Chapter 42. Child Maltreatment

The legal definitions regarding child maltreatment vary from state to state. In general, neglect is the failure to provide adequate care and protection for children. It may involve failure to feed the child adequately, provide medical care, provide appropriate education, or protect the child from danger. Physical abuse is the infliction of nonaccidental injury by a caretaker. It may take the form of beating, punching, kicking, biting, or other methods. The abuse can result in injuries such as broken bones, internal hemorrhages, bruises, burns, and poisoning. Cultural factors should be considered in assessing whether the discipline of a child is abusive or normative. Sexual abuse of children refers to sexual behavior between a child and an adult or between two children when one of them is significantly older or more dominant. The sexual behaviors include the following: touching breasts, buttocks, and genitals, whether the victim is dressed or undressed; exhibitionism; fellatio; cunnilingus; penetration of the vagina or anus with sexual organs or with objects; and pornographic photography. Emotional abuse occurs when a caretaker causes serious psychological injury by repeatedly terrorizing or berating a child. When serious, it is often accompanied by neglect, physical abuse, sexual abuse, and exposure to domestic violence.

The psychiatric classification of abuse and neglect in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) appears in the chapter “Other Conditions That May Be a Focus of Clinical Attention” and in the section “Problems Related to Abuse or Neglect.” The categories of abuse and neglect take a number of factors into consideration including: whether the maltreatment consisted of physical abuse, sexual abuse, or neglect; whether the victim was a child or an adult; whether the focus of clinical attention is on the victim or the perpetrator; and whether, in the case of adults, the perpetrator was the victim's partner or a person other than the victim's partner. The DSM-IV-TR categories related to child maltreatment are in given in the Box above. These conditions are coded on Axis I.

DSM-IV-TR classification of child maltreatment

Practitioners in private practice, as well as those employed by courts or other agencies, see children who may have been emotionally, physically, or sexually abused. As a clinician, the practitioner may provide assessments and treatment for abused children and their families in both outpatient and inpatient settings. As a forensic investigator, the practitioner may work with an interdisciplinary team at a pediatric medical center and assist the court in determining what happened to the child.

Epidemiology

Each year about three million alleged incidents of child maltreatment are reported to protective services (U.S. Department of Health and Human Services, 2005). Of those reports, about one million are substantiated. Of the substantiated cases, about 60% involve neglect; about 20% involve physical abuse; about 10% involve sexual abuse; about 5% involve emotional abuse; and the rest are unspecified. About 1500 children die each year as a result of maltreatment.

Etiology

Child maltreatment is a tragic and complex biopsychosocial phenomenon. There are various models to explain why child abuse occurs, but generally they consider the interaction of five levels of risk factors and protective factors: (1) The individual biological and psychological makeup of the child victim is important. For example, children who are premature, developmentally disabled, and physically handicapped are more likely to be abused. (2) The individual characteristics of the adult perpetrator. For example, child abuse occurs in all strata of society, but it is associated with lower parental education, parental mental illness, and parental substance abuse, especially alcoholism. (3) The family system refers to the family environment, parenting styles, and interactions among family members. Risk factors include single parenting and domestic violence. (4) The community in which the family lives may relate to both risk and protective factors. In general, child abuse is strongly associated with poverty, financial stress, poor housing, and social isolation. However, there may be protective factors in the community related to the parent's workplace, peer groups of family members, and formal and informal social supports. (5) Finally, the values and beliefs of the culture affect the occurrence of child maltreatment. During the twentieth century, for example, there were two major societal shifts that reduced the frequency of child abuse: the concept that child behavior should be socialized primarily through love, not harsh, physical discipline; and the realization that parental authority is not absolute, that is, parents are not entitled to unrestricted authority over their children.

Signs & Symptoms

Children who have been abused manifest pleomorphic symptoms in a variety of emotional, behavioral, and psychosomatic reactions. Abused children may have internalizing symptoms such as withdrawal, anxiety, depression, and sleep problems. Abused children may exhibit externalizing symptoms, such as aggression. Children who have been sexually abused are likely to display inappropriate sexual behavior. Table 42–1 lists symptoms that are associated with child abuse: they are not specific or pathognomonic; the same symptoms may occur in the absence of a history of abuse.

The parents of physically abused children have certain characteristics. Typically, they have delayed seeking help for the child's injuries. The history given by the parents is implausible or incompatible with the physical findings. There may be evidence of repeated suspicious injuries. The parents may blame a sibling or claim the child injured himself or herself.

