child abuse research paper example

127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples

Child abuse is one of the crucial problems that has been overlooked for many centuries. At the same time, it is an extremely sensitive issue and should be recognized and reduced as much as possible.

In this article, you will find child abuse research topics and ideas to use in your essay.

Let’s start!

📝 The Child Abuse Essay Structure

🏆 best child abuse topics & essay examples, 👍 good essay topics on child abuse, 📌 simple research topics about child abuse, 💡 interesting topics on child abuse, ❓ child abuse research questions.

Child abuse is one of the most problematic topics in today’s society. Writing child abuse essays may be challenging because it requires analyzing sensitive issues.

The problem refers to physical, psychological, or sexual mistreatment of children. It is vital to discuss this acute issue in studies and essays on child abuse.

Before working on your essay, you should select a topic for discussion. Here are some child abuse essay topics that we can suggest:

• The problem of child abuse in the US (Canada, the UK)
• Child abuse: Types and definitions
• Child neglect crimes and their causes
• Current solutions to the problem of sexual abuse of children
• The importance of child maltreatment prevention programs
• Child abuse: Legal implications
• Consequences of child abuse and neglect

If you are looking for other possible titles for your paper, you can check out child abuse essays samples online. Remember to only use them as examples to guide your work, and do not copy the information you will find.

One of the most important features of an outstanding essay is its structure. Here are some tips on how you can organize your essay effectively:

• Do preliminary research before writing your paper. It will help you to understand the issues you will want to discuss and outline which of them you will include in the essay. Remember to keep in mind the type of essay you should write, too.
• An introductory paragraph is necessary. In this paragraph, you will present background information on the issue and the aspects that you will cover in the paper. Remember to include a thesis statement at the end of this section.
• Think of the main arguments of your paper. You will present them in the body paragraphs of the essay. What child abuse issues do you want your reader to know about? Dedicate a separate section for each of the arguments. Remember to make smooth transitions between the paragraphs.
• Remember to dedicate a paragraph to identifying the problem of the essay and explaining the main terms. For example, if you are writing a child labor essay, you can discuss the countries in which this practice is present. You can also reflect on the outcomes of this problem.
• Include a refutation section if you are writing an argumentative essay. Discuss an alternative perspective on each of your arguments and prove that your opinion is more reliable than the alternative ones.
• Remember that you should not make paragraphs and sentences too long. It is easier for the reader to comprehend shorter sentences compared to complex ones. You can write between 65 and 190 words per paragraph and include at least 10 words in a sentence. It is a good idea to make all sections of the body paragraphs of similar length.
• A concluding paragraph or a summary is also very important. In this paragraph, you will discuss the arguments and counter-arguments of your paper.
• Do not forget to add a reference page in which you will include the sources used in the paper. Ask your professor whether you need a title page and an outline too.
• If you are not sure that the selected structure is good, check out child abuse essay examples online. Pay attention to how they are organized but do not copy the facts you will find in them.

For extra help, see our free samples and get some ideas for your paper!

