Child abuse and neglect are an unfortunate reality for many children in our community. The past thirty years have witnessed a growth in our awareness of and attention to the problems faced by children exposed to violence in their homes. The consequences of maltreatment can be devastating. For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive, and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attentional problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations all the way to extraordinarily violent behaviors. Thus, the consequences of abuse and neglect affect the victims themselves and the society in which they live.
REVIEW OF DEFINITIONS
A 1989 conference convened by the National Institute of Child Health and Human Development recommended that maltreatment be defined as “behavior towards another person, which (a) is outside the norms of conduct, and (b) entails a substantial risk of causing physical or emotional harm. Behaviors included will consist of actions and omissions, ones that are intentional and ones that are unintentional” (Christoffel et al., 1992). The term child maltreatment refers to a broad range of behaviors that involve risk for the child. Four general categories of child maltreatment are now generally recognized: (1) physical abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category, in turn, covers a range of behaviors. Physical abuse includes scalding, beatings with an object, severe physical punishment, and a rare form of the abuse called Munchausen by proxy, wherein an adult will feign or induce illness in a child in order to attract medical attention and support. Sexual abuse includes incest, sexual assault by a relative or stranger, fondling of genital areas, exposure to indecent acts, sexual rituals, or involvement in child pornography. Child neglect is the presence of certain deficiencies in caretaker obligations (usually the parent, although neglect can be found in residential centers or foster care homes) that harm the child’s psychological and/or physical health. Child neglect covers a range of behaviors including educational, supervisory, medical, physical, and emotional neglect, and abandonment, often complicated by cultural and contextual factors. Several authors (Mrazek and Mrazek, 1985; Zuravin, 1991) have noted the relative lack of attention to definitional issues of child neglect, particularly given its greater reported prevalence (NCCAN, 1981, 1988b; Wolock and Horowitz, 1984). Emotional maltreatment, a recently recognized form of child victimization, includes such acts as verbal abuse and belittlement, symbolic acts designed to terrorize a child, and lack of nurturance or emotional availability by caregivers.
Effects of child abuse and neglect
Physical Health Consequence
The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. According to the National Survey of Child and Adolescent Well-Being (NSCAW), more than one-quarter of children who had been in foster care for longer than 12 months had some lasting or recurring health problem (Administration for Children and Families, Office of Planning, Research and Evaluation [ACF/ OPRE], 2004a). Below are some outcomes researchers have identified:
Shaken baby syndrome: Shaking a baby is a common form of child abuse. The injuries caused by shaking a baby may not be immediately noticeable and may include bleeding in the eye or brain, damage to the spinal cord and neck, and rib or bone fractures (National Institute of Neurological Disorders and Stroke, 2007).
Impaired brain development: Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006). NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/ OPRE, 2004a).
Poor physical health: Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).
The immediate emotional effects of abuse and neglectaa‚¬”isolation, fear, and an inability to trustaa‚¬”can translate into lifelong consequences, including low self-esteem, depression, and relationship difficulties. Researchers have identified links between child abuse and neglect and the following:
Difficulties during infancy: Depression and withdrawal symptoms were common among children as young as 3 who experienced emotional, physical, or environmental neglect (Dubowitz, Papas, Black, & Starr, 2002).
Poor mental and emotional health: In one long-term study, as many as 80 percent of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21. These young adults exhibited many problems, including depression, anxiety, eating disorders, and suicide attempts (Silverman, Reinherz, & Giaconia, 1996). Other psychological and emotional conditions associated with abuse and neglect include panic disorder, dissociative disorders, attention-deficit/ hyperactivity disorder, depression, anger, posttraumatic stress disorder, and reactive attachment disorder (Teicher, 2000; De Bellis & Thomas, 2003; Springer, Sheridan, Kuo, & Carnes, 2007).
Cognitive difficulties: NSCAW found that children placed in out-of-home care due to abuse or neglect tended to score lower than the general population on measures of cognitive capacity, language development, and academic achievement (U.S. Department of Health and Human Services, 2003). A 1999 LONGSCAN study also found a relationship between substantiated child maltreatment and poor academic performance and classroom functioning for school-age children (Zolotor, Kotch, Dufort, Winsor, & Catellier, 1999).
Social difficulties: Children who experience rejection or neglect are more likely to develop antisocial traits as they grow up. Parental neglect is also associated with borderline personality disorders and violent behavior (Schore, 2003).
