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CHILD MALTREATMENT, TRAUMA AND SELF INJURIOUS BEHAVIOR

Course Overview:
Historically, ‘child abuse” has primarily been associated with thoughts of physical abuse or severe cases of child neglect, however, more contemporary views of child abuse focus on four primary sources of maltreatment: physical, sexual, emotional/ psychological or neglect. There are also frequent reports of multiple maltreatment, or poly-victimization, where a child is subjected to more than one form of abuse. Many of the children suffering from abuse develop symptoms of post traumatic stress disorder (PTSD), and it is anticipated that the prevalence rates for reporting PTSD at earlier ages will increase given the new DSM-5 criteria for diagnosing PTSD in the under 6 population. Although most countries agree on the four types of abuse, there is wide variation among different cultures as to what constitutes abuse within those categories, depending on cultural norms of acceptable methods of discipline. Due to these variations, the definitions for maltreatment in this paper are derived from definitions found in the World report on violence and health developed by the World Health Organization (WHO; Krug, Dahlberg, Mercy, Zwi & Lozano, 2002). According to the WHO, any definition of child maltreatment, “must take into account the differing standards and expectations for parenting behavior in the range of cultures around the world “ and with this underlying premise in mind, the WHO drafted the following definition of child abuse and maltreatment:
“Child abuse or maltreatment constitutes all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.’’ (Krug, Dahlberg, Mercy, Zwi & Lozano, 2002, p. 59).

This course will provide readers with an increased understanding of:

  • The characteristics of different types of abuse and maltreatment;

  • Prevalence rates for the different types of abuse, internationally,

  • Potential outcomes for children exposed to maltreatment, including the development of self injurious behaviors (self inflicted injuries without suicidal intent), and

  • Risks and protective factors for child and family characteristics associated with maltreatment

Introduction to Child Maltreatment

Historical Background
Prior to the nineteenth century, dominated by theories of social control, child-rearing was influenced by the prevailing religious, cultural and social climate. Within this context, children were perceived as miniature adults, and childhood was not considered to be a unique period of development. Children were seen as chattel belonging to parents who had sole ownership to do with as they pleased (Scannapieco and Connell-Carrick, 2005). Although poor children continued to be in high demand for the labor force for quite some time, by the beginning of the 15th century, scholars, philosophers and educators began to see a brighter future for children from the privileged classes. During the 17th and 18th centuries, there was considerable philosophical debate regarding the potential role of parents in the process of child rearing which ultimately resulted in two extreme positions. In England, the philosopher John Locke supported the position that it was the parents’ duty to educate and nurture children who are born with a blank slate (tabula rasa). For Locke, child rearing was serious business and a child’s future was totally dependent on the success of the parents in fulfilling their responsibilities and obligations to teach and nurture the child. In France, the philosopher Jacques Rousseau took an opposing position. For Rousseau, the best and most successful parents, were those who recognized that children should be allowed to blossom and grow without interference (stated as “lassiez faire” or leave them alone). The famous nature nurture debate has continued for centuries with some (like Francis Galton and Charles Darwin) taking the stand that we owe more of our intelligence and personality to our genetics (nature), while others emphasize the importance of environmental influences (nurture) on development (such as, the behaviorist John Watson).

In the wake of the industrial revolution, the work force moved from farming to factories, and children were often seen as ideal laborers since they were often easier to control and cheaper than adult laborers. Soon many children in the United States could be found working in glass and textile factories, mines, and canneries. Growing opposition to child labor in the north caused many factories to move further south, and by 1900 many states were beginning to advocate for children’s rights, calling for the development of child labor laws. However, the movement to protect children from harsh labor practices backfired in some situations. Children who were not allowed to work in factories lost their appeal as chattel, since they no longer provided parents with income, and in fact now were costing the parents additional money to support them. As a result, many children were abandoned by their parents and forced to live on the streets in squalid conditions, such as “alms” or poorhouses and many ended up begging for food and shelter. Eventually, the street children were taken into orphanages which were later replaced by foster homes (Scannapieco and Connell-Carrick, 2005).