• Daniel Valerio Child Abuse In the end, it was an electrician who identified the typical signs of abuse in Daniel that finally led police to investigate, thereby exposing the weakness and ineffectiveness of the Dual Track System; the child […]
• Ethical Dilemma of Child Abuse In the above example, a nurse has to apply rational judgment to analyze the extent and threats when making decisions in the best interest of the victim of child abuse.
• Child Abuse in the Victorian Era in Great Britain This was unacceptable in the eyes of the factory owners resulting in the implementation of the practice of children being sent into the mechanisms of machines while they were still operating since they were supposedly […]
• Child Abuse: Preventive Measures My artifact is an infographic that communicates the various forms of child abuse and how to report them to the necessary authorities.
• Child Abuse Problem The study of the problem of child abuse has begun in the 60s with focusing attention to children problems. In such a case the early recognition of child abuse is of great importance.
• Problem of Child Abuse The most common form of child abuse in America and in most parts of the world is child abuse. The cost of child abuse is dire to both the children, healthcare organizations, parents, and the […]
• Hidden Epidemic of Child Abuse and Neglect Child abuse should be perceived as a form of deviant behavior to which researchers give different explanations: biological, psychological, socio-cultural.
• Physical Child Abuse Usually the child is unaware of the abuse due to the na ve state of mind or innocence. Physical abuse also lowers the social-economic status and thus high chances of neglect or abuse due to […]
• Discipline and Child Abuse: Motivation and Goals The first proof of the justice and reasonableness of discipline is that it is permitted by law to be considered to be the most authoritative source to consult.
• Child Abuse: A Case for Imposing Harsher Punishments to Child Abusers While harsh punishments appear to offer a solution to the problem, this measure may be detrimental to the welfare of the child in the case where the abuser is its guardian.
• Child Abuse Versus Elder Abuse The second distinction is that older people frequently encounter issues that might lead to abuse or neglect, particularly in nursing homes, such as mental disability, loneliness, and physical limitation.
• The Relationship Between Child Abuse and Embitterment Disorder Some emotions, like the dread of tests in school or sibling rivalry and conflicts, are a regular part of growing up.
• Trafficking Causes Child Abuse and Neglect The dissociation of children from their families and the exposure to intense trauma they are subjected to during and after trafficking may cause the minors to have attachment problems.
• Child Abuse and Maltreatment Discussion Additionally, this may cause a child’s behavior to change, such as making a sad or melancholy face or becoming furious with parents or other adults. When it comes to emotional abuse, a child may feel […]
• Impact of Child Abuse on Adulthood: An Idea Worth Spreading A frequent argument of those who do not want to recognize the scale of the problem of abuse in the world is “Beating is a sign of love!”.
• Effects of Child Abuse on Adults Second, she was so irrationally averse to the idea of having children that I knew immediately that it would be a contentious point in her future relationships.
• Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
• Child Abuse: Screening Methods and Creating Financial Programs When the reporting is mandatory, it is easy to follow its guidelines which should be carefully elaborated not to be harsh on parents and at the same time offer protection to a child.
• Child Abuse Allegations: Multidisciplinary Team Approach In children with allegations of child abuse, what is the effectiveness of the multidisciplinary team approach compared to the non-multidisciplinary team approach on prosecution rates, mental health referrals, and provision of medical examinations?
• Criminal Justice System: Child Abuse During the consideration of cases as part of a grand jury, citizens perform some functions of the preliminary investigation bodies.
• Promoting Child Abuse Prevention Services in Oahu, Hawaii, and the US The primary goal the Hui Hawaii organization is trying to achieve is to improve the well-being of American children by preventing abuse, neglect, and depression.
• Child Abuse in Singapore The second reason for child abuse in Singapore to continue being one of the most underreported illegal offenses is the country’s collectivist culture.
• Protocol for Pre-Testing the Child Abuse and Neglect Public Health Policy Based on the above, it is necessary to identify the conditions of child abuse like the quality of family relations and improper upbringing.
• Child Abuse: Term Definition However, there is a component that is not so clearly represented in other crimes: a third party, who has observed the abuse or the consequences of abuse has the legal obligation and reasonable cause of […]
• Sociological Perspective on “Punishment” as a Major Contributor to Child Abuse This is done with the aim of ensuring that the child is disciplined and is perceived as a legitimate punishment. This has offered a loophole to parents to abuse the child in the name of […]
• Critical Statistical Data Regarding the Issues Related to Child Abuse Due to acts of abuse children suffer greatly and it will not be wrong to say that these experiences are definitely engraved into the child’s personality.
• Child Abuse and Culture: Juan’s Case Analysis The following is the list of reflective insights that I came to while getting myself familiarized with Juan’s case and analyzing this case’s discursive implications: When addressing the issue of children being suspected to have […]
• New Jersey’s Bill on Child Abuse and Neglect The legislation’s impact is expected to be large because it is targeted at raising awareness of the pervasive issue of child abuse and encouraging the public to stay active and not to disregard any signs […]
• Child Abuse in the UAE and Explaining Theories The interest of carrying out the study on child abuse is based on the fact that it is a critical issue in any society, especially due to the actual and possible consequences on the child […]
• Child Abuse and Neglect and Family Practice Model Also, psychological violence can be either the only form of violence or the consequence of psychological or sexual abuse or neglect. Inadequate evaluation of the child’s capabilities and overstated requirements can also be a form […]
• Child Abuse and Neglect: Drug and Alcohol Problems The families of individuals who have committed a drug related offense should be investigated in order to ensure the practice is acceptable and capable of supporting the needs of more societies.
• Child Abuse: History and Causes The purpose of this paper is to explore the history, and causes of child abuse as well as the legislation implemented to address its cases.
• Child Abuse as a Result of Insufficient Policies According to Latzman and Latzman, child abuse may be manifested in the use of excessive physical force when disciplining a child or an adolescent.
• The Prevention of Child Abuse From the interview conducted with the school administrator of the local elementary school and the director of a local preschool, it is clear that both institutions have some advocacy plans for the prevention of child […]
• Child Abuse and Neglect A church/synagogue/mosque retreat activity for parents and they children can be beneficial in strengthening parents to deal with the issues of child abuse and neglect.