Not all victims of child abuse and neglect will experience behavioral consequences. However, behavioral problems appear to be more likely among this group, even at a young age. An NSCAW survey of children ages 3 to 5 in foster care found these children displayed clinical or borderline levels of behavioral problems at a rate more than twice that of the general population (ACF, 2004b). Later in life, child abuse and neglect appear to make the following more likely:
Difficulties during adolescence: Studies have found abused and neglected children to be at least 25 percent more likely to experience problems such as delinquency, teen pregnancy, low academic achievement, drug use, and mental health problems (Kelley, Thornberry, & Smith, 1997). Other studies suggest that abused or neglected children are more likely to engage in sexual risk-taking as they reach adolescence, thereby increasing their chances of contracting a sexually transmitted disease (Johnson, Rew, & Sternglanz, 2006).
Juvenile delinquency and adult criminality: According to a National Institute of Justice study, abused and neglected children were 11 times more likely to be arrested for criminal behavior as a juvenile, 2.7 times more likely to be arrested for violent and criminal behavior as an adult, and 3.1 times more likely to be arrested for one of many forms of violent crime (juvenile or adult) (English, Widom, & Brandford, 2004).
Alcohol and other drug abuse: Research consistently reflects an increased likelihood that abused and neglected children will smoke cigarettes, abuse alcohol, or take illicit drugs during their lifetime (Dube et al., 2001). According to a report from the National Institute on Drug Abuse, as many as two-thirds of people in drug treatment programs reported being abused as children (Swan, 1998).
Abusive behavior: Abusive parents often have experienced abuse during their own childhoods. It is estimated approximately one-third of abused and neglected children will eventually victimize their own children.
While child abuse and neglect almost always occur within the family, the impact does not end there. Society as a whole pays a price for child abuse and neglect, in terms of both direct and indirect costs.
Direct costs: Direct costs include those associated with maintaining a child welfare system to investigate and respond to allegations of child abuse and neglect, as well as expenditures by the judicial, law enforcement, health, and mental health systems.
Indirect costs: Indirect costs represent the long-term economic consequences of child abuse and neglect. These include costs associated with juvenile and adult criminal activity, mental illness, substance abuse, and domestic violence. They can also include loss of productivity due to unemployment and underemployment, the cost of special education services, and increased use of the health care system.
Possible Treatment Strategies
Descriptions of treatment for child sexual abuse, physical abuse, and neglect have been reported separately within the literature, with much more attention paid to treatment of child sexual abuse. In fact, there are relatively few studies or reports of individual treatment of the physically abused or neglected child. In practice, however, treatment programs often address individual needs of children. The emphasis here is cognitive behavioral treatments, as these have shown the greatest effects in controlled studies.
General Issues for Treatment
First and foremost, it is important that the child be safe from potential harm from the offender as well as from non-believing or unsupportive family members. In addition to ethical issues of treating a child within an unsafe environment, treatment of abuse related problems is not likely to be effective if the child is living in such conditions.
The targets for treatment are determined to a large degree by the child’s presenting symptoms and are defined following the initial assessment. There are, however, certain overriding goals that should guide the treatment process. Treatment should be directive and focused on the abuse or trauma itself.
Help and encourage the child to talk and think about the abuse/neglect without embarrassment or significant anxiety.
Help the child to modulate and express feelings about the abuse;
Reduce the intensity and frequency of behavioral and emotional symptoms;
Clarify and change distorted, inaccurate, or unhealthy thinking patterns that might negatively affect the child’s view of self and others;
Help the child develop healthier attachments;
Strengthen the child’s coping skills
Enhance social skills, and
Educate the child regarding self-protective strategies.
An additional goal, accomplished specifically through group therapy is to reduce the child’s sense of isolation or stigma through exposure to other victims of abuse. Group treatment for victims of child physical abuse can have positive effects but may also be associated with increased behavior problems. Therefore the therapist should be cautious and monitor group participants’ behavior closely (Kolko & Swenson, 2002).
Strategies for treating the abused child are varied and are used as appropriate to the child’s presenting problems. Recommended treatment approaches include (Finkelhor & Berliner, 1995): 1) cognitive-behavioral strategies, 2) graduated exposure to aspects of the abusive experience, 3) relaxation training , 4) education regarding abuse process and effects of abuse, 5) skills training, 6) supportive strategies teaching self-protective strategies, 7) behavioral strategies/parent training.
