CHAPTER 20 Child Maltreatment: Developmental Consequences
In the 21st century, child maltreatment continues to be a major medical, psychological, social, and public health issue that affects almost a million children every year in the United States. It is a problem that crosses all racial, ethnic, and socioeconomic boundaries and affects not only the victims but also their families and their communities.
Child maltreatment has been defined by the Federal Abuse Reporting Act of 1974 as “the physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child by a person who is responsible for the child’s welfare under circumstances which indicate harm or threaten harm to the child’s health or welfare.”1 Helfer, a pediatrician who was one of the coauthors with Kempe and others of the seminal article on child abuse entitled, “The Battered Child,”2 provided a definition that highlights the core elements of child maltreatment that are essential to the identification and appropriate treatment of these children. He defined child maltreatment as “any interaction or lack of interaction between family members which results in nonaccidental harm to the individual’s physical and/or developmental status.”3
There is currently no absolute checklist or set of symptoms or injuries by which clinicians can validly and reliably predict or verify that abuse or neglect has occurred to a child. There are certain physical findings that are known to be the result of inflicted injuries, such as spiral fractures of the femur in very young children, “bucket handle” fractures,4 and immersion burns. In addition, professionals should be aware of situations that are frequently associated with valid abusive or neglectful incidents. These are situations in which professionals should consider that maltreatment may have occurred or that a child is at high risk for abuse or neglect.
Neglect should be considered when a child is significantly underweight for age for no apparent reason or when this could be the result of inadequate intake, excessive output, or a combination of both; when a child does not have necessary medical or dental care or has an untreated illness or injury; when a child has chronic poor hygiene, such as lice, body odor, or scaly skin; when a child reports no caregiver or adult in the home; when a child lacks a safe, sanitary shelter or appropriate clothing for the weather; or when a child is abandoned or left with inadequate supervision.
Psychological maltreatment should be considered when a child is rejected (there is no affection or acknowledgement of the child as a person), terrorized (the child is threatened with injury and/or lives in a climate of unpredictability), ignored (the parent or caretaker is psychologically unavailable), isolated (the child is prevented from having social relationships), or corrupted (the child is encouraged to engage in antisocial behavior).5 These conditions can lead to the child’s failure to thrive, being depressed and anxious, and not being responsive to his or her environment. These situations should be considered “red flags” for possible maltreatment, but, as mentioned earlier, some may also be children’s responses to other stressful situations in their lives.
The methods and standards by which data are collected vary considerably. In 1993, the National Research Council reviewed the data-gathering process and made recommendations to improve the methods and reduce the disparity in the reports from the states. However, few changes have been made at the state or national levels to standardize the data-gathering process. Reporting or referral biases may skew the rate statistics of maltreatment in certain ethnic and socioeconomic groups. For example, African-American children6 and children living in poverty7 are more often reported and found to be maltreated than are children from other ethnic and socioeconomic groups.
Taking these caveats into consideration, we note that in 2003, about 3,353,000 reports of suspected child maltreatment were filed. About 31.7w% of these reports, involving 906,000 children, were substantiated. The rate of victimization in 2003 was 12.4 per 1000 children; 61.9% of these children were neglected, 18.9% were physically abused, 9.9% were sexually abused, 2.3 % were medically neglected, and 16.9% met the “other” category, including abandonment, threats (psychological abuse), and congenital drug addiction. (These percentages add up to more than 100% because children who were victims of more than one kind of abuse were counted in each category.) Of the maltreated children, 48.3% were boys and 51.7% were girls. In addition, the rate of abuse by age was as follows: For every 1000 children aged 0 to 3 years, 16.4 were abused; for every 1000 aged 4 to 7 years, 13.8; and of children younger than 1 year, 9.8%. With regard to the variable of race, 53.6% of maltreated children were white, 25.5% were African-American, 11.5% were Hispanic, 1.7% were Native American or Alaskan, 0.6% were Asian, and 0.2% were Pacific Islanders. With regard to perpetrators, 83.8% of children were abused by either or both parents; 13.4%, by nonparental adults; and 2.8%, by unknown perpetrators. Finally, approximately 1500 children died in 2003 as a result of their maltreatment, of whom 78.7% were younger than 4 years.8
Children with disabilities are much more vulnerable to maltreatment.9 In 2003, 6.5% of victims of maltreatment from the 34 states that reported this category had a disability, such as mental retardation, emotional disturbances, behavioral problems, physical disability, visual disturbances, and learning disabilities. Other studies suggest that children with disabilities are at least one to two times more likely to be abused than are typically developing children.10 Goldson,11 in a review of the literature on children with special health care needs, concluded that such children were at least three to four times more likely to be maltreated than were typically developing children.12,13,14
