KAPLAN, SANDRA J. M.D.; PELCOVITZ, DAVID Ph.D.; LABRUNA, VICTOR Ph.D.
Objective: To review the clinically
relevant literature on the physical and emotional abuse and neglect of children
and adolescents published during the past 10 years.
Method: Literature published between 1988 and 1998 was reviewed following a systematic search of Medline, PsychInfo, and the National Clearinghouse on Child Abuse and Neglect.
Results: During the last decade
there has been substantial progress in understanding the symptomatology associated
with maltreatment. However, prevention and intervention research studies
are relatively rare and frequently have important methodological limitations.
Conclusions: Child maltreatment
research in the next decade needs to focus on understanding factors leading
to resilient outcomes and on assessing the effectiveness of psychotherapeutic
and psychopharmacological treatment strategies. Increased resources are needed
to support child maltreatment research studies and investigators.
The last decade has witnessed an increasing
recognition by child mental health professionals that child physical and
emotional maltreatment are major public health issues. As the field matures,
research has informed clinical practice with a more sophisticated understanding
of the correlates of abuse and neglect, including the potential impact of
maltreatment on multiple domains of child functioning. This article reviews
research pertinent to the mental health care of physically and emotionally
maltreated children and adolescents published during the past decade (1988-1998)
selected from Medline, PsychInfo, and the National Clearinghouse on Child Abuse and Neglect database. A subsequent article will cover sexual abuse.
Although many definitions of maltreatment
exist, physical abuse and neglect are generally referred to in this review
as defined in the most recent National Incidence Study (NIS-3) (Sedlak and Broadhurst, 1996).
The NIS-3 defines physical abuse as present when a child younger than age
18 years has experienced injury (harm standard) or risk of injury (endangerment
standard) as a result of having been hit with a hand or other object or having
been kicked, shaken, thrown, burned, stabbed, or choked by a parent or parent-substitute.
Physical neglect refers to harm or endangerment as a result of inadequate
nutrition, clothing, hygiene, and supervision. Emotional abuse includes verbal
abuse, harsh nonphysical punishments (e.g., being tied up), or threats of
maltreatment, while emotional neglect covers failure to provide adequate
affection and emotional support or permitting a child to be exposed to domestic
There are 2 major sources of national
epidemiological data on child maltreatment. The NIS-3 sampled child protective
services (CPS), law enforcement, juvenile probation, public health, hospital,
school, day-care, mental health, and social service agencies for a 3-month
period during 1993. Using the harm standard, the incidence of physical abuse
was estimated to be 5.7 per 1,000 children, an increase over the 2 previous
incidence studies of 1986 and 1980 (Table 1).
The incidence of physical neglect per 1,000 children increased at an even
greater rate, while similar increases in emotional maltreatment were also
Whether these statistics reflect actual
increased incidence of maltreatment or an increased sophistication in detection
and/or reporting has been debated. However, the significant increases in
severity of injuries from child maltreatment between 1980 and 1993 for all
levels except fatalities suggests an actual increase in the incidence of
maltreatment (Sedlak and Broadhurst, 1996).
The second major source of child maltreatment information is represented by Child Maltreatment 1996: Reports From the States to the National Child Abuse and Neglect Data System (U.S. Department of Health and Human Services [DHHS], 1998).
This report, as well as its earlier versions, presents data compiled from
state CPS agencies of known maltreatment cases. In 1996, physical neglect
was involved in 57.7% of maltreatment cases, while physical abuse involved
22.2% and emotional maltreatment was involved in 5.9% of cases. However,
emotional maltreatment in both surveys is likely underreported because of
most agencies' primary emphasis on the physical safety of children.
In 1996, reporters of child maltreatment
to state CPS were most often educators and legal, social service, and medical
professionals. The fewest reports came from anonymous reporters, relatives,
victims, and friends/neighbors (DHHS, 1998).
Gender and age distributions indicate
that unlike sexual abuse, there is little difference between boys and girls
in the overall incidence of physical and emotional maltreatment. However,
gender distributions may vary with the age of the victim, such as a greater
representation of female victims of adolescent physical abuse (Powers et al., 1990).
