Child Abuse

PHYSICAL ABUSE AND NEGLECT Beth M. Schwartz-Kenney, Michelle McCauley

PSYCHOLOGICAL MALTREATMENT Stuart N. Hart, Marla R. Brassard, Nelson J. Binggeli, Howard A. Davidson

SEXUAL ABUSE Kathleen Kendall-Tackett

Defining Child Physical Abuse and Neglect

The definition of abuse and neglect is difficult to determine even within a particular country. For example, Joaquín De Paúl and Olaya González (2001) note that before 1987 professionals in Spain could not reach an agreement concerning how one should classify child maltreatment cases: There was no commonly used definition of child abuse and neglect. Given the many cultural and societal influences affecting the way in which a country defines abuse, defining abuse globally is obviously a formidable task, although definitions of abuse and neglect do contain commonalities across countries. Child maltreatment includes both the abuse and neglect of a child, two different types of problems with slightly different causes, perpetrators, and outcomes. Furthermore, abuse occurs in a number of different forms including physical abuse, psychological maltreatment, and sexual abuse. These categorizations of abuse are fairly common across cultures.

Physical abuse often is described as a situation in which a child sustains injury due to the willful acts of an adult. This type of abuse can be defined very loosely, where abuse is defined as the illtreatment of children. However, the definition may be as specific as stating that the injuries are inflicted by particular acts such as hitting, biting, kicking, or slapping; and/or occur through the use of objects such as belts, sticks, rods, or bats. These more specific definitions are usually the result of laws created to protect children. For instance in Spain the 21/87 Act improved the consistency of definitions used throughout the country in identifying child abuse (De Paúl and González 2001). In Israel in 1989 an amendment was passed known as the Law for the Prevention of Abuse of Minors and the Helpless. Specific types of abuse were defined within this amendment, creating a more definitive classification of each type of abuse in Israel (Cohen 2001). In many countries, the definition of physical abuse involves the presence of a physical mark created by intentional physical contact by an adult. One advantage of clear definitions is that they result in a more accurate reporting of physical abuse to authorities (Kasim 2001).

Physical abuse occurs more often in families with female children and in those with four or more children. Child victims are more likely than nonvictims to experience post-traumatic stress disorder, depression, attachment difficulties, and low self-esteem. ROY MORSCH/CORBIS

Physical abuse can also be a result of parental and/or school discipline in which a child is punished by beating or other forms of corporal punishment. It should be noted, however, that there are large cultural differences in the interpretation of corporal punishment as abuse. Many Western countries classify corporal punishment of any kind as physical abuse, although this is not true for the United States or Canada. In fact, twenty-three U.S. states allow corporal punishment in the public school system (National Coalition to Abolish Corporal Punishment in Schools 2001). Corporal punishment of children is also accepted in other countries. In Sri Lanka, caning a child is still a permitted form of punishment in government schools, and parents and teachers believe they have the right to impose corporal punishment (de Silva 2001). This is also the case in Kenya, where physical punishment is an acceptable way of disciplining children (Onyango and Kattambo 2001). In Romania 96 percent of the population are comfortable with beating a child as a form of discipline and do not feel that this beating would have any negative impact on the child's development (Muntean and Roth 2001). In India, Uma Segal (1995) examined the incidence of physical abuse defined as "discipline." Her results indicate that 57.9 percent of parents stated that they had engaged in "normal" corporal punishment, 41 percent in "abusive" discipline, and 2.9 percent in "extreme" discipline.

Physical abuse also includes acts of exploitation. This type of physical abuse is prevalent in a number of countries such as Sri Lanka, the Philippines, and Thailand where sexual exploitation of children is well documented (de Silva 2001). Exploitation is also seen in the form of child labor in a number of countries, such as India (Segal 2001), and in the conscription into the military of children in Sri Lanka (de Silva 2001). Finally, one less common form of psychical abuse results when a caretaker fabricates a child's illness, known as Munchausen Syndrome by Proxy. The pattern of events accompanying this syndrome often results in physical injury to the child (Wiehe 1996). Munchausen Syndrome by Proxy has been identified in a number of different countries (Schwartz-Kenney, Mc-Cauley, and Epstein 2001).

In the United States, following C. Henry Kempe and his colleagues' (1962) identification of battered-child syndrome, physical abuse was identified more objectively through the use of medical definitions. The Child Abuse Prevention and Treatment Act of 1974 led to a federal definition of child abuse and neglect. This Act provided definitions for all types of abuse and led to greater public awareness and response to problems associated to child maltreatment. This federal definition was changed in 1996 by the U.S. Congress. Child abuse and neglect in the United States is now defined as ". . . any recent act or failure to act on the part of a parent or caretaker, which results in the death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which present an imminent risk of serious harm" (42 U.S.C. §5106g[2] [1999]). This change gave greater discretion to the states, allowing each state to define abuse more broadly.

