Child Maltreatment

Preface

Child maltreatment in its various forms remains a significant problem confronting children and their families worldwide. The incidence and prevalence statistics surrounding child maltreatment continue to be staggering when compared to the reduction in pediatric morbidity and mortality associated with infectious diseases over the past 100 years. This reference is put forth to help healthcare professionals, social service providers, and law enforcement personnel meet the challenges that arise in dealing with this preventable problem that harms children and their families. Although the text is approached primarily from a healthcare point of view, the information contained will also benefit other disciplines and professionals such as social service workers, attorneys, law enforcement officers, state agencies, and others who might be involved with children of suspect child maltreatment. Collected in this third edition is information concerning the multidisciplinary team approach to physical abuse, sexual abuse, psychological abuse, and neglect that has evolved over the past 40 years from the work of dedicated professionals.

The previous two editions of Child Maltreatment: A Clinical Guide and Reference, edited by James A. Monteleone, MD, were well-received by clinicians dealing with abused and neglected children and serve as a solid foundation on which this nearly total revision is based. As the new editors, we have recruited 70 new contributing authors to add their expertise. The text has expanded from 28 chapters in the second edition to the current 43 contained in this volume. Since no one person or discipline could effectively address all aspects of child maltreatment, we sought specific expertise in each area and found dedicated colleagues who were willing to share their time and knowledge for this project. The contributing authors are all individuals who have been extensively involved in issues related to child health and protection activities for significant periods of time and are uniformly acknowledged as leading figures in their fields by peers and colleagues.

Child Maltreatment Overview

John M. Leventhal, MD

Since 1962, when Kempe and colleagues first described the “battered child syndrome,” 1 it has become increasingly clear that child maltreatment, including physical abuse, neglect, sexual abuse, and emotional abuse, is far too common, has profound short- and long-term effects on children and families, and is extremely costly to society. It also has become clear that much greater attention and financial support will be necessary to increase dramatically the efforts aimed at preventing child maltreatment and supporting families.

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Child Maltreatment Defintions and Epidemiology

Maltreatment of children includes neglect, physical abuse, sexual abuse, and emotional maltreatment. Neglect is defined as acts of omission and includes the failure to provide adequate nutrition, clothing, shelter, or supervision; abandonment; and failure to ensure that the child receives adequate healthcare, dental care, or education. Although neglect can be a single event, such as leaving a young child unsupervised in an unsafe setting, it often is a pattern of unsafe or inadequate care, such as a pattern of inadequate supervision or inadequate nutrition because of a serious mental health problem or substance abuse on the part of the caregiver. Physical abuse is defined as acts of commission toward the child by a parent or caregiver. Such acts can result in harm to the child or they might intend to harm, although there may be no harm or only a minor injury. It can include injuries that occur when a child is punished severely or when a parent loses control and shakes a crying infant. Injuries that are suspicious for abuse or neglect must be distinguished from unintentional (or accidental) injuries. Also, clinicians must take care to distinguish neglect from episodes of less serious failures to provide adequate care to a child, such as when a 10-month-old rolls off of a bed or a child has missed a few appointments for well-child care and has not received all of the appropriate immunizations. Sexual abuse is the involvement of adults, older children

Child Maltreatment: Opportunities for Federal Funding and Collaboration

Margaret M. Feerick, PhD
Cheryl A. Boyce, PhD
Angelo P. Giardino, MD, PhD

The necessity for rigorous research in the area of child abuse and neglect has long been recognized along with the reality that such inquiry presents monumental methodological challenges. Increasing attention over the past 2 decades has focused on child maltreatment research efforts that address key questions about defining, measuring, preventing, and developing effective interventions for this social and public health problem.1,2 The 1993 publication of a book-length report entitled “Understanding Child Abuse and Neglect” was a landmark event in child maltreatment research.1 The report of the National Research Council’s (NRC) Panel on Research on Child Abuse and Neglect set the stage for future scientific investigation in the area of child maltreatment. The Panel set 17 research priorities intended to guide clinicians, researchers, and policy makers (Table 40-1).

Setting research priorities was particularly important for child maltreatment because researchers in the field find that child maltreatment–related research may be overshadowed by other pediatric research priorities at the federal level, limiting the number of high-quality investigations.3-6 Many federal agencies have historically supported research and program efforts dealing with child maltreatment (eg, the Administration for Children and Families, the Department of Justice), but only recently have concerted efforts at collaboration been made across federal agencies to significantly improve funding for this research. The National Institutes of Health (NIH) Child Abuse and Neglect Working Group (CANWG) is an effort oriented toward promoting coordination and increasing the amount of high-quality research in the scientific inquiry on child maltreatment. Although the NIH has long been interested in research related to understanding child maltreatment, establishing a working group on this topic has led to increased opportunities for federal funding and collaboration.7,8 The establishment of the CANWG has also led to new partnerships that aim to address specific research needs in the scientific literature.