With regard to maltreatment incidence by age, the national surveys indicate
that physical abuse peaks in the 4- to 8-year-old range. Emotional maltreatment
has been reported to peak in the 6- to 8-year-old range and to remain at
a similar level through adolescence.
To aid child protective agencies triage
cases and determine the level of case supervision required, great emphasis
has been placed on determining a child's risk for continued maltreatment.
Risk factors found to predict recurrent abuse include the following: young
age of victim, number of previous CPS referrals, and caretaker characteristics
such as emotional impairment, substance abuse, lack of social support, presence
of domestic violence, and history of childhood abuse (English et al., in press). Unfortunately, these risk factors are often not carefully assessed by CPS caseworkers.
In addition, although numerous models
have been investigated, attempts to predict which children reported to CPS
are at risk for severe or fatal maltreatment have been unsuccessful. What
is known is that younger children are at the greatest risk, with more than
75% of maltreatment fatalities in 1996 involving children younger than age
3 years (DHHS, 1998). Uniform Crime Reports
of child and adolescent homicide by parents between 1976 and 1985 indicate
that male and female children were at equal risk during the first week of
life, but that male children were victims in 55% of homicide cases from week
1 to age 15 years and 77% of cases between ages 16 and 19 years. Mothers
almost always perpetrated homicides occurring during the first week of life,
and either parent was equally likely to fatally injure his/her child from
week 1 to 13 years. However, fathers committed 63% of parent-perpetrated
homicides occurring in 13- to 15-year-olds and 80% of those occurring in
16- to 19-year-olds (Kunz and Bahr, 1996).
The NIS-3 estimated that 1,500 children were fatally abused in the United
States in 1993, but child homicides are often ruled as accidental deaths
and the actual incidence of fatal abuse may be much greater.
The psychiatric and psychological problems
associated with physical abuse and neglect are extremely varied. Overall,
research studies have found that physical abuse and/or neglect is associated
with a large number of interpersonal, cognitive, emotional, behavioral, and
substance abuse problems and psychiatric disorders, and increased mental
health services utilization has also been reported for maltreated children
(Garland et al., 1996). It is important to
note that child maltreatment research often fails to identify the exact type(s)
of maltreatment experienced by subjects. This is due to limited information
from state child protection agencies, unreliable subject self-reports, and
the frequent co-occurrence of different forms of physical and emotional abuse
and neglect. Furthermore, multiple risk factors for poor functioning (in
addition to maltreatment) are frequently present in subjects' environments.
These problems may limit studies' conclusions concerning the specificity
of effects of various types of maltreatment.
Consistent deficits in the social functioning
of abused children and adolescents have been found in analyses of information
from multiple informants (parents, teachers, and peers) (i.e., Dodge et al., 1994). In the case of abused infants, these deficits can may be seen as insecure (particularly disorganized) patterns of attachment (Cicchetti and Barnett, 1992)
which may set the stage for later peer rejection and for intimate relationships
marked by revictimization or the victimizing of others. Physically abused
children also have been found to be more disliked and less popular than their
nonabused peers (Salzinger et al., 1993), and
even with close friends they exhibit less intimacy, more conflict, and more
negative affect than non-abused children do with friends (Parker and Herrera, 1996).
The peer difficulties of abused children are present even with control for
variables such as socioeconomic status and negative life events (Okun et al., 1994).
Adolescents with abuse histories also report impaired styles of interpersonal
attachment, engage in more aggression in their peer relationships, and exhibit
more abusive or coercive behaviors in dating relationships (Wolfe et al., 1998).
Although studies have infrequently examined
neglect, recent data suggest that physically neglected children also have
deficits in social functioning, including greater conflict with friends and
fewer reciprocated friendships (Bolger et al., 1998).
There is evidence that the interpersonal problems of maltreated children
are related to difficulty in understanding appropriate affective responses
to interpersonal situations and to limited social problem-solving skills
(Haskett, 1990; Rogosch et al., 1995).
