negative” alternatives while others score the most “positive” [ 41 ]. In this study however, it might be assumed that pupils would rather tend to overreport, alternatively underreport both exposure (abuse) and outcome (health) and that skewness in results would not arise. This also touches upon the problem of that outcome and predictor variables were assessed by the same individual, which tends to strengthen relationships [ 42 ]. It was on the other hand not in the framework for this large study where data was collected anonymously from the children themselves. Further the use of different informants bring new problems with informant variance (see e.g. Edelbrock [ 43 ]) concerning mental health problems [ 44 ] and child maltreatment [ 45 ]. Furthermore, the drop-out of children absent from school the day the questionnaire was given out may distort the results since this might be a group of more disadvantaged pupils. Their absence could depend on truancy or illness and lead to an underestimation of the true prevalence of physical abuse as well as poor health.

One strength of the present study implies the use of anonymous questionnaire in the school situation (away from home and without parental immediate influence) provides an opportunity to obtain information about the real extent of children’s exposure to and the implications of CPA. The confidentiality of the survey makes it possible for children to answer these sensitive issues. Only eight percent of the abused had told any authority about their exposure implying that this study-design captures a quite different spectrum of children than a clinical sample would do. The fact that the study was performed in a representative group of the general youth population, in other words a non-clinical group of children, is another strength of this study, not to mention the large sample and the overall high response rate which have made it possible to perform analyses of different subgroups. The addition of the question of last year exposure, is an improvement compared with many previous studies since it allows for more accurate reporting of prevalence avoiding recall bias to the same extent that occurs if one asks for life-time experiences [ 20 ]. However, it is still important to measure both lifetime and point prevalence (last year exposure) to examine the associations between abuse and poor health.

Finally, it is important to note that in this study analyses were performed in a group consisting only of exposed children and characteristics of CPA and other background factors are solely compared to each other. In studies also including non-exposed children, figures of correlations between abuse and poor health would probably been higher since previous studies show that exposed children report poor health more than not exposed children do [ 18 , 19 ].

This study adds to the literature, suggestions of how different characteristics and background factors are associated with poor health among children exposed to CPA. In the existing literature on child maltreatment there are many studies on how single characteristics of the abuse are associated with outcomes of poor health. To our best knowledge, no previous studies have compared these factors in order to examine which ones that have the greatest impact on health or how they interact with each other.

Despite the limitations that cross-sectional studies imply, this study provides new knowledge about factors associated with poor health among physically abused children. It describes details of CPA that have significant associations to different aspects of poor health and thus what needs to be addressed by professionals within mental health providers and social services. Understanding how different factors contribute to different health outcomes for exposed children is important in future research and needs further studies.

Abbreviations

• Child physical abuse

Conflict Tactic Scale

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Authors’ contributions

All three authors participated in the drafting and the revision of the manuscript, and in drawing conclusions from data. They all read and approved the final manuscript. EMA had primary responsibility for design development and ÖD contributed with methodological support and performed the statistical analyses. All authors read and approved the final manuscript.

Acknowledgements

The authors want to acknowledge all pupils who participated in the survey and who shared their experiences of their lives and thereby made this study possible.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Our permission from the Ethics Committee does not include permission to share the data.

Data on certain topics might however be available from the authors upon reasonable request and with permission of the respective institutions.

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The study was approved by the Regional Ethical Review Board of Linköping, Sweden.

(Dnr, M180-08 and 2012/45-32). All procedures were in accordance with the 1964 Helsinki declaration and its later amendments.

The study was made possible by support from Centre for Clinical Research in Sörmland County council, Uppsala University, Sweden. The Centre had no involvement in designing or in conducting of the study.

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Eva-Maria Annerbäck

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Barnafrid, Child and Adolescent Psychiatry, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden

Carl Göran Svedin

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Annerbäck, EM., Svedin, C.G. & Dahlström, Ö. Child physical abuse: factors influencing the associations between self-reported exposure and self-reported health problems: a cross-sectional study. Child Adolesc Psychiatry Ment Health 12 , 38 (2018). https://doi.org/10.1186/s13034-018-0244-1

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127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples

Child abuse is one of the crucial problems that has been overlooked for many centuries. At the same time, it is an extremely sensitive issue and should be recognized and reduced as much as possible.

In this article, you will find child abuse research topics and ideas to use in your essay.

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Child abuse is one of the most problematic topics in today’s society. Writing child abuse essays may be challenging because it requires analyzing sensitive issues.

The problem refers to physical, psychological, or sexual mistreatment of children. It is vital to discuss this acute issue in studies and essays on child abuse.

Before working on your essay, you should select a topic for discussion. Here are some child abuse essay topics that we can suggest:

• The problem of child abuse in the US (Canada, the UK)
• Child abuse: Types and definitions
• Child neglect crimes and their causes
• Current solutions to the problem of sexual abuse of children
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If you are looking for other possible titles for your paper, you can check out child abuse essays samples online. Remember to only use them as examples to guide your work, and do not copy the information you will find.

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For extra help, see our free samples and get some ideas for your paper!