REPORTING, CLINICAL ASSESSMENT, AND TREATMENT OF THE MALTREATED CHILD
If a physician is the first professional to see a child and suspects maltreatment or is the person to whom a parent reports suspicions of abuse, he or she should document the history and perform a physical examination of the child. In addition, he or she must make a report to the appropriate state social services agency and/or the police. The investigation and substantiation of suspicions of abuse or neglect are the responsibility of the state or tribal child protection system or law enforcement, rather than the reporting individual. These agencies employ professionals who are trained to conduct investigations and are responsible for determining whether a child should be removed from the caregiver’s custody. In many clinical programs, social workers are trained to conduct forensic interviews with suspected victims and to work closely with the child protection system and law enforcement during the investigation. Many larger communities have specialized children’s advocacy centers with trained personnel to interview the child. Whenever child maltreatment is suspected, the physician must record accurate, complete documentation of the suspicion or allegations; how the suspicion of maltreatment occurred, such as an injury to the child or the child’s statements; and the results of the examination and subsequent actions, such as contact with the child protection system, law enforcement, or other professionals. Careful documentation is important when a report of suspected abuse is made, during the investigation, and in any future legal or court involvement. Finally, physicians must avoid influencing the content of the child’s report, being sure that the child speaks for himself or herself, both to maintain the child’s credibility and also to best protect the child.
The approach to the clinical assessment and treatment should follow a developmental psychopathology model,15 wherein the child’s developmental functioning and abilities are taken into consideration. The goal of the clinical assessment is to determine the child and caregivers’ overall functioning, adaptation, and level of symptoms. A thorough assessment of the family’s strengths and problems should be conducted, including the types of problems that need to be addressed at the parental, child, family, and social systems levels.16 The assessment may include interviews; paper-and-pencil measures; or structured observations with the child, siblings, and caregivers. In addition to the use of standard measures to assess cognitive functioning and general behavior, several specific measures have been developed and standardized to evaluate the child’s symptoms associated with the abuse. These measures include general assessments of trauma symptoms, such as the Trauma Symptom Checklist for Children,17 and a measurement of sexual behavior problems, such as the Child Sexual Behavior Inventory.18 To assess psychological maltreatment, the Psychological Maltreatment Rating Scale19 provides an observational structure for evaluating mother-child interactions. Bonner and colleagues20 provided a complete review of assessment.
Evaluations of various treatment approaches for abused children and adolescents are increasing. Treatment interventions for abused children are conducted in therapeutic nurseries, day treatment programs, psychiatric or residential settings, and outpatient clinics. Clinicians must rely on techniques and approaches that are appropriate for the child’s cognitive and developmental level of functioning and are effective in reducing the child’s targeted symptoms. Reviews of the current treatment outcome literature indicate that abuse-specific cognitive-behavioral therapy is effective in reducing symptoms of posttraumatic stress disorder (PTSD).21 The treatment components include anxiety management techniques, exposure, education, and cognitive therapy. Treatment for families in which physical abuse has occurred has typically focused on the abusive parents and, more recently, has addressed the symptoms in the child victims.22–24 For some forms of neglect, research has yielded promising results for interventions that include home visitation as a primary approach.25–27
NEUROLOGICAL CONSEQUENCES OF NONACCIDENTAL TRAUMA
Although the focus of this chapter is on the cognitive and affective consequences of maltreatment, some of the physical consequences, particularly of injury to the central nervous system, are also considered. Ewing-Cobbs and associates28 characterized the neuroimaging, physical, neurobehavioral, and developmental findings in 20 children aged 0 to 6 years old who had experienced traumatic brain injury (TBI) as a result of inflicted or nonaccidental trauma (NAT) and compared them with 20 children with accidental TBI 1.3 months after the injury. They found that in 45% of the children with NAT, there were signs of preexisting injuries, such as cerebral atrophy, subdural hygromas, and ventriculomegaly. There were no such findings among the children with accidental injuries. In addition, subdural hematomas and seizures were more common among the children with NAT, and none of the children with accidental injuries had retinal hemorrhages. Glasgow Coma Scale scores in the children with NAT were suggestive of a worse prognosis, and of these children, 45% had mental retardation, in comparison with 5% of the children with accidental TBI.
