American Academy of Pediatrics: Committee on Child Abuse and Neglect and Committee on Children With Disabilities. Assessment of maltreatment of children with disabilities

Widespread efforts are continuously being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this statement is to ensure that children with disabilities are recognized as a population that is also at risk for maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, should be acknowledged.     

Child maltreatment among Asian Americans: characteristics and explanatory framework

This article systematically reviews the characteristics of child maltreatment among Asian Americans and provides a theoretical explanatory framework. The reported rate of child maltreatment among Asian Americans is disproportionately low. A high rate of physical abuse and low rates of neglect and sexual abuse are found among Asian American victims. Some protective factors (e.g., the emphasis on family harmony and reputation and the indulgence to infants and toddlers) may lead to low probability of child maltreatment among Asian Americans. Some others (e.g., parental authority and beliefs in physical punishment) may be risk factors of child maltreatment, especially physical abuse. Meanwhile, many other coexisting factors (e.g., children's obedience to parents and families' invisibility to authorities) may prohibit child maltreatment from being disclosed. Therefore, the overall low reported rate of child maltreatment among Asian Americans may be a combination of low incidence and underreporting. Implications for practice and research are discussed.     

Maltreatment of children with disabilities

Widespread efforts are being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population that is also at risk of maltreatment. Some conditions related to a disability can be confused with maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, are the subject of this report.     

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.     

Stress and anger as contextual factors and preexisting cognitive schemas: predicting parental child maltreatment risk

Progress in the child maltreatment field depends on refinements in leading models. This study examines aspects of social information processing theory (Milner, 2000) in predicting physical maltreatment risk in a community sample. Consistent with this theory, selected preexisting schema (external locus-of-control orientation, inappropriate developmental expectations, low empathic perspective-taking ability, and low perceived attachment relationship to child) were expected to predict child abuse risk beyond contextual factors (parenting stress and anger expression). Based on 115 parents' self-report, results from this study support cognitive factors that predict abuse risk (with locus of control, perceived attachment, or empathy predicting different abuse risk measures, but not developmental expectations), although the broad contextual factors involving negative affectivity and stress were consistent predictors across abuse risk markers. Findings are discussed with regard to implications for future model evaluations, with indications the model may apply to other forms of maltreatment, such as psychological maltreatment or neglect.     

Child maltreatment and substance abuse among U.S. Army soldiers

Although substance abuse has consistently been linked to child maltreatment, no study to date has described the extent of substance abuse among child maltreatment offenders within the military. Analysis of U.S. Army data on all substantiated incidents of parental child maltreatment committed between 2000 and 2004 by active duty soldiers found that 13% of offenders were noted to have been abusing alcohol or illicit drugs at the time of their child maltreatment incident. The odds of substance abuse were increased for offenders who committed child neglect or emotional abuse, but were reduced for child physical abuse. The odds of offender substance abuse nearly tripled in child maltreatment incidents that also involved co-occurring spouse abuse. Findings include a lack of association between offender substance abuse and child maltreatment recurrence, possibly because of the increased likelihood of removal of offenders from the home when either substance abuse or spouse abuse were documented.     

Understanding the ecology of child maltreatment: a review of the literature and directions for future research

Studies examining neighborhood characteristics in relation to social problems, including child maltreatment, have proliferated in the past 25 years. This article reviews the current state of knowledge of ecological studies of child maltreatment. Taken as a whole, these 18 studies document a stable ecological relationship among neighborhood impoverishment, housing stress, and rates of child maltreatment, as well as some evidence that unemployment, child care burden, and alcohol availability may contribute to child abuse and neglect. The authors include a discussion of methodological difficulties in conducting research at the neighborhood level and present a set of recommendations for future research that emphasizes movement from a simple examination of neighborhood-level characteristics toward a theoretically driven explication of processes and mechanisms supported by appropriate multilevel modeling techniques. The final goal of such efforts would be to enable practitioners to develop evidence-based neighborhood interventions that would prevent and reduce child abuse and neglect.     