• Ethical Dilemma of Child Abuse In the above example, a nurse has to apply rational judgment to analyze the extent and threats when making decisions in the best interest of the victim of child abuse.
• Child Abuse in the Victorian Era in Great Britain This was unacceptable in the eyes of the factory owners resulting in the implementation of the practice of children being sent into the mechanisms of machines while they were still operating since they were supposedly […]
• Problem of Child Abuse The most common form of child abuse in America and in most parts of the world is child abuse. The cost of child abuse is dire to both the children, healthcare organizations, parents, and the […]
• Physical Child Abuse Usually the child is unaware of the abuse due to the na ve state of mind or innocence. Physical abuse also lowers the social-economic status and thus high chances of neglect or abuse due to […]
• Child Abuse: Preventive Measures My artifact is an infographic that communicates the various forms of child abuse and how to report them to the necessary authorities.
• Daniel Valerio Child Abuse In the end, it was an electrician who identified the typical signs of abuse in Daniel that finally led police to investigate, thereby exposing the weakness and ineffectiveness of the Dual Track System; the child […]
• Hidden Epidemic of Child Abuse and Neglect Child abuse should be perceived as a form of deviant behavior to which researchers give different explanations: biological, psychological, socio-cultural.
• Effects of Child Abuse The nature of the effects of child abuse, their consequences in a society, and the most appropriate preventive methods should be considered.
• Child Abuse Issues and Its Effects The recognition of child abuse signs is a very important step as it is wrong to believe that child maltreatment takes place because of the presence of a single sing or poor understanding of child […]
• Child Abuse: A Case for Imposing Harsher Punishments to Child Abusers While harsh punishments appear to offer a solution to the problem, this measure may be detrimental to the welfare of the child in the case where the abuser is its guardian.
• Child Abuse in the UAE and Explaining Theories The interest of carrying out the study on child abuse is based on the fact that it is a critical issue in any society, especially due to the actual and possible consequences on the child […]
• Child Abuse and Capstone Project This is why the problem of child abuse remains to be crucial for analysis, as people have to understand its urgency and effects on human behavior.
• Child Abuse Versus Elder Abuse The second distinction is that older people frequently encounter issues that might lead to abuse or neglect, particularly in nursing homes, such as mental disability, loneliness, and physical limitation.
• The Relationship Between Child Abuse and Embitterment Disorder Some emotions, like the dread of tests in school or sibling rivalry and conflicts, are a regular part of growing up.
• Trafficking Causes Child Abuse and Neglect The dissociation of children from their families and the exposure to intense trauma they are subjected to during and after trafficking may cause the minors to have attachment problems.
• Child Abuse and Maltreatment Discussion Additionally, this may cause a child’s behavior to change, such as making a sad or melancholy face or becoming furious with parents or other adults. When it comes to emotional abuse, a child may feel […]
• Impact of Child Abuse on Adulthood: An Idea Worth Spreading A frequent argument of those who do not want to recognize the scale of the problem of abuse in the world is “Beating is a sign of love!”.
• Effects of Child Abuse on Adults Second, she was so irrationally averse to the idea of having children that I knew immediately that it would be a contentious point in her future relationships.
• Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
• Child Abuse: Screening Methods and Creating Financial Programs When the reporting is mandatory, it is easy to follow its guidelines which should be carefully elaborated not to be harsh on parents and at the same time offer protection to a child.
• Mandated Reporter Statute in Case of Child Abuse The mandated reporter statute recognizes such steps of reporting child abuse, abandonment, and neglect: The signs of abuse, abandonment, or neglect should be reported immediately to the Florida Department of Children and Families through the […]
• Discussion of Child Abuse: Case of COVID-19 In Cincinnati, 3-year-old Nylo Lattimore was missed in December 2020, and only after 143 days, the child’s body was discovered in the Ohio River.
• Child Abuse Allegations: Multidisciplinary Team Approach In children with allegations of child abuse, what is the effectiveness of the multidisciplinary team approach compared to the non-multidisciplinary team approach on prosecution rates, mental health referrals, and provision of medical examinations?
• Criminal Justice System: Child Abuse During the consideration of cases as part of a grand jury, citizens perform some functions of the preliminary investigation bodies.
• Promoting Child Abuse Prevention Services in Oahu, Hawaii, and the US The primary goal the Hui Hawaii organization is trying to achieve is to improve the well-being of American children by preventing abuse, neglect, and depression.
• Child Abuse in Singapore The second reason for child abuse in Singapore to continue being one of the most underreported illegal offenses is the country’s collectivist culture.
• Protocol for Pre-Testing the Child Abuse and Neglect Public Health Policy Based on the above, it is necessary to identify the conditions of child abuse like the quality of family relations and improper upbringing.
• Child Abuse: Term Definition However, there is a component that is not so clearly represented in other crimes: a third party, who has observed the abuse or the consequences of abuse has the legal obligation and reasonable cause of […]
• Discipline and Child Abuse: Motivation and Goals The first proof of the justice and reasonableness of discipline is that it is permitted by law to be considered to be the most authoritative source to consult.
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• Critical Statistical Data Regarding the Issues Related to Child Abuse Due to acts of abuse children suffer greatly and it will not be wrong to say that these experiences are definitely engraved into the child’s personality.
• Socio-Economic Standing and Propensity for Child Abuse Physicians were the first to notice and report evidence of child abuse and neglect in the 1960s. The UNICEF corroborates the relationship of poverty with child abuse, neglect, and maltreatment.
• Child Abuse and Culture: Juan’s Case Analysis The following is the list of reflective insights that I came to while getting myself familiarized with Juan’s case and analyzing this case’s discursive implications: When addressing the issue of children being suspected to have […]
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• Cause and Effect of Child Abuse Parental response to the children is also presented in a form of abuse of the rights of the children, as they feel neglected or disowned.
• Abuse in Childhood Common Among Alcohol Addicts Dwelling upon the impact of the violence and abuse during childhood, the connection with the further disabilities and disorders is obvious.
• Child Abuse and Neglect Children in Court The objective of this paper was to determine the level of knowledge and nature of attitudes among maltreated children who appeared in court during their detention case hearings.
• Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse exhibiting […]
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• Promoting Help for Victims of Child Abuse: Which Emotions Are Most Appropriate to Motivate Donation Behavior
• Describing Child Abuse, Its Different Forms, and Solutions to the Problem
• Child Abuse: The Four Major Types of Abuse, Statistics, Prevention, and Treatment
• Causes and Risk Factors Behind Child Abuse
• Child Abuse, Cause, and Effect on the Rest of Their Lives
• Child Abuse Has Severe Negative Psychological Effects on Children
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• Child Abuse Prevention and Control: Can Physical, Sexual or Psychological Abuse Be Controlled Within the Household?
• Child Abuse and the Effect on Development Into Adulthood
• Child Abuse: Victim Rights & the Role of Legal Representative
• Child Abuse and the Legal System – Developmental Forensic Psychology: Unveiling Four Common Misconceptions
• Parent Stress Factors and Child Abuse: A Tutoring Proposal
• Approaching Child Abuse From a Multi-Dimensional Perspective
• Child Abuse, Alcoholism, and Proactive Treatment
• Adverse Effects and Prevention of Child Abuse
• Suspected Child Abuse and the Teacher´S Role in Reporting It
• Child Abuse and Its Correlation to Poverty
• Sexual Child Abuse Exploring the Mind of the Perpetrator
• Relationship Between Domestic Violence and Child Abuse and How to Protect the Children From It
• Child Abuse Saddest and Most Tragic Problem Today
• Child Abuse and Academic Performance of Children
• Why Should People Care About Child Abuse?
• Why Should Child Abuse Be Addressed as a Social Problem?
• How Child Abuse and Neglect Affect Childhood?
• How Has Child Abuse Been Conceptualised and Addressed in Policy and Law?
• How to Protect Children From Abuse and Neglect?
• What Are the Negative Effects of Child Abuse?
• How Is the United States Dealing With Child Abuse Problem?
• How Can Therapy Help Victims of Child Abuse?
• How Can the Community Stop Child Abuse and Neglect?
• When Should Teachers Report Child Abuse?
• What Cause Child Abuse?
• Does Child Abuse and Neglect Lead To Bullying?
• How Do the Government and Society Have a Responsibility to Help Child Abuse Victims?
• Parent Support Groups Can Reduce Child Abuse?
• When Child Abuse Overlaps With Domestic Violence: The Factors Influencing Child Protection Workers’ Beliefs?
• How Can Spanking Lead to Child Abuse?
• How the Government and Society Have a Responsibility to Help Child Abuse Victims
• What Does Victimology Say About Child Abuse Data?
• Are There Any Biomarkers for Pedophilia and Sexual Child Abuse?
• When Does Discipline Cross the Line to Child Abuse?
• How Child Abuse Affects a Hero, a God, and a Monster in Greek Mythology?
• Does Child Abuse Create a Psychopath?
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• How Can Sexual Child Abuse Affect the Child’s Psychological Development?
• How Child Abuse Effects Students Education?
• How Do Abuse and Neglect Impact a Child’s Whole Life?
• Should Pregnant Drug Abusers Be Charged With Child Abuse?
• How Children Carry the Weight of Child Abuse?
• Does Child Abuse Cause Crime?
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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.

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2 Describing the Problem

Child abuse and neglect is well established as an important societal concern with significant ramifications for the affected children, their families, and society at large (see Chapter 4 ). A critical step in devising effective responses is reasonable agreement on the definition of the problem and its scope. Yet achieving clarity in the area of child abuse and neglect has been an ongoing challenge. Legal definitions vary across states; researchers apply diverse standards in determining incidence and prevalence rates in clinical and population-based studies; and substantial obstacles hamper learning about the experiences of children, especially young children, with caregiver-inflicted abuse or neglect. As a result, definitions of the characteristics of the problem and determinations of its scope will differ depending on the data source used for analysis. This challenge was articulated in the 1993 National Research Council (NRC) report ( NRC, 1993 ) and continues to impede a full understanding of the nature of the child abuse and neglect problem. The purpose of this chapter is to describe briefly what is known about the problem from current data sources and to highlight issues that remain problematic, as well as identify areas in which advances have been made. The chapter addresses, in turn, definitions of child abuse and neglect, incidence rates and the problem of underreporting, trends in the incidence of child abuse and neglect, and how cases are determined by medical and mental health professionals and the legal system. The final section presents conclusions.

• DEFINITIONS

A key definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA) 1 :

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

This definition is especially important because it is enshrined in federal legislation. To be eligible to receive funding under Section 106 2 of the act, states must, at a minimum, include the conduct described in Section 3 in their state child abuse and neglect authorizing legislation. All 50 states, as well as American Samoa, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, the District of Columbia, Guam, and the Virgin Islands, have mandatory child abuse and neglect reporting laws that define the terms slightly differently for their jurisdiction and lay out the requirements for mandatory reporting ( CWIG, 2011 ). Federal law defines child abuse and neglect and identifies reporting requirements on tribal lands 3 (see CWIG, 2012b , for further information) and on military installations 4 (see Military OneSource, n.d., for further information); in some circumstances, state laws on child abuse and neglect reporting also apply to tribal lands and military installations. The Victims of Child Abuse Act 5 (also see Chapter 8 ) lays out requirements for reporting child abuse that occurs on federal lands and in federal facilities.

The National Child Abuse and Neglect Data System (NCANDS) is the official government data source to which all states must contribute information about child abuse and neglect reports. To collect data on reported and confirmed cases of child abuse and neglect uniformly from all states, NCANDS provides the following somewhat more comprehensive definition of child abuse and neglect:

An act or failure to act by a parent, caregiver, or other person as defined under State law that results in physical abuse, neglect, medical neglect, sexual abuse, emotional abuse, or an act or failure to act which presents an imminent risk of harm to a child. ( ACF, 2012 )

Many states, reflecting the words “at a minimum” in CAPTA, have more expansive definitions of the conduct that legally constitutes child abuse and neglect for purposes of mandatory reporting. In some states, for example, only conduct by current caregivers is defined as reportable child abuse and neglect; in other states, the conduct must be reported regardless of the perpetrator's relationship to the child. Pennsylvania, for example, considers only acts of abuse as reportable acts of maltreatment and uses a different mechanism for capturing neglect. CAPTA permits states to limit reporting to “recent” acts, but most states have no time limit on when the conduct occurred for the mandatory reporting requirement to be invoked. A summary of the differences in states' child abuse and neglect reporting laws is available ( CWIG, 2011 ).

How child abuse and child neglect are defined and who is obligated to report them are subject to changes in awareness or level of concern about possible abuse- and neglect-related hazards faced by children. It is common for a specific case, especially one involving an egregious situation not addressed by extant law, to prompt advocacy for legislative change ( Gainsborough, 2010 ). Newly identified problem areas, changes in societal consensus about child protection, and revelations that certain groups of professionals are not included in mandatory reporting laws are typical scenarios for bringing about statutory reforms. In 2012, 107 bills addressing child abuse and neglect reporting were introduced in 30 states and the District of Columbia ( NCSL, 2012 ). For example, a number of states expanded mandatory reporting to apply to university employees in response to the Penn State Sandusky scandal.