• The Causes and Effects of Child Abuse The main problem of the project is the presence of a number of effects of child abuse and parental neglect on children, their development, and communication with the world.
• A True Nature of the Effects of Child Abuse and Neglect in a Society The outcomes of child abuse usually depend on a variety of factors like the age of a child, the type of relation between a child and a perpetrator, and, of course, the type of maltreatment.
• Child Abuse Problems and Its Effects on a Future Child’s Life In fact, there were the three main challenges in writing the literature review just completed that were overcome due to the ability to organize the work, follow the suggestions of the experts, and keep in […]
• Effects of Child Abuse The nature of the effects of child abuse, their consequences in a society, and the most appropriate preventive methods should be considered.
• Effects of Child Abuse and Neglect Antisocial behaviour is one of the outcomes of child abuse and parental neglect that may be disclosed in a variety of forms.
• Child Abuse Issues and Its Effects The recognition of child abuse signs is a very important step as it is wrong to believe that child maltreatment takes place because of the presence of a single sing or poor understanding of child […]
• Child Abuse and Capstone Project This is why the problem of child abuse remains to be crucial for analysis, as people have to understand its urgency and effects on human behavior.
• The Effects of Child Abuse: Capstone Project Time Line The development of a Capstone Project will become a new step in solving the problem and thinking about the possible ways of improvement the situation and creation the most appropriate living conditions for children.
• Introducing Improvements to Children Abuse Reporting System The paper is connected with the analysis of the quality of the current child abuse report systems because of the serious problems in the sphere of childcare.
• Biological Underpinnings Behind Child Abuse The dimension of the baby’s head is also seen to decrease in quantity from on third of the whole body at birth, to a quarter at the age of two years and to an eighth […]
• Cause and Effect of Child Abuse Parental response to the children is also presented in a form of abuse of the rights of the children, as they feel neglected or disowned.
• Child Abuse and Neglect Children in Court The objective of this paper was to determine the level of knowledge and nature of attitudes among maltreated children who appeared in court during their detention case hearings.
• Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse exhibiting […]
• Child Sexual Abuse: Impact and Consequences Due to the adverse consequences of sexual abuse, efforts to have Jody share her ordeal and get immediate help would be my priority.
• Educational Program on Child Abuse The report “Initial reliability and validity of a new retrospective measure of child abuse and neglect” by Bernstein, Fink and Handelsman provides the findings of the consistency and validity of some of the conservative measures […]
• Public Health Media Campaign Proposal for Child Abuse
• Child Abuse and Lack of Communication in Marriages the Main Factors of Failed Family
• The Reasons and Three Most Common Factors Contributing to Child Abuse in Our Society
• Child Abuse and Its Effects on Social and Personality Development
• Neo-Liberal and Neo-Conservative Perspectives on Child Abuse
• Physical and Behavioural Indicators of Possible Child Abuse
• Defining Child Abuse and Its Different Forms in the 21st Century
• Child Abuse and Neglect: Recognizing the Signs and Symptoms
• Behind Closed Doors: The Correlation Between Multiple Personality Disorder and Child Abuse
• Child Abuse and Later Maladjustment in Adulthood
• Modern Beliefs Regarding the Treatment of Child Abuse Victims
• Neighborhood Poverty and Child Abuse and Neglect: The Mediating Role of Social Cohesion
• The Connection Between Child Abuse, Child Discipline, and Adult Behavior
• State the Possible Types, Signs and Symptoms of Child Abuse and Why It Is Important to Follow the Policies and Procedures of the Work Place
• Child Abuse and Its Effects on the Physical, Mental, and Emotional State of a Child
• Child Abuse, and Neglect and Speech and Language Development
• Social Issue: Child Abuse and How It Affects Early Childhood Development
• Child Abuse Scandal Publicity and Catholic School Enrollment
• Physical Abuse: The Different Types of Child Abuse
• Promoting Help for Victims of Child Abuse: Which Emotions Are Most Appropriate to Motivate Donation Behavior
• Describing Child Abuse, Its Different Forms, and Solutions to the Problem
• Child Abuse: The Four Major Types of Abuse, Statistics, Prevention, and Treatment
• Causes and Risk Factors Behind Child Abuse
• Child Abuse, Cause, and Effect on the Rest of Their Lives
• Child Abuse Has Severe Negative Psychological Effects on Children
• Child Abuse and the Professional Network Working Within the Child Protec
• Child Abuse Prevention and Control: Can Physical, Sexual or Psychological Abuse Be Controlled Within the Household?
• Child Abuse and the Effect on Development Into Adulthood
• Child Abuse: Victim Rights & the Role of Legal Representative
• Child Abuse and the Legal System – Developmental Forensic Psychology: Unveiling Four Common Misconceptions
• Parent Stress Factors and Child Abuse: A Tutoring Proposal
• Approaching Child Abuse From a Multi-Dimensional Perspective
• Child Abuse, Alcoholism, and Proactive Treatment
• Adverse Effects and Prevention of Child Abuse
• Suspected Child Abuse and the Teacher´S Role in Reporting It
• Child Abuse and Its Correlation to Poverty
• Sexual Child Abuse Exploring the Mind of the Perpetrator
• Relationship Between Domestic Violence and Child Abuse and How to Protect the Children From It
• Child Abuse Saddest and Most Tragic Problem Today
• Child Abuse and Academic Performance of Children
• Why Should People Care About Child Abuse?
• Why Should Child Abuse Be Addressed as a Social Problem?
• How Child Abuse and Neglect Affect Childhood?
• How Has Child Abuse Been Conceptualised and Addressed in Policy and Law?
• How to Protect Children From Abuse and Neglect?
• What Are the Negative Effects of Child Abuse?
• How Is the United States Dealing With Child Abuse Problem?
• How Can Therapy Help Victims of Child Abuse?
• How Can the Community Stop Child Abuse and Neglect?
• When Should Teachers Report Child Abuse?
• What Cause Child Abuse?
• Does Child Abuse and Neglect Lead To Bullying?
• How Do the Government and Society Have a Responsibility to Help Child Abuse Victims?
• Parent Support Groups Can Reduce Child Abuse?
• When Child Abuse Overlaps With Domestic Violence: The Factors Influencing Child Protection Workers’ Beliefs?
• How Can Spanking Lead to Child Abuse?
• How the Government and Society Have a Responsibility to Help Child Abuse Victims
• What Does Victimology Say About Child Abuse Data?
• Are There Any Biomarkers for Pedophilia and Sexual Child Abuse?
• When Does Discipline Cross the Line to Child Abuse?
• How Child Abuse Affects a Hero, a God, and a Monster in Greek Mythology?
• Does Child Abuse Create a Psychopath?
• Does Not Get Noticed Enough Around the World Is Child Abuse?
• How Can Sexual Child Abuse Affect the Child’s Psychological Development?
• How Child Abuse Effects Students Education?
• How Do Abuse and Neglect Impact a Child’s Whole Life?
• Should Pregnant Drug Abusers Be Charged With Child Abuse?
• How Children Carry the Weight of Child Abuse?
• Does Child Abuse Cause Crime?
• Childhood Essay Topics
• Attachment Theory Essay Topics
• Child Development Research Ideas
• Mental Health Essay Ideas
• Child Welfare Essay Ideas
• Childcare Research Topics
• Alcohol Abuse Paper Topics
• Foster Care Titles
• Chicago (A-D)
• Chicago (N-B)