Child neglect also can take on a number of different forms. For instance a child's nutritional needs can be ignored, resulting in a deficient diet and, in turn, a "failure to thrive." This nutritional neglect is not necessarily intentional and may result from a parent's lack of knowledge regarding a healthy diet or from poverty. Physical neglect results when a child is not provided with adequate food, shelter, and clothing. Neglect can also come in the form of inadequate medical care, lack of proper supervision, and lack of educational opportunities. Finally, neglect also includes inadequate emotional care, where a child experiences a continuous lack of response to his or her crying or any other behavior in need of a response.

The type of neglect experienced by children is dependent upon the culture in which one lives. For instance, in India one problem still faced by many young women is child marriage. Due to extreme poverty, many girls are perceived as a financial burden to their families and are in turn forced to marry in exchange for money. In some cases, young women are sold to brothels. As Segal (2001) notes, under both circumstances these children are inevitably physically abused.

A very distinct type of neglect occurs in Japan, where coin-operated lockers have been a part of the problem. For years, unwanted children were placed in these lockers and, in many cases, died when not found in time. This became a serious social problem in the mid-1970s. According to Akihisa Kouno and Charles Felzen Johnson (1995), approximately 7 percent of infanticides in Japan during this period were of coin-operated locker babies. Since that time, this type of neglect has dropped dramatically due to an increase in locker inspection and relocation and to educational programs on contraception.

Abuse and neglect in Romania often takes the form of child abandonment, believed to be due to poverty, lack of education, and lack of assistance to families in need (Muntean and Roth 2001). Additional abuse and neglect takes place within the family given the existing living conditions. Ana Muntean and Maria Roth state that the "emotional, physical, and even sexual abuse is quite frequent within the Romanian-family system, as well as neglect" (p. 185).

Differences in prevalence of particular subtypes of abuse are therefore evident when examining child maltreatment from an international perspective. Although evidence of abuse can be found in all countries, how abuse is defined, prevented, and treated is often determined by social agencies such as the U.S. Department of Health. The definition itself is dependent upon the national boundaries in which the agency exists. One common thread within the prevalence data in most countries is that the individuals responsible for collecting these data often state that it is likely that the numbers underestimate the degree of child abuse due to the underreporting of incidents to legal authorities (Schwartz-Kenney, McCauley, and Epstein 2001).

Prevalence of Abuse and Neglect

Internationally, child abuse is more common than previously acknowledged. Historically, it was hard for many to believe that parents or caregivers would intentionally inflict harm towards their children. Thus, in many countries child abuse and neglect were often ignored or denied as a result of people's acceptance of violence in a given culture or due to their belief that the culture must focus on preserving the family (Schwartz-Kenney, Mc-Cauley, and Epstein 2001). Some cultures simply denied that child neglect or abuse occurred. For example, Mohd Sham Kasim (2001) states that in Malaysia the problem of abuse was at one time believed to be a problem only for Western cultures. This stemmed from the idea that the strong family ties and assistance from the extended family prevalent in Malaysia prevented the problem from occurring.

Internationally, it has always been the case that the culture had to acknowledge the problem of neglect and abuse before national organizations concerned with prevention and treatment could be created. Unfortunately, it took many years (often decades) before many societies recognized it as a problem worthy of governmental resources. As mentioned above, the noted physician C. Henry Kempe dramatically increased many countries' public awareness regarding the abuse and neglect of children in his lectures on the battered-child syndrome (Kempe et al. 1962).

The prevalence of each type of maltreatment is a question that can be answered in some countries but not others. For example, this type of data is available in the United States, Australia, Malaysia, and Ireland. Other countries, such as Canada, are studying this question, whereas others, such as Mexico and Romania, are grappling with how to identify children in need rather than placing their resources in the assessment of prevalence rates for each type of abuse. When comparing countries in which the numbers are available, it is evident that there are differences with regard to the prevalence of each type of abuse. For instance, in Australia, 31 percent of reports were of emotional abuse, 28 percent included physical abuse, 16 percent consisted of sexual abuse, and 24 percent represented neglect (Hatty and Hatty 2001). This is compared to the prevalence reports in Ireland, where 34 percent of reports involved sexual abuse, 8 percent included emotional abuse, 11 percent were identified as physical abuse, and 47 percent were of neglect (Ferguson 2001). In the United States, the Child Protective Services (CPS) state that neglect is the most prevalent type of maltreatment, accounting for 45 percent of all reports, followed by physical abuse in 25 percent of cases, sexual abuse in 16 percent of cases, and finally psychological abuse in 6 percent of all reports (Briere et al. 1996).

