Chapter 12 Child Abuse and Neglect
PATHOPHYSIOLOGY
The Federal Child Abuse Prevention and Treatment Act, as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as, at a minimum, “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” There are four major types of abuse: physical abuse, sexual abuse, emotional abuse (psychologic, verbal, or mental injury), and child neglect. It is of interest to note that emotional abuse is almost always present when other forms are identified. The most recent research suggests several other types or subcategories of maltreatment, including congenital child abuse, sibling abuse, and child abandonment.
Child maltreatment crosses all areas of society and all cultural, racial or ethnic, religious, socioeconomic, and professional groups. It is most common, however, among adolescent parents and in low-income families. Risk factors and statistics associated with child maltreatment are categorized as they relate to parents, children, families, and the environment.
Perpetrators of child maltreatment are the persons responsible for a child’s well-being, such as parents or caretakers, who have abused or neglected the child. Maltreating parents consistently report having been physically, sexually, or emotionally abused or neglected as children. However, not all maltreated children grow up to be abusive parents. Approximately 80% of perpetrators are parents. Other relatives account for 6%, and unmarried partners of parents account for 4% of perpetrators. The remaining perpetrators include persons with other relationships (e.g., camp counselor, school employee) or unknown relationships to the child victims. Common characteristics identified in abusive parents include low self-esteem, low intelligence, social isolation, depression, low frustration tolerance, immaturity, lack of parenting and/or coping skills, lack of knowledge of child development, marital problems, single or adolescent parenthood, closely spaced pregnancies, substance abuse, physical illness, and criminal behavior.
A number of characteristics have been associated with children who are victims of abuse. Children at greater risk for abuse are those who are born prematurely and/or with congenital anomalies or who have difficult-to-soothe temperaments, frequent illness, or special needs. Children from birth to 3 years of age are at highest risk for physical abuse. Girls are slightly more likely to be victims than boys (52% to 48% of victims). Children are consistently vulnerable to sexual abuse from age 3 years and up. More recently, public attention has been directed to recognizing the vulnerabilities that youth may encounter with adult sexual predators through the Internet and from adult authority figures in schools, social organizations, and even religious institutions. Pacific Islander, American Indian, Alaska Native, and African-American children have the highest rate of victimization according to the national population.
Some known characteristics are associated with families at high risk for abusing children. Children in single-parent families had a 77% higher risk of physical abuse, an 87% higher risk of physical neglect, and an 80% higher risk of serious injury or harm from abuse or neglect than children living with both parents. Children in the largest families were physically neglected nearly 3 times more often than those from single-child families. Children from families with annual incomes below $15,000 were more than 22 times more likely to suffer some form of maltreatment as defined by the Harm Standard and more than 25 times more likely to experience some form of maltreatment as defined by the Endangerment Standard than were children from families with annual incomes above $30,000. Harm Standard refers to child maltreatment as identification of children who have experienced observable harm; endangerment standard refers to child maltreatment as identification of children based on risk for being harmed.
Children from the lowest-income families were 18 times more likely to be sexually abused, almost 56 times more likely to be educationally neglected, and over 22 times more likely to suffer serious injury as defined by the Harm Standard than were children from higher-income families. Children living in the same home for less than 2 years and living in the same community less than 5 years have a 60% higher risk of being abused.
Environmental factors related to child abuse include ethnic and/or racial prejudices, poor living conditions, lack of community and family resources, poor access to health care and follow-up services, economic pressure, varied cultural beliefs concerning the role of the child in the family, and varied cultural attitudes toward use of physical punishment. Ineffective child protection laws are another culprit in the environment. Studies have shown that nearly half of the children killed by caretakers are killed after they come to the attention of the child welfare service. Keeping the family intact may no longer be the goal if maltreatment is significant.
INCIDENCE
1. In 2003, child protective services investigated more than 2.9 million reports alleging maltreatment of more than 5.5 million children.
2. Two thirds (68%) of these reports prompted investigations, which resulted in the identification of 906,000 victims.
3. An estimated 1500 child maltreatment fatalities occurred in the 50 states and the District of Columbia in 2003. Children younger than 1 year of age accounted for 44% of all deaths, and 79% of child fatalities were in children younger than 4 years of age.
4. More than half of all victims (60%) suffered neglect (including medical neglect), 20% suffered physical abuse, and about 10% of victims were sexually abused. Victims of emotional maltreatment accounted for 5% of all victims. Other types of maltreatment including abandonment, congenital drug addiction, and threats to harm the child accounted for 16% of victims. (Percentage totals are higher than 100% because some children suffered multiple types of abuse.)
5. Sexual abuse is most common among girls, stepfamilies, and children living with one parent or a primary caregiver who is an unrelated male.
6. Abuse occurs in 11 per 1000 white, 21 per 1000 Pacific Islander, 21 per 1000 American Indian and Native Alaskan, and 20 per 1000 African-American children.
CLINICAL MANIFESTATIONS
See Box 12-1 for a list of the clinical manifestations of child abuse.
Box 12-1 Clinical Manifestations of Child Abuse and Neglect
Skin Injuries
Skin injuries are the most common and easily recognized signs of maltreatment in children. Human bite marks appear as ovoid areas with tooth imprints, suck marks, or tongue-thrust marks. Multiple bruises or bruises in inaccessible places are indications that the child has been abused. Bruises in different stages of healing may indicate repeated trauma. Bruises that take the shape of a recognizable object are generally not accidental.