In some cases, such changes have unintended consequences. An example is the occasional inclusion of exposure to domestic violence as a statutorily specified form of reportable child abuse and neglect, a result of increasing awareness of the association between domestic violence and child abuse and neglect and concern for the welfare of children exposed to this violence, so that affected children would receive protection and services. The Minnesota state legislature instituted such a change in 1999. The result was a dramatic increase in the number of referrals, emanating mainly from law enforcement officials who responded to reports of domestic violence and, as mandated, reported the family to child protective services. Parents, primarily mothers, who themselves were victims of domestic violence thus became the subjects of neglect reports based on their alleged failure to protect their children from exposure to the violence. This was not the intent of the legislation, and the provision was quickly rescinded ( Edleson et al., 2006 ).

Child abuse and neglect laws are for the most part concerned with parental behaviors of omission or commission that place children in jeopardy. Acts of omission usually are characterized as neglect. They include failing to provide adequate supervision; not protecting children from known dangers; and not providing for basic needs, such as proper medical care, adequate food and clothing, safe/hygienic shelter, and school attendance. Child neglect reports may also be made in some states if a child is born affected by illegal drug or alcohol abuse by the mother or if a child is living where drugs are being manufactured and/or distributed.

Child abuse, on the other hand, refers to acts of commission by a caregiver. Physical abuse encompasses physical assaults that exceed permitted corporal punishment. States may define explicitly the types of behavior that fall in this category. In some cases for example, the age of the child may determine whether a behavior is acceptable discipline (e.g., slapping an infant versus an older child across the face). Sexual abuse generally includes the range of sexual behaviors that are defined by criminal statutes, including sexual exposure, sexual touching, rape, and sexual exploitation. Emotionally abusive behaviors include threatening, terrorizing, or deliberately frightening a child; rejecting, ridiculing, shaming, or humiliating behaviors; extreme isolating or restricting behaviors; and corruption or encouraging involvement in illegal behaviors. However, of the 48 states that mention emotional abuse in law, only Delaware identifies specific emotionally abusive caregiver behaviors; most states define emotional abuse by its impact on the child's mental health ( CWIG, 2011 ). Because the involvement of the child protection system focuses on caregivers, cases of abuse committed by non-family members or siblings may be classified as neglect. In those cases, it is the presumed or alleged failure of the caregiver to protect the child that drives the designation. For example, the majority of sexual abuse and a notable proportion of serious physical abuse cases involve non-family members as perpetrators ( Finkelhor and Dziuba-Leatherman, 1994 ). Instances of abuse committed by a non-family member, a sibling, or another person regularly present in the household are classified as neglect if it is determined that the caregiver failed to protect the child victim from that individual.

As noted, child abuse and neglect laws also vary in how mandated reporters are defined. Some states define all adult citizens as mandated reporters, but most specify certain groups of professionals and others who work with children ( CWIG, 2012a ). State laws usually exempt from a reporting obligation priests acting in the role of receiving confession; states vary, however, as to whether reporting is required of priests or pastors acting in other capacities. Regardless of the groups specified, anyone not listed as a mandated reporter can still make a report. Both mandated reporters and others are legally protected for good faith reports, while mandated reporters who fail to report may be prosecuted for that failure. No evidence-based research has assessed whether the breadth of inclusion in mandatory reporting laws makes a difference in rates of reporting, although it may affect substantiation rates ( McElroy, 2012 ; also see the discussion of mandatory reporting laws in Chapter 8 ).

Some acts of child abuse and neglect are also crimes. The specific statutory definitions and names of those crimes vary by state, but in general, criminal statutes cover the same acts in all states. Sexual abuse is always a crime; most cases are classified as felonies. Physical abuse is a crime unless the behavior falls within the discipline exception for corporal punishment. Most cases of physical abuse are likely to be classified as misdemeanors unless a child is seriously injured or dies. A minority of neglect cases involve criminal conduct. When the failure to supervise, protect, or provide care for a child rises to a certain level of negligent treatment, it may meet the criteria for violation of criminal codes (e.g., child endangerment or criminal neglect) and can be prosecuted. Just because child abuse and neglect falls within the statutory definition of a crime, however, does not mean it will be fully investigated by law enforcement and prosecuted. Law enforcement investigations and prosecutions tend to focus on sexual abuse and on serious physical abuse and very serious neglect that have resulted in a child's experiencing physical harm or death (e.g., starvation, inflicted medical trauma).

As with state laws, child abuse and neglect is defined in various ways for research purposes. The National Incidence Study (NIS)-4 ( Sedlak et al., 2010a ) applies two definitional standards: a harm standard and an endangerment standard. The harm standard is restricted to cases in which children have been harmed by child abuse and neglect, whereas the endangerment standard encompasses children who have not yet been harmed under certain circumstances. The numbers vary depending on which definition is used (NIS-4 harm standard = 1.25 million children; endangerment standard = 3 million children). Under both standards, alleged instances of abuse or neglect are classified according to eight major categories. Table 2-1 lists actions or failures to act that are representative of each type of abuse or neglect and, for the purposes of this chapter, provides examples of how these forms of maltreatment can be defined in a research setting.

National Incidence Study (NIS)-4 Abuse and Neglect Classifications.

A widely used method of defining child abuse and neglect in research is the classification scheme developed by Barnett and colleagues (1993) . Many studies focused specifically on child abuse and neglect use these definitions rather than the officially reported labels (e.g., English et al., 2005 ). The Centers for Disease Control and Prevention (CDC) also has recommended a set of uniform definitions for public health purposes to allow for monitoring of incidence over time and detection of trends ( Leeb et al., 2008 ). Notably, both the classification scheme developed by Barnett and colleagues and the CDC recommendations are designed for analysis of existing information from public sources, primarily child protective services case records.

Slack and colleagues (2003) note that research definitions developed for analysis of child protective services case records may not be applicable to survey research. They argue that these definitions may capture risk factors associated with the detection of child abuse and neglect rather than risk factors associated with the commission of child abuse and neglect. They have built on the framework created by Barnett and colleagues (1993) to develop a set of research definitions for neglect that they intend for use in survey research.

Likewise, other investigators develop their own study-specific designations. These definitions vary in comprehensiveness and behavioral specificity. For example, a study not focused specifically on child abuse and neglect but interested in it as one of many independent variables may use a single general question to get at the construct.

Finding: Child abuse and neglect are defined differently for different purposes. Legal definitions at the state level are properly subject to the legislative process. In research, however, the variability in definitions compromises learning the true scope and characteristics of the problem, understanding trends over time, and determining the relationship between child abuse and neglect and various outcomes. Finding: State laws vary in what groups are specified as mandated reporters of child abuse and neglect. No evidence-based research has assessed whether the breadth of inclusion in mandatory reporting laws makes a difference in rates of reporting, although it may affect substantiation rates.

• INCIDENCE RATES AND THE PROBLEM OF UNDERREPORTING

Determining the true incidence of child abuse and neglect is problematic for the same reason encountered in attempting to quantify any social problem: discrepancies between actual rates and the number of cases reported to authorities. It is well established that most crimes (the exception being homicide) are not reported ( Langton et al., 2012 ). Data on the incidence of child abuse and neglect are derived from three primary sources: NCANDS, the official reporting system for cases of child abuse and neglect referred to state child protective services; two U.S. government surveys—the Uniform Crime Reporting (UCR) system, administered by the Federal Bureau of Investigation (FBI), and the National Crime Victimization Survey (NCVS), administered by the Bureau of Justice Statistics (BJS) to a large representative sample of U.S. citizens aged 12 and older; and the NIS, a study conducted every decade by the Department of Health and Human Services on a nationally representative sample that captures both cases of abuse and neglect reported to child protective services and unreported cases identified by professionals working with children.

National Child Abuse and Neglect Data System

Each state receiving a federal Basic State Grant for child abuse and neglect prevention and treatment programs is required to submit data annually to NCANDS. 6 In fiscal year (FY) 2011, all states, the District of Columbia, and all territories contributed to NCANDS counts of the number of cases referred to child protective services, the number accepted for investigation, the number substantiated, the case characteristics, and the case outcomes. As previously noted, the definitions of child abuse and neglect used by child protective services vary by state, as do reporting requirements. Because NCANDS collects information from child protective services case files in each state, the data reflect inconsistencies in state-level definitions of types of maltreatment, reporting requirements, and procedures for responding to reports of child abuse and neglect.

NCANDS reports are issued annually. According to the FY 2011 NCANDS report ( ACF, 2012 ), there were 3.4 million referrals involving 6.2 million children; some of the children were the subject of more than one referral. Nationally, more than three-quarters of these cases are classified as neglect, 18 percent as physical abuse, and 9 percent as sexual abuse. The specific rates vary among states but overall reflect the general pattern that a substantial majority of cases are neglect, with physical and sexual abuse representing much smaller groups.

Based on NCANDS, victims of child abuse and neglect are approximately evenly divided between males and females. The highest rates of child abuse and neglect occur among the very youngest children (see Table 2-2 ). Perpetrators are mainly parents (81 percent) and among parents are primarily biological parents (88 percent), which reflects the legal definition for reportable cases. Somewhat more than half of perpetrators are female ( ACF, 2012 ). These demographic characteristics are also reflected in other data sources, such as the NIS-4 ( Sedlak et al., 2010a ).

Child Maltreatment Cases/Victims, Rates per Thousand Population Ages 0-17, by Various Characteristics, 2002-2011.

