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Unintentional Child Neglect: Literature Review and Observational Study

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• Published: 15 November 2014
• Volume 86 , pages 253–259, ( 2015 )

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• Emily Friedman 1 &
• Stephen B. Billick 2  

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Child abuse is a problem that affects over six million children in the United States each year. Child neglect accounts for 78 % of those cases. Despite this, the issue of child neglect is still not well understood, partially because child neglect does not have a consistent, universally accepted definition. Some researchers consider child neglect and child abuse to be one in the same, while other researchers consider them to be conceptually different. Factors that make child neglect difficult to define include: (1) Cultural differences; motives must be taken into account because parents may believe they are acting in the child’s best interests based on cultural beliefs (2) the fact that the effect of child abuse is not always immediately visible; the effects of emotional neglect specifically may not be apparent until later in the child’s development, and (3) the large spectrum of actions that fall under the category of child abuse. Some of the risk factors for increased child neglect and maltreatment have been identified. These risk factors include socioeconomic status, education level, family composition, and the presence of dysfunction family characteristics. Studies have found that children from poorer families and children of less educated parents are more likely to sustain fatal unintentional injuries than children of wealthier, better educated parents. Studies have also found that children living with adults unrelated to them are at increased risk for unintentional injuries and maltreatment. Dysfunctional family characteristics may even be more indicative of child neglect. Parental alcohol or drug abuse, parental personal history of neglect, and parental stress greatly increase the odds of neglect. Parental depression doubles the odds of child neglect. However, more research needs to be done to better understand these risk factors and to identify others. Having a clearer understanding of the risk factors could lead to prevention and treatment, as it would allow for health care personnel to screen for high-risk children and intervene before it is too late. Screening could also be done in the schools and organized after school activities. Parenting classes have been shown to be an effective intervention strategy by decreasing parental stress and potential for abuse, but there has been limited research done on this approach. Parenting classes can be part of the corrective actions for parents found to be neglectful or abusive, but parenting classes may also be useful as a preventative measure, being taught in schools or readily available in higher-risk communities. More research has to be done to better define child abuse and neglect so that it can be effectively addressed and treated.

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Friedman, E., Billick, S.B. Unintentional Child Neglect: Literature Review and Observational Study. Psychiatr Q 86 , 253–259 (2015). https://doi.org/10.1007/s11126-014-9328-0

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Published : 15 November 2014

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DOI : https://doi.org/10.1007/s11126-014-9328-0

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Screening Children for Abuse and Neglect: A Review of the Literature

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• 1 Author Affiliations: College of Nursing, East Tennessee State University.
• PMID: 28212197
• DOI: 10.1097/JFN.0000000000000136

Child abuse and neglect occur in epidemic numbers in the United States and around the world, resulting in major physical and mental health consequences for abused children in the present and future. A vast amount of information is available on the signs and symptoms and short- and long-term consequences of abuse. A limited number of instruments have been empirically developed to screen for child abuse, with most focused on physical abuse in the context of the emergency department, which have been found to be minimally effective and lacking rigor. This literature review focuses on physical, sexual, and psychological abuse and neglect, occurring in one or multiple forms (polyabuse). A systematic, in-depth analysis of the literature was conducted. This literature review provides information for identifying children who have been abused and neglected but exposes the need for a comprehensive screening instrument or protocol that will capture all forms of child abuse and neglect. Screening needs to be succinct, user-friendly, and amenable for use with children at every point of care in the healthcare system.

Publication types

• Child Abuse / diagnosis*
• Mass Screening / instrumentation*
• Mass Screening / methods*
• Physical Examination

Preventing Child Abuse

A website that aims for stopping Child Abuse around the world

Literature Review

Impact Of Child Abuse On Young Adults Mohamed Kharma, Edwar Amean, Nusaibh Talabah, Haifa Ali ENGL 21003 Instructor: Pamela Stemberg The City College of New York

Child abuse is a significant global problem that happens in all cultural, ethnic, and income groups. Child abuse can be in the form of physical, sexual, emotional or just neglect in providing the needs of the child. These factors can leave the child with severe long – lasting psychological damage. Abuse may also cause serious injury to the child and may even result in death. This resource guide examines the available data of child abuse and neglect. We will describe exactly what child abuse is in a broad sense, as well as specific types of abuse and neglect. The research aims to show which population of children are most likely to be abused and neglected as well as which adults are likely to be abusers when they become parents. Also, the goal of this research is to explain what are the reasons that lead for the abuse by exploring and going over each and all the types of child abuse.