Thus, cultural differences significantly influence the way in which forms of abuse are defined and in turn the prevalence rates that result. Given differences in defining abuse, it is not surprising that the prevalence numbers such as those reported above differ dramatically from one country to the next. For instance, as Kouno and Johnson (2001) indicate, "the disparity between prevalence rates of report abuse cases in the United States and Japan may be the result of differences in lifestyle and reporting laws between Western countries and Japan" (pp. 102–103). Comparing abuse from one country to the next is a difficult task given the differences in definition, lifestyle, and legal system. In all cases, authorities believe the prevalence rates represent approximately one-third of all cases of child abuse because these statistics are based only on reported cases and therefore ignore the remaining two-thirds of all occurrences of maltreatment. With the introduction of mandatory reporting laws in numerous countries, however, these numbers are rising. In addition, an increase in public awareness of the problem of abuse and neglect directly relates to an increase in reporting of abuse to authorities.

Perpetrators and Families in which Neglect Occurs

Who is more likely to neglect a child? Researchers have examined the characteristics of families often associated with neglect. One finding is that the perpetrator of neglect in the United States and other Western countries is likely to be female (Ferguson 2001; Juvenile Justice Bulletin 1999). This may be a function of the fact that neglect is more likely to occur in single-parent families and homes in which the mother is young. Children born to women under the age of twenty in the United States are 3.5 times more likely to experience neglect and abuse than children born to older mothers (Lee and Goerge 1999). In addition, neglect occurs more often in families with mothers who are childlike in nature—for instance, those who are more dependent on others, act more impulsively, cannot assume responsibility for themselves or others, and show poor judgment. These mothers often receive very little social support, were neglected as children themselves, have higher rates of depression than the overall population, experience high degrees of stress, and were part of families that lived in environments that did not provide adequate mental and health services or educational facilities (Wiehe 1996). Domestic abuse has also been found related to maternal neglect in Western countries such as Ireland (Ferguson 2001) and the United States (Briere et al. 1996). Researchers have also found that children born to substance abusers are more likely to experience neglect and injury compared to children of non-substance abusers (Bijur et al. 1992). Concerning family factors, children of neglect were most often from families living in poverty, families without a father present (Ferguson 2001; Polansky et al. 1981) or with an unemployed male adult (Hawkins and Dunkin 1985), families with four or more children ( Juvenile Justice Bulletin 1999), and families in which the interaction between the children and adults was primarily negative (Wiehe 1996). All of these factors often lead to a parent's inability to adequately parent, resulting in neglect of one form or another.

Perpetrators and Families in which Physical Abuse Occurs

Researchers have identified a number of factors associated with the physical abuse of a child, such as the characteristics of individuals who abuse and the characteristics of families in which child abuse occurs. In the United States less than 10 percent of child abuse is committed by non-family members ( Juvenile Justice Bulletin 1999). Obviously, the non-family abuse rate may be higher in countries such as Sri Lanka where conscription into the military and child prostitution are greater problems (de Silva 2001). In addition, in the United States only 3 percent of child maltreatment occurs at day care facilities or other institutions (Prevent Child Abuse America 1997). This rate may be higher in countries such as Romania (Muntean and Roth 2001) and Russia where institutional abuse of children has been identified as a serious problem (Berrien, Safonova, and Tsimbal 2001).

In general, there are a number of individual perpetrator differences that predict abuse in the West. For instance, individuals who were abused as children are believed to be more at risk to become abusers as adults (Straus, Gelles, and Steinmetz 1980). Physical abuse is also more likely to occur in family situations in which parental knowledge of parenting skills is inadequate, when high levels of stress are present, when parents are very young, when parental expectations are too high regarding a child's behaviors, when substance abuse is present, and/or when adults in the family have low levels of empathy towards a child (Kolko 1996). Abuse is found more often in families with female children (Sedlack and Broadhurst 1996) and in families with four or more children ( Juvenile Justice Bulletin 1999). Finally factors such as economic distress, lack of social support, and cultural or religious values have been linked to incidences of physical abuse in most countries that have addressed this problem (Schwartz-Kenney, McCauley, and Epstein 2001).

Effects of Abuse and Neglect: Long-Term and Short-Term Effects

There is little cross-cultural data on differences in harm to victims of child neglect and abuse in different countries. However, when one looks at studies from different countries there are a number of similarities. In general, empirical studies indicate that various forms of child maltreatment negatively affect the victim's development physically, intellectually, and psychosocially (Kempe and Kempe 1978; Mullen et al. 1993). Child victims of neglect and/or abuse are 1.75 times more likely to experience posttraumatic stress disorder as adults compared to individuals who did not experience neglect and/or abuse (Widom 1999). In addition, child victims are more likely to experience depression, attachment difficulties, and low self-esteem (Kolko 1996). A Canadian study found that a history of child abuse was one of the leading predictors of psychological problems in adulthood (Mian, Bala, and MacMillan 2001). Many studies also indicate the long-term effects of maltreatment given the carry-over from one generation to the next (Zuravin et al. 1996).

