Child abuse and neglect is a widespread problem in American society. A child of any age, sex, race, religion and socioeconomic background can fall victim to maltreatment, which may include both acts of commission and those of omission. Media stories tend to highlight the sensational aspects of child abuse and neglect: babies abandoned or killed by their mothers; toddlers beaten by their parents; school-aged children who are subjected to sexual abuse. While such stories attract tremendous interest and empathy for the victims, these accounts fail to reveal the complex interplay of factors that influence the origin and consequences of child maltreatment. In fact, we know that no single risk factor provides the overriding catalyst for child abuse and neglect. Multiple stresses and conditions are implicated in contributing to abusive or neglectful behavior (National Research Council, 1993). It is entirely appropriate to examine the relationship between child abuse and neglect and substance abuse, as we know that these problems are interrelated and affect many American families. We must understand the relationship between substance abuse and child maltreatment in order to maximize opportunities for successful intervention with troubled children and families.
The first step in preventing and treating child abuse and neglect effectively is to reach a common understanding of the definition of the phenomenon and its causes. Unfortunately, the field lacks consistent definitions and faces difficulty in developing valid instruments to identify and assess maltreatment. The very nature of child maltreatment, which tends to co-exist with many other problems, including individual psychopathology, poverty, domestic violence and other forms of victimization, as well as substance abuse, makes it difficult to define it conclusively and isolate key factors in its causation (National Research Council, 1993). Despite the difficulty in determining its causes, there is some consensus on its definition. For working purposes, child maltreatment is commonly divided into four categories: (1) physical abuse; (2) neglect; (3) sexual abuse; and (4) emotional maltreatment. The Child Abuse Prevention and Treatment Act of 1996 (CAPTA, P.L. 104-235) contains definitions of child abuse and neglect and sexual abuse for purposes of interpreting the legislation. The law states, "the term 'child abuse and neglect' means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm" (Section 111(2)).
Although it is difficult to isolate the causal factors of child maltreatment, much progress has been achieved by researchers and practitioners who study and work with abusive and neglectful families. Anecdotal assumptions have been refined to incorporate research findings about the nature of child maltreatment, the characteristics of individuals, families, neighborhoods, and social and cultural values that affect the presence or absence of abuse and neglect. The importance of the developmental level of the child has been recognized in studying the consequences of child maltreatment and in designing prevention and intervention programs. The relationship between experiences with child maltreatment and a broad range of health and behavioral disorders has been explored through longitudinal studies with increasingly larger samples (National Research Council, 1993).
The original notion of the nature of child maltreatment was univariate, centering on the portrait of "the battered child," and referring primarily to physical abuse perpetrated by a mentally unstable and cruel parent (National Research Council, 1993). The current perspective on the problem of child maltreatment is more ecological, encompassing not only a broader range of causes, both intrinsic and extrinsic to the individual, but also a wider continuum of types and severity of abuse. Each category covers a range of behaviors, and is not perfectly discrete from the others. Despite this, each category has become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment. These studies have led to the development of unique frameworks for each type of abuse, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment), but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear with other forms of child maltreatment) (National Research Council, 1993).
Physical abuse is characterized by physical injury (for example, bruises and fractures), resulting from punching, beating, kicking, biting, burning or otherwise physically harming a child. Although the injury is not an accident, the parents or caretaker may not have intended to hurt the child. The injury may have resulted from too much discipline, physical punishment that is inappropriate to the child's age or condition, an unexpected loss of control in response to a child not meeting parental expectations, or poor coping skills on the part of the parent (DePanfilis and Salus, 1992). In 1996, 24 percent of confirmed child maltreatment reports involved physical abuse (U.S. Department of Health and Human Services, Children's Bureau [HHS/CB], 1998d).
The injury may be the result of a single episode or of repeated episodes and can range in severity from minor bruising to death. According to 1996 data collected under the auspices of the National Child Abuse and Neglect Data System (NCANDS), some 1,077 children died in the U.S. that year due to maltreatment, about half as a result of physical abuse and half as a result of neglect. Children younger than age 4 accounted for 76 percent of fatalities (HHS/CB, 1998d). Any injury resulting from physical punishment that requires medical treatment is considered outside the realm of normal disciplinary measures. A single bruise may be inflicted inadvertently; however, old and new bruises in combination, bruises on several areas of the face, or bruising in an infant suggest abuse. In addition, any punishment that involves hitting with a closed fist or an instrument, kicking, inflicting burns, or throwing the child is considered child abuse regardless of the severity of the injury sustained (DePanfilis and Salus, 1992).