Studies during the last decade have
consistently documented impaired cognitive abilities and poor academic achievement
in maltreated youth. Language skills have been most frequently scrutinized,
with deficits reported for both receptive and expressive language (Coster et al., 1989; Fox et al., 1988; McFadyen and Kitson, 1996). There is some evidence that neglect results in greater deficits than abuse (Culp et al., 1991b).
These findings are important because expressive language difficulties have
been associated with risk for aggressive and conduct-disordered behavior,
particularly in abused children (Burke et al., 1989).
The academic performance of maltreated children reflects their cognitive
impairments; both abuse and neglect have been associated with large deficits
on both mathematics and language tests, with neglect having the strongest
association with poor achievement (Eckenrode et al., 1993; Wodarski et al., 1990).
Aggressive and delinquent behaviors are among the most frequent correlates of physical abuse. Lewis (1992)
hypothesized that physical abuse exposure increases the risk for the expression
of aggression by increasing levels of impulsivity and irritability, engendering
hypervigilance and paranoia, and curtailing the recognition of pain in both
self and others. Relative to peers, abused preschool children have been found
to engage in frequent aggressive behavior (Klimes-Dougan and Kistner, 1990) and to more often attribute hostile intent to their peers' behaviors (Dodge et al., 1990).
The increased aggression exhibited by physically abused school-age children
is also associated with increased rejection by peers (Salzinger et al., 1993) and a greater likelihood that abuse victims will be "blamed" by others for being abused (Muller et al., 1993). As abuse victims develop, they are at risk for engaging in violent, criminal behavior in both adolescence (Herrenkohl et al., 1997) and adulthood (Widom, 1989).
An increasing number of studies have
reported an association between physical abuse and risk for suicidal behavior,
particularly in adolescents (Garnefski et al., 1992; Kaplan et al., 1997; Riggs et al., 1990).
Risk-taking, often related to suicidal behavior, has also been investigated
in abused populations. Physically abused youth are more likely than their
nonabused counterparts to take part in behaviors endangering their health,
including cigarette smoking, substance use, and sexual risk-taking (Riggs et al., 1990).
Sexual risk-taking may explain why physical abuse and neglect have also been
associated with teenage parenthood for both males and females (Herrenkohl et al., 1998).
In light of the difficulties described
above, it is not surprising that abuse victims are at increased risk for
a variety of child and adolescent psychiatric diagnoses, including depressive
disorders, anxiety disorders, conduct disorder, oppositional defiant disorder,
attention-deficit/hyperactivity disorder, and substance abuse (Famularo et al., 1992; Flisher et al., 1997; Kaplan et al., 1998; Livingston et al., 1993).
The reported rates of each disorder often vary with subjects' age, socioeconomic
status, family characteristics, and severity of abuse. However, some of the
most consistent findings are that approximately 8% of children and adolescents
documented as physically abused have current diagnoses of major depressive
disorder, approximately 40% have lifetime major depressive disorder diagnoses,
and at least 30% have lifetime disruptive disorder diagnoses (oppositional
defiant disorder or conduct disorder). These prevalence rates are several
times higher than those found in community samples of children and adolescents
(see Lewinsohn et al., 1993). Although posttraumatic
stress disorder (PTSD) may be present in cases of extreme physical abuse,
it does not appear to be commonly associated with mild physical maltreatment
(Pelcovitz et al., 1994).
Unlike earlier research, recent studies
of psychiatric disorders in abused children have more often used non-referred
samples and comparison groups, greatly improving the quality of research.
However, cross-sectional research designs predominate, limiting causal inferences
between abuse and disorders. For example, depressive disorders may be a direct
or indirect consequence of abuse, depressed children may be more frequently
targeted for abuse, or depression may be related to causal factors in abusive
environments other than the abuse itself. Longitudinal studies are needed
to further our understanding of the relationship between abuse and psychiatric
Additional resources are also needed
to study parents with Munchausen syndrome by proxy (MSBP) who commit physical
abuse in the course of intentionally fabricating illnesses in their children.