In cases of intrafamilial sexual abuse and other sexual abuse that occurs over a period of time, there is a typical sequence of events: (1) engagement, when the perpetrator induces the child into a special relationship; (2) sexual interaction, in which the sexual behavior progresses from less intimate to more intimate forms of abuse; (3) the secrecy phase; (4) disclosure, when the abuse is discovered; and (5) suppression, when the family pressures the child to retract his or her statements (Sgroi, 1988).

The child sexual abuse accommodation syndrome is sometimes seen when children are sexually abused over a period of time. This syndrome has five characteristics: (1) secrecy; (2) helplessness; (3) entrapment and accommodation; (4) delayed, conflicted, and unconvincing disclosure; and (5) retraction (Summit, 1983). The process of accommodation occurs as the child learns that he or she must be available without complaint to the parent's demands. The child often finds ways to accommodate: by maintaining secrecy in order to keep the family together, by turning to imaginary companions, and by inducing in herself altered states of consciousness. Other children become aggressive, demanding, and hyperactive.

It is possible to distinguish the psychological sequelae of children who have experienced single-event and repeated-event trauma (Terr, 1991). The following four characteristics occur after both types of trauma: (1) visualized or repeatedly perceived intrusive memories of the event; (2) repetitive behavior; (3) fears specifically related to the trauma; and (4) changed attitudes about people, life, and the future. Children who sustain single-event traumas manifest full, detailed memories of the event; an interest in “omens,” such as looking retrospectively for reasons why the event occurred; and misperceptions, including visual hallucinations and time distortion. In contrast, many children who have experienced severe, chronic trauma (e.g., repeated sexual abuse) manifest massive denial and psychic numbing, self-hypnosis, dissociation, and rage.

Clinical Evaluation

The professional who evaluates children who may have been abused has several important tasks: finding out what happened; evaluating the child for emotional disorder; considering other possible explanations for any disorder; being aware of developmental issues, avoiding biasing the outcome with his or her preconceptions; pursuing these objectives in a sensitive manner so as not to retraumatize the child; being supportive to family members; and keeping an accurate record which may be subpoenaed for future court proceedings.

It is important to be familiar with the normative sexual behavior of children for two reasons. First, normal sexual play activities between children should not be taken to be sexual abuse. In assessing this issue, the evaluator should consider the age difference between the children; their developmental level; whether one child dominated or coerced the other child; and whether the act itself was intrusive, forceful, or dangerous. Second, sexually abused children often manifest more sexual behavior than do typical children. Sometimes they have sexual knowledge beyond what would be expected for their age and developmental level. For example, behavior such as trying to undress other people, masturbating with an object, performing fellatio, and imitating sexual intercourse are red flags that suggest a child has been sexually abused.

Patient Interview

The clinical interview may need modification when assessing a child who may have been abused. The following sections describe the components of an interview that is particularly suited for forensic evaluations (Poole & Lamb, 1998; Yuille et al., 1993):

Build Rapport and Make Informal Observations

Build rapport with the child and make informal observations of the child's behavior, social skills, and cognitive abilities.

Ask the Child to Describe Two Specific Past Events

In order to assess the child's memory and to model the form of the interview for the child by asking nonleading, open-ended questions, a pattern that will hold through the rest of the interview. For example, prior to interviewing the child, one can obtain specific information from the parent about a recent birthday party, trip to the zoo, etc.

Establish the Need to Tell the Truth

Reach an agreement that in this interview only the truth will be discussed, not “pretend” or imagination. For example, the interviewer can say, “If I said I’m wearing a purple hat today, would that be the truth or a lie?” Reach an agreement that it is fine to say, “I don't know.” For example, the interviewer can say, “Do I have a dog named Charlie?” and the child should say, “I don't know.”

Introduce the Topic of Concern

Start with more general questions, such as, “Do you know why you are talking with me today?” Proceed, only if necessary, to more specific questions, such as, “Has anything happened to you?” or “Has anyone done something to you?” Drawings may be helpful in initiating disclosure. For example, either the child or the interviewer draws an outline of a person. Then the child is asked to add and name each body part and describe its function. If sexual abuse is suspected, the interviewer could ask, when the genitals are described, if the child has seen that part on another person and who has seen or touched that part on the child. If physical abuse is suspected, the interviewer could ask if particular parts have been hurt in some way.

Elicit a Free Narrative

Once the topic of abuse has been introduced, the interviewer encourages the child to describe each event from the beginning without leaving out any details. The child is allowed to proceed at his or her pace, without correction or interruption. If abuse has occurred over a period of time, the interviewer may ask for a description of the general pattern and then for an account of particular episodes.