In FY 2011, NCANDS reported 1,545 child fatalities resulting from abuse and neglect. Again, young children were at greatest risk: 80 percent of victims were less than 4 years old. Deaths were higher among boys than girls. About 70 percent of the fatalities are associated with neglect and nearly half are attributed to physical abuse, either exclusively or in combination. A Government Accountability Office ( GAO, 2011 ) report notes that the NCANDS method relies only on cases reported to child protective services for these figures. The report states that not all child fatalities due to abuse and neglect are known to the child welfare system, suggesting that the actual figure is likely higher, although it acknowledges the difficulty of obtaining an accurate count.

An important limitation of NCANDS is that it does not capture accurate rates of child abuse and neglect among American Indian children. Only states submit information to NCANDS; there are no mechanisms for tribal child welfare systems to submit data to the system. American Indian and Alaska Native families and children whose cases are reported to and investigated by state child protection authorities and who self-identify as American Indian or Alaska Native are included in NCANDS. Children served by tribal child welfare systems, the Bureau of Indian Affairs, or the Indian Health Service are not. Thus, “it is estimated that 40 percent of all cases of child abuse and neglect among American Indian and Alaska Native children are not reported to NCANDS” ( Cross and Simmons, 2008 , p. 3; also see Earle and Cross, 2001 ). NCANDS is further limited in its ability to reveal the levels of abuse and neglect suffered by American Indian and Alaska Native children by the fact that state or county employees, rather than tribal workers, collect the data reported to NCANDS. Therefore, not only does NCANDS lack data on many cases that occur on tribal lands, but the data it does include may be flawed because non-Native workers with American Indian or Alaska Native culture often are tasked with making determinations of abuse or neglect in such settings ( Fox, 2004 ).

U.S. Government Surveys

The U.S. government uses the two surveys noted above to learn about crime rates. The UCR covers crimes reported to police, whereas the NCVS is a household survey of a large representative sample of individuals aged 12 and older that asks about both reported and unreported crimes. Self-reported rates of crime victimization frequently are several times the rates of official reports, with the discrepancies being especially high for sexual assault.

The ability of such surveys to capture cases accurately hinges, in part, on how the question is asked. Using official terminology or labels for acts of child abuse and neglect requires respondents to label their own experiences as abusive or neglectful. In some cases, respondents may not know the official definitions or exactly what they encompass. For example, many children and adults may consider hitting a child with a belt appropriate corporal punishment. In other cases, the victim may be reluctant to define what happened as abusive. For example, evidence suggests that labeling acts as intentionally abusive is associated with increased distress in children ( Kolko et al., 2002 ).

These labeling considerations are particularly acute in cases of sexual assault. Asking a single question—such as “Have you ever been raped?”—yields far fewer responses than a series of behaviorally specific questions about acts that meet the legal definition of sexual abuse and rape. For example, rates of endorsement of child sexual abuse in self-report research vary substantially based on how the question is posed. A meta-analysis of studies that used self-report surveys to examine childhood sexual abuse experiences around the world found that differences in the way sexual abuse was defined and the specific questions asked produced dramatically different rates of sexual abuse prevalence ( Stoltenborgh et al., 2011 ).

In addition to these survey design issues, the point in time and circumstances under which respondents provide information about child abuse and neglect are crucial. Surveys of adults about their childhood experiences may yield very different rates than surveys of children. For example, population-based telephone interviews of youth aged 10 and older provide extensive information about self-reported victimization and exposure to violence ( Finkelhor, 2009 ; Kilpatrick and Saunders, 1995 ). However, the rates of intrafamilial sexual and physical abuse reported in these studies are relatively low compared with the rates reported among adult samples when asked their childhood abuse experiences. Children may be less likely to report intrafamilial crimes when they are still children and are living at home.

Another method of learning about child abuse and neglect is asking adults about their behavior toward their children. Surveys using the Conflict Tactics Scale can provide a picture of self-reported corporal punishment and parental acts that would meet legal criteria for child physical abuse ( Straus and Stewart, 1999 ; Straus et al., 1998 ; Theodore et al., 2005 ). This method has the obvious limitation, however, that even when responding to anonymous surveys, parents may underreport socially undesirable or illegal acts.

Discrepancies between official reports and child and adult self-reports can be in either direction. Children or adults may not define their experiences as child abuse and neglect because they do not know better or believe the conduct was deserved or acceptable, or because of the distress associated with reporting that caregivers are behaving abusively toward them. Adults may not define their own behavior as abusive or neglectful because of fears of being reported, social undesirability, or shame about the conduct. On the other hand, substantial evidence shows that careful and detailed questioning of children about their experiences produces substantially higher rates than official reports. For example, computer-assisted interviews were used to obtain self-reports of abuse and neglect from a sample of youth aged 12-13 enrolled in a prospective study of high-risk and abused children ( Everson et al., 2008 ). This method yielded rates that were four to six times higher than those in the official child protective services records. At the same time, close to half of adolescents in the sample with confirmed child protective services reports failed to note that experience in the interview.

The National Incidence Study

The NIS is a congressionally mandated report on the incidence of child abuse and neglect that has been issued periodically since 1974 ( OPRE, 2009 ). It estimates national rates of reported and unreported child abuse and neglect based on a representative sample of counties. The study uses official data and also collects information from “sentinels” representing community professionals who may encounter child abuse and neglect victims during the course of their work. The methodology of the NIS is explicitly designed to uncover child abuse and neglect that may not have been reported to authorities but was identified by professionals. The most recent report, issued in 2010, is based on data collected in 2005-2006 ( Sedlak et al., 2010a ). As noted above, the NIS defines child abuse and neglect differently from federal and state law, applying both a harm and an endangerment standard. All cases sampled in the study—both those identified by child protective services agencies and those reported by sentinels—are evaluated to determine whether they meet the definitional standards of the NIS for physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, and educational neglect. The NIS considers only abuse and neglect perpetrated or permitted by a parent or caregiver, aligning its definitions with those of child protective services.

The primary investigators of the NIS-4 note that findings of differential incidence rates for abuse and neglect of black and white children are limited by the range of risk factors available for analysis in multifactor risk models, which exclude such key elements as neighborhood characteristics, social isolation, substance use, and mental illness ( Sedlak et al., 2010b ). Likewise, many children's records lacked information on socioeconomic status, and the socioeconomic status measures used classified black and white children differently, limiting the utility of the data for examining socioeconomic status as a risk factor for child abuse and neglect.

Reasons for Underreporting

It is well known that not all child abuse and neglect cases come to the attention of authorities at the time they happen. Retrospective reports from adults abused or neglected as children reveal that most cases are not reported to anyone, and fewer still are reported and investigated by child protection workers or law enforcement officials (e.g., Finkelhor, 1994 ; MacMillan et al., 2003 ). Adults abused or neglected as children give a variety of explanations for why they did not tell anyone or make an official report, including not realizing that what was happening was wrong, illegal, or a form of child abuse and having fears or concerns about what would happen if they reported the experience or attempted to seek help.

Child abuse and neglect can sometimes be identified without a child's making a statement about it. Examples include certain types of injuries or medical conditions that are noticed by others or become known to a medical provider. Some types of neglect can also be detected through observable behaviors, such as young children found wandering the streets or coming to school unclean or very disheveled. But detection of many cases of physical abuse and neglect and almost all cases of sexual abuse depends largely on children making statements and adults acting on those statements. The statements may be made spontaneously or may be in response to adult inquiries about behaviors, circumstances, or injuries observed in the children. Once abuse or neglect has been detected, many variables can affect whether adults take action, including personal attitudes and beliefs about what will happen as a result of reporting, the relationship of the adult to the child or the caregiver who may have committed the abuse or neglect, the certainty of the concern about maltreatment, and understanding of the child abuse reporting laws ( Alvarez et al., 2004 ; Khan et al., 2005 ; Sedlak et al., 2010a ).

Therefore, official reports do not capture all instances in which child abuse and neglect is suspected or even is detected and acted upon. For example, adults in a child's life may learn about child abuse and neglect and take informal actions on behalf of the child without necessarily reporting to authorities. Although citizens are protected if they make a good faith report of suspected child abuse or neglect, there are many reasons why they might be hesitant about or deterred from making an official report even if strong evidence or suspicion exists. For example, they may fear retaliation or rejection by the abuser or negative consequences for the child or family. Indeed, despite the fact that relatives, neighbors, and friends are most likely to observe or hear about child abuse or neglect because of their proximity and involvement in children's lives, they account for only a minority (18 percent) of reporters of cases to child protective services ( ACF, 2012 ).

Professionals account for the other three-fifths of child abuse and neglect reports, with teachers (16 percent), law enforcement officials (17 percent), and social service providers (11 percent) making the majority of these reports ( ACF, 2012 ). However, mandated reporters do not always make a report when they suspect child abuse or neglect. Among mandated reporters involved as sentinels in the NIS-4, a significant percentage have had suspicion and not made a report. Professionals identify a variety of reasons for not reporting their suspicions ( Sedlak et al., 2010a ). The most common reasons given are concerns that intervention by child protective services will be more harmful than helpful and the professionals' belief that they can do a better job of addressing the suspected child abuse or neglect on their own without involving the authorities. Rates of reporting also may vary by profession and relationship with the family. In one state survey of pediatricians, only 10 percent had ever not reported a suspected case of abuse or neglect; the most common reason given was not feeling that the evidence for suspicion was strong enough or believing that the case could be better handled by the physician or family without the involvement of child protective services ( Theodore and Runyan, 2006 ). For mental health providers, the dilemma may be more acute. For example, Steinberg and colleagues (1997) found that among psychologists who had made a report to child protective services, 27 percent stated that their client ended the therapy relationship because of the child abuse report.

