Child Maltreatment
Addressing the problem of CM from a public health perspective is clearly warranted, given the magnitude of the problem and the burden it places on the health of the public. In the following section, we will review various definitions related to child maltreatment, followed by discussion of its incidence and prevalence and consequences that include risks to physical health; cognitive development and academic achievement; and emotional and behavioral health.
Definitions
Kempe, Silverman, Steele, Droegemueller, and Silver (1962) first coined the term "battered child syndrome" in the early 1960s, yet defining and operationalizing experiences of child abuse and neglect still challenge researchers and practitioners today. Not only are experiences of CM heterogeneous in nature, with multiple types and subtypes, but often the definition of CM is dependent upon the context in which it is used. In particular, varied definitions employed by the multiple sectors addressing CM (e.g., Child Protective Services [CPS]; law enforcement and legal communities; medical professionals; public health officials; other advocates) often limit effective communication across disciplines and this variation constitutes a major barrier to effective surveillance, treatment, and prevention of child maltreatment (Leeb, Bitsko, Merrick, & Armour, 2012).
In an attempt to aid in the collection and use of public health-based CM data, the Centers for Disease Control and Prevention (CDC) partnered with professionals in CM research, prevention, and surveillance from a variety of settings, including universities, state health departments, hospitals, research firms, and other federal agencies, to develop conceptual definitions of CM and guidelines for use in public health settings. Because the definitions were developed through a collaborative effort, they draw upon definitions already in use in other sectors, complement existing definitions, and have been modified to fit the needs of public health professionals whose mission is to prevent child abuse and neglect before it occurs (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008).
The CDC defines CM as any act or series of acts of commission (abuse) or omission (neglect) by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child (Leeb et al., 2008). Brief CDC definitions for the subtypes of CM (i.e., physical abuse [including abusive head trauma], sexual abuse, psychological abuse, and two forms of neglect: failure to provide and failure to supervise) are presented in the Table. These definitions are aligned with the World Health Organization's (WHO) definitions and support Article 19 of the United Nations Convention on the Rights of a Child, which specifically protects children from all forms of violence, exploitation, and abuse while in the care of parents and other caregivers (Runyan et al., 2002; UNICEF, n.d.).
The Box below highlights a related area of domestic and international concern: child sexual exploitation. Due to the clandestine nature of child sexual exploitation, it is among the most difficult childhood adversities to measure and study, yet can have some of the most severe physical and mental health consequences. Such types of cases are often likely to present in emergency departments and other medical settings at various points during the victimization experience (IOM and NRC, 2013).
Incidence and Prevalence
The lack of consistent, reliable definitions and related information on CM has contributed to varied conclusions about the number of children and families affected, greatly lessening the ability to accurately gauge and track the magnitude of CM in relation to other public health problems. In addition, because experiences of CM, specifically certain types (e.g., sexual abuse), are often known to the victim and the perpetrator alone, official estimates typically represent a gross underestimate. Despite these limitations, in 2012, United States (US) state and local CPS agencies still received 3.4 million reports of children as victims of CM (78.3% of these reports were due to neglect, followed by 18.3% due to physical abuse, 9.3% due to sexual abuse, and 10.6% due to "other" types of maltreatment). Substantiations were made in 686,000 (9.2 per 1,000 in the population) of these cases (U.S. Department of Health & Human Services [USDHHS], 2013).
However, when children are asked directly about their experiences of CM, the rate in the general U.S. population is substantially higher, affecting approximately 1 in 10 U.S. children (Finkelhor, Turner, Ormrod, Hamby, & Kracke, 2009; Finkelhor, Turner, Shattuck, & Hamby, 2013). U.S. CPS data indicate that young children are at highest risk for CM (USDHHS, 2013), yet self-report data from a national survey of violence against children indicate that rates of CM are highest among 14- to 17-year-olds (Finkelhor et al., 2009). As such, cases of CM coming to the attention of official agencies may be different in type or nature than those that do not. Data from official sources may also distort descriptions of the type of persons at risk and characteristics of the problem, as these also are often discordant from self-reports (Pinto & Maia, 2012). Consequently, studies relying on data from official sources are likely to vastly underestimate the true magnitude of the problem and may not accurately reflect the groups at highest risk. In general, gathering information on multiple indicators and from multiple sources in the assessment and surveillance of CM can lead to better estimates of the true magnitude of the problem and will allow for more accurate surveillance and monitoring of the scope of CM.
Consequences
The last several decades of research are clear: consequences of CM can be profound and may endure long after the maltreatment occurs. The effects can appear in childhood, adolescence, and/or adulthood, and may impact multiple aspects of an individual's development (e.g., physical, cognitive, psychological, and behavioral). These effects range in consequence from impaired functioning to brain damage, chronic disease, and death. The following sections will focus on outlining consequences that fall into the following three overlapping areas: physical health; cognitive development and academic achievement; and emotional and behavioral health.