Pose General Questions

The interviewer may ask general questions in order to elicit further details. These questions should not be leading and should be phrased in such a way that an inability to recall or lack of knowledge is acceptable.

Pose Specific Questions, If Necessary

It may be helpful to obtain clarification by asking specific questions. For example, the interviewer may follow up on inconsistencies in a gentle, nonthreatening manner. Avoid repetitive questions and the appearance of rewarding particular answers in any way.

Use Interview AIDS, If Necessary

Anatomically correct dolls may be useful in developing exactly what sort of abusive activity occurred. The dolls are not used to diagnose child abuse, only to clarify what happened (Everson & Boat, 1994).

Conclude the Interview

Toward the end of the interview, the interviewer may ask a few leading questions about irrelevant issues (e.g., “You came here by taxi, didn't you?”). If the child demonstrates a susceptibility to suggestions, the interviewer would need to verify that the information obtained earlier did not come about through contamination. Finally, the interviewer thanks the child for participating, regardless of the outcome of the interview. The interviewer should not make promises that cannot be kept.

Parent Interview

In order to evaluate a child who may have been abused, it is necessary to do more than simply interview the child and ask him or her what happened. It is also important to interview the parents and perhaps other caregivers. The parents should be able to provide information regarding the child's experiences with particular people; the duration and evolution of the child's symptoms; the child's developmental and medical history; and factors in the child's life, other than abuse, that might explain the symptoms. It may also be important to assess the parents’ motivations and psychological strengths and weaknesses. For instance, some parents (who perpetrated the abuse or allowed another individual to do so) may be motivated to deny or minimize the possibility that the child was abused. Other parents (who are vengeful or overly suspicious of another person) may be motivated to exaggerate the possibility that the child was abused or may even fabricate symptoms of abuse.

Psychological Testing

Although psychological testing cannot diagnose child abuse, it may be a useful part of the evaluation. For example, the Child Sexual Behavior Inventory is a questionnaire to be completed by a parent, usually the child's mother. This questionnaire helps the clinician identify sexual behaviors that can be considered normative for the child's age and gender and sexual behaviors that can be viewed as relatively atypical for the child's age and gender, and which raise the suspicion of possible sexual abuse. Intellectual testing may be used to establish the child's developmental level. A general psychiatric evaluation may help with the differential diagnosis and clarify the child's treatment needs.

Record Review

In evaluating a child who may have been abused, it is frequently important to obtain information from outside sources such as medical, mental health, and educational records. It may be helpful to review the investigation conducted by child protective services, although those records may not be available.

Johnson TC: www.TCavJohn.com has useful tools for assessment, treatment, and family education regarding child sexual abuse.

Children may make false statements in psychiatric evaluations. Sometimes they falsely deny abuse; sometimes they make false allegations. A number of mental processes, both conscious and unconscious, can result in false allegations. For example, a delusional mother, who believed that her ex-husband had been molesting their daughter, induces the girl to state that the father had rubbed against her in bed. By repeatedly asking leading or suggestive questions, inept interviewers have induced children to make false allegations of abuse. Some children manifest pathological lying in making false allegations. Young children may tell tall tales, making innocent statements that evolve or are molded into false allegations of abuse. Older children may lie about abuse for revenge or personal advantage. In the past, multiple allegations of abuse have been generated through group contagion or spread by parental panic and overzealous clinical investigation.

Credibility refers to the child's truthfulness and accuracy, which sometimes is an issue in assessing children who allege abuse. The following factors indicate that the child is credible: the child uses his or her own vocabulary rather than adult terms and tells the story from his or her own point of view; the child displays advanced sexual knowledge; the child reenacts the trauma in spontaneous play; sexual themes are present in play and drawings; the child's affect is consonant with the accusations; the child's behavior is seductive, precocious, or regressive; the child has good recall of details, including sensory motor and idiosyncratic details; and the child has a history of telling the truth.

The following factors indicate the child is making unreliable or fictitious allegations: the child's account is vague and lacks details, due to lack of information, not resistance or defensiveness; the child's statements are dramatic or implausible, for example, involving the presence of multiple perpetrators or situations in which the perpetrator has not taken ordinary steps against discovery; the child's statements become increasingly inconsistent over time; and the child's accounts progress over time from relatively innocuous behavior to increasingly intrusive, abusive, and aggressive activities.