In addition to the concerns of professionals about the consequences of reporting for themselves and their practice, a lack of clarity exists as to what constitutes reasonable suspicion as defined by the law. There is little dispute about suspicion when the basis for concern is clear-cut (e.g., the child makes a credible statement about being sexually abused or has hand print bruises on the cheek). In many cases, however, the information available to the reporter is vague, inconclusive, or only suggestive. Is it neglect when a child comes to school in dirty clothes and smelling bad? How young a child can be left alone at home? What if a child says, “I am afraid to go home”? If a child is engaging in highly sexualized behavior, is that indicative of abuse? There is a substantial gray area that is open to interpretation with respect to whether a statement or behavior meets criteria for triggering a legally mandated report of child abuse and neglect. A lack of consensus exists even among expert child abuse doctors. Levi and Crowell (2011) found no agreement among experts on how high child abuse and neglect would have to be on the list of differential diagnoses and how certain the provider would have to be that child abuse and neglect accounted for the child's presentation to meet the reporting criterion of reasonable suspicion.

On the other hand, only about 60 percent of referrals to child protection authorities are accepted and screened in for some type of official response ( ACF, 2012 ). Cases may be screened out because they do not meet the legal criteria for child abuse and neglect or state standards for accepting cases, or because information about the case is insufficient to enable completing a report. Among states, screen-in rates range from a low of 25 percent to a high of virtually all referrals ( ACF, 2012 ). Thus citizens and professionals likely recognize many situations in which they suspect child abuse and neglect, but their suspicions do not meet the threshold of concern required by local statute to justify an investigation.

Disproportionality

Concerns have been raised about possible racial and ethnic bias in child abuse and neglect reporting and investigations because African American and American Indian children are referred to child protective services at higher rates than their representation in the population, whereas Asian American and Latino children are referred at lower rates. A recent study used a birth cohort methodology and linked vital statistics and child abuse report records for young children ( Putnam-Hornstein, 2011 ). Prior child abuse reports were associated with an almost sixfold increase in the probability of intentional death and double the rate of unintentional fatal injury; the rates were higher for African American and American Indian children and lower for Asian American and Latino children relative to the general population. In other words, the racial/ethnic patterns of injury and death mirror the child abuse and neglect reporting rates by racial and ethnic group. Moreover, the overall underrepresentation of Latino children in referrals to the child welfare system masks significant differences between the experiences of Latino children of U.S.-born mothers and Latino children of foreign-born mothers, both in rates of referral ( Putnam-Hornstein et al., 2013 ) and in type of abuse or neglect ( Dettlaff and Johnson, 2011 ). Authoritative commentators ( Drake et al., 2011 ; Putnam-Hornstein, 2012 ; Putnam-Hornstein et al., 2013 ) agree that there are real group differences in the rates of child abuse and neglect and conclude that these differences reflect the higher burden of social ills borne by some groups. As Putnam-Hornstein concludes: “The findings suggest that the overrepresentation of black and Native American children in the child welfare system may be a manifestation of historical and contemporary racial inequities that place these minority children at a disproportionate risk of maltreatment” (2012, p. 171).

Disproportionality extends beyond referrals. Miller (2011) examined disproportionality in Washington state at both the referral point and key decisions points after cases had been screened in (e.g., risk rating, placement, length of time in care). As with other states, disproportional rates of referral were seen. When disproportionality from the point of referral was examined, virtually no differences were found among whites, Asians, and Latinos following case entry into the child welfare system. After case receipt, rates of disproportionality were reduced for African American families at most decision points, with the largest discrepancy remaining in length of time in care. For American Indian cases, the disproportionality continued at every decision point following case acceptance. These results suggest that the observed disproportionality may have a variety of causes, some that reflect larger social forces and others that may be more reflective of professional assumptions and local practices. Disproportionality is discussed further in Chapter 5 of this report.

Finding: According to NCANDS data from FY 2011, there were 3.4 million child abuse and neglect referrals involving 6.2 million children. Nationally, more than three-quarters of these cases are classified as neglect, 18 percent as physical abuse, and 9 percent as sexual abuse. The highest rates of child abuse and neglect occur among young children, specifically those less than 3 years old. Finding: Tribal child welfare systems, the Bureau of Indian Affairs, and the Indian Health Service do not report to NCANDS and are therefore not included in the datasets, thus limiting the ability to determine levels of abuse and neglect among many American Indian and Alaska Native populations. Moreover, non-Native workers report on cases of child abuse and neglect without familiarity with or consideration of the culture in these communities. Finding: Difficulties arise in determining rates of child abuse and neglect. When researchers attempt to identify instances of child abuse and neglect through survey instruments, results can vary based on the types of questions asked and the point in time and circumstances under which respondents provide the information. Conducting retrospective surveys of childhood experiences, asking children about recent experiences, and surveying parents about their behaviors toward children all can yield different results. Finding: African American and American Indian children are referred to child protective services at disproportionate rates relative to their representation in the general population.

• INCIDENCE TRENDS

Questions about whether child abuse and neglect are increasing, decreasing, or being detected and reported more often have become prominent in recent years. At the time of the 1993 NRC report, there was a general consensus that child abuse and neglect was underreported. Since that time, substantial changes have occurred in the social climate with regard to awareness of child abuse and neglect, attitudes toward reporting it, and the availability of programs and services for children and families affected by it. These developments have explicitly been intended to increase reporting of child abuse and neglect by victims, the general public, and professionals. However, establishing whether changes in official reporting represent true changes in incidence is complicated by the limitations of the reporting systems discussed above, as well as the difficulties inherent in ascertaining rates of events that happen to children, many of whom are very young, and that occur mainly in the private context of family life. As revealed by the review below, discrepancies exist in some areas and considerable ambiguity in others regarding the conclusions to be drawn from the available trend data, suggesting outstanding questions that would benefit from more systematic empirical analyses of these trends over time.

Sexual abuse has shown the largest decline in reported rates. NCANDS reports a decline of 62 percent since 1992 ( Finkelhor and Jones, 2012 ). The sharpest declines occurred during the late 1990s, but the downward trajectory has continued, with a 3 percent decline being reported between 2009 and 2010. This same pattern is demonstrated in the NIS-4, issued in 2010, which reported a 47 percent decline from the mid-1990s through 2005, when the data for that report were collected ( Finkelhor and Jones, 2012 ).

Additional information on trends in sexual abuse is derived from surveys of youth. The NCVS documents a 68 percent decrease in reported and unreported sexual assault or rape of 12- to 17-year-olds between 1993 and 2010 ( White and Lauritsen, 2012 ). In a national survey on sexual and reproductive activity, young women (aged 15-24) reported a 39 percent decline in sexual experiences with a partner 3 or more years older before the age of 15 ( Finkelhor and Jones, 2012 ). This survey follows the same pattern as NCANDS, with the declines being steepest in the 1990s and tapering off although still continuing in the 2000s. Finkelhor and colleagues (2010b) compare results from the National Survey of Children Exposed to Violence (NatSCEV) in 2003 and 2008 and find that reports of sexual assault declined from 3.3 percent of all children aged 2-17 in 2003 to 2.0 percent of children in 2008. In contrast, the National Survey of Adolescents (NSA), a survey of a large nationally representative sample of youth, found no decline in self-reported sexual assault between 1995 and 2005 ( Finkelhor and Jones, 2012 ).

The trend data are more ambiguous with respect to physical abuse. NCANDS reports a decline of 56 percent in physical abuse reports from the early 1990s through 2010 ( Finkelhor et al., 2010a ). The decrease for physical abuse began somewhat later than that for sexual abuse but has followed the same slope, with steep declines in the late 1990s that tapered off by 2009. Likewise, the NIS-4 reported a 29 percent drop in endangerment-standard physical abuse starting in the early 1990s ( Finkelhor and Jones, 2012 ).

Survey results produce a somewhat different picture. The NCVS reports a 69 percent decline in aggravated physical assaults on children (aged 12-17) from 1993 through 2008; however, these events are mainly peer and sibling assaults rather than physical abuse by parents ( Finkelhor and Jones, 2012 ). Zolotor and colleagues (2011) compared results from a 2002 survey of parents in North Carolina (Carolina Survey of Abuse in the Family Environment) using the Parent-Child Conflict Tactics Scale with the findings of a Gallup survey completed in 1995 and the results of two National Family Violence Surveys, conducted in 1975 and 1985, that used the same scale. The results show a decline in parental reports of physical abuse. On the other hand, neither the NatSCEV nor the NSA found significant declines in youth-reported physical abuse by caregivers ( Finkelhor and Jones, 2012 ).

Another source of data on physical abuse is admissions to a hospital for abuse-related injury. Physical abuse encompasses a broad range of acts. The most common is striking a child such that bruising results—ranging from relatively minor, temporary, and localized marks caused by pinching or slapping to significant marks caused by whipping or hitting with an object that may leave scars. These types of injuries do not typically entail admission to a hospital or even require medical care. On the other hand, a relatively small percentage of physical abuse cases involve injuries, such as fractures, burns, blunt trauma, and abusive head trauma (formerly known as shaken baby syndrome), that require medical care and possibly hospitalization ( Zolotor and Shanahan, 2011 ). Approximately 1.4 percent of physical abuse cases are estimated to result in hospitalization ( Leventhal et al., 2012 ).

