Child Abuse and Neglect

The concept of child abuse and neglect is relatively new to American society. Although children have been neglected, beaten, exploited, and even murdered by their parents and caregivers for hundreds of years, it is only since the mid–twentieth century that legislation requiring the reporting and prosecution of child abuse has been enacted. In 1974 Public Law 93-247, known as the Child Abuse Prevention and Treatment Act (CAPTA) was passed by Congress. Under this statue, only parents or caregivers can be perpetrators of child abuse or neglect. CAPTA provides minimum standards for the definition of child abuse and neglect for states that receive federal funds, and each state is left to define more specifically what constitutes maltreatment and to develop public policy that will guide courts, law enforcement, health care, and social services in the protection and care of children who are neglected or abused.

All fifty states and the District of Columbia have enacted laws that require that child abuse and maltreatment be reported to a designated agency or official. The purpose of these laws are to specify the conditions under which a state may intervene in family life; define abuse and neglect; encourage a therapeutic treatment approach to child abuse and neglect–rather than a punitive approach; and encourage coordination and cooperation among all disciplines that deal with abused and neglected children.

A number of terms are used to refer to the maltreatment of children, including the following:

• Neglect. An act of omission by a parent or care-giver that involves refusal or delay in providing health care, education, or basic needs such as food, clothes, shelter, affection, and attention. Neglect also includes inadequate supervision and abandonment.
• Emotional abuse. An act or omission by a parent or caregiver that involves rejecting, isolating, terrorizing, ignoring, or corrupting a child. Examples include, but are not limited to, verbal abuse; withholding food, sleep, or shelter; exposing a child to domestic violence; refusing to provide psychological care; and confinement. An important component of emotional abuse is that it must be sustained and repetitive.
• Physical abuse. An act of commission by a parent or caregiver that results in, or is likely to result in, physical harm to the child–including death. Examples include hitting, kicking, biting, shaking, burning, and punching the child. Spanking a child is usually considered a form of discipline, unless the child is bruised or injured.
• Sexual abuse. An act of commission by an parent or caregiver of sexual intrusion or penetration, molestation with genital contact, sodomy, rape, exhibitionism, or other forms of sexual acts in which the child is used to provide sexual gratification to the perpetrator. This type of abuse can also include child pornography.

Discussions of the number of children who are abused or neglected involve the use of two terms: prevalence, which describes the number of children who have suffered from a specific type of abuse at least once in their lifetime; and incidence, which describes the number of specific cases that are reported in a given time period. Obviously, incidents of physical abuse or extreme neglect are somewhat easier to identify and report than are other types of abuse. These are the cases that most frequently appear in child welfare offices and court cases. Actual reports of sexual abuse, emotional abuse, and neglect are generally thought to be grossly underrepresentative of the number of children affected by abuse.

Efforts to quantify the number of abuse cases in the United States include self-report surveys, in which parents are asked to report their own behavior toward their children; surveys of cases of abuse that were observed by someone outside the family and reported to community and public-agency professionals; and the collection of statistical information from child protective agencies. In 1990, the National Child Abuse and Neglect Data System was established. Information from this database indicates a growing trend in child abuse and neglect during the 1990s. In general, neglect is the most common form of child abuse reported, accounting for more than half of all reported cases. According to national statistics, approximately 2.8 million referrals for abuse and neglect are made annually. Less than half of these (approximately 1 million) are found to be substantiated cases. Of those that are substantiated, over half are for neglect, about 25 percent are for physical abuse, and slightly more than 10 percent are for sexual abuse. Approximately three children die each day of abuse or neglect in the United States.

Causes of Abuse and Neglect

According to the Child Welfare League of America, children whose parents abuse drugs and alcohol are almost three times more likely to be abused and four times more likely to be neglected than children of parents who are not substance abusers. Eighty-five percent of states that report statistics for child abuse and neglect cite parental substance abuse and poverty as the top two issues related to child abuse and neglect. Additionally, studies have shown that the most consistent finding in substantiated child abuse cases is that the abusive parents often report having been physically, sexually, or emotionally abused or neglected as children.

Certain children are at increased risk for abuse. Younger children are particularly vulnerable to certain types of abuse, such as shaken baby syndrome and battered child syndrome. Shaken baby syndrome is a severe form of head injury that occurs when a baby is shaken hard enough to cause the baby's brain to bounce against its skull. This causes bruising, swelling, and bleeding in the brain that can lead to permanent, severe brain damage or death. Even with immediate medical treatment, the prognosis for a victim of this syndrome is very poor. Most babies will be left with significant damage to their brain that can cause mental retardation or cerebral palsy. One of the difficulties in identifying this type of abuse is that there are usually no outward physical signs of trauma, which often creates a delay in the child receiving treatment.

Battered child syndrome is characterized by a group of physical and mental symptoms caused by long-term physical violence against the child. The abuse takes the form of cuts, bruises, broken bones, burns, and internal injuries from hitting, punching, or kicking. Nearly half of the victims of this type of abuse are under the age of one. Parents who bring their abused children to an emergency room frequently offer complicated and vague explanations of the child's injuries. Medical personnel must be trained and knowledgeable of the causes of various types of injuries. For example, medical professionals have learned to recognize a spiral pattern on X-rays of broken bones, particularly in the arms and legs, that indicate an injury is the result of the twisting of a child's limb. Trained professionals also look for evidence of old injuries, such as a bruise that is several days old and bones that have broken and healed, in addition to the presenting injuries. Such a pattern of injuries helps constitute the diagnosis of battered child syndrome.