Strategies for treating abuse victims which have received some scientific support, have been those derived from a cognitive behavioral perspective and which focus on the abuse itself. Cognitive behavioral strategies typically address the child’s thinking patterns, affective response, and behavioral reactions to the abuse. In particular, the child’s attributions of blame and responsibility for the abuse should be addressed. That is, the child should be helped to recognize that it is adults rather than children who are responsible for healthy parent-child interactions (Finkelhor & Berliner, 1995). Gradual exposure or discussion of abuse experiences helps to reduce the child’s anxiety and embarrassment and provides opportunities to modify inaccurate or self-defeating thinking processes. Relaxation training further addresses the child’s fear or anxiety reaction to abuse-related cues and can facilitate more effective affect regulation. Educational approaches facilitate clarification of misperceptions developed in response to the abuse. Skills training are used to teach the child coping strategies to manage negative emotions and to improve social/interpersonal functioning. Supportive techniques also are required, as the child may be coping with non-supportive family members, upcoming court proceedings, and/or negative reactions from peers.
Education in the use of self-protective strategies is important for minimizing the likelihood that the child will be abused/neglected again (Finkelhor & Berliner, 1995). It is important to establish a safety plan within the home, delineate danger cues, and identify support persons in the child’s environment to decrease the secrecy within previously abusive/neglectful families. This, in turn, is expected to minimize the risk of repeated abuse.
The treatment approach should be appropriate to the age of the child. For example, a four year old child should not be expected to come into a therapist or counselor’s office, sit on a couch, and recount the details of her abuse. The therapist can utilize a variety of play techniques to encourage the young child to communicate about his or her abuse. Many cognitive behavioral strategies which are used with adolescents and adults can be modified or simplified for use with young children (Kolko & Swenson, 2002). For example, there are numerous scripts for relaxation training which are humorous and which engage the child in the therapeutic process. Puppets and drawings are useful as well for helping children to tell of their experiences, learn strategies for coping with negative emotions, and behaving in a more organized and directed manner.
In contrast, older children and adolescents are more able to directly communicate their thoughts and feelings about their abuse experiences. It is recommended, however, that the therapist be flexible in method of approach. Drawings, therapeutic stories, and therapeutic games can be very helpful for engaging children of all ages.
There are no clear guidelines regarding the length of treatment for the abused or neglected child, although most studies of treatment effectiveness have examined short-term interventions. Clinical experience suggests that while some children can resolve their negative reactions to the abuse in a relatively brief period (i.e., 12 – 16 sessions), many will require more extended treatment. Typically, treatment length will be determined by the nature of the child’s social, behavioral, or emotional difficulties. That is, the child who is experiencing a wide array of problems of a serious nature is likely to require more intensive treatment over a long period of time. In addition, the quality of support that the child is receiving from the non-offending caregiver or other family members will affect treatment length. That is, child problems are typically more significant if there is no support coming from the non-offending caregiver, and, therefore, treatment of the child whose non-offending parent is disbelieving or non-supportive is likely to be more extensive than that of a child who has the support of a non-offending parent. Additional treatment approaches
Family involvement in treatment
Children should not be treated in isolation of intervention with their family and/or current living situation. Thus, many in the field recognize the importance of incorporating family members, particularly parents or primary caregivers, into treatment addressing abuse and neglect (Kolko & Swenson, 2002). The goal of family work is to reduce the risk of recurring abuse, increase safety, and promote healthy growth and development of all family members. Family approaches address the needs of all family members while also targeting the interactions between them. However, it is difficult to specify the precise structure of therapeutic work addressing family issues. The specific approach with the family will vary; depending upon the child’s living context and the level of acknowledgement of abuse by offender(s) and non-offending caregiver(s). For example, a child who has been placed in foster care due to parent-child abuse and lack of a supportive non-offending caregiver will be addressing different issues than the child who is receiving support from a non-offending caregiver and/or whose abusive parent is acknowledging abuse and is committed to treatment. Family work is not indicated if the child is in out-of-home placement and there are no plans for reunification.
Treatment involving the entire family and that has as a goal family reunification is generally of a much longer duration than individual treatment of the child. Initial stages involve the child, offender, and non-offending caregiver in individual treatment, allowing members to first address individual issues related to the development and outcomes of the abuse. In addition, marital work is recommended to address relational issues between the child’s caregivers prior to any reunification efforts. If early work with caregivers is successful, family therapy may ensue. The clarification session can serve as the bridge between each family member’s individual treatment and treatment addressing the entire family’s needs.
Therapeutic interventions with caregivers typically begin with individual sessions addressing the abuse itself, as well as the specific needs of family members. These stages of treatment encourage assumption of responsibility by the offender and non-offending caregiver(s). An alleged perpetrator who is denying having abused the child or a non-offending parent who does not believe that abuse has occurred cannot fully benefit from abuse-specific treatment. Therefore, initial treatment efforts focus on reducing denial. If such efforts fail, family treatment is contraindicated.
