83: Abuse and Neglect

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CHAPTER 83 Abuse and Neglect

OVERVIEW

Children and the elderly are particularly vulnerable to abuse and to neglect because of special needs that often require them to be dependent on others. This dependence may render them vulnerable to mistreatment by caregivers of all types. Psychiatrists need to understand how to diagnose and to respond to abuse and to neglect, both in the interest of providing sound clinical treatment to their patients and because of specific legal and ethical obligations that physicians have in the setting of abuse and neglect. In addition, notwithstanding increased attention to vulnerable populations, both the number of reports alleging mistreatment and the number of confirmed cases of abuse and neglect have increased in both children and the elderly.1 Furthermore, as the birth rate and average life expectancy continue to increase in the United States, the safety and welfare of these groups will increasingly pose major health, economic, and societal concerns. According to the United States Census Bureau, our nation’s youth will increase 8% between 1995 and 2015. As of 2005, individuals under age 18 made up approximately one-fourth of the United States population, or approximately 73.5 million children, an increase in the child population of more than 50% since 1950. Similarly, but to an even greater degree, between 1950 and 2000 the number of persons over age 65 increased by 188%, and this number is expected to increase an additional 36% between 1995 and 2015.24

Both federal and state laws address the abuse and neglect of children and the elderly. In 1974, Congress passed landmark legislation to provide federal support to aid in the battle against child mistreatment. In the federal Child Abuse Prevention and Treatment Act (CAPTA), the federal government provided states with federal funding for the prevention and treatment of child abuse. This funding was conditional on the states adopting mandatory reporting laws.5 Currently, all states have mandatory reporting statutes for child abuse and neglect that require certain groups of professionals (such as physicians, day care providers, and teachers) to notify authorities when they become aware that a child may be the victim of abuse or neglect. However, each state provides its own definition of child abuse and neglect, and states have differences as to who must report and the circumstances under which the report must be made.6

By comparison, legislation to protect the elderly from mistreatment grew from the child protection system. Federal interest to protect this population first appeared in the 1960s when legislation was created to protect those adults seen as defenseless and susceptible to being harmed by others. In 1962, bearing some similarity to the earlier parens patriae (or state as parent) authority of the state to protect helpless citizens, Congress passed Public Welfare Amendments to the Social Security Act.7 These Amendments authorized payments to the states to establish protective services for “persons with physical and/or mental limitations, who were unable to manage their own affairs.…or who were neglected or exploited.”8

Twelve years later, in 1974, the Title XX amendment to the Social Security Act established Adult Protective Services (APS) as a state-mandated program with umbrella coverage for all adults age 18 years and older.9 The funding for these protective services was earmarked from social services block grants (SSBGs) given by the federal government to the states, which had been used exclusively for child social protective services. This legal change marked the beginning of heightened focus on elder care and protection.

In the 1970s a series of major scandals about nursing home quality gave rise to both congressional and state investigations and further focused attention on the protection of the elderly. Legislative changes at the state level ensued. By 1985, 46 states designated a responsible agency for elder protective services. In 1998, the current National Center on Elder Abuse (NCEA) was established.8 State agencies and national professional organizations have established numerous guidelines and reference sources to assist in the detection, intervention, monitoring, and treatment of both child and elder abuse and neglect. The American Psychiatric Association (APA), American Medical Association (AMA), National Center on Child Abuse and Neglect (NCCAN), National Center on Elder Abuse (NCEA), and state social service agencies are some of the groups that have provided extensive information to address abuse and neglect in these populations. Every state, every United States territory, and the District of Columbia now have laws governing child and elder abuse and neglect. While the minimum standards for defining abuse and neglect are federally mandated, individual states may develop their definitions and standards regarding abuse and neglect, so long as they exceed the federal standard.6,7 For example, in some states, voluntary reporting is permitted for some entities. However, in every state, reporting is mandatory for professional caregivers (including doctors, nurses, therapists, and social workers). Every state has laws that require physicians to report suspected abuse or neglect, and in some states suspicion of abuse or neglect alone, or “reasonable grounds,” is sufficient to trigger the duty to report. It is critical that physicians and other mental health providers familiarize themselves with the specific standards and requirements for mandated reporting in every jurisdiction in which they practice. For example, some physicians and mental health clinicians may feel that reporting a caregiver or a child’s parents might pose difficulties in terms of the therapeutic alliance. These professionals may be tempted to try to work with these families before notifying state social services. It is important to note that doing so can leave mandated reporters vulnerable to legal prosecution for failure to file a timely report and to civil liability for failure to protect a patient from harm by delaying a mandated report.10 Finally, many state laws grant immunity to physicians who report in good faith, thereby minimizing exposure to liability for reporting abuse and neglect.11