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114 Child Abuse Research Topics & Essay Examples

📝 child abuse research papers examples, 💡 essay ideas on child abuse.

• ✍️ Child Abuse Essay Topics for College

🏆 Best Child Abuse Essay Titles

🎓 simple research topics about child abuse, ❓ child abuse research questions.

• Posttraumatic Stress Disorder: Effects of Child Sexual Abuse Psychology essay sample: Child sexual abuse is among the common problems facing children. This paper looks at the causes and effects of child sexual abuse, the posttraumatic stress disorder, and its treatment.
• Family Violence: Adult-Child Sexual Abuse Psychology essay sample: This paper explores the risk and protection factors for child abuse in the light of Macro-system, microsystem, mesosystems; and programs that target the prevention of child abuse.
• Childhood Sexual Abuse and Its Impact on Future Life Psychology essay sample: The paper explores how sibling incest and childhood sexual abuse affect persons’ interpersonal relationships and adulthood sexual functioning.
• Child Abuse: Perpetrated by Parents on Children Psychology essay sample: ‘Child neglect’ is an ambiguous and all-encompassing term used to describe actions perpetrated by parents on children which are universally deemed harmful by society.
• The Link Between Child Abuse and Delinquency Psychology essay sample: Five elements of parenting that can be positive or negative influences include: Discipline, Monitoring, Reinforcement, Involvement and Problem-solving.
• Social and Emotional Outcomes of Child Abuse Psychology essay sample: This can be further and in a meaningful manner determine the results by paying attention to a sound and the experience of the child.
• Understanding Child Abuse and Neglect Psychology essay sample: A paper explores reasons for the prevalence of child abuse in society and possible remedies. Child abuse is an activity that subjects a child to physical, emotional, or sexual trauma.
• Child Advocacy. Keeping an Eye Out Psychology essay sample: In the current social settings, the voice of young people and particularly children have been occasionally neglected.
• Child Sexual Abuse Issue Review Psychology essay sample: Posttraumatic stress disorder, increased stress levels and poor health in individuals are some of the long-term effects of child sexual abuse.
• Catholic Church and Child Sexual Abuse Allegations Psychology essay sample: Over the last two years, the Catholic church has come under a lot of criticism due to allegations of its priests sexually assaulting children in their congregation.
• Abuse and Neglect: An Orientation Psychology essay sample: Child abuse and neglect are severe issues, affecting the most vulnerable section of the population and often causing permanent trauma.
• Bullying Children: The Analysis of Various Examples Psychology essay sample: This discussion provides a detailed analysis of various examples of bullying and some of the evidence-based strategies to prevent the malpractice.
• Child Neglect and Abuse: Causes, Effects, Prevention, and Treatment Psychology essay sample: Child maltreatment is a broad and complex concept that entails a wide range of problematic issues, including neglect, sexual, physical, and emotional abuse.
• Should There Be a Law Banning Spanking of Children Psychology essay sample: Spanking is a disciplinary method that has over the years been fought against in many countries, spanking has a long-run negative effect on the child.
• The Children Abuse and Social Behavior Psychology essay sample: This research paper will define child abuse, review the statistics and other data on the topic and discuss the impact of abuse on the social behavior of children.
• The Level of Abuse to Children Psychology essay sample: This paper highlights the extent of child abuse cases in our society with a special focus on its relation to our culture.
• The Long-Term Impact of Abuse and Neglect on Children Psychology essay sample: The purpose of this paper is to explain the impact of abuse on children, examine how different types of abuse impact a child’s cognitive and socio-emotional development.
• Child Abuse: The Case Study Psychology essay sample: The abused child is vulnerable because he needs parental care more than any sort of support does. In fact, providing support only caters for the physical aspects of the problem.
• Neglect and Abuse in "Romanian Orphanage" Video Psychology essay sample: This article focuses on the video "Romanian Orphanage" - a good example of how emotional neglect negatively affects the development of young people.
• Child Abuse and Neglect in Daycares Psychology essay sample: Millions of children face acts of negligence in various forms. During the tender age, the child needs and depends on the parent or caregiver critically.
• The False Memories of Abuse in Sexual Child Abuse Psychology essay sample: In circumstances where a child is sexually abused theirs follows trauma on the child leading to a series of memories that occur from time to time.
• Child Abuse and Elder Abuse Psychology essay sample: Child and elder abuses are worldwide problems that are on the increase. The paper represents two recent criminal cases, one of child abuse and the other of elder abuse.
• Child and Elder Abuse Are Underreported Psychology essay sample: Elderly abuse and child abuse take different forms, including physical and psychological. The paper discusses how and why elder abuse and child abuse are underreported.
• Childhood Trauma Etiology Associated With Social and Mental Disorders Psychology essay sample: This paper will showcase the five themes that were revealed during the review process to better understand the associations between childhood trauma and various disorders.
• Identifying Child Abuse and Neglect: Teacher Training Psychology essay sample: Apart from physical and psychological trauma, the experience of abuse or neglect impacts executive functioning and cognitive skills, potentially causing difficulties in learning.
• Child Emotional Neglect and Its Risk Factors Psychology essay sample: Child emotional neglect is a common phenomenon observed in terms of raising healthy children. Negligent parents experience the same attitude from their parents in childhood.
• Childhood Traumatic Experience Psychology essay sample: This paper examines the effect of childhood traumas on adulthood, including cognitive abilities, social behavior, and mental health, through the prism of scientific evidence.
• Physical Punishment as an Ineffective Way to Influence a Child Psychology essay sample: Physical punishments such as spankings always have a more comprehensive range of consequences that increase aggressiveness and violence.
• Child Abuse and Neglect: “A Child Called It” Psychology essay sample: This paper compares symptoms of abuse detailed within the work by Dave Pelzer known as “A child called It” and analyzes them using recognized guidelines for child abuse victims.
• Sexual and Emotional Child Abuse Examination Psychology essay sample: This paper focuses on the issues of sexual and emotional aggression towards children in their homes, discussing relevant concepts, and abuse statistics.
• Experience of Childhood Trauma from Child Abuse/Maltreatment Psychology essay sample: This paper aims to analyze the experience of childhood trauma from child abuse/maltreatment, outcomes included, and relevant literature search results and annotated bibliography.
• Child Abuse and Depression Psychology essay sample: This essay argues that neglect, emotional distress, and limited access to psychological treatment during childhood alleviate depression and other mental conditions.
• Childhood Maltreatment and Behavior Problems Psychology essay sample: The research centers on examining whether or not early childhood maltreatment (before the age of four) affected the long-term behavioral deviations.
• Early-Life Stress and Behavioral Outcomes Psychology essay sample: The study aims to understand the mechanisms behind the long-lasting consequences of early-life stress exposure. It is accomplished by comparing the results of tests.
• Child Abuse: Corporal Punishment, Intimidation Psychology essay sample: The paper describes that the problem of violence and ill-treatment of children in the family today is an issue that needs to be discussed and taken measures to solve.
• Suicidal Ideation as a High-Risk Event Psychology essay sample: People with a tendency toward suicidal ideation represent one of the largest high-risk populations because thoughts of death affect a high percentage of humans.
• Child Neglect and Its Impact on Self-Esteem of a Young Adult Psychology essay sample: The investigation of the theme of child neglect and its mediating effect on the self-esteem of young adults can be conducted with the help of a quantitative questionnaire.
• Spanking as a Punishment Method Psychology essay sample: Raising children is arduous as parents are tasked with introducing their children to society and acceptable norms of behavior in it.
• Death Due to Childhood Abuse and Household Dysfunction Psychology essay sample: The paper discusses how health risk behavior and various diseases in adults are related to household dysfunction and different types of abuse during childhood.
• Complex a Child Abuse Situation Psychology essay sample: The case of James is a unique illustration of how complex a child abuse situation can become due to the involvement of a multitude of parties.
• Experience of Trauma from Child Maltreatment Psychology essay sample: Summing up the findings of various researchers as well as using databases, studies confirm an undeniable influence of maltreatment on the later development and life of a child.
• Child Abuse and Attention Deficit Hyperactivity Disorder Psychology essay sample: The given case illustrates child abuse and neglect as a problem involving not only a child and a parent but also grandparents.