The existing research, based on a small number of cases, suggests that victims
of MSBP experience significant psychological and psychiatric symptomatology
in both childhood and adulthood (Bools et al., 1993; Libow, 1995).
Because most cases of MSBP go undetected, the actual incidence of this type
of abuse is unknown. However, a prospective study surveying all consultant
pediatricians in Great Britain and Ireland reported the incidence to be 2.8
per 100,000 for children younger than age 1 year (McClure et al., 1996).
Due to the often extreme abuse inflicted by parents with MSBP (e.g., broken
bones, poisoning), their children are at great risk for serious physical
and psychiatric morbidity.
There is little research devoted to
psychopathology in neglected children, and what does exist is often contradictory.
For example, Wodarski and colleagues (1990)
reported that according to parents and teachers, physical abuse was associated
with behavior problems, but physical neglect was not. This contrasts with
previous reports that neglect may be the most harmful type of maltreatment
with regard to psychopathology (Erickson et al., 1989).
Although the contradiction may be due to differences in sample characteristics
or to the exact nature of the neglect, it is clear that additional research
on physical neglect is needed.
Studies of the biological correlates
of abuse and neglect are still relatively rare, especially studies that include
children or adolescents as subjects. Adults with PTSD related to severe childhood
physical and/or sexual abuse have been found to exhibit decreased hippocampal
size, which may help to explain memory impairment in victims of severe physical
and sexual abuse (Bremner et al., 1995, 1997).
In children, psychiatric inpatients with a history of physical and/or sexual
abuse have been reported to exhibit frontotemporal and anterior brain electrophysiological
abnormalities (Ito et al., 1993). More advanced
quantitative EEG examination of severely maltreated children has also found
altered brain development, indicative of decreased cortical differentiation
(Ito et al., 1998).
Hormonal changes have also been associated with physical abuse, including changes in the hypothalamic-pituitary-adrenal axis (Hart et al., 1996).
More specifically, Hart and colleagues reported elevated afternoon cortisol
levels in maltreated children, as well as an unexpected pattern of increased
afternoon cortisol levels in depressed maltreated children which was not
found in depressed nonmaltreated children. Differences in growth hormone
levels of physically maltreated and comparison children have also been documented,
indicating that delayed growth is a possible correlate of maltreatment (Jensen et al., 1991).
In other areas, Glod and colleagues (1997)
reported that physically abused children exhibited impaired sleep efficiency
with increased activity during sleep and prolonged sleep latency, and Scarinci and colleagues (1994)
investigated the relationships between child abuse and pain perception in
adult female patients with gastrointestinal disorders. Subjects abused during
childhood had significantly lower pain threshold levels in response to finger
pressure than nonabused subjects, more frequently blamed themselves for their
pain, and reported more maladaptive pain coping strategies.
Research indicates that emotional maltreatment
(also referred to as psychological maltreatment) occurs in an overwhelming
majority of physical abuse cases but also occurs independently of other types
of maltreatment (Claussen and Crittenden, 1991).
As a result, emotional abuse and neglect are likely the most frequent forms
of maltreatment experienced by children and adolescents. Unfortunately, emotional
maltreatment has not been a focus of research until recently because it was
often thought to be less damaging than physical maltreatment, and it can
be more difficult to quantify compared with physical evidence of trauma.
The existing research suggests that emotional maltreatment may actually have
a stronger relationship to long-term psychological functioning than other
forms of maltreatment. Regression analyses have indicated that emotional
abuse is a stronger predictor than physical maltreatment of a wide array
of problems, including internalizing and externalizing behaviors, social
impairment, low self-esteem, suicidal behavior, as well as current and previous
psychiatric diagnoses and hospitalizations (McGee et al., 1997; Mullen et al., 1996; Vissing et al., 1991).
With regard to suicide, Mullen and colleagues reported that a history of
physical abuse increased a subject's odds of attempting suicide by almost
5 times, while a history of emotional abuse increased the odds of a suicide
attempt by more than 12 times. Emotional neglect has received less attention,
but perceived emotional rejection by parents has been associated with poor
adolescent and young adult outcomes in at least 2 areas: substance abuse
(Campo and Rohner, 1992) and delinquency (Simons et al., 1989).