Effects of Abuse on Children

By its very nature, child abuse is threatening and disruptive to normal child development. The very persons charged with the care and nurturing of a child, and to whom the child turns for food, love, and safety, can cause the child pain and injury. The child then learns to distrust adults. Children who are neglected and abused exhibit a wide array of characteristics and behaviors. Most common among these are anger, acting out, depression, anxiety, aggression, social withdrawal, low self-esteem, and sleep difficulties. At the extreme end, abuse can cause a child to dissociate and develop disorders such as schizophrenia, amnesia, and personality disorder. Personality disorder is a mental disorder that affects a person's ability to function in everyday activities such as work, school, and interpersonal relationships. Borderline personality disorder is a frequent diagnosis for children who are victims of abuse or neglect. Symptoms can include paranoia, lack of impulse control, limited range of emotions, and inability to form close and lasting relationships.

Prevention of Child Abuse

Prevention is generally categorized as primary, secondary, or tertiary. Primary prevention includes the general distribution of information related to child abuse, including how to recognize and report abuse and what resources are available for the prevention, intervention, and treatment of child abuse. Secondary prevention combines information with services and interventions targeted to families identified at high risk for child abuse. Tertiary prevention is directed to families where abuse has already occurred, with the goal of decreasing the possibility of recurrence.

Health care–related prevention programs typically focus on encouraging pregnant women to receive prenatal care, teaching child care techniques, providing home health visits for newborns, and assisting parents of children with special needs in obtaining support and services. Community-based organizations such as YMCAs and YWCAs, Boys and Girls Clubs; community centers, food banks, shelter programs, and a wide array of advocacy and faith-based organizations target their efforts toward high-risk families and youth. These programs address the lack of resources such as adequate shelter, child care for working parents, appropriate nutrition, health and mental care, transportation, and education. Organizations providing tertiary prevention include crisis and emergency services, parent education, domestic violence shelters, and health and mental health treatment for victims.

In 1993 Public Law 103-66, also known as the Family Preservation and Support Initiative, was passed, providing federal funds for family support services and family preservation services with the intention of keeping families intact. This was followed by Public Law 105-89, also known as the Adoption and Safe Families Act of 1997. This second act clarified the congressional intent of Public Law 103-66 by changing the name of the funding program from Family Support and Family Preservation Services to Promoting Safe and Stable Families. This was a significant change in focus. Under the 1993 legislation, the goal of the program had been to keep families intact by providing services in the home. But service providers came to the realization that not every family can, or should be, kept together. Sometimes children must be removed for their own safety. Thus the 1997 legislation focused on two key outcomes for children and families: safety and stability. The Adoption and Safe Families Act recognizes the importance of timely, goal-directed, family-centered services within the larger context of assuring the safety of children and promoting their stability and permanence.

Schools play an important role in the identification, reporting, and treatment of child abuse. Neglect and abuse perpetrated on school-age children frequently first come to the attention of school officials in the form of truancy. Parents who neglect their children often fail to get their children to school, fail to provide the needed health screenings and immunizations necessary for admission to school, and fail to provide school supplies. Children who are physically abused often show similar patterns of truancy because parents are reluctant to send children with obvious bruises or injuries to school. When children are at school, signs of neglect and abuse may include children in dirty clothing, children who appear very fatigued and fall asleep during class, and children who appear malnourished, depressed, withdrawn, aggressive, angry, or sad. Obviously, a child who is frequently absent from school, tired, hungry, angry, worried, depressed, and scared is not able to learn as effectively as other children. School personnel also need to be trained to look for signs of learning difficulties due to brain damage, hidden wounds or bruises (a child may be reluctant to dress for physical education class for fear of showing hidden injuries), hearing loss, untreated dental caries, and a wide variety of learning disabilities due to malnutrition, medical neglect, and physical abuse.

School personnel who are trained to observe these and other signs of abuse, and who know how and to whom to report abuse, can be very helpful to law enforcement and child protective services officials in providing documented patterns of neglect and abuse. Schools can also be helpful in cooperating with community-based agencies in the treatment plans for families, and in assuring that children are receiving school-based health, mental health, tutoring, food, and social services.

Child Protective Services (CPS) comprises a highly specialized set of laws, funding streams, agencies, lawyers, partnerships, and collaborations that together form the government's response to reports of child abuse and neglect. Criticisms of this system have led professionals to consider ways to reform the system to better identify, prevent, and treat child abuse. The criticisms include:

• Overinclusion. Many referrals for abuse and neglect are not substantiated. This exposes some families and their children to unnecessary investigations and intrusions and overburdens the system with investigations that cause delays in getting help to the families that really need it.
• Capacity. The number of referrals to the CPS system exceeds the system's ability to respond effectively. Both federal and state laws require CPS agencies to accept and respond to all reports of child abuse, but the resources dedicated to these activities have not kept pace with the demand. Most professionals agree that the system is significantly overloaded.
• Underinclusion. Some cases of abuse and neglect are not identified and reported. In both very rural areas and high-density cities, many cases of child abuse and neglect go unrecognized and unreported.
• Service orientation. The two basic service orientations of the CPS system are family preservation (keeping the child at home with services); and child safety and rescue (removing the child from the home for the protection of the child). These orientations are in direct conflict with each other and frequently do not serve families well.
• Service Delivery. Many suitable services are not always available, service delivery is unequal across communities and states, there is a shortage of culturally appropriate services, and services are often fragmented.

Those who propose to reform the CPS system see two changes as fundamental: (1) improvement of identification and reporting systems to focus on high-risk cases that need immediate intervention, and (2) the creation of community partnerships to provide services in more culturally appropriate ways. A third element is an emphasis on tailoring interventions to fit the needs of each family. Although these reforms do not necessarily cost additional dollars, they do require a significant shift in thinking and planning, and the reformers must develop new ways to track accountability. CPS is a very high-risk business, and by creating community partnerships the risk will be shared with other agencies. The challenge in reform is to create a system that manages the risk in a way that assures the safety of the children who depend upon it.