Definitions of Child Maltreatment: Historical Evolutions

The definition of child maltreatment has evolved historically, and continues to be somewhat illusive due to variations in definitions resulting from different cultural perspectives, the prevailing social policies at the time, and an individual’s professional or organizational affiliation. Given disparities in definitions, communication between various professionals in the field can often be difficult (Giovannoni, 1989). Differences in definitions also pose a barrier to research efforts such as providing accurate estimates for prevalence rates for the various forms of maltreatment. In addition, lack of consistency in definitions also limits opportunities for conducting a meta analysis, thereby reducing the prospect of finding patterns / themes or relationships that can assist in uncovering risks and protective factors for the various forms of abuse.

Historically, the term “child abuse” has been associated with physical abuse or severe cases of child neglect. Holtz was one of the first to document emotional neglect in the mid 1930’s in his manuscript, The Diseases of Infancy and Childhood where he described conditions of infants suffering from malnutrition linked not to lack of physical care, but associated with clinical factors, a term he later referred to as ‘failure to thrive’ (Holtz, as cited in Schwartz, 2000). Several years later, Spitz (1946) wrote of his observations of emotional neglect in institutionalized infants who he described as “wasting away” (a condition referred to as marasmus), despite attention to their physical needs. According to Spitz, the infants seemed listless and displayed continual sobbing, which he believed was an early form of depression which he referred to as anaclitic depression.

Failure to thrive or ‘maternal deprivation syndrome’ (later re-named ‘parental deprivation syndrome’) was finally recognized by the American Psychiatric Association (APA) when ‘reactive attachment disorder’ was officially entered into the third edition of the Diagnostic and Statistical Manual of Mental Disorders in the late 1960’s (Schwartz, 2000). A timely article on “the battered child syndrome’ published in the early sixties, by Kempe, Silverman, Steele, Droegemueller, and Silver (1962) was a wake-up call to the medical profession to recognize the growing problem: “physicians have a duty and responsibility to the child to require a full evaluation of the problem and to guarantee that no expected repetition of trauma will be permitted to occur.” (p. 17).

More contemporary views of child maltreatment now recognize that abuse can occur as a result of acts of ’commission’ ( physical, sexual or emotional abuse) or by acts of ‘omission’ ( severe emotional, educational or physical neglect) that can jeopardizes a child’s physical health and emotional well being (Ronan, Canoy and Burke, 2009).

Definitions of Child Maltreatment: Contemporary Perspectives.
Perpetrators of abuse and maltreatment can have many different faces, and can include a variety of significant individuals in the child’s life who the child is familiar with and trusts, such as: parents, caregivers, siblings and peers. According to the American Psychological Association (APA, 1996), because the perpetrator is often known to the child and may be a close relative or close to other family members, children who experience maltreatment can be caught in a conflicted pattern of ambivalence between wanting to put an end to the violence but feeling a sense of loyalty and belongingness to the perpetrator. Another possible pattern that may develop is one where the abuse may be followed by reconciliation and affection which can serve to reinforce the child’s hope that the situation has changed for the better. Furthermore, the longer the patterns are in existence, the acts of abuse and the abuser’s power tend to increase over time, resulting in lowering the child’s threshold for victimization.

Prevalence Rates of Child Maltreatment:
Problems in obtaining accurate prevalence rates: It is difficult to obtain accurate prevalence rates for maltreatment for several reasons. As was previously discussed, different definitions make collating data difficult. While some studies do not include all forms of maltreatment in their prevalence rates, others combine data masking prevalence statistics for specific forms of abuse. Consistency in prevalence rates is also compromised by studies that include samples that vary in a number of important ways, including: SES, education level, or clinical versus community samples, making it difficult to generalize results. Studies also differ in the the type of statistics reported, the measures used to obtain the data and the nature of the actual prevalence rates reported (e.g., lifetime versus annual prevalence rates). Finally, since many incidents of child abuse go unreported, it is difficult to know the level of accuracy represented by prevalence estimates (Feather & Ronan, 2009).

