Adverse behavioral and emotional outcomes from child abuse and witnessed violence

This article examines mental health outcomes of children who have witnessed violence in their social environment and/or have been physically abused. Participants (n = 167) come from a longitudinal study on child maltreatment. Outcomes-including depression, anger, and anxiety--are measured by the Child Behavior Checklist and the Trauma Symptom Checklist for Children. The authors used adjusted multivariate analyses to test the statistical significance of associations. The majority of children were female (57%) and non-White (64%). One third had been physically victimized; 46% had witnessed moderate-high levels of violence. Results confirm that children are negatively affected by victimization and violence they witness in their homes and neighborhoods. Victimization was a significant predictor of child aggression and depression; witnessed violence was found to be a significant predictor of aggression, depression, anger, and anxiety. Implications will be discussed.     

Suicidal ideation among 8-year-olds who are maltreated and at risk: findings from the LONGSCAN studies

Suicidal ideation was examined among 1,051 8-year-old children identified as maltreated or at risk for maltreatment. Of these children, 9.9% reported suicidal ideation. Many variables, including maltreatment, had bivariate associations with suicidal ideation. Severity of physical abuse, chronicity of maltreatment, and the presence of multiple types of maltreatment strongly predicted suicidal ideation. In multivariate analyses of the domains of proximity, only ethnic background remained significant among demographic variables, only witnessed violence and maltreatment remained significant among family or contextual variables, and only child psychological distress, substance use, and poor social problem solving remained significant among child variables. The effects of ethnicity, maltreatment, and witnessed violence on suicidal ideation were mediated by child functioning. There were few interactions between maltreatment and other factors to predict suicidal ideation. Children who are maltreated and those exposed to community and domestic violence are at increased risk of suicidal ideation, even by age 8.     

Direct and mediated effects of nativity and other indicators of acculturation on Hispanic mothers' use of physical aggression

This study used data from 845 foreign-born (n = 328) and native-U.S. born (n = 517) Hispanic mothers who participated in the Fragile Families and Child Wellbeing Study (FFCWS) to examine four indicators of acculturation--nativity, years lived in the United States, religious attendance, and endorsement of traditional gender norms--as predictors of maternal physical aggression directed toward young children. The authors also examined whether psychosocial risk factors associated with child maltreatment and acculturation--maternal alcohol use, depression, parenting stress, and intimate partner aggression and violence--mediate relationships between acculturation and maternal aggression. Foreign-born Hispanic mothers had significantly lower rates of physical aggression than native-born Hispanic mothers. In path modeling results, U.S. nativity, along with maternal alcohol use, parenting stress, and child aggressive behavior, emerged as the strongest risk factors for maternal physical aggression. Among the four acculturation indicators, only foreign birth was directly associated with lower maternal aggression. Study findings suggest immigrant status is a unique protective factor that contributes to lower levels of physical aggression among Hispanic mothers.     

Effects of child abuse and neglect: does social capital really matter?

OBJECTIVE: To explore whether social capital and social support moderate the relationship between child maltreatment and emotional and behavioral outcomes such as depression-anxiety and aggression in 6-year-old children. DESIGN: Data from Longitudinal Studies of Child Abuse and Neglect were used. Data were collected through interviews and questionnaires at the child's birth and at the age of 6 years. SETTING: General community. PARTICIPANTS: Two hundred fifteen maternal caregivers of children at high risk for child abuse and neglect were included in this study. MAIN OUTCOME MEASURES: Depression-anxiety and aggression were measured through the Child Behavior Checklist. RESULTS: Among 5 potential effect modifiers (3 social capital constructs and 2 measures of social support), only 1 (instrumental support) significantly modified the relationship between maltreatment and child aggression. CONCLUSIONS: Social capital did not modify the relationship between child maltreatment and either aggression or depression-anxiety. This might be related to the fact that many previous studies looked at social capital ecologically, whereas this study uses individuals as the unit of analysis. The results of this study might also indicate that previous studies of social capital and health outcomes might actually be using social capital as a proxy for social support.     