In the most general sense, child neglect is characterized by failure to provide for the child's basic needs, including food, clothing, shelter, supervision, and/or medical care. Neglect covers a range of behaviors and is difficult to define. It can be confounded by differences in cultural norms between families and the child protective service system, poverty, the current state of knowledge about what constitutes adequate care, and other factors. Further, its manifestations can derive from many causative or concurrent conditions. For example, abandonment of the child may stem from parental alcoholism, drug abuse, and/or depression. Inattention to dangerous, avoidable hazards in the home may stem from lack of knowledge, poverty, and/or apathy. A significant delay in obtaining medical treatment for illness or injury may be the result of lack of knowledge, lack of transportation, prohibitive costs, or other barriers to seeking medical services.
It is important to note that the majority of cases reported to the child protective services system, 61 percent according to 1996 NCANDS data, involve a primary allegation of neglect or emotional maltreatment, and that the majority of such cases occur in families with very low incomes. However, it is equally important to note that most impoverished families do not neglect their children, and provide strong, nurturing care for their children. Even among impoverished families, neglectful families tend to be the "poorest of the poor," often lacking adequate housing, health care and child care (National Research Council, 1993). As will be discussed in detail in Chapter 4, neglect is especially predominant in child maltreatment reports in which the parent has a substance abuse problem.
Neglect can be broken down into two types for purposes of discussion: physical and educational. (Emotional neglect will be covered in the discussion of emotional maltreatment). Physical neglect includes failure to provide or allow needed care in accordance with recommendations of a competent health care professional for a physical injury, illness, medical condition, or impairment (also called medical neglect); inadequate or nonexistent supervision of a child; chronically leaving a child with others who are not qualified to take care of him or her for days or weeks at a time; inattention to avoidable hazards in the home; inadequate nutrition, clothing, or hygiene, and other forms of reckless disregard of the child's safety and welfare, such as leaving a young child unattended in a motor vehicle. Educational neglect includes allowing or condoning chronic truancy; the failure to register or enroll a child in school; the refusal to allow or failure to obtain recommended remedial educational services, or neglect in obtaining or following through with treatment for a child's diagnosed learning disorder or other special education need (DePanfilis and Salus, 1992).
Sexual abuse includes a wide variety of behaviors, including fondling a child's genitals, intercourse, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. According to the Child Abuse Prevention and Treatment Act (CAPTA, section 111(4)), "the term 'sexual abuse' includes: (A) the employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or (B) the rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children." Most State laws distinguish between sexual abuse and sexual assault. To be considered sexual abuse, these acts have to be committed by a person responsible for the care of the child (for example, a parent, baby-sitter, day care provider, or other person responsible for a child). Sexual assault is usually defined as sexual acts committed by a person who is not responsible for the care of the child.
Sexual abuse can involve varying degrees of violence and emotional trauma. The most commonly reported cases involve incest (sexual abuse occurring among nuclear family members), which most often occurs between father or stepfather and daughter. However, mother-son, father-son, mother-daughter, and brother-sister incest also occurs. Sexual abuse may also be committed by other relatives such as aunts, uncles, grandfathers, grandmothers, and cousins.
Emotional maltreatment includes acts of commission or omission by the parents or other persons responsible for the child's care that have caused serious behavioral, cognitive, emotional, or mental disorders. This can include extreme or bizarre forms of punishment, such as torture or confinement of a child in a dark closet, or more subtle forms of abuse, such as belittling, scapegoating, or terrorizing a child.
Emotional abuse is the most difficult form of child maltreatment to identify. First, the effects of emotional maltreatment, such as lags in physical development, learning problems, and speech disorders are often evident in children who have not experienced emotional maltreatment. Second, the effects of emotional maltreatment may only become evident in later developmental stages of the child's life. Third, the behaviors of emotionally abused and emotionally disturbed children are often similar (DePanfilis and Salus, 1992).