Child abuse and neglect and the brain--a review

Developmental psychology and the study of behaviour and emotion have tended to be considered in parallel to the study of neurobiological processes. This review explores the effects of child abuse and neglect on the brain, excluding nonaccidental injury that causes gross physical trauma to the brain. It commences with a background summary of the nature, context, and some deleterious effects of omission and commission within child maltreatment. There is no post-maltreatment syndrome, outcomes varying with many factors including nature, duration, and interpersonal context of the maltreatment as well as the nature of later intervention. There then follows a section on environmental influences on brain development, demonstrating the dependence of the orderly process of neurodevelopment on the child's environment. Ontogenesis, or the development of the self through self-determination, proceeds in the context of the nature-nurture interaction. As a prelude to reviewing the neurobiology of child abuse and neglect, the next section is concerned with bridging the mind and the brain. Here, neurobiological processes, including cellular, biochemical, and neurophysiological processes, are examined alongside their behavioural, cognitive, and emotional equivalents and vice versa. Child maltreatment is a potent source of stress and the stress response is therefore discussed in some detail. Evidence is outlined for the buffering effects of a secure attachment on the stress response. The section dealing with actual effects on the brain of child abuse and neglect discusses manifestations of the stress response including dysregulation of the hypothalamic-pituitary-adrenal axis, and parasympathetic and catecholamine responses. Recent evidence about reduction in brain volume following child abuse and neglect is also outlined. Some biochemical, functional, and structural changes in the brain that are not reflections of the stress response are observed following child maltreatment. The mechanisms bringing about these changes are less clearly understood and may well be related to early and more chronic abuse and neglect affecting the process of brain development. The behavioural and emotional concomitants of their neurobiological manifestations are discussed. The importance of early intervention and attention to the chronicity of environmental adversity may indicate the need for permanent alternative caregivers, in order to preserve the development of the most vulnerable children.     

The cutaneous manifestations of child abuse and neglect.

The most easily recognizable physical manifestations of child abuse and neglect are seen in the skin. The findings may be the result of intentional trauma, neglect to provide adequate child care, alterations in family dynamics, or the emotional problems secondary to the maltreatment.     

Update on child maltreatment

PURPOSE OF REVIEW: The authors discuss the significance of studies published over the previous year regarding assessment and treatment and prevention of child maltreatment, including physical and sexual abuse, inflicted traumatic brain injury, and child neglect. RECENT FINDINGS: The evidence base for many forms of child abuse is growing. As clinicians begin to understand the factors which may increase child vulnerability to abuse, more sophisticated and focused prevention efforts are being implemented. In response to a very public reprimand by the General Medical Council of two child abuse pediatricians, which was felt by many to be unwarranted, the UK government re-emphasized its commitment to the protection of children. In the US, this well-publicized set of events has renewed the medical community's commitment to the recognition of child abuse pediatrics as a formal subspecialty. Several authors detail the short-term and long-term outcome of varying forms of abuse for children as they grow into adults, reinforcing the importance of community efforts to prevent abuse and support families during times of heightened stress such as the current war in Iraq. SUMMARY: The short-term and long-term impact of child maltreatment is significant not only for individuals, but for families and communities where abuse is taking place. General pediatricians have an important role to play with families and in the community as advocates for the protection of children.     

Child maltreatment and women's adult sexual risk behavior: childhood sexual abuse as a unique risk factor

This study investigated (a) whether childhood sexual abuse (CSA) was uniquely associated with adult sexual risk behavior, after controlling for other types of childhood maltreatment and (b) whether there were additive or interactive effects of different types of maltreatment on adult sexual risk behavior. Participants were 414 women (M age = 28 years) attending a publicly funded STD clinic. All women completed a computerized survey assessing childhood maltreatment (sexual, physical, psychological abuse, and neglect) and sexual risk behavior. Analyses showed that sexual abuse, physical abuse, psychological abuse, and neglect were associated with adult sexual risk behavior. Multivariate analyses that controlled for all other forms of child maltreatment showed that only CSA was uniquely associated with adult sexual risk behavior (i.e., percentage of episodes of unprotected sex in the past 3 months and number of lifetime partners). The authors found little support for an additive or an interactive model of the effects of different types of childhood maltreatment on adult sexual risk behavior; CSA alone was the best predictor of adult sexual risk behavior. Sexual risk reduction interventions are needed for women who were sexually abused as children. Continued research on the effects of multitype maltreatment on adult sexual risk behavior is needed.     

Child maltreatment trends in the 1990s: why does neglect differ from sexual and physical abuse?

Substantiated cases of child maltreatment have declined more than 20% since a peak in 1993. However, although sexual abuse and physical abuse showed significant declines during the 1990s (47% and 36%, respectively), neglect fluctuated, with only a small overall decline during this period (7%). Available data suggest that at least part of the declines in sexual and physical abuse is likely to be real. Some evidence also suggests that a decline in neglect may have been masked in some states. Possible sources for declines in child maltreatment include direct prevention efforts, economic improvements, more aggressive criminal justice efforts, dissemination of psychiatric medication, and generational changes. Public health models suggest that population-level prevention initiatives are the most promising options for further reducing maltreatment rates. However, better epidemiological and evaluation research will be needed to identify the key factors.     