A number of studies have investigated changes in rates of admission for head injuries resulting from child physical abuse—the most common reason for child abuse-related hospital admission. Leventhal and Gaither (2012) found a small but concerning increase in the rate of serious injuries as documented in coding on medical records in a series of children's hospitals (from 6.1 to 6.4/100,000) from 1997 to 2009. Additional studies, attempting to show an association between economic indicators and child abuse, similarly have found increases in rates of injuries coded as child abuse occurring during the 2000s ( Berger and Waldfogel, 2011 ; Berger et al., 2011 ; Wood et al., 2012 ). A national study conducted in Taiwan also found a significant increase from 1996 to 2007, but only for infants and largely accounted for by changes in coding practices since 2003 ( Chiang et al., 2012 ).

Neglect reports show the most mixed trends picture. NCANDS neglect reports declined by 10 percent between 1990 and 2010 ( Finkelhor et al., 2010a ), but there was significant variability across states. From 1992 to 2010, for example, fluctuations ranged from a 90 percent decline in neglect in Vermont to a 189 percent increase in Michigan. These dramatic state variations are not mirrored in the sexual and physical abuse rates, which declined across almost all states over the same period. The NIS-4 found no decline in neglect cases ( Sedlak et al., 2010a ). Self-report survey data are not available for neglect to permit comparisons over time. In part, this is due to the fact that retrospective self-report surveys are poorly suited to gathering information about neglect involving very young children, which is the most frequent form of child abuse and neglect.

Child maltreatment–related fatalities include deaths caused by both physical abuse and neglect, with a majority being attributed to neglect. NCANDS reports an increase of 46 percent in abuse- and neglect-related fatalities between 1993 and 2007 ( Finkelhor and Jones, 2012 ). In contrast, homicide rates for children fell by 43 percent during the same period, with a 26 percent decline for the youngest children (aged 0-5) ( Finkelhor and Jones, 2012 ); between 1980 and 2008, 63 percent of murdered children aged 0-5 were killed by a parent ( Cooper and Smith, 2011 ). It is unclear to what extent cases officially reported by law enforcement as homicides correspond to cases included in the NCANDS child abuse and neglect dataset, most of which, as noted, are attributed to neglect.

Trends in child abuse and neglect occur in the larger context of rates of crime and violence in the United States. The consensus is that crime has decreased substantially, although there are some year-to-year fluctuations and pockets where these results are not seen. Both official reports as reflected in the UCR and population-based counts of reported and unreported crime as determined by the NCVS reveal declines in virtually all crime categories since the mid-1990s ( FBI, 2010 ; Truman and Planty, 2012 ). These declines extend to sexual assault and domestic violence, crimes that share characteristics of child sexual and physical abuse and often involve people in close interpersonal relationships or family members. As with child abuse and neglect, extensive efforts have been undertaken to change the social climate around these crimes, encourage reporting, and expand service availability. The NCVS shows a 68 percent decline in the number of children aged 17 and younger living in households in which someone aged 12 and older was the victim of sexual assault or violent crime between 1993 and 2010 ( Truman and Smith, 2012 ).

In sum, trends are inconsistent across types of child abuse and neglect, and in the case of neglect are inconsistent across states. Sexual abuse reporting appears to indicate a clear decline that is not reflected in only a single data source. Although most sexual abuse is not committed by immediate family members, the declines here appear to extend equally to family and nonfamily sexual assaults. It is worth noting that the declines in child sexual abuse began about the same time as general declines in crime and have followed a similar slope. Physical abuse presents a more complicated picture, with some official sources showing overall declines and several surveys not showing declines. Although physical assaults in general (e.g., nonfamily assault, bullying) appear to be down, it is not clear that these trends extend to intrafamilial physical abuse.

Increases in child abuse-related hospital admissions are especially concerning because these data represent the most severe assaults, even though they make up a very small subgroup of child abuse cases. There are several possible explanations for these increases. First, they may represent actual increases in serious injury. Several studies have directly examined the correlation between the increases in identified cases and larger economic forces ( Berger and Waldfogel, 2011 ; Berger et al., 2011 ; Wood et al., 2012 ). Berger and colleagues (2011) hypothesize an association between the economic recession and rising rates of child abuse-related injury, citing increases in child abuse and neglect reports from the prerecession to the recession period. However, they find no association with local unemployment rates. Wood and colleagues (2012) link data on child abuse-related hospital admissions to mortgage delinquency, foreclosures, and unemployment rates between 2000 and 2009. They find increases in admission rates to be correlated with mortgage foreclosure and delinquency rates but not with unemployment rates. Another possibility is that the increases reflect greater awareness and willingness of health care providers to label injuries as child abuse. The increases coincide with the advent of growing use of hospital diagnostic and billing codes that specify child abuse as the injury cause and a period when a child abuse subspecialty was created in pediatrics. These changes may have contributed to greater willingness to identify child abuse as the cause of injury in official records. Now that abusive head trauma is being captured more accurately in administrative data, it could potentially account for a decline in other forms of head injury ( Leventhal and Gaither, 2012 ). It is also possible that caregivers who inflict severe injuries have more severe psychopathology or are otherwise different from the typical child abuser, and are therefore less amenable to the influences associated with general societal changes and less likely to accept offers of voluntary assistance.

The lack of a significant decline in child neglect and the large jurisdictional variations in this area remain the least understood. The past two decades have seen a growing emphasis on encouraging recognition of neglect as its deleterious effects have increasingly been documented. Awareness campaigns have been undertaken to encourage reporting of neglect, and in some cases its definition has been expanded to incorporate a variety of risky circumstances and conditions. For example, the relationship of parental substance abuse to child abuse and neglect has received widespread attention. These forces may have contributed to increased reporting of a broader spectrum of neglect cases. Greater awareness and expanded definitions may have offset any declines in reports of traditionally defined neglect.

Poverty often is considered a major contributor to neglect, yet there is little empirical support for a strong relationship between changes in indicators of poverty and neglect reporting rates. For example, there was a great deal of concern that welfare reform, especially the timelines for receiving Temporary Assistance for Needy Families (TANF), would produce an increase in cases of neglect as parents were forced off income support. However, no significant change in neglect rates was seen during this period. And as mentioned, two separate investigations failed to find a relationship between unemployment rates and child abuse and neglect reports.

A better understanding is needed of whether and why rates of physical and sexual abuse are declining while no change in neglect is being observed. Criminologists have focused on understanding the substantial declines in crime rates as well as the occasional fluctuations or stubborn persistence of high crime rates in a few areas. Multiple commentators have examined possible causes and explanations ( Finkelhor et al., 2010b ; Levitt, 2004 ; Oppel, 2011 ; Zimring, 2008 , 2011 ). Other fields, such as medicine, would certainly have devoted extensive scientific inquiry to understanding an epidemiological phenomenon as significant and inconsistent across different forms of the same problem area. Yet there has been no similar focus in the field of child abuse and neglect. Attention to the topic has been limited to a few investigators who have repeatedly reported on trends (e.g., Finkelhor and Jones, 2012 ) and to targeted examinations of specific subareas, such as hospital admissions (e.g., Chiang et al., 2012 ; Leventhal and Gaither, 2012 ). A greater focus on understanding the fluctuations in child abuse reporting data and other indicators of child injury both nationally and within specific communities and populations could have important implications for the design and targeting of intervention and prevention efforts.

Finding: Strong evidence indicates that sexual abuse has declined substantially in the past two decades; the balance of evidence favors a decline in physical abuse, especially its more common and less serious forms. There is no evidence that neglect is declining overall; however, states vary significantly as to whether neglect is increasing, decreasing, or remaining constant. These disparate trends have important implications for understanding the nature of child abuse and neglect and the forces that potentially affect its trends. Social policy endeavors are hampered when insufficient attention is paid to understanding the various aspects of the problem. Finding: Understanding is incomplete with respect to whether and why rates of physical and sexual abuse are declining while no change in neglect is being observed. Research on these trends has received inadequate attention given their important implications for intervention and prevention efforts.

• DETERMINATION OF CHILD ABUSE AND NEGLECT

This section reviews the various methods of determining whether child abuse and neglect has occurred. The basis for the determination can range from a citizen's or family member's simply believing what a child says about being abused or neglected or being convinced by something observed, to a medical examination and diagnosis or the formation of a professional opinion, to the results of administrative or legal procedures. The process for making a determination by medical and mental health professionals is established by professional standards of practice, whereas legal standards of investigative practice, rules of evidence, and burdens of proof govern how legal determinations are made.

Determination by Medical and Mental Health Professionals

Medical determination or diagnosis is relevant in a small but very high-stakes minority of child abuse and neglect cases. A medical opinion is the only way to determine whether certain physical injuries—especially very serious injuries such as head injuries, fractures, and burns—are the result of child abuse and neglect in children who are too young to provide a verbal account of how the injury occurred. In certain cases involving children old enough to say what happened, a medical opinion may be necessary to distinguish accidental from nonaccidental injuries when the children's or parents' accounts are discrepant. In some neglect cases, such as those entailing malnutrition or failure to thrive, a medical opinion may be an essential component of the investigative process.