Introduction

​Child abuse is a major topic in the world. Child abuse is one of the most prevalent things in our society, but not for everyone. Child abuse is divided into four types of abuse.The four kinds of child abuse; physical abuse, sexual abuse, emotional abuse, and neglect; however, all of them are different from each other. There are many causes of child abuse. The effect it has on a child can be permanent, but other times child abuse may have life lasting consequences. These abuses have different forms that both of the child and the adult show signs and symptoms of. The acts of the abusers play a significant role in the long-term implications for the abused children. Therefore, parents have a significant responsibility towards their children. According to ​Child Welfare, ​households that suffer from alcoholism, drug abuse and anger issues have higher child abuse incidents compared to other households. Child abuse can lead to injury on both the short and long term or even death. Some kids may be simply be unaware of being victims of child abuse just because they got used to it. Physical abuse involves a child’s unintentional harm, such as burning, beating, or breaking bones. Verbal abuse involves harming a child by threatening physical or sexual acts or belittling them.

Childhood abuse, physical abuse, emotional maltreatment, neglect, sexual abuse, violence, emotional abuse, mental disorders

Methodology

​For the literature review on the impact of child abuse on young adults each group member began their research for four articles on their subtopic. It was not difficult for each group member to find the articles for their subtopics, however when we limited the time frame, many of the articles had to be replaced. The publication date played a major role in the findings of the articles, because we would either find very old articles or a review of a prior literature review. As a group, we discussed what is child abuse and we divided the topics. Eventually we came to an agreement to use keywords such as sexual abuse, physical abuse, emotional abuse, and neglect. While researching articles we targeted young adults and adolescence as our age group to speak about, due to the implications they will face after experiencing abuse as a child. As a group, we came to an agreement to separately conduct our research on our sub-topics with the limitation of articles before 2014. After selecting our articles and verifying the time frame it was published in, and if it was truly a scholarly article, we sought the approval of our professor to see if our articles fit the description of the assignment. Professor Stemberg soon verified our articles and rejected others due to the limitation of the publication date. While collecting articles for our assignment we came together with a total of sixteen articles, four from each group member from multiple sources. Firstly, we searched within the CCNY library to find our articles, however there was not many so we were forced to seek our articles from google scholar. The articles in which were searched with the key word “Neglect”, focused on parents who neglected their children whether it was with the way they dressed, or the food they eat and the impacts it had on these children growing up. Secondly, the articles in which focused on physical abuse informed us the readers on children whom were beaten and intentionally harmed physically and the impacts it had on these children growing up. Thirdly we searched for articles that informed us of emotional abuse, and those articles discussed children whom were bullied from parents or caregivers, in these articles they focused on verbal aggression, manipulation, humiliation and intimidation. These articles focused on how emotional abuse can impact a child’s life as he/she grows older. Lastly, the articles in which was focusing on sexual abuse, informed us of the types of sexual abuse being contact and non-contact and, the implications a child who faced sexual abuse experiences. Surely after a considerable amount of reading and analyzation of these articles we began our literature review. Although we directly resorted to CCNY library via psycinfo and Academic search complete, there were many limitations such as the inability to view the full text and the publication date being earlier than 2014. Therefore we also used google scholars and narrowed our search extensively. While using google scholar it was much easier, because we were able to set the limitation to the publication date. While researching using google scholar it was much easier because, we were able to find exactly what we needed. Nonetheless we collected all of our articles and began our literature review.

Sexual Abuse

There are many forms of child abuse that an individual can face, such as neglect, physical abuse, emotional abuse, and sexual abuse. Child abuse is most commonly known to occur from a parent, or caregiver, however, it can also come from individuals whom the child is not familiar with. Child abuse is when pain or harm is inflicted upon a child intentionally. Throughout this section, you will be informed of the psychological and interpersonal impacts of child sexual abuse on young adults.