Furthermore, there are particular risks and harm associated with certain types of abuse, which are more prevalent in certain countries. For example, in addition to the negative outcomes discussed above, conscription into the military carries with it the risk of physical injury or death. Being forced to work as a prostitute significantly increases the chance of becoming infected with HIV or other sexually transmitted diseases. In India, which has a very high rate of child labor, children are often forced to work in dangerous conditions at exhausting hours (Segal 2001).

Finally, in addition to the harm of neglect and abuse to the individual child, there is also a broader harm or cost to society as a whole. Researchers have established a link between experiencing neglect and abuse as a child and engaging in illegal and delinquent behaviors as a teenager and adult (Widom 2001).

Cultural Differences

One must take into account the vast cross-cultural differences that exist when defining any type of child maltreatment. By examining comparative data from a diverse group of cultures, perhaps cultural factors and social structures can be identified to help us gain a better understanding of factors that contribute to abuse and factors that might assist in effectively preventing abuse. Simple definitions of child abuse and neglect do not exist, although there are a number of similarities in definitions even across cultures. Regardless of the differences in how abuse is defined, the number of reports of abuse has risen dramatically in the last decade without the needed growth in staff to respond to this increase in reports. This clearly indicates the need for greater prevention, resources dedicated to staffing, and effective treatment of this worldwide social problem.

Definition

The lack of an adequate definition of psychological maltreatment was a major obstacle to making progress dealing with the issue during the first decades of serious societal consideration of child maltreatment (1960–1990). Since the early 1980s recognizable advances have been made in articulating rationally defensible definitions of psychological maltreatment that have substantial professional and public support.

The first U.S. law on child abuse—Public Law 93–247, originally passed in 1974—included attention to psychological maltreatment under the category of "mental injury." Early attempts to elaborate this ambiguous category in national policy and state law were not adequate and resulted in a confusing diversity of terms and standards. Significant progress toward a useful definition occurred through the processes and outcomes of the International Conference on Psychological Abuse of the Child (Office for the Study of the Psychological Rights of the Child 1983); through conceptual and empirical research (Baily and Baily 1986; Brassard, Germain, and Hart 1987; Garbarino, Guttman, and Seely 1986; Hart and Brassard 1989–1991); and through the development of related standards by the American Professional Society on the Abuse of Children (APSAC) (1995). Concern about psychological maltreatment internationally is displayed in the laws of Sweden prohibiting emotional psychological abuse of children, and in the expansion of child protection law in Singapore to include "emotional injury" in the definition of when a child or young person needs care and protection (Children and Young Persons [Amendment] Act 2001; source: Ministry for Community Development and Sports, Singapore).

The term psychological maltreatment has come to be preferred to other labels (e.g., emotional abuse and neglect, mental abuse or injury). It includes both the cognitive and affective (psychological) meanings of maltreatment as well as perpetrator maltreatment acts of both commission and omission.

The strongest expert-supported definition of psychological maltreatment is presently in the APSAC Guidelines for Psychosocial Evaluation of Suspected Psychological Maltreatment of Children and Adolescents (1995). These guidelines include the following conceptual statement and psychological maltreatment categories:

• Psychological maltreatment means a repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, flawed, unloved, unwanted, endangered, or only of value in meeting another's needs (p. 2).
• Psychological maltreatment includes: (1) spurning (i.e., hostile rejecting/degrading verbal and nonverbal caregiver acts that reject and degrade a child); (2) terrorizing (i.e., caregiver behavior that threatens or is likely to physically hurt, kill, abandon, or place the child or child's loved ones or objects in recognizably dangerous situations); (3) isolating (i.e., caregiver acts that consistently deny the child opportunities to meet needs for interacting or communicating with peers or adults inside or outside the home); (4) exploiting/corrupting (i.e., modeling, permitting, or encouraging antisocial behavior); (5) denying emotional responsiveness (i.e., caregiver acts that ignore the child's attempts and needs to interact and show no emotion in interactions with the child); and (6) mental health, medical, and educational neglect (i.e., ignoring the need for, failing, or refusing to allow or provide treatment for serious emotional/behavioral, physical health, or educational problems or needs of the child).