✍️ Abuse Child Essay Examples for College

• Child Maltreatment: Background Psychology essay sample: The phenomenon of child maltreatment in the home setting is thoroughly examined by researchers, who intend to present a link between the unhealthy environment in families.
• Impacts of Physical Trauma on Children and Family Psychology essay sample: In the presented scenario the main recipient of physical trauma as a result of abuse is Kolomalu. It discusses the short-term impacts of physical abuse.
• Profiles of Childhood Trauma and Psychopathology Psychology essay sample: This article presents the results of studying the long-term effects of childhood traumas and reveals a connection between types of traumas and mental disorders.
• Child Maltreatment Factor of Personality Formation Psychology essay sample: This research aims to analyze the external factors involved in developing personality formation, particularly race and ethnicity.
• Growth Mindset Considering Spanking Issue Psychology essay sample: On the basis of learning, I have changed my belief related to the spanking of children that had been previously regarded as a common and even beneficial practice.
• Mental Health of Children: A Study of Human Rights Violations Through Terrorism Psychology essay sample: It can be concluded that there is a direct interlink between terrorist acts and various mental health disorders, including those among children, who are highly prone to mental trauma.
• The Problem of Child Abuse and Maltreatment Psychology essay sample: In this paper, the authors focus on how corporal punishment may lead to abusive acts, injury, and maltreatment among children and adolescents.
• Preventing Child Maltreatment by Caregivers Psychology essay sample: In the paper, the strategies to reduce maltreatment involving older children by promoting healthier interactions between them and their caregivers.
• Long-Term Outcomes of Childhood Sexual Abuse Psychology essay sample: The paper reviews the literature providing information on the psychological, psychiatric, and physical outcomes of child sexual abuse.
• Sexual Violence and Mental Health Effects Psychology essay sample: Sexual violence is widespread and is used even against children. There are treatment options for negative mental health effects for sexually abused children.
• Childhood Trauma and Attachment Theories Psychology essay sample: Childhood trauma is a life-threatening and violent event in a child's life. It significantly impacts a person's behavioral and emotional functioning.
• Bullying: Collaborating with Parents to Increase Proactive Bystander Message Psychology essay sample: Bullying could potentially lead to anxiety, depression, and post-traumatic stress. These symptoms could be typical also to the bystanders.
• Secondary Post Traumatic Stress Disorder in Children Psychology essay sample: Understanding child PTSD is fundamental in determining or predicting the future tendencies and outcomes of future life in terms of health, behavior, and social well-being.
• Codependence, Narcissism, and Childhood Trauma: Analysis of Article Psychology essay sample: In their research, the authors wanted to test the concept of codependency and how it is relevant to real-life situations.
• Childhood Trauma: Causes, Effects, and Preventive Measures Psychology essay sample: It is salient to understand the causative factors and the effects of childhood trauma while also highlighting applicable preventive measures.
• The Child Maltreatment and Anxiety Relationship Psychology essay sample: This paper discusses the impact of maltreatment on children's well-being and protects their physical and psychological health and research brings attention to the problem.
• Prevention of Child Abuse and Neglect Psychology essay sample: Child abuse and neglect are cases when an underaged individual's emotional needs are overlooked and three out of eight children in the United States are affected by this problem.
• Spanking Is Detrimental and Should Be Outlawed Psychology essay sample: Spanking teaches children ways of avoiding being caught instead of generating forms of positive behaviors. It is detrimental to children and should be outlawed.
• Children’s Mental Health: Codependency and Alcoholic and Narcissistic Parents Psychology essay sample: The concept of codependency is one of the recurring themes in the discussions of childhood struggles, caused by alcoholic and narcissistic parents.
• Trauma and Its Effect on Children Psychology essay sample: The paper examines the notion of trauma and its effect on children. Moreover, it looks into the consequences, causes, reactivation of trauma, and prospective treatment.
• Child Abuse and Special Needs or Behavioral Challenging Children
• Child Abuse Has Severe Negative Psychological Effects on Children
• The Characteristics and Forms of Child Abuse: Physical Abuse, Physical Neglect, Sexual Abuse, and Emotional Abuse
• Child Abuse Potential: Correlates With Child Maltreatment Rates and Structural Measures of Neighborhoods
• Child Abuse and Children Can Be Saved From Experiences
• Connection Between Child Sexual Abuse & Dissociative Identity Disorder
• The Reasons and Factors Contributing to Child Abuse in Our Society
• Child Abuse and Adolescent Dating Violence
• Defining Child Abuse With the Aid of a Case Study
• Approaching Child Abuse from a Multi-Dimensional Perspective
• The Fine Line Between Child Abuse and Parental Punishment with Justification
• Behind Closed Doors: The Correlation Between Multiple Personality Disorder and Child Abuse
• Protecting Our Children from Domestic Violence and Child Abuse
• Juvenile Who Commit Homicide or Parricide and the Presence of Child Abuse
• Child Abuse and Children Are Being Abused Each Day
• Child Abuse as a Major Social Dilemma Healthcare professionals examine possible signs of child abuse and offer adequate education to empower more members of the community to deal with this problem.
• Child Abuse and Neglect: Recognizing the Signs and Symptoms
• The Inspiration and Enlightenment from the Film Confronting Child Sexual Abuse
• Early-Intervention Service for Non-Abusing Parents of Victims of Child Sexual Abuse
• Child Sexual Abuse: The Repressed Memories Recovered
• Describing Child Abuse, Its Different Forms, and Solutions to the Problem
• Child Abuse and Lack of Communication in Marriages the Main Factors of Failed Family
• Long and Short-Term Consequences of Child Abuse and the Different Treatment
• Child Abuse and Its Effects on Social And Personality Development
• Child Abuse and How it Relates to the Developmental Stages
• Child Abuse and Maltreatment Is Not Limited to a Particular Age and Can Occur in the Infant, Toddler, Preschool, and School-Age Years
• Dealing with the Growing Concern About Child Sexual Abuse in Our Society
• Child Abuse and Its Effects on the Physical, Mental, and Emotional State of a Child
• Children are Suffering From a Hidden Epidemic of Child Abuse and Neglect
• Family Interventions With Child Physical Abuse and Neglect
• Child Abuse and Its Effects on Our Nation’s Most Serious Public Health
• Child Sexual Abuse, Sexual Coercion in College, and the Effects of Intervention
• Treatment For Women Survivors Of Years of a Child Abuse
• International Society for the Prevention of Child Abuse and Neglect
• Child Abuse Leads to Anxiety and Social Disorders
• Child Abuse Too Much or Too Little Emphasis in Today’s Society
• Adverse Effects and Prevention of Child Abuse Social Work
• The Difference Between Child Abuse and Child Discipline
• Modern Beliefs Regarding The Treatment Of Child Abuse Victims
• Mass Media’s Role and Possible Solutions on Child Abuse
• The Relationship Between Child Abuse and Adult Psychopathy
• Are There Any Biomarkers for Pedophilia and Sexual Child Abuse? A Review.
• How Childhood Sexual Abuse Affects the Child Through?
• Should Pregnant Drug Abusers Be Charged With Child Abuse?
• Why are Child Victims of Sexual Abuse at Greater Risk of HIV?
• When Does Discipline Cross the Line to Child Abuse?
• How Children Carry the Weight of Child Abuse?
• Why Child Abuse Should Be Addressed as a Social Problem?
• How the Government and Society have a Responsibility to Help Child Abuse Victims?
• What are the Negative Effects of Child Abuse?
• When Should Teachers Report Child Abuse?
• Why Might the Experience of Child Sexual Abuse Lead to Mental Health Problems in Adulthood?

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Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central nexus of more comprehensive research activity.

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment.

The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own typology and framework of reference terms, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom mal-

treatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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Child Abuse and Neglect

Charles h zeanah , md, kathryn l humphreys , phd, edm.

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The authors are grateful for the families that have allowed them to work with and learn from them, as well as the excellent colleagues, mentors, and students who have shared their insights. Special thanks to the faculty, trainees, and staff of the Tulane Parenting Education Program. The authors also wish to thank Madeleine Landrieu, JD, Loyola University of New Orleans, and Peter Digre, MSW, MPA, DMin, Consultant, for helpful contributions to this article.

Correspondence to Charles H. Zeanah, MD, 1430 Tulane Avenue #8055, New Orleans, LA 70112; [email protected]

Physical, sexual, and emotional abuse and various forms of neglect of children are associated with substantially increased risk for concurrent and subsequent psychopathology and are among the common problems encountered by clinicians in many clinical settings. Such cases pose additional challenges for clinicians because of the many complex family and system forces that engulf these children and their families. Assessing maltreated children generally requires more time than evaluations of children who have not experienced maltreatment. Young children, who experience the highest rates of maltreatment, present especially complex assessments because they are so dependent upon their caregiving environments. Treatment of psychopathology associated with maltreatment, which is often multimodal, requires addressing a variety of external factors that may perpetuate or exacerbate symptoms and impaired functioning. We suggest that the more clinicians understand the different cultures of the legal and child protective services systems will help them advocate more effectively for maltreated children’s bests interests so that the complexity of their problems is matched by the comprehensiveness of our efforts to minimize their suffering, enhance their development, and promote their competence.

Keywords: child abuse, child neglect, child maltreatment, child protective services, legal system

Maria, a 12-year-old bilingual undocumented immigrant, disclosed to her school counselor that her stepfather sexually abused her for several years. After an investigation by child protective services (CPS), she was placed in foster care because her mother initially denied that any abuse had occurred. Following this, the stepfather disappeared. Maria was referred by CPS to receive an evaluation for depressed mood.

James, an 8-year-old boy, was flagged by his teacher for cuts and bruising on his forehead. He reported that his father (a single parent) smashed his head into a glass table because he had not cleaned his room. The school reported his injuries to CPS who placed him in foster care after investigating. James’s father was arrested. James and his father were referred for assessment and treatment as indicated.

Jacqueline, a 22-month-old girl, was found wandering by a police officer several houses away from her home. After Jacqueline waited 30 minutes outside her home with the police, her mother arrived. She was combative towards the police and had a long history of substance-related arrests. Jacqueline was taken into custody and placed with nonrelative foster parents since no relatives were identified by CPS. Her mother was referred to substance abuse intervention and to a parenting intervention. Jacqueline was also referred for evaluation of her status.