There are some guidelines that can help distinguish an emotionally disturbed child from an emotionally maltreated one. The parents of an emotionally disturbed child generally recognize the existence of the problem and seek help, whereas the parents of an emotionally maltreated child often blame the child for the problems or ignore the existence of a problem. These parents often refuse offers of help and appear punitive and unconcerned about the child's welfare (DePanfilis and Salus, 1992).
Although any form of maltreatment may be found in isolation, they often occur in combination. Emotional maltreatment is almost always present when other forms of maltreatment are identified (DePanfilis and Salus, 1992).
Beyond the immediate physical injuries children may suffer, child abuse and neglect can also have longer lasting impacts across the developmental spectrum. The effects of chronic neglect are especially significant for later social and emotional functioning. Individual child characteristics, such as temperament and intelligence, may mediate the effects of neglect and abuse. Problematic school performance is among the more common problems associated with child abuse and neglect, with neglected children most adversely affected. Neglect during early childhood has negative consequences for later social relationships, problem solving, and the ability to cope with new or stressful situations. Some abused or neglected children develop aggressive behavior patterns, while others become withdrawn. Children experiencing abuse or neglect are at risk for delinquency, violence and other self destructive behaviors as well as at risk for post-traumatic stress disorder, major depression disorder, and other diagnostic conditions (National Research Council, 1993).
As noted above, it is difficult to isolate the factors that lead to abuse. It is also hard to classify the personality characteristics of abusers. Attempts to identify such characteristics have produced inconsistent and contradictory results, largely because many factors interact to produce the occurrence of child maltreatment (English, 1995). Maladaptive parenting can arise in a variety of ways, especially when a parent's behavioral characteristics or personal history, such as excessive anger, anxiety, impulsivity, depression, background of abuse, or poor coping skills, are exacerbated by such stresses as marital conflict, social isolation, unemployment, substance abuse, the disability of a child, lack of community support systems, and other violence in the environment. In general, several studies have found that abusive parents are more psychologically disturbed than non-abusive parents, though true psychosis is seen in only the most violent and abusive parents (English, 1995). The relationships among all these factors are not well understood in determining the origins of child maltreatment. It is important to be aware that what may be the cause of maltreatment in one family may not be the cause in another. Thus, it is important to use a holistic model in analyzing child abuse, examining the interplay of many conditions and circumstances, including those affecting the parents, the family, and the community, that combine to produce an abusive or non-abusive situation.
We know from the most recent NCANDS data (1996) that 77 percent of perpetrators of child maltreatment are parents, and an additional 11 percent are relatives of the victim. It is estimated that over 80 percent of all perpetrators are under age 40 and that almost two-thirds are female. An estimated three-quarters of neglect and medical neglect cases are associated with female perpetrators, while almost three-quarters of sexual abuse cases are associated with males.
The most consistent finding in the child abuse literature is that maltreating parents often report having been physically, sexually, or emotionally abused or neglected as children. Steele (1980) found that the presence of additional circumstances interacting with a prior history of abuse can increase the likelihood of abusive behavior, e.g., situational crisis, lack of social support, and a perception of the child as "unsatisfactory." However, it is incorrect to draw the conclusion that maltreated children all grow up to become maltreating parents. There are individuals who have not been abused as children who become abusive, as well as individuals who have been abused as children but do not subsequently abuse their own children. Some researchers have identified protective factors that seem to break the cycle of abuse. Parents with reported histories of abuse who do not abuse their own children are more likely to have (1) a better current social support system, including a supportive spouse; (2) a positive relationship with a significant adult in childhood or a positive experience with therapy as an adolescent or adult; (3) an ability to provide a clear account of their childhood abuse, with anger appropriately directed at the perpetrator, not at themselves (National Research Council, 1993).
Certain children are more physically and emotionally vulnerable than others to maltreatment. The child's age and physical, mental, emotional, and social development can greatly increase or decrease the likelihood of maltreatment, depending on the interactions of these characteristics with parental factors previously discussed. Younger children, due to their small size and development, are particularly vulnerable to certain forms of maltreatment. In addition, the child's behavior, such as chronic crying or unresponsiveness, can increase the likelihood of maltreatment, particularly if the parents have impulsivity problems and cannot empathize with the child. Children with disabilities are also at higher risk for abuse and neglect (National Research Council, 1993).