These six categories of psychological maltreatment are further delineated through detailed subcategories that clarify their meanings (APSAC 1995). Empirical and conceptual support for these categories and definitions will be found in child-study research (Rohner and Rohner 1980; Claussen and Crittenden 1991; Egeland and Erickson 1987; Binggeli, Hart, and Brassard 2001); and in expert- and public-opinion research (Burnett 1993; Portwood 1999).

Incidence and Prevalence

Incidence of maltreatment generally refers to the number of new cases coming to the attention of authorities within a given year. Prevalence represents the total number of people in a sample who have ever experienced the maltreatment.

The true incidence of psychological maltreatment is unknown. The best available estimates of the incidence of psychological maltreatment come from findings of the National Incidence Study and research on verbal aggression. The National Incidence Study of the Federal Office on Child Abuse and Neglect (Sedlak and Broadhurst 1996) applies both an existing Harm Standard and a projected Endangerment Standard in gathering data from local social service, health and law enforcement professionals, and child welfare agencies. Data for 1993 supported estimates of more than 1.5 million children abused or neglected under the Harm Standard and three million under the Endangerment Standard, with approximately 532,000 of these children emotionally abused and 585,100 emotionally neglected. High annual levels of verbal/symbolic aggression (defined as "communication intended to cause psychological pain to another person, or a communication perceived as having that intent," [Vissing et al. 1991, p. 224]) were found in a telephone survey of the tactics used by a national sample of 3,458 parents to deal with conflicts in relations with their children. Over 11 percent if the children were reported to have experienced an average of more than two such incidents per month, whereas 63 percent experienced at least one such incident per year (Vissing et al. 1991).

Prevalence estimates can be made from data collected in studies of the childhood-experience histories of adults, retrospectively surveyed, using definitions similar to those in the APSAC Guidelines (1995). Nelson Binggeli, Stuart Hart, and Marla Brassard (2001) concluded, from reviews of such studies, that over one-third of the adult population has had significant psychological maltreatment experiences and that 10 to 15 percent of the adult population has suffered chronic or severe psychological maltreatment. Confidence in these estimates is further supported by the facts that the definitions used in these studies were fairly conservative, the types were considered appropriate by both researchers and community representatives, and it is more likely that the subjects minimized rather than exaggerated their maltreatment histories.

Evidence of Impact

Evidence that psychological maltreatment is a threat and destructive to the well-being and development of children is vital to producing the societal concern and interventions necessary to combat it. Until recently, however, the relationship between psychological maltreatment and negative developmental consequences for victims have had to be accepted as somewhat speculative because the construct was not well defined.

The existence of the broadly supported definitions for spurning, terrorizing, isolating, corrupting/exploiting, and denying emotional responsiveness has made it possible to carry out more rigorous reviews of related research literature. The available knowledge base indicates that psychological maltreatment probably has the most severe, longest lasting, and broadest range of negative developmental consequences of any form of child abuse or neglect (with the exception of the killing of a child), and that it is the core component in child abuse (Hart, Brassard, and Binggeli 1998).

Longitudinal and cross-cultural research has identified psychological maltreatment as a significant contributor to the following conditions: children who become angry, assaultive, or aggressive; delinquent, criminal, and/or substance abusers; persons who feel unloved and inadequate; and persons who develop negative feelings and perspectives about the purposes and possibilities for enjoyment of life, including having a happy marriage and being a good parent (Egeland and Erickson 1987; Rohner and Rohner 1980). Studies comparing the effects of various forms of child maltreatment have documented that (a) combinations of verbal abuse and emotional neglect tend to produce the most powerfully negative outcomes; (b) psychological maltreatment is a better predictor of detrimental developmental outcomes for young children than is the severity of physical injury experienced by children; (c) psychological maltreatment is the indicator most related to behavior problems for children and adolescents, and is more strongly related to physical aggression, delinquency, or interpersonal problems than parental physical aggression; (d) psychological abuse is a stronger predictor than physical abuse of both depression and low self-esteem and, in particular, is strongly related to anxiety, depression, interpersonal sensitivity, dissociation (disruption in usually integrated functions of consciousness, identity, or perception of the environment), and low self-esteem; and (e) psychologically unavailable caretaking is the most devastating of all maltreatment forms (Briere and Runtz 1990; Claussen and Crittenden 1991; Egeland and Erickson 1987; Vissing et al. 1991).