Maltreatment of children, comprising various types of abuse and neglect, is a major public health challenge and one of the most powerful risk factors for concurrent and subsequent psychopathology, later health morbidity, and compromised development. In severe cases of maltreatment, children are often placed in foster care, and as a group are at particularly at high risk for negative mental health consequences. Halfon and colleagues 1 found that foster children represented less than 4% of Medicaid eligible children in California but accounted for 41% of all users of mental health services. Costs of the maltreatment that occurred in the United States in 2008 was estimated to be $124 billion, with a per victim lifetime cost estimated to be $210,012 for nonfatal and $1,272,900 for fatal maltreatment. 2

Clinicians working with children who have experienced maltreatment will be more effective when their approach extends beyond a focus on symptom patterns and functional impairment. In order to do so, they must become knowledgeable about the systems in which maltreated children are entwined. Specifically, the child protection system and the legal system each play an important role in the physical placement and well-being of children who have experienced abuse and neglect. Clinicians may be asked and should be willing to provide input regarding visits, transitions, custody, and related issues. In addition, work in this arena is a potent elicitor of countertransference, 3 and having trusted colleagues with whom to review perceptions and plans is essential.

SCOPE OF THE PROBLEM

In Federal Fiscal Year 2016, approximately 676,000 children in the United States were confirmed as victims of abuse and neglect by child protective service (CPS) systems, an incidence of 0.91%; a much greater number (approximately 3.5 million children) were referred for potential maltreatment. 4 Younger children are more likely to be maltreated and are more likely to die from abuse and neglect. American Indian/Alaskan Native (1.42%) and African American (1.39%) children experience the highest rates of maltreatment. Nevertheless, underreporting of child maltreatment is widely recognized as a problem, 5 and adult retrospective reports of maltreatment are substantially higher 6 , 7 than substantiated rates of maltreatment in official records. Failure of true cases to be identified by legal authorities, in addition to the challenges of measurement, infantile amnesia, recall bias in retrospective reports, and differing definitions for maltreatment, make ascertaining true prevalence rates challenging.

For the past several years, roughly 250,000 to 275,000 children are taken into foster care each year and a total of 400,000 to 500,000 children are in foster care at any time in the United States. 8 Thus, the majority of child victims who have maltreatment substantiated are maintained with their families and provided with access to services designed to prevent removal. These cases are often referred to as family services, “in home” services, family preservation, or similar terms.

CLASSIFICATION

Types of maltreatment are shown in Table 1 . 9 Each of the major headings subsumes many specific types within the broad type. Although neglect is by far the most prevalent type of maltreatment identified by CPS, 4 the important point is that co-occurrence of different types is the rule rather than the exception. In fact, in a recent study of more than 2,200 maltreated school-aged children and adolescents, a minority of children experienced only a single type of maltreatment 10 : only 1% of sexually abused children, 4% of physically abused children, 10% of emotionally maltreated children, and 25% of neglected children had no co-occurrence with one or more other types of maltreatment. 10

Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) Modified Maltreatment Classification System

Note: Adapted from 9 . Severity ratings 1–5 are included for each type of maltreatment.

ADVERSE EFFECTS

Maltreatment is associated with compromises in development across virtually every domain (eg, cognitive, language, socioemotional, and neurobiological development.) 11 Mental health problems are among the most salient sequelae of child abuse and neglect. For example, using data from the National Survey of Child and Adolescent Well Being, Burns et al . 12 reported that nearly half (48%) of 3,803 children (2 14 years old) who had completed child welfare investigations had clinically significant emotional or behavioral problems. A study of more than 1,000 children 5 to 9 years old who were recruited from pediatric practices determined that those children who had been maltreated were nearly three times more likely to be diagnosed with an internalizing or externalizing disorder. 13 Population estimates attribute that the proportion of childhood psychiatric disorders due to experiences of adversity, including abuse and neglect, is approximately 45%, 7 suggesting that there may be no single greater environmental predictor of mental health difficulties than experiences of maltreatment.

Developmental psychopathologists have highlighted the importance of considering both multifinality and equifinality in the course of adverse experiences and psychopathology. 14 Although many children who have experienced severe neglect in early life develop a psychiatric disorder in childhood and adolescence, a greater proportion do not. 15 , 16 For some disorders, there is an explicit requirement for the role of environmental circumstances in order to meet diagnostic criteria (eg, trauma is required for posttraumatic stress disorder [PTSD], and inadequate care is a necessary criterion for reactive attachment disorder). For other disorders, although experiences of stress are known risk factors, such experiences are not required for diagnosis (eg, major depressive disorder). Furthermore, even diverse forms of maltreatment that are thought to have different consequences for brain development 17 may result in risk for the same forms of psychopathology 18 (eg, both abuse and neglect are associated with increased risk for externalizing psychopathology). Taken together, we understand that maltreatment is associated with dramatically increased risk for psychopathology, but that several individual (eg, genetics, temperament) and external factors (eg, consistent and attentive caregivers) may be protective and/or promote resilience in children who have experienced significant adversity. 19 In addition, there is no one-to-one mapping between the severity or type of maltreatment experience and subsequent neurobiological or behavioral consequence. In fact, nearly all psychiatric disorders common in childhood and adolescence (eg, internalizing disorders, externalizing disorders, trauma and stress-related disorders, neurodevelopmental disorders [eg, attention deficit/hyperactivity disorder], and substance use disorders) have been linked to experiences of maltreatment, such that abuse and neglect may play either an etiological role and/or worsen the presentation and course of the disorder. Impairments in functioning, including academic problems, delinquency, and difficulties in social relationships are also associated with maltreatment.

Recent attempts to clarify the potential mechanisms underlying increased risk for psychopathology following maltreatment have examined the processes and constructs that represent intermediate phenotypes (eg, Research Domain Criteria). 20 This approach often focused on the processing and response to emotional content, including rewards, threats, as well as alterations in executive function, among individuals with histories of neglect. 21 These processes are theoretically linked to disorders (eg, threat processing to anxiety disorder and reduced reward sensitivity to depression) and may be useful targets in developing interventions to prevent or treat psychopathology following onset. McCrory and Viding 22 have proposed the theory of latent vulnerability, positing that targeting intermediate phenotypes provides a means of altering risk trajectories following maltreatment but before psychiatric disorders emerge.

In addition to attempts to characterize mechanism, it is important to consider how development might moderate the presentation of symptoms. For example, PTSD presents somewhat differently in preschool age children compared to adolescents, 23 and recent adaptations to the DSM have begun to define developmental differences. 24

For young children (age 5 years and younger), alternative diagnostic criteria for a number of disorders of early childhood are provided by DC:0–5. 25 Although new and incompletely validated, the criteria for disorders in DC:0–5 were empirically derived in an effort to identify the manifestations of psychopathology in young children. In addition, the approach outlined provides an emphasis on characterizing the relational context of child behavior problems. Furthermore, there is an impetus to identify and treat these children at the youngest possible ages, in order to improve long-term outcomes and reduce the risk for intergenerational transmission of maltreatment. 26

SYSTEMS ISSUES

In our experience, clinical effectiveness is enhanced greatly if clinicians are knowledgeable about and engage with child protection and legal systems when needed. These systems are best thought of as distinct cultures, each with its own language, values, and priorities. Understanding how they differ from the values and priorities of the clinical enterprise is an important asset when evaluating and treating maltreated children.