Taking a medical history is standard practice when medical professionals conduct a medical examination. In situations involving child abuse and neglect, especially when sexual abuse is suspected or the cause of an injury is in dispute, the child's history may be the primary basis for a medical professional's opinion or diagnosis. In such cases, although medical professionals may have specialized expertise in interviewing children, they, like other professionals and ordinary citizens, have no special ability to distinguish true from false or mistaken statements. However, statements made to a health care provider may be admissible in legal proceedings as an exception to the hearsay rule.

Overall, within the child abuse medical subspecialty, substantial consensus exists regarding the diagnostic criteria for forming a medical opinion about whether injuries or medical conditions are attributable to child abuse and neglect. However, there have been high-profile controversies about medical opinions in some child abuse cases. For example, questions have been raised about certain medical diagnoses, such as shaken baby syndrome, which as noted, is now called abusive head trauma. In some cases, child abuse experts have concluded that intentional injury has occurred, but other medical professionals have attributed the injuries to causes such as brittle bones or vitamin deficiencies. In large part, such conflicting opinions are due to the adversarial nature of the U.S. legal system. Opposing experts provide testimony to contradict a child abuse and neglect allegation and opine that alternative medical explanations account for the injuries, often, it has been argued, invoking scientifically unsupported assertions ( Chadwick et al., 1998 ). Although there have been some salient scientific developments in terms of the causes of injuries, in most cases these disputes do not reflect significant scientific uncertainties.

Outstanding questions do remain about the types of tests and procedures that are most appropriate for making a determination of child abuse and neglect. For example, radiographic skeletal survey is the standard procedure for detecting clinically unsuspected fractures in possible child abuse victims since a certain percentage of children will have occult fractures. Standards for additional tests and their timing have not been definitively established. Absent consensus standards, practice shows considerable variability.

Other presentations for which a medical opinion is absolutely necessary include complex conditions such as Munchausen syndrome by proxy, or medical child abuse ( Davis and Sibert, 1996 ; Fisher and Mitchell, 1995 ; Roesler and Jenny, 2008 ). While this condition is very rare (0.5/100,000 children), the potential consequences to children are extreme and severe ( McClure et al., 1996 ). Parents repeatedly take their children to medical providers, often many different ones, with reports of multiple and sometimes extremely serious symptoms or conditions. In some cases, the child has or had a legitimate underlying condition, and the parents have extreme anxiety and repeatedly seek out additional tests and procedures or exaggerate symptoms. In other cases, parents fabricate or cause the medical symptoms to obtain psychological gratification from the attention they receive in the role of concerned parent. Making a determination of medical child abuse in these cases is fraught with complications and frequently cannot occur until the child has suffered significant harm or endured unnecessary tests, procedures, and even surgeries. Suspicion does not even arise until the pattern of visits, procedures, and contacts with multiple providers emerges. Child abuse doctors face a daunting task in challenging the opinions and practices of other medical providers who may have been mistaken, but genuinely believed the child had a serious medical condition.

In sexual abuse cases, although medical assessment is the standard of care, medical diagnosis is relevant in only a small subset of cases. Physical signs or symptoms, such as genital changes or injuries, sexually transmitted diseases, pregnancy, or the presence of seminal fluids or sperm, are present in only about 4 percent of cases; the vast majority of children medically evaluated for sexual abuse have normal exams ( Heger et al., 2002 ). Even when there are genital findings, most are nonspecific and cannot be linked conclusively to sexual assault ( Heger et al., 2002 ). Cases with definitive medical evidence, such as the presence of semen or pregnancy, are exceedingly rare. Standards for making a medical determination of sexual abuse have been published ( Kellogg and Committee on Child Abuse and Neglect, 2005 ).

There are two important reasons beyond medical diagnosis why medical assessment of children who may have been or report being sexually abused is the standard of care. One purpose is to allay the child's and parents' worries about the potential physical effects of sexual contact. A visit with a medical provider creates a nonstigmatizing opportunity for support and validation, psychoeducation about the impact of sexual abuse, and encouragement to engage in available treatment services. The second is that citizens, judges, and juries assume that medical findings will be present in sexual abuse cases, even though this frequently is not the case. Child protection and criminal legal professionals believe it is often necessary to have a medical exam and expert medical testimony primarily to counter this widespread misconception.

Mental health professionals may be asked by parents or other professionals to provide a professional opinion as to whether a child was abused. Most such requests involve concern about sexual abuse. A diagnosis is not made because sexual abuse is an event, not a medical or psychiatric condition. In many cases, the mental health professional's opinion is sought in a forensic context when a report has been made to authorities or a legal action has been initiated, and the opinion is expected to help guide legal decision making or provide the basis for expert testimony in a legal proceeding. In other cases, however, the opinion is sought to determine whether to initiate reporting or other legal actions.

Typically in these situations, mental health providers consider a range of information, including what the child says in an interview, what the child has told others, the circumstances of the discovery of abuse concerns, results of medical examinations, and the emotional and behavioral functioning of the child based on a psychosocial assessment or administration of a standardized checklist of tests. The degree of thoroughness and the formality of the process depend largely on the purpose the opinion will serve.

Whereas child abuse mental health professionals do bring specialized expertise, knowledge, and skills to the evaluation process, there are scientific limits on the conclusions that can be drawn about whether an event occurred based on psychosocial assessment. No psychological profile has sufficient specificity to permit conclusions about an event as the cause of a presentation ( APA, 2013 ). In addition, the emotional and behavioral consequences of child abuse and neglect are varied and nonspecific (see Chapter 4 ). Conditions typically associated with child abuse and neglect, such as posttraumatic stress, anxiety, depression, and behavioral problems, are common mental health problems for children and have many other causes. The only behavioral problem that has a specific and significant relationship with child abuse and neglect is inappropriate sexual behavior. However, the majority of sexually abused children do not have sexual behavior problems, and there are other potential causes for sexual behavior in children ( Friedrich, 1993 ; Friedrich and Trane, 2002 ; Friedrich et al., 1998 , 2003 ).

To a large extent, professional opinions on child abuse and neglect rely heavily on determinations about the credibility of children's statements. There is no reason to believe that children cannot give reliable and accurate information about events or that they are prone to making false complaints about abuse ( Brown et al., 2007 ; Cederborg et al., 2008 ; Lamb et al., 2007 ; Lyon, 1999 ). On the other hand, it is well established that memory, especially in young children, is susceptible to error and distortion, and that children can form false beliefs that they have experienced events ( Cederborg et al., 2008 ; Lyon, 1999 ). It turns out that the characteristics of true and untrue statements have many commonalities; some true statements are not very credible, and some untrue statements are highly detailed and convincing. Mechanisms devised for rating child reports about abuse and neglect and classifying them as accurate or inaccurate have not proven reliable ( Hershkowitz et al., 2007 ). In other words, professionals have no special ability to detect truthfulness, nor is there a scientifically reliable method for doing so. This is why courts generally do not permit professionals to opine about the credibility of witnesses, but reserve that function for the fact finder ( Myers, 2012 ).

Standards have been established for conducting forensic assessments for purposes of providing an opinion about possible sexual abuse (e.g., Kuehnle and Connell, 2009 ; Sparta and Koocher, 2006 ). The standards cover the assessment process, interviewing approaches, the proper use of psychosocial information, and limits on the accuracy of opinions based largely on statements that cannot be verified and behaviors that are nonspecific. Unfortunately, the types of cases for which such assessments are sought are those that are most ambiguous and complex, such as when children are unable or unwilling to give a clear and credible history, they are very young, they have not made statements, their statements are vague or inconsistent, or they suffer from emotional and behavioral problems that affect their credibility.

Mental health professionals routinely form opinions on the basic truth of reports about historical events that are potentially relevant in explaining why clients present with emotional and behavioral problems. Mental health providers commonly inquire about a range of past events, such as child abuse and neglect; other forms of trauma; events and experiences such as divorce, family moves, and experiences at school or with peers; illness and hospitalization; and other relevant life experiences. This information is integrated with information derived from clinical observation and the results of assessment measures with respect to symptoms and behaviors. Except for what providers observe directly in session, nearly all the information that serves as the basis for an opinion about events and mental health problems is derived from self-reports. Reliance on self-reports, including reports of child abuse and neglect, is therefore a cornerstone of standard clinical practice.

Determination by the Legal System

Legal investigations.

Before a child abuse and neglect case arrives before a legal fact finder (judge or jury), an arm of the government investigates the case. Child protective services and law enforcement conduct the investigations that serve as the basis for the state's actions regarding dependency or prosecution. In many cases, the parents or defendants come to an agreement with the government, and no actual fact-finding hearing takes place. If it does, the official legal determination is made by civil or criminal court.

Child protective services usually is responsible for investigating civil dependency cases; such cases are screened in by the child welfare system, and they fall under the jurisdiction of the juvenile court. Given that the greatest number of reported cases involve neglect, and most do not involve criminal conduct, the child protective services investigation is the only process applied to making a determination about child abuse and neglect in the majority of cases. Caseworkers make home visits and observe the safety and hygiene status of the household; inspect bruises and injuries; and conduct interviews with children (when appropriate), caregivers, reporters, and others who may have relevant information (such as relatives, teachers, and health care providers). They then draw conclusions about whether the information and evidence thus obtained meet the legal standards for child abuse and neglect.