Numerous studies have identified the possible effects of psychological maltreatment within families. This evidence found through these studies fits nicely within the conceptual framework used by the nation's schools to guide identification of child "emotional disturbance" (federal Individuals with Disabilities Act Law 94–142). Findings indicate relationships between psychological maltreatment and problems with intrapersonal thoughts, feelings, and behaviors (e.g., anxiety, depression, low self-esteem, negative life views, post-traumatic symptoms and fears, and suicidal thinking ); emotional problem symptoms (e.g., emotional instability, impulse control problems, unresponsiveness, substance abuse, and eating disorders); social competency problems and anti-social functioning (e.g., attachment problems, self-isolating behavior, low social competency, low empathy, noncompliance, dependency, sexual maladjustment, aggression and violent behavior, and delinquency or criminality); learning problems (e.g., decline in mental competence, lower measured intelligence, non-compliance, lack of impulse control, impaired learning, academic problems and lower achievement test results, and impaired development of moral reasoning); and physical health problems (e.g., allergies, asthma and other respiratory ailments, hypertension, somatic complaints, physical growth failure, physical and behavioral delay, brain damage, and high mortality rates) (Hart, Brassard, and Binggeli 1998).

Theoretical Perspectives

Psychological maltreatment is an interpersonal experience. The essential role of interpersonal relations in human development and need fulfillment establishes an inherent vulnerability to psychological maltreatment. Many of the major theories in psychology contain constructs that are related to psychological maltreatment, particularly in the way they describe critical factors of the developmental process susceptible to the influences of various kinds of interpersonal experiences. Human needs theory, psychosocial stage theory, attachment theory, parental acceptance-rejection theory, the coercion model and the prisoner of war model each have value for psychological maltreatment research and interventions. They clarify the ways in which psychological maltreatment interferes with need fulfillment and development processes and produce retardation and/or distortions in growth and behavior (Binggeli, Hart, and Brassard 2001).

Psychological Maltreatment and the Law

In general, psychological maltreatment has not led to coercive or punitive governmental intervention, unless it accompanied other forms of maltreatment. Judicial precedents on psychological maltreatment are, for most part, unavailable to courts because there have been few reported appellate court decisions on stand-alone psychological maltreatment. Child protection officials and judges must largely be guided by the relevant language in state laws. Current state laws indicates that the federal "mental injury" principle has proven difficult for many legislatures to define.

Some states have simply used the term mental injury—or some similar term—without further explanation. Other states have incorporated one or more of the following standards or requirements:

• The child has experienced serious psychological or mental injury caused by recognizable acts;
• Injuries must be observable, substantial, sustained, and identifiable impairments of the child's intellectual or psychological capacity or emotional stability;
• A child displays substantially diminished psychological or intellectual functioning;
• Failure to provide for a child's "mental or emotional needs";
• Application of a list of problem-related symptoms (see earlier lists of impact);
• Failure to provide needed health services;
• Expert witness opinion (e.g., a licensed physician or qualified mental health professional);
• Specific recognition of certain forms of psychological maltreatment (e.g., isolation through use of mechanical devices to physically restrain).

The psychological maltreatment experienced by children due to exposure to domestic violence in the home is an emerging area of concern. Evidence of negative child-impact from observed domestic violence is growing (Hughes and Graham-Bermann 1998). California (Domestic Violence Unit 1999) has taken deliberate efforts to work toward identifying and serving domestic violence–exposed children as abused.

Despite the myriad of potential statutory variations for legal intervention where psychological harm has been inflicted upon children by their parents, it should be possible for judicial and CPS agency efforts to be applied to psychological maltreatment cases. For this to occur, it will require a change from the status quo: child welfare agency personnel, attorneys, and juvenile court judges will need to be educated on psychological maltreatment (Hart et al. 2001).

Interventions for Psychological Maltreatment

Substantial progress has been made in guiding assessments in cases of suspected psychological maltreatment of children, whereas only small beginnings have been made in developing effective correction and prevention strategies. The APSAC Guidelines (1995) provides the best available framework for professionals in evaluations of suspected psychological maltreatment. The guidelines were designed to assist in case planning, legal decision making, and treatment planning for psychological maltreatment that occurs as a powerful single instance or continual pattern, and maltreatment that occurs in isolation from as well as in conjunction with other forms of abuse and neglect. The Guidelines assist in making determinations of the nature and severity of psychological maltreatment, including extant or predicted developmental impact, through direct observation, interviews, review of records and collateral reports, and consultation. The Guidelines also help professionals apply ethical standards, weigh cultural factors, and report findings.

In general, the development of effective strategies for prevention and treatment of child maltreatment has been elusive, and psychological maltreatment has received relatively little direct attention in this regard. Intervention models applied to perpetrators and families that have shown improved outcomes have devoted resources (e.g., reduced client load, highly trained and well-supervised therapists, and many client contact hours) well beyond those usually available to child protective services or contracted private agencies. Although the development and study of specific treatments for children has genuine potential, according to existing research findings, it remains uncommon. Available research does indicate that children generally experience greater treatment gains than adults and provides unquestionable evidence of intergenerational transmission of child maltreatment.