Child Maltreatment: Screening and Anticipatory Guidance

Child maltreatment is a problem of epidemic proportions in the United States. Given the numbers of children affected by child maltreatment and the dire consequences that can develop, prompt identification of child maltreatment is crucial. Despite support of the implementation and development of protocols for child maltreatment screening by professional organizations such as the National Association of Pediatric Nurse Practitioners and American Academy of Pediatrics, little is available in the literature regarding the screening practices of pediatric nurse practitioners and other pediatric health care providers. This Continuing Education article will help pediatric nurse practitioners incorporate this vital screening intervention into their practice. Practical examples of when and how to incorporate screening questions and anticipatory guidance for discipline practices, crying, intimate partner violence (domestic violence), physical abuse, and sexual abuse will be discussed.     

Child abuse and domestic violence in families of children seen for suspected sexual abuse

We surveyed families of children seen in a sexual abuse evaluation clinic regarding domestic violence in the child's home and physical and sexual abuse during childhood among the mothers. Domestic violence occurred in 54% (216/402) of the children's homes; 28% (111/392) of mothers reported childhood physical abuse, and 42% (167/395) reported sexual abuse. There were no differences in the rates of domestic violence (chi 2 = 0.42, 2 df, p = 0.8), maternal physical abuse (chi 2 = 2.40, 2 df, p = 0.3), or maternal sexual abuse (chi 2 = 2.11, 2 df, p = 0.3) based on whether our current, patient was at high, medium, or low risk for having actually experienced sexual abuse. Neither domestic violence in the child's home nor the mother's childhood experience of abuse was increased if the child's perpetrator was a relative or lived in the home. Domestic violence in the child's home was more frequent if the mother had experienced physical abuse during childhood (65% 70/107) than if she had not (48%, 130/271; chi 2 = 8.69, p < 0.01). Child sexual abuse is part of a global pattern of victimization, and clinicians must address other forms of family violence when evaluating a child for allegations of sexual abuse.     

A descriptive survey of Swedish child health nurses' awareness of abuse and neglect. II. Characteristics of the children

AIM: To determine whether children considered by child health nurses to be at risk of abuse or neglect differed from the general population in gender, age and health status, and whether such child characteristics were related to nurses' perceptions of case seriousness, or to reporting to the child protection services (CPS). METHODS: Questionnaires were sent to nurses in the preventive Child Health Services, 951 of whom identified a total of 6044 children aged 0 to 6 y as suspected of risk of maltreatment. RESULTS: Boys and older children were over-represented among the identified children, possibly because the attention of the nurses was attracted by salient symptoms in older boys. Children with health problems and boys exposed to disturbed parenting/neglect were perceived as more serious cases than other children. Children aged 4-6 y were more likely to be reported to the CPS than children under 3 y of age. CONCLUSION: The findings raise the question whether possibly maltreated children who are very young, female or in good health run a particularly high risk of non-detection, of being considered non-serious cases and of not being reported to the CPS. The risk of going unnoticed may be higher for some children at risk of maltreatment than for others.     

Prevalence and characteristics of child physical abuse in Sweden – findings from a population‐based youth survey

Aim: To examine prevalence rates of child physical abuse perpetrated by a parent/caretaker, abuse characteristics and the extent of disclosures. Methods: A population‐based survey was carried out in 2008 amongst all the pupils in three different grades (n = 8494) in schools in Södermanland County, Sweden. The pupils were asked about their exposure to violence and their experiences of parental intimate‐partner violence. Data were analysed with bi‐ and multivariate models and a comparison between means of accumulating risk factors between three groups were performed. Results: A total of 15.2% of the children reported that they had been hit. There were strong associations between abuse and risk factors and there was a dose–response relationship between risks and reported abuse. It was shown that children who reported parental intimate‐partner violence were at a considerably higher risk for abuse than other children and that only 7% of the children exposed to violence had disclosed this to authorities. Conclusion: Even though child abuse in Sweden has decreased markedly during the last 40 years, violence against children is still a considerable problem. It is a challenge to develop methods of assessment and interventions that will ensure that the violence and its underlying causes are directly addressed.     