Child Protection System

CPS generally includes distinct divisions responsible for hotline receipt of allegations, investigations of alleged maltreatment, services to families who have a substantiated finding of maltreatment where children are not removed, children placed in foster care, and adopted children following termination of parental rights. It is important to understand which of these divisions is involved with the child, because the roles of the professionals in each are quite different.

CPS is based either at the state or county level. Foster care may be provided by CPS and/or contracted with private entities—some systems (eg, Florida’s Community Based Care) are entirely privatized, meaning that foster care and related services are outsourced to local community agencies. When agencies are contracted to provide foster care, understanding their relationship to CPS staff is critical. Staff within CPS are hierarchically arranged; for example, frontline case workers report to supervisors who report to managers who report to directors. Identifying how best to access information and implement leverage within these hierarchies is key to useful collaboration.

Key events in child welfare in the United States are noted in Table 2 . 27 , 28 As directed by the Federal government, child welfare systems in the United States were originally focused on children’s physical safety. There is increasing emphasis on permanency in child welfare systems, 29 because many children seemed to be languishing in foster care, which was intended to be a temporary intervention. Throughout the past 100 years, the proverbial pendulum has swung back and forth between a primary emphasis on protecting children and another on preserving families. Still, as Table 2 indicates, there has been a steady broadening of scope of what we mean by child protection over time.

Selected Key Developments in American Child Welfare

Note: Adapted from references 27 and 28 .

In cases in which there are substantiated reports of maltreatment but parental rights are not immediately terminated, the emphasis has been focused on time-limited opportunities for parents to rehabilitate and resume unencumbered care of their children. Much more recently, child well-being has been made an explicit Federal priority. 30 This provides more impetus for mental health services, although well-being remains a newer and less well integrated emphasis in many settings.

In virtually every case, reunification of children with the parents from whom they have been removed is the goal for CPS. Furthermore, reunification hinges on demonstration of minimal safety and caregiving effectiveness, which typically falls far below the standard approach in clinical treatment. Often, continuing treatment after children are returned to parents is necessary to address a child’s symptoms and functional impairment and/or to assist with family stabilization.

Legal System

Courts concerned with child protection are called juvenile court, family court, dependency court, or something similar in different states. Larger jurisdictions may have full-time judges in these courts, but in smaller jurisdictions, judges may oversee child protection cases as only one of many other roles. Judges are “triers of fact” and make the ultimate decisions regarding most phases of child protection and child custody. There are differences in state-level laws and within individual judges about how to interpret and implement the law. Judges’ perspectives derive from the United States Constitution, especially the due process clause of the 14th Amendment, which has been used to limit government interference in family life. As an initial assumption from a legal perspective, parents are presumed by courts to have their children’s best interest guiding their parenting behavior. Thus, the thrust of most laws pertaining to governmental intervention restricts it to instances in which the child’s physical safety is endangered. Furthermore, at the earliest indication that parents can be minimally safe, many judges are inclined to return children and eliminate the state’s involvement in the family’s life. This inclination runs counter to clinical efforts to delay return until it is clear that parents are sufficiently rehabilitated so that risk of recidivism is minimized.

Nevertheless, courts in all 50 states are required to consider whether their decisions about placement of children, services provided to them, and custody are in the child’s “best interest.” 31 Although the best interests of the child are considered, they do not trump parental rights in cases in which those conflict. Mental health professionals may be called as experts to testify about what is in children’s best interest, providing an opportunity to address current and future needs of the child.

Safety, permanence, and well-being of the child also should inform psychiatric assessments of maltreated children. The most important initial question to address is ensuring that children are physically and psychology safe in their current placements. Second, understanding the timeline and whether the current placement is short-term or long-term and what CPS plans for the child may affect treatment strategies. Finally, child well-being, which encompasses psychiatric symptoms and functional impairment, as well as adequacy of the caregiving environment, form the crux of the assessment.

Assessment of children involved with CPS is complicated by the need for information from multiple sources. Having CPS records available at the time of the evaluation is important. Speaking to the case worker before or during the evaluation provides important supplemental information that may be unavailable from the records, such as information about the legal status and timeline of the case, for example. If the child is in foster care, meeting with foster parents is essential, but biological parents also will provide important history when that is possible. Observing interactions of children with their foster parents as well as with their biological parents will often reveal important differences in children’s behavior. For young children (less than 5 years old), this is essential.

PTSD deserves special mention. It is clearly important to assess for PTSD symptomatology in every child with a history of maltreatment and exposure to violence. In our experience, PTSD may be both over- and underdiagnosed in these children. That is, not every symptomatic child assessed after exposure to a trauma has signs or symptoms of PTSD—many disorders can result from trauma, although there is some evidence that PTSD serves a gateway function to new-onset disorders following traumatic exposure. 32 Regarding underdiagnosis, PTSD in children can be challenging to identify, especially if children present with re-experiencing and hyperarousal in the form of aggressive behavior. Systematic inquiry about exposure to possible traumatic exposures is key, as well as assessing triggers of challenging behaviors.

Special Issues in Early Childhood

Because the majority of maltreatment cases onset in children less than 5 years old, and because of the developmental vulnerability of the early years, there has been increasing recognition of the importance of bringing insights from developmental science to bear on practice in child welfare. 33 This rationale derives from a convergence of neuroscience documenting the effects of experience on the developing brain, child development data about the centrality of relationships in promoting adaptive relationships, and economic data about the return on investment of early intervention. 34

From a clinical perspective, we know that young children may be markedly symptomatic with one caregiver and asymptomatic with another caregiver. 35 This is especially likely in the context of young children seen with foster parents and biological parents. In addition to the usual history and developmentally modified mental status examination, a relationship assessment between the young child and all important caregivers is recommended for young children who have been maltreated. 36 Importantly, AACAPPractice Parameters on assessments of infants and toddlers 37 recommends that assessments of young children should typically involve three to five sessions—evaluating young maltreated children will be among the more complex assessments conducted. Formal methods for assessing relationships in young children are available, 38 , 39 but attending to observed interactions and parents’ perceptions of their children in order to understand the relationship are recommended. In addition, Axis II of the DC:0–5 25 pro-vides guidelines for comprehensive characterization of the relational context of young children. Although derived from a large body of evidence regarding the importance of primary caregiving relationships and co-parenting for young children’s development, the specific DC:0–5 guidelines about the relational context of young children await explicit validation.