It appears wise to give prevention the top intervention priority for child maltreatment, and particularly for psychological maltreatment because it is such a pervading, insidious, and powerfully destructive force. Studies of resilience have identified affiliation and self-efficacy (i.e., realistic confidence in one's competence to deal effectively with life's challenges and opportunities) as necessary to support healthy development under difficult conditions. Prevention and correction are well served by programs supporting development of secure attachment to adult caretakers through sensitive, responsive parenting and pre-school and elementary school teacher-student relations; through modeling and promoting appropriate childcare and interpersonal skills for parents and children; and through helping children develop a genuine sense of practical competence in school and community play and work, including problem solving and conflict resolution. Progress can be made if high quality intervention research and effective programs are supported through societal commitment and funding.

The Effects of Sexual Abuse

The effects of sexual abuse are its most highly studied aspect—and its most political. Some claim sexual abuse is always harmful. Others maintain that some children actually benefit from these sexual experiences. And some children show no symptoms at all (Kendall-Tackett, Williams, and Finkelhor 1993). Allegations of abuse also raise legal and custody issues.

Short-term effects. Children experience a wide range of symptoms after they have been sexually abused. Some symptoms show up immediately, and others appear as delayed responses. Still others get better over time. Traumatic events, including sexual abuse, can alter the brains of children, and the effects may not be obvious for several years (Perry 2001).

Posttraumatic stress disorder (PTSD) is common, but not specific to sexual abuse. Sexualized behavior is the most characteristic symptom, but not one that every child manifests. It is also one of the more disturbing symptoms and includes public masturbation, sexual play with dolls, and asking other children and adults to participate in sexual activity.

Symptoms by age of child. The symptoms that children manifest also vary by age of the child. For example, preschool-age children are more likely to experience anxiety, nightmares, or sexual acting out. Common symptoms for school-age children include fear, aggression, school problems, hyperactivity, and regressive behaviors. Adolescents are more likely to be depressed, attempt suicide, abuse substances, or participate in illegal behaviors. Symptoms often change over time. For example, a preschooler who is sexually acting out may become an adolescent with multiple sexual partners (Kendall-Tackett et al. 1993).

Long-term effects. The effects of child sexual abuse can continue well into adulthood. Symptoms adult survivors manifest are often logical extensions of dysfunctional coping mechanisms developed during childhood. While these dysfunctional behaviors may have helped the child cope with on-going abuse, they have a negative impact on adult functioning. Long-term effects can be divided into seven categories (Briere and Elliot 1994; Kendall-Tackett and Marshall 1998):

• Posttraumatic stress disorder (PTSD). Post-traumatic stress disorder (PTSD) is a commonly occurring symptom among adult survivors of sexual abuse. According to John Briere and Diana Elliot (1994), 80 percent of abuse survivors have symptoms of PTSD, even if they do not meet the full diagnostic criteria. These reactions include hypervigilance, sleep disturbances, startle responses, intrusive thoughts, and flashbacks.
• Cognitive distortions. Sexual abuse survivors often learn to perceive the world as a dangerous place. These cognitive distortions make them more vulnerable to both re-victimization and depression because they believe they are powerless to change their lives.
• Emotional distress. Emotional distress is another common symptom among adult survivors. Sexual abuse survivors have a lifetime risk of depression that is four times higher than their nonabused counterparts. They may also experience mild-to-severe anxiety and anger on a regular basis.
• Impaired sense of self. Survivors may have difficulty separating their moods and emotional states from the reactions of others. If their partners are depressed or angry, survivors are too, without necessarily considering whether they really feel the same way. Impaired sense of self can also inhibit self-protection, increasing survivors' risk of re-victimization.
• Avoidance. Avoidance includes some of the more serious sequelae of past abuse. Survivors may experience dissociation, which includes feeling separated from their bodies, emotional numbing, amnesia for painful memories, and multiple personality disorder. Other types of avoidant behavior are substance abuse, suicidal ideation and attempts, and tension-reducing activities, including indiscriminate sexual behavior, bingeing and purging, and self-mutilation.
• Interpersonal difficulties. Adult survivors may have problems with interpersonal relationships. They may adopt an avoidant style, characterized by low interdependency, self-disclosure, and warmth. Or they may adopt an "intrusive" style, characterized by extremely high needs for closeness, excessive self-disclosure, and a demanding and controlling style. Both styles result in loneliness (Becker-Lausen and Mallon-Kraft 1997).
• Physical health problems. Adult survivors have substantially higher rates of health care use than their nonabused counterparts. Pain syndromes are the most common type of illness and include irritable bowel syndrome, fibromyalgia, headache, pelvic pain, and back pain. Adult survivors also had overall lower satisfaction with their physical health than their nonabused counterparts (Kendall-Tackett 2000).