Indicators of Well-Being Among Children in the United States Child Welfare System

The second National Survey of Child and Adolescent Well-Being (NSCAW II) is a longitudinal study intended to answer a range of fundamental questions about the functioning, service needs, and service use of children who come in contact with the child welfare system. The study includes 5,873 children ranging in age from birth to 17.5?years old at the time of sampling. The current analysis summarizes the well-being of these children at NSCAW II baseline. Overall, children reported for maltreatment in 2008?C2009 were at higher risk for poor health and negative developmental, behavioral/emotional, and cognitive outcomes than children in the general population. Overall, 32.2?% of children from birth to 5?years old had a score indicating developmental problems. Among school-aged children and adolescents, 10.3?% showed some risk of cognitive problems or low academic achievement and 41.6?% exhibited risk of emotional or behavioral problems. Child well-being outcomes differed by age and gender but not by substantiation status or type of maltreatment. Proactively providing needed services at an early age to all children in need in the CWS is urged, because early services may well preempt these children??s need for extensive future developmental, mental health, and educational services.     

Patterns of reporting by health care and nonhealth care professionals to child protection services in Canada

BACKGROUND:

All Canadian jurisdictions require certain professionals to report suspected or observed child maltreatment. The present study examined the types of maltreatment, level of harm and child functioning issues (controlling for family socioeconomic status, age and sex of the child) reported by health care and nonhealth care professionals.

METHODS:

χ² analyses and logistic regression were conducted on a national child welfare sample from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003), and the differences in professional reporting were compared with its previous cycle (CIS-1998) using Bonferroni-corrected CIs.

RESULTS:

Analysis of the CIS-2003 data revealed that the majority of substantiated child maltreatment was reported to service agencies by nonhealth care professionals (57%), followed by other informants (33%) and health care professionals (10%). The number of professional reports increased 2.5 times between CIS-1998 and CIS-2003, while nonprofessional reports increased 1.7 times. Of the total investigations, professional reports represented 59% in CIS-1998 and 67% in CIS-2003 (P<0.001). Compared with nonhealth care professionals, health care professionals more often reported younger children, children who experienced neglect and emotional maltreatment, and those assessed as suffering harm and child functioning issues, but less often reported exposure to domestic violence.

CONCLUSION:

The results indicate that health care professionals play an important role in identifying children in need of protection, considering harm and other child functioning issues. The authors discuss the reasons why under-reporting is likely to remain an issue.     

On Hitting Children: A Review of Corporal Punishment in the United States

Research has clearly demonstrated associations between corporal punishment of children and maladaptive behavior patterns such as aggression and delinquency. Hitting children is an act of violence and a clear violation of children's human rights. In this article, the position of the United States on corporal punishment of children is discussed. Professional and international progress on ending corporal punishment is explained, and the relationship between corporal punishment and child abuse is discussed. An appeal is made for prevention efforts such as parent education and removal of social sanctions for hitting children that may hold significant promise for preventing child maltreatment.     

Rates and risk factors for sexual violence among an ethnically diverse sample of adolescents

OBJECTIVES: To investigate the occurrence of rape/attempted rape and verbal sexual coercion among an ethnically diverse adolescent population and to evaluate whether unique risk factors existed for victims of either type of forced sexual experience. DESIGN: Cross-sectional survey assessing sexual violence within the past 12 months, behaviors that occurred on each subject's most recent date, and the occurrence of unwanted sexual experiences on any dates in the past year and details about that date. Subjects identified as experiencing either rape/attempted rape or verbal sexual coercion were compared with nonvictims using bivariate and multivariate analyses. SETTING: Urban adolescent health care facility. PARTICIPANTS: Female adolescents and young adults (n = 689) between the ages of 14 and 23 years who presented for care and met the eligibility criteria. RESULTS: Approximately 30% of young women reported having an unwanted sexual experience in the past year. The risk of rape/attempted rape was increased by past mild to moderate (adjusted odds ratio [AOR] = 4.27) or severe (AOR = 15.24) physical aggression by the dating partner; date-specific behaviors, including decreased level of romantic involvement (AOR = 0.63 per point decline) and going to the perpetrator's house to be alone (AOR = 3.01); past sexual victimization as an adolescent (AOR = 4.70); and lower levels of self-reported ethnic identity (AOR = 1.07 per point decline). More important, alcohol use by the victim or perpetrator was unrelated to an increased risk of rape/attempted rape. The risk of verbal sexual coercion was increased by past mild to moderate (AOR = 4.38) or severe (AOR = 13.79) verbal aggression from the dating partner; date-specific behaviors, including decreased level of romantic involvement (AOR = 0.70 per point decline) and greater number of past dates (AOR = 7.53); going to the perpetrator's house to be alone (AOR = 3.52); past sexual victimization as an adolescent (AOR = 9.83); pressures to use alcohol (AOR = 9.49); the victim not drinking alcohol during the date (AOR = 14.38); and increasing age discrepancy between victim and perpetrator (AOR = 1.23 per year increase). CONCLUSIONS: Approximately 1 in 4 urban young women reported having experienced verbal sexual coercion or rape/attempted rape by a date or acquaintance in the past year. Distinct risk profiles for rape/attempted rape and verbal sexual coercion were identified when compared with those who did not report any victimization.     