If the offender is acknowledging having abused and/or neglected the child, then he or she can engage in abuse-specific treatment that addresses faulty thinking patterns, behavioral actions, emotional responses, and physiologic reactions. Sexual abuse offenders will be targeting their sexual arousal to children, thought patterns which allow them to justify perpetrating sexual abuse, and examining the behavioral repertoire that lead up to abuse. Physical abuse offenders will learn strategies for managing anger, parenting skills, and non-physical means of discipline. Caregivers who are neglectful will receive assistance in securing basic goods and resources, will learn parenting strategies and be taught skills which facilitate independent management of the children and family’s needs.
In the treatment of all forms of abuse it is important to address attributions of blame. Invariably child abuse/neglect offenders minimize their own responsibility for the abuse/neglect and project blame on other family members, most often the victim. The abuse clarification process (Lipovsky et al., 1998), which addresses such attributions, should be included in treatment if at all possible. The abuse clarification involves an acknowledging offender who has proceeded through treatment to a sufficient degree to be able to clarify the nature of the abuse, assume responsibility for the abuse, demonstrate empathy for the child’s responses to the abuse, and begin to participate in the development of a family safety plan. The abuse clarification process is addressed in the offender’s individual or group treatment and is ongoing, often for many months before an abuse clarification session is possible. The abuse clarification session provides the opportunity for the offender to read a letter written to the child victim that focuses on the offender’s assumption of responsibility, empathy for the child, and commitment to developing the family safety plan. This session is likely to occur some months after the abuse are disclosed, allowing the offender sufficient opportunity to engage in and progress in his/her own treatment.
Ideally, at least one supportive adult should be included in the treatment process. Several programs around the country have targeted non-caregivers parents in their approach to treating child sexual abuse and have found success with such an approach.16, 32, 50 Treatment with non-offending caregivers also must also be built upon a foundation of acknowledgement that abuse has occurred. In most cases, where non-offending caregivers believe and support their child, family work addresses the caregiver’s individual needs. Early treatment strategies must address denial if it is present.
Treatment of the non-offending caregiver(s) addresses his/her emotional responses to the abuse and individual mental health needs. In addition, treatment includes focus on the caregiver’s responses to the child’s abuse, education regarding the child’s symptoms and provides assistance for developing strategies for reducing these symptoms.
It is recommended that the non-offending parent be involved in an abuse protection clarification (Wilson & Ralston, 1995). This process is similar to the abuse clarification conducted with the offender. The protection clarification involves clarification of the abuse, commitment to protection of the child, and participation in the development of a family safety plan. The protection clarification may be initiated relatively early in treatment, especially if the non-offending parent believes and supports the child from the time of disclosure.
Long-term family resolution of parent-child abuse is a life-long process and involves changing many aspects of family functioning. Some type of resolution must occur in all cases, regardless of whether the child or offender has been removed from the home. Resolution may take the form of helping a child adjust to permanent foster care and cope with a non-supportive family or may involve reunification of the family following the successful completion of individual/group treatment, the clarification process, and family therapy which addresses a safety plan, alteration of family member’s rigid patterns of thinking and behaving (Saunders & Meinig, 2000).
Home-Based Services and Family Preservation Services
Home-based services and family preservation services address the overall needs of families, include both children and parents, and focus directly on contextual factors, such as poverty, single parenthood, and marital discord, that increase stress, weaken families, and elicit aggressive behavior (Kolko, in press). These programs target functional relationships among diverse individual, family, and systemic problems by combining traditional social work with various therapeutic counseling approaches.
The use of home-based services has been advocated in response to the multiple problems found among abusive and neglectful families, difficulties in providing services in a traditional format, and interests in reducing the number of children placed in foster care. The breadth of potential family dysfunction has encouraged hands-on approaches that address risk factors at multiple levels of the family system, such as financial problems, disruption, social isolation, and behavioral deviance (Frankel, 1988).
Self-Help Services for Abusive Adults
Self-help support and treatment programs are based on the premise that individuals can benefit from learning about the victimization experiences of others. These programs have attracted popular support in a wide range of health services, including the treatment of alcoholism, weight loss, and rape counseling programs, and they have also been applied in the treatment of both physically and sexually abusive adults.. A self-help component has also been integrated into treatment programs for intra-familial sexual abuse (Giaretto, 1982).