International Prevalence Rates: The U.S. Department of Health and Human Service (2000) estimated that 10 out of every 1000 children will experience some form of maltreatment. In the United Kingdom, Hobbs (2005) reported that about 1 million out of 13 million children would experience maltreatment, in the form of bullying, or family-based violence. Cawson, Wattam, Brooker & Kelly (2000) found that 20% of children in the United States and the United Kingdom admitted to being physically threatened (bullied) outside the family context. However, despite this high rate, within the United Kingdom, children are still at more risk of being maltreated within the context of their family, and the the greatest risk for maltreatment is in the form of physical or emotional abuse, compared to potential for sexual abuse (Cawson et al., 2000).
In the Netherlands, based on data about cases of child maltreatment reported by professionals, and those registered with the Dutch Child Protection Services (CPS), Euser, van IJzendoom, Prinzie & Bakermans-Kranenburg, (2010) found that the overall rate of maltreatment in the Netherlands was 30 cases per 1,000 children. In their report, Euser and colleagues (2010) stated that only 12.6% of the total number of maltreatment cases were ever reported to CPS.

In Germany, based on their survey of youth 14 years of age and older (representative sample of over 2,500 individuals), Hauser, Schmutzer, Brahler, Glaesmer and Roseveare (2011) reported the following rates for the different forms of abuse: 1.6% reported severe emotional abuse; 2.8% reported severe physical abuse; and 1.9% reported severe sexual abuse. The study divided neglect into two types, physical and emotional neglect. The prevalence rates for neglect were: 6.6% for severe emotional neglect, and another 10.8% for severe physical neglect.

Ronan and colleagues (2009) did a comparative analysis of lifetime prevalence rates for maltreatment in the United States, United Kingdom and New Zealand. The researchers found comparable prevalence rates among these locations with an average prevalence for sexual abuse around 10% and an average prevalence for physical abuse, between 7 and 9%.
Prevalence Rates in the United States:. One of the most recent and comprehensive reviews of data on child maltreatment in the United States is available in the Fourth National Incidence Study of Abuse and Neglect (NIS-4; Sedlak et al., 2010). This report summarizes data collected during 2005-2006 and represents over 6,000 reports by designated staff from schools, day care centers, hospitals, in addition to over 10,000 forms completed by staff from Child Protective Services (CPS). The reason why this is probably one of the most accurate estimates of prevalence rates is due to the methodology used. For purposes of data analysis, maltreatment was defined by one of two conditions, involving the harm standard (measure of demonstrated harm or abuse) or the endangerment standard (included all children who met criteria for the harm standard, plus those children deemed at risk of abuse or neglect). Based on their analysis, Sedlak et al. (2010) report that 1 child out of every 25 children (almost 3 million children) met criteria for having been abused, neglected or endangered; a figure that did not differ appreciably from data collected in the previous report NIS-3 in 1993 (Sedack & Broadhurst, 1996). However, when rates for individual categories were compared, it was found that while prevalence rates for physical, sexual and emotional abuse decline between the two collection periods, rates for emotional neglect more than doubled. According to NIS-4, 29% of children met criteria for the endangered standard for abuse, with the following breakdown of categories: physical abuse 57%; emotional abuse 36%; sexual abuse 22%. Within the category of neglect, 77% of children met criteria for maltreatment, with the following subcategory breakdown: physical neglect 53%; emotional neglect 52% and educational neglect 16%. The report emphasized that increased awareness was needed in the area of emotional neglect since the numbers had increased dramatically since data was collected for the NIS-3 report. Based on this report, physical and emotional neglect have surfaced as the most prevalent forms of maltreatment of children within the United States. Developmentally, prevalence rates were lowest for children in the older categories (15-17 years) and highest for children in the younger category (6-8 years of age).

Types of Child Maltreatment

Overview

As mentioned previously, although most agree that there are four major types of maltreatment,
some researchers have also mentioned subtypes within these major classifications. There are also situations where individuals may experience more than one type of maltreatment or multiple maltreatment, or be victimized by more than one perpetrator, as in polyvictimization. The following discussions will outline some of the most common characteristics that have been identified within each category of abuse. However, since some studies report findings for “maltreatment” in general, it is also important to identify some generalized risk and protective factors which apply to maltreatment in a global way and how maltreatment may impact outcomes for children and adolescents that may influence their development in cognitive, behavioral, social, medical and mental health areas. Finally a discussion of the outcomes of maltreatment would not be complete without understanding the association between maltreatment and non-suicidal self injury, a growing area of concern.
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