CHILD ABUSE AND NEGLECT

Types of Maltreatment

The federal Child Abuse Prevention and Treatment Act (CAPTA) provides minimum standards for the definition of child abuse and neglect. Under CAPTA, which was recently amended by the federal Keeping Children and Families Safe Act of 2003, child abuse and neglect is defined as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.”12 The federal definition in CAPTA has been the subject of many different interpretations. Specifically, there are many competing approaches to how this legislation should be applied and incorporated into state law. For example, certain states define child abuse and neglect as a single concept whereas others consider abuse and neglect as different entities that require separate definitions. In addition, the standard for what constitutes abuse can also vary among states. Despite these jurisdictional differences, abuse is most often defined by states as “harm or substantial risk of harm” or “serious threat or serious harm” to a child.6 For example, the state of Massachusetts defines child abuse as “physical or emotional injury.…which causes harm or substantial risk of harm to the child’s health or welfare including sexual abuse, or from neglect, including malnutrition, or who is determined to be physically dependent upon an addictive drug at birth.”13,14 As mentioned previously, each state can determine the grounds for intervention to protect a child, but there are common trends among states. For example, a “child” is generally defined as a person who is under age 18 and not an emancipated minor. Emancipation status is not available in every state, but, in the majority of states in which it is, emancipation is a legal status that allows minors to attain the rights of legal adulthood, provided certain criteria are met, before the age at which they would normally be considered adults. Twenty-eight states provide emancipation status and 22 states do not. (States with some form of emancipation status are Alabama, Alaska, California, Colorado, Connecticut, Florida, Hawaii, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Dakota, Virginia, Washington, West Virginia, and Wyoming.) For example, in some states a child who is married, a parent, or in the armed forces can be considered emancipated.15 It is important to review the relevant statutes specific to each state of practice to know which criteria apply.

Physical Abuse

Worldwide, definitions of what constitutes physical abuse vary among (1) individual country, state, or jurisdiction; (2) cultural norms; and (3) biological predispositions. When physical abuse is suspected, it is important to consider the cultural and ethnic influences that may validate different interpretations of abuse.16,17

In the United States, Dr. C. Henry Kempe’s landmark 1962 publication18 coined the term battered child syndrome. Kempe described findings consistent with a pattern of abuse that included the existence of multiple bone fractures in different stages of healing that were suggestive of child maltreatment.18 Since that time, the types of physical findings linked to nonaccidental injuries have grown dramatically in scope and the methods of detection have become increasingly sophisticated. Even with increased knowledge and diagnostic abilities, one of the most common methods used to screen for the presence of physical abuse remains a discrepancy between the physical findings and the parent’s or caregiver’s explanation of the mechanism of injury.19 The identification of inconsistencies between the report provided and the objective data on physical examination are important as evidence that the stories given do not reflect reality and that injuries may be sustained as the result of intentional infliction rather than by accidental means.