Until recently, most treatment studies
focused on reducing maltreatment by providing abusive or neglectful parents
with combinations of social support, anger control, and parent training focusing
on appropriate child management strategies (Wolfe and Wekerle, 1993). High rates of depression, substance abuse, and antisocial behavior seen in abusive parents (Egami et al., 1996)
will likely decrease the effectiveness of these types of interventions, highlighting
the need for diagnosis and treatment of parental disorders.
However, preventing further abuse is
only one aspect of treatment, and abuse-related problems in victims must
also be addressed. Therapeutic day-care programs have most often been utilized
in the treatment of young victims of physical abuse and neglect, providing
safe, nurturing environments and abuse-specific interventions. This combination
appears to have the potential to improve impaired social and cognitive skills
and to in-crease self-esteem (Culp et al., 1991a).
The literature on psychotherapy for
abused children is dominated by play therapy approaches, while the use of
anger management, social skills training, and cognitive-behavioral techniques
has also been described. Unfortunately, the effectiveness of these approaches
has generally not been empirically evaluated. In a review of treatment research
for physically abused children, Oates and Bross (1995) cite only 13 empirical studies between 1983 and 1992 meeting even minimal research standards. However, one recent study by Fantuzzo and colleagues (1996),
using several methodological improvements, explored the use of peers to help
socially withdrawn physically abused and/or neglected young children. Play
sessions with socially adept peers resulted in increased interactive play
and decreased solitary play in maltreated children.
Although most clinicians agree that
abused children should be routinely assessed to determine treatment needs,
the reality is that social service agencies and juvenile courts refer only
a minority of victims for treatment (Chapman and Smith, 1987).
As a result, the psychological and psychiatric problems commonly associated
with maltreatment will likely go untreated unless access to appropriate mental
health services for victims is increased. The development of new psychotherapeutic
interventions may benefit from a recent focus on identifying factors leading
to adaptive outcomes in high-risk children. Some characteristics of maltreated
children exhibiting resilient social and behavioral functioning have already
been identified, including self-esteem, the ability to modulate impulses
and feelings, and the ability to adapt behavior to meet environmental demands
(Cicchetti et al., 1993). Longitudinal family
studies examining a range of psychological and biological variables will
further the understanding of resilience to maltreatment, enabling the development
of enhanced treatment strategies.
Efficacy studies of psychopharmacological
treatments for abuse-related trauma symptoms utilizing children as subjects
are extremely rare. In one of the few studies examining psychotropic medication
for the treatment of PTSD in children, Famularo et al. (1988), using a treatment reversal design, found that propranolol lessened hyperarousal and hypervigilance in victims of abuse. Terr (1991)
has suggested the use of propranolol or other [beta]-blockers for traumatized
children as an adjunct to behaviorally based treatments. Clonidine has also
been reported to reduce symptoms of aggression, hyperarousal, and sleep problems
exhibited by abused preschool children with severe PTSD (Harmon and Riggs, 1996).
It is important to note that the results of both pharmacological studies
cited here should be considered with caution. The authors of both studies
considered the results as preliminary because of the extremely small subject
samples and the utilization of open medication trials. In addition, neither
study differentiated between physically and sexual abused subjects.
Efforts at primary prevention of physical
child abuse and neglect have focused on targeting at-risk parents, such as
teenage parents (Britner and Reppucci, 1997), impoverished single parents (Wolfe et al., 1995), parents expecting their first child (Affleck et al., 1989), substance-abusing parents (Blau et al., 1994), or parents with cognitive limitations (Feldman et al., 1992).
Most prevention programs use home visits to provide some basic social support
and education concerning normal child development and parenting strategies.
The latter may be particularly important because corporal punishment by a
parent is associated with later physical abuse by that same parent (Giles-Sims et al., 1995),
and corporal punishment has been linked to aggression in children. This increases
the probability that physically disciplined children will eventually be aggressive
toward their own children (Straus and Kantor, 1994), resulting in the intergenerational transmission of abuse.