The first step in the management of child maltreatment is ensuring the child's safety and well-being. The child may need to be removed from an abusive or neglectful family. A clinician who suspects that a child has been abused should perform an assessment within the scope of the clinician's expertise—that is, the psychiatrist conducts a psychiatric evaluation, the pediatrician conducts a pediatric assessment. If the clinician continues to suspect child abuse after conducting his or her assessment, the local child protection agency must be notified (Kalichman, 1999).

Maltreated children who have significant psychological or behavioral symptoms should receive psychiatric treatment. Treatment should not be confused with forensic investigation. Although a specific treatment plan depends on the findings of a diagnostic evaluation, the psychotherapist would generally address issues such as self-esteem, worries, and fears; developing a therapeutic relationship built on trust, in which the child will not be exploited or betrayed; and gaining an understanding over time of the factors that contributed to the child's victimization.

Abused children with posttraumatic stress disorder have been successfully treated with a trauma-focused cognitive behavioral treatment (Cohen et al., 2000, 2004) that has four components: psychoeducation, anxiety management, exposure, and cognitive therapy. Psychoeducation includes teaching the child and the caregivers about strategies to avoid future abuse. Anxiety management includes teaching children how to use relaxation and other coping strategies to reduce fearful responses to memories of abuse. Exposure refers to mastering traumatic anxiety through talking, drawing, or writing about the abuse experiences, either in ordinary conversation or through a variety of play, artistic, or other projective techniques. Cognitive therapy techniques help the child replace cognitive distortions about the event or negative feelings about himself or herself.

If an abused child has no symptoms related to the maltreatment, it is appropriate to provide brief psychoeducational counseling and suggestions for recognizing any problems that arise in the future. For a child whose abuse was a transitory unpleasant experience (e.g., a single, brief episode of fondling by a stranger), it may be adaptive for the child to forget the incident and move on.

The most serious risk in evaluating and treating victims of child maltreatment is that the child will be retraumatized. This can happen if treatment requires the child to remember and relive the traumatic experiences to an unnecessary degree or if the child and family are too emotionally fragile to cope. Although many therapists believe it can be helpful for the child to recall and share painful experiences from the past, it is not therapeutic to dwell on these events repeatedly and endlessly. Retraumatization can also occur when the child, who has already lost important people in her life, develops an attachment to a therapist and that new relationship is interrupted in a premature or painful manner. Another possible complication of therapy is the child's unwitting compulsion to reenact the aggressive or sexual aspects of the abusive relationship with new caregivers. That is, a seriously abused child may be placed with benevolent foster parents but behave in a way to provoke overly punitive behaviors by his new caregivers. Also, a seriously abused child may behave in a way to evoke rejection by an otherwise well-meaning therapist.

Treatment can have an adverse outcome if an overzealous therapist persists in looking for memories of past abuse when the abuse never happened in the first place. If a therapist repeatedly asks the patient—who can be a child or an adult—to remember abuse, the patient may “remember” it to please the therapist. To complicate the situation further, the patient may become convinced of the reality of these false memories.

Sometimes child maltreatment causes no long-term psychological problems at all, but sometimes it causes severe psychological problems. Child maltreatment is more likely to cause subsequent emotional and behavioral disorders if the following factors are present: greater frequency and duration of abuse; greater force; physical injury; perpetration by a family member; the child already has poor coping skills; and lack of family support. Maternal support and validation of the child's statement is correlated with better prognosis.

The long-term psychological consequences of child maltreatment have been studied prospectively by following abused children for more than 20 years (Widom, 1999; Horwitz, 2001). The long-term psychological and physical effects of childhood maltreatment were also examined retrospectively in the Adverse Childhood Experiences (ACE) Study (Dube et al., 2001). In general, individuals who experienced child maltreatment were more likely to have psychological problems—posttraumatic stress disorder, dysthymia, suicidality, alcoholism, and antisocial personality disorder—than were individuals who had not been abused.

Herman (1992) and van der Kolk (2003) have studied the long-term psychological and neurobiological effects of severe child maltreatment. Adults who were severely abused as children may develop a condition called complex posttraumatic stress disorder or a disorder of extreme stress not otherwise specified (DESNOS). The features of DESNOS are: altered regulation of affect and impulses; altered attention and consciousness; altered self-perception; altered relationships; altered systems of meaning; and somatization.

The long-term consequences of child maltreatment may be affected by the victim's genetic makeup. Caspi et al. (2002) found that children who had a variant allele of the MAOA gene and also had been seriously abused were much more likely to be violent and antisocial as adults. This research suggests a mechanism by which genetic makeup and life experience interact to influence psychosocial development and future attitudes and behaviors.