Most parental enhancement programs focus on training abusive parents in child management (e.g., effective discipline), childrearing (e.g., infant stimulation), and self-control skills (e.g., anger control). Programs for neglectful parents typically focus on areas such as nutrition, homemaking, and child care. Parental enhancement programs may help some families who experience child management problems when a sexually abusive father is removed from the home. In these cases, child management skills help develop positive child- parent interaction in sexually abusive families.
The efficacy of parent training approaches for physically abusive parents has been supported by various single-case studies, one study using repeated measures, and group design studies (Azar and Twentyman, 1984; Crimmins et al., 1984; Gilbert, 1976; Jeffrey, 1976; Reid et al., 1981; Szykula and Fleischman, 1985; Wolfe et al., 1981a,b, 1982). Studies of multiple approaches and diverse populations have provided consistent evidence that parents can acquire behavioral skills and use them in interactions with their children, at least in clinical settings (Golub et al., 1987). Some evidence suggests that training has reduced parental distress or symptomatology and, in some instances, improved child functioning (Wolfe et al., 1988) and reduced the likelihood of child placement (Szykula and Fleischman, 1985). Efforts to expand the scope of parental enhancement programs have fostered attention to parents’ cognitive-attributional and affective repertoires (see Azar and Siegel, 1990). Therapeutic directions highlight the need to incorporate diverse skills and to evaluate the effectiveness of individual approaches (see Azar and Wolfe,1989).
Psychopharmacologic treatment for child victims
Medications may be used with child victims of abuse and neglect who are experiencing post-traumatic stress disorder (PTSD). A number of medications may be of use, though the state of our knowledge about which are most appropriate for use in children is limited. Some have recommended that the use of medication may be reserved for those children who do not show improvement with cognitive-behavioral treatments for PTSD. Children experiencing other types of behavioral or emotional difficulties, including depression, anxiety, or attentional problems also can benefit from pharmacologic treatment. In all cases, the choice of medications is determined by psychiatrist through a careful assessment.
Family Income and Supplemental Benefits
The relationship of poverty to child maltreatment, specifically child neglect, is thought to be significant. Several government programs designed to alleviate or mitigate the effects of poverty on children are often part of a comprehensive set of services for low-income, maltreating families. Such programs include Social Security supplemental income programs, Aid to Families with Dependent Children (AFDC), Women with Infants and Children food supplement program (WIC), Head Start, rent subsidy programs, and school lunch programs, among others.
Gil (1970) has stated that almost 60 percent of families reported for incidents of abuse and neglect received aid from public assistance agencies during or prior to the study year. However, while national and local child welfare programs designed to improve the well-being of all poor families may provide food, shelter, and other necessary resources, for children in households characterized by neglect or abuse, the relationship between income support, material assistance, and the subsequent reduction of maltreatment has not been systematically addressed.
Medical, psychological, social, and legal interventions in child maltreatment cases are based on assumptions that such interventions can reduce the negative physical, behavioral, and psychological consequences of child abuse and neglect, foster attitudes and behaviors that improve the quality of parent-child interactions and limit or eradicate recurrences of maltreatment. Interventions have been developed in response to public, professional, legal, and budgetary pressures that often have competing and sometimes contradictory policies and objectives. Some intervention services focus on protecting the child or protecting the community; others focus on providing individual treatment for the child, the offender, or both; others emphasize developing family coping strategies and improving skills in parent-child interactions. Assumptions about the severity of selected risk factors, the adequacy of caretaking behaviors, the impact of abuse, and the steps necessary to prevent abuse or neglect from recurring may vary given the goals and context of the intervention. Little is known about the character and effects of existing interventions in treating different forms of child maltreatment. No comprehensive inventory of treatment interventions currently exists, and we lack basic descriptive and evaluative information regarding key factors that influence the delivery and outcomes of treatment for victims and offenders at different developmental stages and in different environmental contexts. A coherent base of research information on the effectiveness of treatment is not available at this time to guide the decisions of case workers, probation officers, health professionals, family counselors, and judges. Investigations of child maltreatment reports often influence the development and availability of other professional services, including medical examinations, counseling, evaluation of risk factors, and substantiation of complaints.
Administration for Children and Families, Office of Planning, Research and Evaluation. (2004a). Who are the children in foster care? NSCAW Research Brief No. 1. Retrieved August 9, 2007, from the National Data Archive on Child Abuse and Neglect website: www.ndacan. cornell.edu/NDACAN/Datasets/Related_Docs/NSCAW_Research_Brief_1.pdf