We have argued that foster care is a different intervention for younger children (especially less than 3 years old but generally up to age 5 years) than for older children. 40 , 41 This derives from our understanding that the quality of the young child’s attachment relationships is a foundational component of young children’s socioemotional development and an important predictor of subsequent psychosocial functioning, especially within high-risk groups. 42 , 43 Furthermore, young children develop and sustain attachments through substantial contact with caregiving adults. 44 This means that for young children in foster care, foster parents must function as primary attachment figures for them. The vital role of foster parents is too often under recognized, not only by CPS and the courts, but even by mental health professionals. Recognizing its importance has obvious implications for young children and their relationships with foster parents.

Reports from childcare and preschool teachers are especially valuable to include in the assessment, because they provide data about the child’s functioning outside of the family context. This is important for determining which behaviors are pervasive and which are context specific. Given the sometimes contentious relationships between foster and biological parents, teachers can provide a perspective from more objective observers and also from professionals who likely have a keen appreciation of age typical and age-atypical behaviors.

Because of the high rates of cognitive, motor, and language delays in young maltreated children, 45 , 46 referrals for developmental assessments to address suspected or apparent language and/or motor delays are often indicated.

INTERVENTIONS

One component of treatment of maltreated children is virtually identical to treatment of nonmaltreated children—psychotherapy and/or medication as determined by a thorough assessment. Of course, given that maltreated children are at the extreme of the risk continuum, there are compelling reasons to apply evidenced-based interventions to treat their symptoms and impaired functioning. 47 These treatments are key elements of the therapeutic arsenal for the complex pictures of comorbidity with which maltreated children often present, even though most of the interventions, including medication, have not been studied systematically in maltreated children. Fortunately, there are many evidence-based treatments available for infants through adolescents who have experienced maltreatment (eg, trauma-focused cognitive-behavioral therapy; parent–child interaction therapy; child–parent psychotherapy).

Overuse and misuse of psychotropic medication among foster children has become an increasing concern. 48 Reviewing Medicaid data from one month in 2004 in Texas, for example, Zito et al. 49 found that among foster children prescribed psychotropic medication, 41% took three different classes of medication, and 16% took four different classes. Care should be taken about using multiple classes of psychotropic medication in foster children, given the lack of evidence supporting the safety and efficacy of combined pharmacotherapy, particularly for three or more medications. Reduced access to and investment in evidenced-based psychotherapy may contribute to unwarranted psychotropic medication use.

What is different about treatment of maltreated children is that symptom reductions through evidenced-based treatments is rarely sufficient. Comprehensive and multimodal treatments are required, and often over long durations. Myriad factors beyond maltreatment are likely to cause or exacerbate symptoms in maltreated children (eg, maladaptive family interactions, quality of placements, stress of visits, separation inherent in foster placements, separations from siblings, and court and CPS decisions). These challenging stressors require additional clinical efforts to help the child navigate the aftermath of maltreatment.

CASE INTERVENTIONS

Maria had a 5-day inpatient hospitalization for depression with suicidal intent, and completed 4 months of trauma focused cognitive-behavioral therapy (TF-CBT). During this time, her mother received several months of therapy focused on Maria’s stepfather’s controlling relationship with her and how this contributed to her failure to protect Maria. She accepted that the abuse had occurred and indicated that initially her fear of the police and CPS had led her to deny her daughter’s allegations. In addition, the clinical team intervened to address a conflicted relationship between Maria’s family and CPS. Six additional months of family therapy were directed at a role-reversed mother–daughter relationship and the mother’s failure to protect Maria from the stepfather. In the midst of these multifaceted intervention efforts, Maria was successfully returned to her mother’s care, and treatment continued for another 9 months after her return home.

James was treated with 4 months of TF-CBT. His father was enrolled in a 4-month skill-building group therapy for parents (Effective Black Parenting). Following this, James’s father was seen for grief counseling about the loss of James’s mother to cancer 2 years earlier. James and his older and younger sister were seen with their father for family therapy, which focused on the father’s sensitivity to rejection and angry outbursts. James was returned home after 12 months in foster care.

Jacqueline was overly active, aggressive, and socially indiscriminate when she entered her foster placement. Immediate work with her foster parents focused on restricting her contact with unfamiliar adults and establishing a reward-oriented behavior management plan. The foster mother was coached in using the PRIDE skills (labeled praise, reflections, imitations, descriptions, and enthusiasm) from parent–child interaction therapy. Her symptoms gradually dissipated, and she was able to attend childcare without difficulty. Her biological mother tested positive for substances, did not enroll in an intervention program, and after several months stopped attending scheduled visits with Jacqueline. When Jacqueline was 34 months old, her maternal aunt appeared and requested that she be placed with her. Following a hearing on the matter, including expert testimony about best interest, the judge denied the aunt’s request. Jacqueline was adopted by her foster parents after a termination of parental rights trial.

Key Messages.

Child maltreatment—physical, sexual, and emotional abuse, as well as various forms of neglect—leads to increased risk for psychopathology across development, including internalizing disorders, externalizing disorders, trauma and stress related disorders, neurodevelopmental disorders (eg, attention-deficit/hyperactivity disorder), and substance use disorders, as well as academic problems, delinquency, and difficulties in social relationships.

Maltreatment is associated with a substantial proportion of the psychiatric morbidity that presents to clinical settings for children and adolescents, so that affected children are overrepresented in these settings.

Racial and ethnic disparities are apparent. African American and American Indian children have the highest rates of maltreatment, and clinicians should be alert for structural racism affecting decision making.

More effective care will be provided to maltreated children in need of treatment when clinicians are knowledgeable about the legal and child protection systems, each of which has its own priorities, values, and languages and differs from those of clinical work.

Assessments of children presenting for evaluation of problems related to maltreatment, especially if they are involved with legal and child protective systems, are necessarily complex and likely require more time than evaluations of children who have not experienced maltreatment.

Treatment of symptoms and disorders related tomaltreatment should be multimodal and often needs to address external factors that may contribute to their perpetuation and exacerbation.

Young children, who comprise the majority of maltreatment cases, require careful evaluation of the child’s caregiving contexts, which often includes multiple caregivers, so that both assessments and treatment are comprehensive.

Disclosure:

Dr. Zeanah has received funding from the John D. and Catherine T. MacArthur Foundation Research Network on “Early Experience and Brain Development” (Charles A. Nelson, PhD, Chair), the National Institute of Mental Health (NIMH; 1R01MH091363, Nelson), the Substance Abuse and Mental Health Services Administration (SAMHSA; 1U79SM080030-01, Lieberman), the Palix Foundation, the Lumos Foundation, and the Irving Harris Foundation (Zeanah). He has received royalties from Guilford Press and Harvard University Press and honoraria for speaking engagements to professional audiences. Dr. Humphreys has received support from NIMH (F32MH107129), the Brain and Behavior Research Foundation (formerly NARSAD) Young Investigator Award 23819, the Klingenstein Third Generation Foundation Fellowship, and the Jacobs Foundation Early Career Research Fellowship.

Contributor Information

Charles H. Zeanah, Tulane University School of Medicine, New Orleans, LA..

Kathryn L. Humphreys, Tulane University School of Medicine, New Orleans, LA.; Vanderbilt University, Nashville, TN.

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