Emotional Abuse

Mental injury to a child can have pervasive and long-term effects on a child’s development. It is important to recognize that emotional abuse may accompany physical abuse, sexual abuse, or neglect, but may also occur entirely independent of other forms of maltreatment. To date, 48 states include emotional maltreatment within their definition of child abuse.20 (Georgia and Washington do not include emotional abuse in their statutory definitions.) Emotional abuse has been defined by a number of national organizations, including the AMA, the American Academy of Pediatrics, the United States Department of Health and Human Services, and the National Center on Child Abuse and Neglect. According to the American Academy of Pediatrics Committee on Child Abuse and Neglect, emotional abuse is defined as “psychological maltreatment.…[from] a repeated pattern of damaging interactions between parent(s) and child that becomes typical of the relationship.”20,21 In some situations the pattern is chronic and pervasive, whereas in others these damaging interactions occurs only in the setting of specific triggers or “potentiating factors.”22 Overall, emotional maltreatment occurs “when a person conveys to a child that he or she is worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another’s needs. The perpetrator may spurn, terrorize, isolate, ignore, or impair the child’s socialization.”6 Psychological maltreatment assaults a child’s emotional, social, and basic human development. Gabarino and others have described forms of psychically destructive behavior inflicted by an adult on a child and the ways these types of emotional abuses may manifest from a developmental perspective.23,24

Emotional abuse can be manifest in a variety of ways (Table 83-1).2528 Although emotional abuse has been studied and characterized, the text revision of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) does not include a diagnosis for emotional abuse. The DSM-IV-TR instead specifies five “problems” that may arise “related to abuse or neglect”: (1) physical abuse of a child, (2) sexual abuse of a child, (3) neglect of a child, (4) physical abuse of an adult, and (5) sexual abuse of an adult. Another DSM-IV-TR diagnosis that may be encountered when dealing with children who are victims of abuse and neglect is “Reactive Attachment Disorder of Infancy or Early Childhood.” According to the DSM-IV-TR, this is defined as “markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years.…pathogenic care as evidenced by.…persistent disregard of the child’s basic emotional needs.…disregard of the child’s basic physical needs.…and/or repeated changes of primary caregiver that prevent formation of stable attachments.”29 Despite the fact that emotional abuse can lead to long-term harm, it is often difficult to substantiate suspicions or allegations of emotional abuse. Specifically, the damage suffered by the child may not be as apparent as can the outwardly visible signs of physical abuse. Some states therefore require that a psychiatric or psychological diagnosis be linked to the alleged emotional abuse in order to establish a causal connection between the child’s disorder and the wrongful behavior by the parent or the caregiver.

Table 83-1 Manifestations of Emotional Abuse

Neglect

According to the most recent data report from the National Child Abuse and Neglect Data System (NCANDS), neglect is the most common form of child maltreatment reported to state protective services. More children suffer from neglect than from physical and sexual abuse combined.30 Despite the fact that neglect makes up approximately half of all reported cases of child mistreatment in the United States, it receives less consideration in the literature and the media as compared to physical and sexual abuse. Part of the reason that child neglect receives disproportionately less attention than abuse may be related to difficulties in defining what constitutes neglect. Neglect is generally defined as deprivation of adequate clothing, food, medical attention, or shelter, or a failure to provide other needed age-appropriate care. Although the federal government, through CAPTA, provides minimum standards for child neglect, as in the case of child abuse, states have operationalized the federal standard by implementing definitions that vary widely. That being said, neglect is generally considered as an act of omission rather than one of commission and most definitions incorporate the concept of nonprovision of, or inability to provide, adequate care.31,32

Other generalizations may be drawn from state laws about neglect. For example, neglect is typically broken down into five main categories: emotional neglect, physical neglect, medical neglect, failure to thrive (FTT), and educational neglect. Like emotional abuse, neglect is more difficult to identify than is physical abuse because the more easily identified stigmata of scars, marks, or bruises are often not present. In the absence of demonstrable evidence of harm in settings of neglect, it is often difficult for child protective services to intervene since intervention requires such evidence.