Child Neglect: Assessment and Intervention

Neglect is often a neglected form of child maltreatment even though it is the most common and deadliest form of child maltreatment. Pediatric nurse practitioners (PNPs) will most likely encounter neglected children in their practice. It is crucial that PNPs recognize child neglect in a timely manner and intervene appropriately. This continuing education article will help PNPs understand and respond to child neglect. Neglect will be defined and risk factors will be discussed. Children who are neglected can experience serious and lifelong consequences. The medical assessment and plan of care for children with concerns of suspected neglect will be discussed.     

Update on child maltreatment with a special focus on shaken baby syndrome

PURPOSE OF REVIEW: The many forms of child maltreatment exact an unacceptably heavy toll on our children. Recent work exploring the risk factors for child abuse and neglect, long-term consequences of child maltreatment, and potential for primary prevention will be reviewed. In the past year there have been many notable contributions in the field of shaken baby syndrome that have deepened our understanding of this devastating form of child abuse. RECENT FINDINGS: Evidence of the long-term sequelae of child abuse and neglect continues to accumulate, but with increased understanding of the clinical manifestations of child maltreatment has come greater ability to intervene early and perhaps improve long-term outcomes. Although the effectiveness of some home visiting programs to prevent child maltreatment is coming into question, rigorous review of program components is helping to improve quality. There remain controversies in the diagnosis of shaken baby syndrome but several carefully done case-series are clarifying our knowledge of the myriad presentations of this form of non-accidental head trauma. SUMMARY: Pediatricians have an important role to play in the prevention and recognition of child maltreatment.     

Young children's adjustment as a function of maltreatment, shame, and anger

Maltreated children are at increased risk for behavior problems. This study examines a model in which shame mediates the potential relation between maltreatment and anger, and anger mediates the potential relation between shame and behavior problems. Participants were 177 children (ages 3 to 7 years) and their mothers, 90 of whom had histories of perpetrating neglect and/or physical abuse. Physical abuse, but not neglect, was related to increased shame during an evaluative task; shame was related to increased anger; and anger to teacher ratings of total behavior problems and externalizing problems. Age moderated the relation between physical abuse and adjustment, as abuse was related to more total problems only among the younger children. Anger was a significant mediator of shame and both behavior problems and externalizing problems. Shame, anger, age, and type of maltreatment appear to be important factors in explaining variance in behavioral adjustment following a history of maltreatment.     

Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting

The condition widely known as Munchausen syndrome by proxy comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. Although it is a relatively rare form of child abuse, pediatricians need to have a high index of suspicion when faced with seemingly inexplicable findings or treatment failures. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. In this statement, factors are identified that may help the physician recognize this insidious type of child abuse that occurs in a medical setting, and recommendations are provided for physicians regarding when to report a case to their state's child protective service agency.     

The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: a meta-analysis

In this article, a meta-analysis is presented on 40 evaluation studies of early prevention programs for families with young children at risk for physical child abuse and neglect with mostly nonrandomized designs. The main aim of all programs was to prevent physical child abuse and neglect by providing early family support. For the meta-analysis, a multilevel approach was used. A significant overall positive effect was found, pointing to the potential usefulness of these programs. The study demonstrated a significant decrease in the manifestation of abusive and neglectful acts and a significant risk reduction in factors such as child functioning, parent-child interaction, parent functioning, family functioning, and context characteristics.     

Emotional Maltreatment

Child abuse is a problem that affects the lives of many American children. The public is often bombarded with information regarding horrific cases of physical and sexual abuse. Emotional maltreatment, however, has been slow to achieve recognition as a serious social problem for a variety of reasons. Compared with physical or sexual abuse, emotional maltreatment is more difficult to identify and define, and good epidemiological data are not available. An erroneous perception also exists that the sequelae of emotional maltreatment are less severe than that of physical and/or sexual abuse. Prompt identification of emotional maltreatment, appropriate intervention and referral, and reporting of concerns to child protective services are essential to the health and well-being of the child. This article will define emotional maltreatment, discuss consequences of emotional maltreatment, and provide implications for pediatric nurse practitioner practice.     

Pediatric Fractures: Identifying and Managing Physical Abuse

Childhood fractures are a common reason for presentation to the emergency department. Fractures are also an important manifestation of child maltreatment. Therefore, it is critical that healthcare providers understand historical, biomechanical, physical examination, and psychosocial factors that can help differentiate abusive skeletal trauma from accidental injuries and recognize other contributors such as metabolic bone disease. As fractures may not be apparent based on history and examination alone, medical providers with concern for abusive injury in young children should understand when and how to evaluate for occult skeletal and other injuries. While no fracture location is pathognomonic for abuse, certain fracture types have high specificity for abuse and therefore knowledge of their radiologic appearance, mechanism of injury, and association with maltreatment is essential. This article will review current knowledge on the topic of child abuse considerations when children present with fractures.