Disclaimer: The views and opinions expressed herein are solely those of the authors and do not necessarily represent the views or policy of the National Institutes of Health or the US Department of Health and Human Services.

Table 40-1. Overview of the National Research Council’s Report, Understanding Child Abuse and Neglect

OBJECTIVES OF THE NATIONAL RESEARCH COUNCIL PANEL

— Review and assess research on child abuse and neglect, encompassing work funded by ACYF and other known sources under public and private auspices.
— Identify research that provides knowledge relevant to the field.
— Recommend research priorities for the next decade, including building blocks for knowledge development, new areas of research that should be funded by public and private agencies, and suggestions regarding fields that are no longer a priority for funding (p 3).

FIVE KEY REASONS FOR LOOKING AT RESEARCH

1. Research on child maltreatment can provide scientific information that will help with the solution of a broad range of individual and social disorders.
2. Research on child maltreatment can provide insights and knowledge that can directly benefit victims of child abuse and neglect and their families.
3. Research on child maltreatment can reduce long-term economic costs associated with treating the consequences of child maltreatment in areas such as mental health services, foster care, juvenile delinquency, and family violence.
4. Research on child maltreatment can provide empirical evidence to improve the quality of many legal and organizational decisions that have broad-based social implications.
5. Research on the etiology of child maltreatment can provide a scientific basis for primary prevention of child abuse—that is, through programs that will counteract etiological factors before they have a chance to produce child abuse in the next generation (p 2).

RESEARCH PRIORITIES

The Nature and Scope of Child Maltreatment

1. A consensus on research definitions needs to be established for each form of child abuse and neglect.
2. Reliable and valid clinical-diagnostic and research instruments for the measurement of child maltreatment are needed to operationalize the definitions discussed under Research Priority 1.
3. Epidemiological studies on the incidence and prevalence of child abuse and neglect should be encouraged, as well as the inclusion of research questions about child maltreatment in other national surveys.

Understanding the Origins and Consequences of Child Maltreatment

4. Research that examines the processes by which individual, family, community, and social factors interact will improve understanding of the causes of child maltreatment and should be supported.
5. Research that clarifies the common and divergent pathways in the etiologies of different forms of child maltreatment for diverse populations is essential to improve the quality of future prevention and intervention efforts.
6. Research that assesses the outcomes of specific and combined types of maltreatment should be supported.
7. Research that clarifies the effects of multiple forms of child victimization that often occur in the social context of child maltreatment is needed. The consequences of child maltreatment may be influenced significantly by a combination of risk factors that have not been well described and understood.
8. Studies of similarities and differences in the etiologies and consequences of various forms of maltreatment across various cultural and ethnic groups are necessary.

Improving Treatment and Preventive Interventions

9. High-quality evaluation studies of existing program and service interventions are needed to develop criteria and instrumentation that can help identify promising developments in the delivery of treatment and prevention services.
10.Research on the operations of the existing child protection and child welfare systems is urgently needed. Factors that influence different aspects of case-handling decisions and the delivery and use of individual and family services require attention. The strengths and limitations of alternatives to existing institutional arrangements need to be described and evaluated.
11. Service system research on existing state data should be conducted to improve the quality of child maltreatment research information, as well as to foster improved service interventions.
12. The role of the media in reinforcing or questioning social norms relevant to child maltreatment needs further study.

Science Policy for Research on Child Maltreatment

13. Federal agencies concerned with child maltreatment research need to formulate a national research plan and provide leadership for child maltreatment research.
14. Governmental leadership is needed to sustain and improve the capabilities of the available pool of researchers who can contribute to studies of child maltreatment. National leadership is also required to foster the integration of research from related fields that offer significant insights into the causes, consequences, treatment, and prevention of child maltreatment.
15. Recognizing that fiscal pressures and budgetary deficits diminish prospects for significant increases in research budgets generally, special efforts are required to find new funds for research on child abuse and neglect and to encourage research collaboration and collection in related fields.
16. Research is needed to identify organizational innovations that can improve the process by which child maltreatment findings are disseminated to practitioners and policy makers. The role of state agencies in supporting, disseminating, and using empirical research deserves particular attention.
17. Researchers should design methods, procedures, and resources that can resolve ethical problems associated with recruitment of research subjects; informed consent; privacy, confidentiality, and autonomy; assignment of experimental and control research participants; and debriefings (pp 31-36).

Adapted from National Research Council. Understanding Child Abuse and Neglect. Report of the Panel on Research on Child Abuse and Neglect.Washington, DC: National Academy Press; 1993.




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