Physical Health. CM may impact an individual's physical health in a number of direct and indirect ways. Examples of direct physical effects of physical abuse, sexual abuse, and/or neglect may include bruises, burns, broken bones, and sexually transmitted infections. Infants and young children may be particularly vulnerable to the immediate physical consequences caused by physical abuse. Children less than five years of age (with the greatest risk at age 2 to 3 months) are at highest risk of experiencing abusive head trauma that leads to death or severe nonfatal consequences such as visual impairment (e.g., blindness), motor impairment (e.g., cerebral palsy) and/or cognitive impairments (Parks, Annest, Hill, & Karch, 2012).
CM results in not only acute injuries, but also predicts numerous physical health problems perhaps not intuitively associated with abuse and neglect (e.g., Thompson, Arias, Basile, & Desai, 2002). For example, the Adverse Childhood Experiences (ACE) Study has repeatedly demonstrated a strong relationship between abuse exposure and/or household dysfunction during childhood and several of the top risk factors for the major causes of death in adulthood (e.g., ischemic heart disease, cancer, chronic lung disease, skeletal fractures, liver disease; Felitti et al., 1998). The findings of this large scale study also indicated that the impact of these adverse childhood experiences on adult health status is cumulative, such that the greater the number of adverse events (e.g., multiple forms of maltreatment), the greater the likelihood of negative health outcomes.
Recent brain research indicates that many of the negative developmental consequences experienced by victims of maltreatment have, in part, neurobiological explanations; abuse and neglect can cause important regions of the brain to form and function improperly, which in turn has consequences for all areas of development (USDHHS, 2001). For example, the stress of chronic abuse may cause a "hyperarousal" response in certain areas of the brain, which may result in hyperactivity and sleep disturbances (Dallam, 2001; Perry, 2001). This stress may also strengthen the pathway among neurons that are involved in the fear response, and as a result, the brain may become predisposed to experience the world as hostile, which in turn may lead to anxious and aggressive behaviors (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). Recent work also indicates that CM can lead to diminished growth in the left hemisphere, which may increase the risk for depression; this is then related to an increased risk for smoking and alcohol use (Tiecher, 2000).
Cognitive Development and Academic Achievement. Children who have experienced maltreatment are at greater risk than their peers to evidence difficulties in learning and in school performance (Kerr, Black, & Krishnakumar, 2000; Perez & Widom, 1994). The negative impacts of both abuse and neglect have been found even after controlling for potential individual and familial confounders, such as maternal drug and alcohol use; prematurity and birth weight; and maternal anxiety and depression (Mills et al., 2011). Recent work also indicates that children exposed to family violence (physical abuse, sexual abuse, witnessing domestic violence) evidence poorer executive functioning (e.g., cognitive processes such as working memory, inhibition, auditory attention, and processing speed) relative to their peers, even after controlling for internalizing distress and other environmental stressors (DePrince, Weinzierl, & Combs, 2009).
Emotional and Behavioral Health. In general, children who have experienced maltreatment are more likely than their non-maltreated peers to evidence internalizing (e.g., depression, anxiety) and externalizing (e.g., aggression, substance use) behaviors (Bolger & Patterson, 2001; Johnson et al., 2002; Rogosch, Cicchetti, & Aber, 1995). Specifically, children with a history of maltreatment are at higher risk for experiencing depressive disorders, anxiety disorders (e.g., posttraumatic stress disorder), and increased bullying behavior, aggression, and juvenile delinquency than their peers without such histories (Briere & Jordan, 2009; Kaplow & Widom, 2007). One longitudinal study indicated that being maltreated as a child increased risk of arrest as a juvenile by 59% (Widom & Maxfield, 2001).
As adults, victims of maltreatment are more likely than their non-maltreated counterparts to struggle with a number of psychiatric disorders and also to evidence higher rates of alcohol and drug abuse, suicidality, and high-risk sexual behaviors (Hankin, 2005; Lo & Cheng, 2007; MacMillian et al., 2001; Runyan et al. 2002). In one longitudinal study, as many as 80% of young adults who had histories of maltreatment met the diagnostic criteria for at least one psychiatric disorder (e.g., major depressive disorder, posttraumatic stress disorder) at age 21 (Silverman, Reinherz, & Giaconia, 1996).
Given the influential nature of children's early relationships with parents, CM can have severe negative consequences on the development and maintenance of other close relationships throughout childhood and into adolescence and adulthood (Muller, Goebel-Fabbri, & Dinklage, 2000). Children exposed to maltreatment are at increased risk of exposure to other types of violence later in life (Holt, Buckley, & Whelan, 2008; Renner & Slack, 2006). These children also are at greater risk for engaging in violent and criminal behavior themselves, including maltreatment of their own children (Berlin, Appleyard, & Dodge, 2011; Conger, Schofield, Neppl, & Merrick, 2013; Herrenkohl, Klika, Brown, Herrenkohl, & Leeb, 2013; Jaffee et al., 2013; Thornberry et al., 2013). For example, one group of researchers found that women with a history of sexual abuse were twice as likely to be sexually and physically victimized as adults than were non-abused, comparison females (Barnes, Noll, Putman, & Trickett, 2009).