Law enforcement officials investigate crimes. They generally engage in the same activities as child welfare system caseworkers (e.g., interviewing victims and witnesses, examining home conditions); they may also collect evidence from crime scenes, undertake forensic analyses, and interrogate suspects. In many jurisdictions, child protective services and law enforcement officials conduct joint investigations ( Cross et al., 2005 ).

A key activity in many child abuse and neglect dependency and criminal investigations, especially in cases involving sexual abuse and some involving physical abuse, is interviewing the child. Interviewing methods most likely to lead to accurate and complete reports have been extensively investigated (e.g., Cronch et al., 2006 ; Lamb et al., 2009 ; Larsson and Lamb, 2009 ; Saywitz et al., 2002 ). The protocol of the National Institute for Child Health and Development (NICHD) is the approach that has been the most researched in real-life settings and in laboratory analogue experiments, and serves as the model for the current standard of practice ( Lamb et al., 2007 ). Other extant models, none of which has undergone the same level of empirical evaluation, share almost all the same procedures and practices as the NICHD protocol ( Anderson et al., 2010 ).

Legal Determinations

A legal determination of child abuse and neglect is based on the weighing of admissible evidence that is collected following the accepted procedures for the specific legal arena. The common law legal system in the United States is adversarial and is based on principles that protect the due process rights of those who are accused and risk loss of liberty, access to their children, or assets. The legal contexts vary by whether they are criminal or civil, the intended outcomes of the case, and the standard of proof that applies.

The two primary legal systems that make determinations about child abuse and neglect are the child protection system and the criminal justice system ( Myers, 2012 ). The child protection system carries out an administrative and civil justice process that involves the state's seeking to intervene in families, often but not always to assume temporary custody of children (e.g., establishing child abuse or neglect and then obtaining authority of the court for the child's placement) or in a small fraction of cases to terminate parental rights. In these court cases (often called dependency cases), the standard of proof typically is more probable than not; in a case involving termination of parental rights, a higher standard of clear and convincing evidence has been set by the U.S. Supreme Court. The goals of the criminal justice system are to hold lawbreakers accountable and punish them, to bring justice for victims, and to protect the community. The standard of proof here is the highest (beyond a reasonable doubt) because the case involves the government's restricting an adult's liberty, including the possibility of incarceration. Child abuse and neglect also may be addressed in family court custody matters when it is alleged by one parent seeking to restrict the other parent's access to the child. In addition, civil tort actions may be brought in which a child, or someone on his/her behalf, sues a caregiver, the government, or another entity for negligence, seeking monetary damages.

The large majority of both civil and criminal proceedings regarding child abuse and neglect do not progress to a formal fact-finding hearing or a trial. In many child protection cases, usually those not requiring a court order to remove a child from home against parental wishes, no formal legal process is even initiated; the family agrees to a voluntary service plan that is overseen by the state. Even when a dependency petition is filed in court, in the large majority of cases the parent reaches an agreement or case settlement regarding dependency, often without admitting to having committed an act of child abuse and neglect. On the criminal side, charges are not filed in many cases, even when prosecutors may believe a crime occurred, because of difficulties entailed in proving the case and in meeting the legal standard of proof of beyond a reasonable doubt. In the majority of cases when charges are filed, the accused pleads guilty to the crime or to a lesser crime.

Substantiation

The child protection system's classification of a child abuse and neglect case as substantiated is an administrative procedure for making a formal recorded determination about the validity of a child abuse and neglect report. In most states, the result of an investigation of a report is classified as substantiated or unsubstantiated, although some states use other terminology (e.g., founded/unfounded) to describe the investigative outcome. In 2011, approximately 19 percent of screened-in cases were substantiated, or “indicated” ( ACF, 2012 ). Substantiation can be legally disputed because the consequences of a substantiated report can be significant for caregivers (e.g., job loss or being barred from certain professions or by certain employers) ( CWIG, 2013 ; McCarthy et al., 2005 ).

No formal conclusion about whether child abuse and neglect occurred is recorded in cases that are referred for an alternative response (sometimes called a family assessment or differential response) and not formally investigated ( CWIG, 2013 ). In 2011, about 10 percent of all cases reported to NCANDS received an alternative response ( ACF, 2012 ), but that percentage is increasing. As of 2011, 17 states were implementing differential response at some level, and 6 states planned to implement it in the near future.

Rates of substantiation vary dramatically across states ( ACF, 2012 ), and there is little consensus on what accounts for this variation. Overall, every method used to determine the accuracy of child abuse and neglect allegations has weaknesses and cannot be considered definitive. To some extent, this does not matter as long as the victims are safe and receive needed services. For example, most crimes will not be reported or prosecuted or result in conviction of the perpetrator; however, crime victims will still have access to many services designed to help them recover from the effects of the crime, and most can take at least some steps toward protecting themselves from the perpetrator. Although child abuse victims are dependent on caregivers for future protection, many parents can and do take steps to protect their children from known perpetrators or correct their own neglectful or abusive behavior. In terms of access to needed services, what happens officially in a case is unrelated to receipt of services in the child welfare system. The National Survey of Child and Adolescent Well-Being, a large longitudinal study of a nationally representative sample of cases reported to child protective services, produced illustrative results. Comparisons of cases that were closed or kept open, or were substantiated or not, revealed no difference in key variables related to services or outcomes ( Hussey et al., 2005 ; Kohl et al., 2009 ).

The difficulty of ascertaining the validity of cases using official reporting or procedural outcomes may have more of an effect on research and interpretation of findings than on the lives of children who enter the child welfare system. For example, Kohl and colleagues (2009) argue that if substantiation does not discriminate true from untrue cases of child abuse and neglect, it is not a meaningful or accurate way of learning about the characteristics of actual abuse and neglect and its relationships to outcomes since the comparison group of unsubstantiated cases will contain many true cases. Therefore, child abuse research may benefit if consensus is achieved not only on definitions, but also on the meaning of different classification mechanisms for child abuse and neglect reports.

Finding: Significant advances have been made in dealing with children who may have been abused and neglected when they come in contact with medical, mental health, or social services professionals. It has become more common for these professionals to screen children routinely for abuse and other traumatic experiences. The children's accounts are generally accepted, at least for purposes of meeting the “reasonable suspicion” standard for making a child abuse report, except when there is significant evidence for coercion or contamination of their statements. Children who are suspected of being abused are commonly referred for specialized assessment, as well as clinical and support services. Finding: Overall, substantial improvements have been achieved in the assessment and investigative procedures for determining whether child abuse and neglect has occurred since the 1993 NRC report was issued. Widely accepted standards for proper interviewing have been adopted by child protective services, law enforcement officials, and forensic evaluators and are well known even among general health, mental health, and other professionals ( Lamb et al., 2007 ). Finding: Rates of substantiation of child abuse and neglect allegations by child protective services vary dramatically across states, and there is little consensus on what accounts for this variation. Overall, every method of determining the accuracy of child abuse and neglect allegations has weaknesses, and no method can be considered definitive. This limits the substantiation classification as a meaningful way to learn about the characteristics of actual abuse and neglect and their relationships to outcomes.

• CONCLUSIONS

Child abuse and neglect is a pervasive societal problem, with recent NCANDS data indicating that 3.4 million child abuse and neglect referrals involving 6.2 million children were made in a single year across the United States and its territories. As will be discussed in Chapter 4 , these incidents of child abuse and neglect entail a substantial risk for deleterious consequences that can hinder child development and lead to problems that persist across the life course.

Cases of child abuse and neglect are referred to child protective services based on mandatory reports by professionals such as teachers, law enforcement officials, social service providers, and physicians, as well as good-faith reports by citizens. Not all cases of child abuse and neglect are reported, and standards for reasonable suspicion of abuse and neglect are not always clear-cut. Therefore, official reports do not capture all cases in which child abuse and neglect is suspected or even is detected and acted upon. For research purposes, then, sole reliance on referral data from child protective services cannot capture the full scope of child abuse and neglect. Incorporating data from additional sources is necessary to determine the true incidence of the problem.

In addition, child abuse and neglect are defined differently for the varying purposes for which related information is collected, confounding attempts to portray the scope of the problem accurately or examine the surrounding circumstances. Results across studies based on surveys also may vary according to the survey methodology employed. Movement toward a reasonable degree of standardization in these areas is therefore needed.

Difficulties in ascertaining the scope of child abuse and neglect have contributed to uncertainties regarding whether the incidence of the problem is increasing or decreasing or cases are being detected and reported more frequently. Available trend data provide strong evidence that sexual abuse has declined substantially in the past two decades; the balance of evidence favors a decline in physical abuse, especially its more common and less serious forms. There is no evidence that neglect is declining overall. However, states vary significantly as to whether neglect is increasing, decreasing, or remaining constant. Discrepancies and ambiguity across analyses of different data sources highlight a need for more systematic empirical analyses of these trends over time. Research is needed to learn more about trends in child abuse and neglect and the variables that may account for decreases in the incidence of the problem or the lack thereof.

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42 U.S.C. § 5101 note.

42 U.S.C. § 52016a.

25 U.S.C. § 1169.

10 U.S.C. § 1787.

42 U.S.C. § 13001, et seq.

42 U.S.C. § 5106a(d).

• 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. 2, Describing the Problem.
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