Differences in Response to Sexual Abuse

Reactions to child sexual abuse can vary tremendously depending on the child, the family, whether it was reported to law enforcement, and the types of support that were available after disclosure. Responses can also vary by both characteristics of the abuse and ethnicity of the child.

Characteristics of the abuse. Characteristics of the abuse itself can also exert an influence on how people react. Some people are more seriously affected by abuse because their experiences were more severe. In general, abuse will be more harmful if the abuser is someone the child knows and trusts, and the abuse violates that trust. Abuse that includes penetration (oral, vaginal, or anal) often leads to more symptoms. Abuse that occurs often and lasts for years will typically be more harmful than abuse that happens only sporadically and over less time. The exception is the one-time violent assault (Berliner and Elliot 1996; Kendall-Tackett et al. 1993).

Differences among ethnic groups. Researchers have identified some specific ethnic-group differences in both characteristics of abuse and in reactions to it. Although no clear patterns have emerged, there are enough differences for professionals to understand the importance of ethnic group identity and meaning of sexual abuse in a culture.

Asian children tend to be older at the onset of victimization than non-Asians. African-American children tend to be younger at onset than either their Asian or Caucasian counterparts (Berliner and Elliot 1996). African-American victims have approximately the same rates of victimization as Caucasian children, but are more likely to experience penetration as part of their victimization experience (Wyatt 1985). The overall rates of sexual abuse are lowest for Asian women, but high for Hispanic women, when reported retrospectively (Russell 1984). In a sample of 582 Southwestern American Indians, rates of sexual abuse were high, especially among females. Forty-nine percent of females in the sample and 14 percent of males reported a history of sexual abuse. Seventy-eight percent reported intrafamilial abuse (Robin et al. 1997). Worldwide, rates of child sexual abuse have similar ranges (from low to high). According to the World Health Organization (1999), in studies from nineteen countries, including South Africa, Sweden, and the Dominican Republic, rates of sexual abuse range from 7 percent to 34 percent for girls, and from 3 percent to 29 percent for boys. Some of these differences in range are due to varying definitions of sexual abuse from country to country and the accuracy of the reporting system.

Culture and ethnicity also appear related to how symptomatic abuse survivors become in the wake of their abuse experiences. Ferol Mennen (1995) found that Latina girls whose abuse included penetration were more anxious and depressed than African-American or white girls who experienced penetration. The author explains these findings in part as due to the emphasis on purity and virginity in Latino communities. When virginity is lost, the trauma of sexual abuse is compounded because the Latina girls feel that they are no longer suitable marriage partners.

Another ethnic-group difference appeared in rates of re-victimization. In a sample drawn from a community college, black women who were sexually abused in childhood were more likely to be raped as adults than their white, Latina, or Asian counterparts (Urquiza and Goodlin-Jones 1994).

Gordon Nagayama Hall and Christy Barongan (1997) speculated that these differences in rates of sexual aggression might be due to characteristics of specific cultures. For example, cultures with a collectivist orientation, where the group is more important than the individual, tend to have lower rates of sexual aggression. Asian cultures often have a collectivist orientation. Crimes against a single person are perceived as crimes against the entire culture. Shame also keeps these behaviors in check. However, as Catherine Koverola and Subadra Panchandeswaran (in press) describe, shame may not keep the behaviors in check, but may keep people from acknowledging these crimes outside the community. Thus, it is at least possible that even in cultures where the rates appear low, abuse may simply be hidden from view.

How Sexual Abuse Compares with Other Types of Child Maltreatment

Although researchers have focused predominantly on sexual abuse, it is not the most common type of maltreatment. In the Third National Incidence Study of Child Abuse and Neglect, the rate of sexual abuse per 1,000 children was 4.9 for females and 1.6 for males. For physical abuse the rate was 5.6 per 1,000 for females and 5.8 for males. For neglect, the rate was 12.9 per 1,000 for females and 13.3 for males. Physical abuse and neglect are much more common for both boys and for girls. Girls and boys have approximately the same rates of fatal injuries (.01/1000 and .04/1000 for females and males respectively). Sexual abuse can certainly be harmful, but the plight of the physically abused or neglected child also deserves the attention of professionals (Sedlak and Broadhurst 1996).

Conclusion

Abuse experiences vary in their severity, as do reactions of those who are sexually abused. Even when the experience is severe, however, there is hope for healing. In one study, survivors reported that good came from the tragedy of their abuse (McMillen, Zuravin, and Rideout 1995). They described how their abusive pasts made them more sensitive to the needs of others. Many felt compelled to help others who had suffered similar experiences.