Caseworker judgments and substantiation

Substantiation can have an important effect on what interventions are pursued for children investigated for maltreatment, but researchers lack knowledge about how the decision to substantiate is made. Using information from 4,515 children from a national probability study of children investigated for maltreatment, this study examined how caseworker judgments of harm, risk, and evidence predicted substantiation. The substantiation rate was 29.9%, but the majority of cases were substantiated when caseworkers reported at least moderate harm, at least moderate risk, and/or probably to clearly sufficient evidence. Each judgment variable significantly predicted substantiation in a multivariable model, with evidence the strongest predictor. Child gender and age were significant predictors beyond harm, risk, and evidence, suggesting that other judgments also influence substantiation. In 9 of 100 cases, reports were not substantiated despite moderate to severe harm. Thus, substantiation is generally based on judgments of harm, risk, and evidence but not exclusively. The findings underline previous researchers' conclusions that substantiation is a flawed measure of child maltreatment and suggest that policy and practice related to substantiation are due for a fresh appraisal by state child welfare service agencies.     

We Have All Been Working in Our Own Little Silos Forever: Exploring a Cross-Sector Response to Child Maltreatment

ObjectiveA child protective services (CPS) investigation for maltreatment signals risk for childhood toxic stress and poor health outcomes. Despite this, communication between child welfare and health care professionals is rare. We present a qualitative exploration of experiences with, barriers to, and hopes for cross-sector collaboration for children with suspected maltreatment.MethodsWe conducted focus groups with child welfare and health care professionals participating in a cross-sector learning collaborative to improve care for children at high risk for toxic stress. Participants were asked to describe 2 phenomena: identifying and responding to childhood adversities in their professional settings and cross-sector collaboration in cases of suspected maltreatment. Analysis included an iterative process of reading, coding and comparing themes across groups.ResultsHealth care professionals shared positive experiences in screening for social risks in clinic, while child welfare professionals expressed mixed attitudes toward social risk screening during CPS investigations. Consistent with prior research, health care professionals reported limited communication with CPS caseworkers about patients but suggested that relationships with child welfare professionals might reduce these barriers. Child welfare professionals described the poor quality of information provided in referrals from medical settings. Caseworkers also recognized that improved communication could support better understanding of maltreatment concerns and sharing of outcomes of CPS investigation.ConclusionsOur project extends previously published research by describing potential benefits of child welfare and child health care collaboration in cases of suspected maltreatment. Lack of effective cross-sector communication and concerns about confidentiality present significant barriers to uptake of these collaborative practices.     

Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers

AIM: This study explored maternal history of perinatal loss relative to risk of child physical abuse and neglect. METHODS: The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers with no known history of child maltreatment. Interviews and observations were conducted in the participants' homes, and comparisons were made between women without a history of perinatal loss and women with one and multiple losses relative to risk for child maltreatment. RESULTS: Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children. Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse. Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect. CONCLUSION: Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts.     