The actual rate of transmission of physical
abuse from one generation to the next is still debated. Early retrospective
reports estimated a high transmission rate, usually between 75% and 100%.
However, studies with prospective components find considerably lower transmission
rates. Egeland and colleagues (1988) reported
that approximately 38% of mothers who experienced severe maltreatment as
children physically and/or emotionally maltreated their own children. However,
these rates are underestimates to the extent that abuse in either generation
goes undetected or unreported. If Egeland and colleagues had included cases
of suspected maltreatment, their transmission rate would have been greater
than 70%. Overall, the findings highlight the need for prevention efforts
to focus on identifying targets of maltreatment and providing services to
enhance their parenting skills even before they become parents.
Reviewing home-visitation prevention programs, Olds and Kitzman (1993)
concluded that intensive and comprehensive programs are helpful in changing
the behavior of parents at risk for perpetrating maltreatment, improving
the home environment, and decreasing child behavioral difficulties. There
is now some evidence that the benefits of home-visitation programs are durable.
A long-term follow-up of a relatively intense nurse visitation program reported
that comparison mothers were almost twice as likely to be reported for child
abuse/neglect over a 15-year period compared with high-risk mothers participating
in the program (Olds et al., 1997).
A more limited number of studies have
examined prevention efforts targeting children directly. These studies indicate
that even preschool children can learn and retain concepts such as the definition
of physical abuse and how to disclose abuse (Peraino, 1990).
The extent to which these concepts generalize to actual abusive situations
is generally unknown, although recent studies reported that both a school-based
prevention program (Oldfield et al., 1996) and an intensive media program (Hoefnagels and Baartman, 1997) resulted in significantly more abuse disclosures.
An area in need of increased attention,
particularly relevant to psychiatry, is the prevention of child emotional
maltreatment by parents with psychiatric or substance abuse disorders. Numerous
studies have reported that maternal affective or substance abuse disorders
are related to parent-child interactions marked by verbal aggression directed
toward children and decreased emotional nurturance (Field et al., 1990; Hawley et al., 1995; Radke-Yarrow et al., 1993; Zuravin, 1989).
This increased risk for emotional maltreatment may explain the impaired attachment,
disruptive behavioral disorders, and affective disorders exhibited by children
of depressed mothers (e.g., Teti et al., 1995).
Fortunately, interventions developed for mothers with affective disorders
have been found to result in lasting improvement in appropriate parent-child
emotional interactions (Beardslee et al., 1997) and greater rates of secure mother-child attachment (Lyons-Ruth et al., 1990).
Although research on maltreatment prevention
for at-risk parents has increased greatly during the last decade, future
research efforts will benefit from an increasingly comprehensive view of
the etiology of maltreatment and resilience to maltreatment exposure. Ecological
theories, which consider maltreatment as the end result of complex interactions
among potential risk factors within the abuser (e.g., psychiatric disorder),
his/her family (e.g., single-parent families), and their environment (e.g.,
stress, social isolation), continue to require attention in the designs of
future intervention studies (Belsky, 1993).
Another challenge in the coming decade
is the implementation of well-designed studies to understand current services
utilization by maltreated children and the effectiveness of psychotherapeutic
and psychopharmacological interventions according to type of maltreatment.
Again, ecological theories that focus on interactions among a large number
of risk and resilience factors present within the child, his/her parents,
and their sociocultural environment will be important in understanding, preventing,
and treating psychopathology in victims of maltreatment. Finally, the toll
which child maltreatment inflicts on our society highlights the need for
increased resources being made available to support child maltreatment research
studies and investigators. Increased support is also needed for the training
of child and adolescent psychiatrists and other child mental health professionals
in child maltreatment prevention, intervention, and research.
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Key Words: physical abuse; physical neglect; emotional abuse; emotional neglect; research
This series of 10-year
updates in child and adolescent psychiatry began in July 1996. Topics are
selected in consultation with the AACAP Committee on Recertification, both
for the importance of new research and its clinical or developmental significance.
The authors have been asked to place an asterisk before the 5 or 6 most seminal