In a later paper, Ewing-Cobbs and associates29 evaluated 28 children between the ages of 20 and 42 months, 1 and 3 months after their inflicted TBI, using the Bayley Scales of Infant Development–Second Edition. In comparing these children with those who had suffered accidental TBI, they found that the children with NAT had deficits in cognitive and motor functioning and that more than 50% showed persisting deficits in attention/arousal, emotional regulation, and motor coordination. As would be expected, the more severe the injury, as reflected in the lower Glasgow Coma Scale scores, the longer was the period of unconsciousness, and in the presence of cerebral edema and cerebral infarctions, the outcome was poorer. Perez-Arjona and coworkers,30 in a review of the literature, found that children with cerebral NAT had worse clinical outcomes than did those with accidental TBI. The abused children were cognitively impaired and had more severe neurological consequences. Late findings on computed tomographic scans and magnetic resonance images provided evidence of cerebral atrophy in 100% and cerebral ischemia in 50% of the NAT group. Thus, the conclusions that can be drawn from these studies are that inflicted injuries to the central nervous system are significantly more harmful than accidental injuries and that the outcome for children sustaining NAT is quite poor.
EFFECTS OF CHILD MALTREATMENT
An issue of importance to developmental-behavioral pediatricians is the effect of child maltreatment on children with disabilities.11 There has been a significant lack of research on the maltreatment of children with disabilities, and few state child welfare agencies document the presence or type of disability status of children entering the child protection system.31 This issue was addressed by Sullivan and Knutson,32 who studied a school-based population of more than 50,000 children to assess the prevalence of maltreatment among children identified with an existing disability; they related the type of disability to the type of abuse, and determined the effects of maltreatment on academic achievement and attendance rates for children with and without disabilities. They found a 31% prevalence rate of maltreatment of children with existing disabilities and a 9% rate among children without disabilities, which indicates that children with disabilities are 3.4 times more likely to be maltreated than are children who are not disabled. These authors further documented a significant relationship between maltreatment and disability that affected the child’s school performance.
Three factors appear to contribute to the heightened effect of abuse on children with disabilities: (1) their state of dependency; (2) being in institutional care; and (3) communication problems.33 Research has shown that physical disabilities that reduce a child’s credibility, such as mental retardation, deafness, or blindness, increase children’s risk for abuse,34 which emphasizes the necessity of increased protective measures for such children.
Physical Abuse
Children who are physically abused experience different kinds of injuries, ranging from bruises to skull and other fractures and to death. Studies suggest that the severity of a child’s physical injuries is related to young age,35 and according to national statistics, child fatalities caused by maltreatment are substantially higher in infants and children younger than 4 years.36 Earlier researchers explored the relationship between a child’s early medical and health status and subsequent abuse. Their findings suggested that factors such as a physical disability, low IQ, or birth complications might increase a child’s risk37; however, researchers did not find the factors to significantly increase a child’s risk beyond parental characteristics.38 Other studies have suggested that neonatal problems and failure to thrive were present in children who experienced physical abuse.39
Children’s responses to physical abuse are related to their age, developmental status, the severity and duration of the abuse, and the physical and psychological effects on the child. Their responses range from becoming passive and withdrawn to having high levels of hostility and aggressive behavior. An extensive body of research documents the heightened levels of aggression and related externalizing behavior in physically abused children.16 These problems include poor anger management40; increased rule violations, oppositional behavior, and delinquency41; drinking, smoking cigarettes, and drug use42; and property offenses and criminal arrests.43 Other studies have reported a relationship between physical abuse and borderline personality disorder,44