Violence exposure and traumatic stress symptoms as additional predictors of health problems in high-risk children

OBJECTIVE: To test the hypotheses that both violence and traumatic stress symptoms are associated with negative health status among poor preschool children. STUDY DESIGN: This cross-sectional analysis of a Head Start preschool age cohort (n = 160) studied health outcomes parallel to those assessed in the 2001 National Health Interview Survey of child health (asthma, allergy, attention deficit hyperactivity disorder, global appraisal) as well as two stress-related somatic complaints, gastrointestinal problems and headache. Risk factors include sociodemographics, mothers' health factors, extent of exposure to violence and maltreatment, and mother- and teacher-reported traumatic stress symptoms. RESULTS: Compared with poor children in the National Health Interview Survey and their Head Start peers, children exposed to violence and those with high levels of traumatic stress had significantly worse outcomes, in a dose-response relation. Being abused, exposed to domestic violence, and having a mother using substances were associated with a higher number of health problems. The hierarchical model established the mother's own poor physical health and the child's level of traumatic stress as the strongest predictors of poor child health. CONCLUSIONS: These two risk factors are amenable to intervention by health care providers who treat children.     

Primary prevention of child physical abuse and neglect: gaps and promising directions

Reviews on primary prevention have identified effective strategies to prevent child maltreatment but have ignored potentially promising interventions that have not yet been evaluated as well as gaps in the development of programs. The goal of this review was to identify these gaps and recommend future directions for developing interventions from a public health perspective. To this end, a systematic review of the literature for 1980-2004 utilizing existing databases and found 188 primary prevention interventions that addressed a broad range of risk factors was conducted. However, few had been rigorously evaluated, and only a handful demonstrated impact on child maltreatment or its risk factors. From a public health perspective, interventions that target prevalent and neglected risk factors such as poverty, partner violence, teenage pregnancy, and social norms tolerating violence toward children need to be developed and evaluated. In addition, more attention should be given to low cost interventions delivered to the public, by society, or that require minimal effort from recipients.     

What are providers' reporting requirements for children who witness domestic violence?

Each year, 3.3 to 10 million children are exposed to domestic violence/abuse (DV). Providers' reporting obligations for these children are unclear. The child maltreatment statutes available on state's web sites (through August 2003) were reviewed. Only Alaska defines DV in the presence of a child as child abuse within its juvenile code. Within their child abuse definition and reporting statutes, many states include language such as "substantial risk" or "imminent danger" of "physical harm" or "mental injury." Although knowledge of the state law is an important first step, abiding by it may be challenging because most statutes are open to wide interpretation. As a result, providers are encouraged to seek advice from local child maltreatment specialists who understand the local legal interpretations and resources.     

Identification during the postpartum period of infants who are at high risk of child maltreatment

To determine whether clinicians correctly identify newborn infants who are at high risk of child maltreatment, we examined the outcomes of high-risk and non-high-risk children. Infants who were born at Yale-New Haven Hospital from 1979 to 1981 and who were referred by clinicians during the postpartum period to the hospital's child abuse registry because they were considered at high risk of child abuse or neglect became the high-risk group. For each high-risk infant, a comparison infant was selected and matched according to date of birth, gender, race, and method of payment for the hospitalization. For both groups, the occurrence of maltreatment was ascertained by reviewing the medical records until the child's fourth birthday. Each injury for which medical care was sought was classified into one of seven categories (from definite child abuse to accident) by a pediatrician who was unaware of the child's risk status. Information also was recorded about nonorganic failure to thrive and changes in the child's caretaker. Maltreatment (defined as abuse or neglect) occurred more frequently in the high-risk group than the comparison group (adjusted matched odds ratio = 4.3; 95% confidence interval = 1.41, 6.93; p less than 0.001), as did poor weight gain from a nonorganic cause (matched odds ratio = 7.0; 95% confidence interval = 1.59, 30.79; p less than 0.01) and changes in the child's caretaker (matched odds ratio = 9.0; 95% confidence interval = 3.80; 20.55; p less than 0.001). We conclude that as early as the postpartum period, clinicians can identify some families who are at high risk of maltreatment and other major adverse outcomes resulting from poor parenting.