It is now generally recognized that a community-wide approach to the prevention of child maltreatment is the most promising technique for reducing its incidence and prevalence. Since child maltreatment is such a multivariate phenomenon, the resources of many different professional disciplines, as well as the resources of neighborhoods and communities at large, must be enlisted in a coordinated fashion. Child abuse and neglect stem partially from broad socioeconomic difficulties, so a response is required by society in general. It is also a problem that is caused in part by psychosocial factors, which requires the intervention of many branches of the helping professions. The interactions between child, parent, and environmental factors in precipitating maltreatment further indicate the necessity of comprehensive approaches. In short, the most effective prevention and intervention strategies must be:
Some specific activities that characterize a comprehensive, ecologically-based model of prevention and intervention include:
Health Care Initiatives, such as prenatal and early childhood health care to improve pregnancy outcomes and health among new mothers and young children; home health visitors to provide support, education and community linkage for new parents; and support programs for parents of special-needs children to assist them with their unique problems.
Community-Based Initiatives, such as self-help and mutual aid groups like Parents Anonymous, which provide nonjudgmental support and assistance to troubled families; child care programs to reduce the stress for employed parents; programs that address the impact of lack of economic resources on children and families such as the lack of adequate shelter, nutrition and health care, and public education; and media campaigns to increase public knowledge and awareness about the importance of prevention of child abuse and neglect.
A good example of a community-based initiative founded on the principles of coordination and collaboration of related services is mandated by the Child Abuse Prevention and Treatment Act of 1996. Title II of the Act established the Community-Based Family Resource and Support Grants Program whose purpose is "to support State efforts to develop, operate, expand, and enhance a network of community-based, prevention-focused, family resource and support programs ... to foster an understanding, appreciation, and knowledge of diverse populations in order to be effective in preventing and treating child abuse and neglect."
Parent Education Programs,such as those geared toward young parents, first-time parents, and parents with young children, which provide training in developmental stages, behavioral expectations and alternative disciplinary techniques.
Workplace Initiatives, such as the provision of flexible work schedules to help families balance the demands of their work with parenthood; education and support programs on parenting; employer-supported child care; and liberal parental leave polices.
Family-Centered Welfare to Work Programs which provide family support services both pre- and post-employment.
Social Service Programs, such as parent aide programs to provide a supportive relationship for parents at risk of harming their children; crisis and emergency services to provide respite at times of crisis; alcohol, substance abuse and mental health treatment; treatment for abused children to prevent intergenerational abuse; comprehensive prevention programs to provide multi-disciplinary services and support to families at risk; and respite care for women experiencing domestic violence, or taking care of a disabled family member.
Prevention Programs in Schools, such as self-protection training for children; family life education to equip children and adolescents with skills for coping with family problems and to prepare them for their future roles as parents, and programs for children with special needs to help reduce the stress on families with a disabled child. These may also include child abuse/neglect prevention and intervention programs in the school or in other settings which specifically address the needs of children of substance abusing parents.
It is clear that while our understanding of the nature of child maltreatment has expanded greatly as a result of years of research, demonstration, and clinical observation, there is still much to be learned and determined about the etiology, prevention, and treatment of this complex problem. We have come to understand the extreme importance of a coordinated response to child maltreatment, one that incorporates a recognition of its relationship to a multiplicity of factors, both within and outside the family system. Substance abuse is certainly one of the most important of these factors.
As far back as 1989, Congress recognized the link between substance abuse and child maltreatment. That year the Child Abuse Prevention and Treatment Act was amended to establish the Emergency Child Abuse and Neglect Prevention Services Program. This legislation authorized the Secretary of the Department of Health and Human Services to establish "a grant program to make grants to eligible entities to enable such entities to provide services to children whose parents are substance abusers." No funds were authorized until fiscal year 1991, when approximately $18 million was made available for grants to prevent the maltreatment of the children of substance abusing parents through comprehensive, multi-disciplinary, coordinated services addressing the needs of these children and their families. Ninety-four grants were funded by the National Center on Child Abuse and Neglect in four sub-categories: comprehensive emergency services, public information and education, improvement of services to substance abuse-affected families, and multi-disciplinary/interdisciplinary training. Some excellent projects emerged from this effort, and many lessons affecting policy, planning and service delivery were learned. Results from these grants are discussed in Chapter 7. The program was later combined with several other discretionary grant programs into what has become the Community-Based Family Resource Program.
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