According to the National Society for the prevention of child sexual abuse of cruelty to children, there are two different types of child sexual abuse which are called contact abuse and non-contact abuse. Contact abuse involves any activities where the predator forces physical contact upon the child, which includes touching the child’s body or making a child take off their clothes and touch another individual’s gentiles. It also includes rape or penetration. Nonetheless non-contact abuse involves activities in which the abuser persuades the child to perform sexual acts over the internet (NSPCC,2009, P.2) Child sexual abuse increases the risk for several mental illnesses, such as psychosis, anxiety, substance abuse, and personality disorders. However, the most common symptom in a victim of child sexual abuse is post-traumatic stress disorder (Ronser et al, Trials 2014, 15:195). Furthermore it was indicates that comorbidity is secondary to PTSD which often develops in adolescence and early adulthood. The victim plays a major role in the trauma-related outcomes, it depends on how the child and/or victim fights the trauma. A victim of child abuse should seek help, or be treated at an earlier stage because victims tend to develop a suicidal or self-injurious coping mechanism (Ronser et al, Trials 2014, 15:195). Survivors of child sexual abuse often experience difficulties in emotion regulation, behavior and emotion management techniques (Ronser et al, Trials 2014, 15:195). In this study, the participants that were tested on and targeted were adolescents and young adults who are diagnosed with post-traumatic stress disorder after experiences abuse after the age of three. Participants who were in the study must be on stable medication, moreover living in a safe and stable home, and informed consent (Ronser et al, Trials 2014, 15:195). Participants had a set of rules that must be complied with, such as the participants were needed to attend five sessions within four weeks, also participants were required to learn how to tolerate and control intensive trauma-related emotions without acting out, participants also had to attend fifteen sessions of cognitive processing therapy, and lastly teach the victims how to minimize future victimization and prevent the choice of abusive partners (Ronser et al, Trials 2014, 15:195). Although the article failed to publish their results after their trials it is known that victims of CSA suffer from psychological illnesses due to the trauma they have been through.

There are many victims of child sexual abuse whom may never speak their story, and there are victims who speak their story in which it could be formally and informally, however many victims delay telling their stories until about five years after the abuse has happened. This could make it difficult for researchers to understand exactly what happened, and how the victim is coping with the trauma they have faced. According to the article ​individuals who disclose childhood sexual abuse decide to disclose or not to in their adulthood. It is believed that the transition into adulthood opens up the door for new obstacles, and victims of abuse are exposed to new people and a new environment who are not aware of the trauma they have experienced (Tener, D., & Murphy, S. B. (2014). Many individuals fear if they speak their story it will taint the new environment they were exposed to. Victims fear if they speak about the abuse the endured, they will have to face negative responses from the community which they are in. There are adult survivors who are fully aware of past abuse, however they choose to not disclose it, theses adults refer to shame, guilt, self-blame, and anxiety as their barriers as to why they refuse to disclose the abuse they have faced (Tener, D., & Murphy, S. B. (2014)). When speaking of CSA many survivors indicated they are fearful of other reactions to their story. Victims are often

fearful of not being believed or being emotionally hurt after disclosing their abuse. Other survivors indicated that if they speak about what has happened to them, it may ruin their present lives, and what they have achieved in their life including their partners, and children (Tener, D., & Murphy, S. B. (2014)). Things could be worse for individuals who were abused by family members because they are unable to separate themselves from these individuals, and if they disclose about their abuse they may jeopardize their relationship with other members of the family and are fearful that they will be targeted as a liar. Victims of child abuse who were abused by a family member fear they will have to face abandonment by people they cherish due to the members of the family siding with the perpetrator (Tener, D., & Murphy, S. B. (2014)). One may find that victims often only speak out once due to the reaction they received, negative responses causes the victim to further disclose their story, and to isolate themselves, and find it difficult to trust people. However, if the victim received their negative response from a professional, they tend to seek out other professionals until they receive a positive response (Tener, D., & Murphy, S. B. (2014)). Child sexual abuse is linked to many long-term consequences, including depression, suicidal ideations, anxiety disorders, post-traumatic stress disorder, as well as physical health problems and at-risk sexual behaviors (Hébert, M., Lavoie, F., & Blais, M. (2014). Post-traumatic stress disorder appears to be one of the most frequent symptoms in a victim who has experienced sexual abuse. It was discovered that post-traumatic stress disorder is diagnosed in 57 % of teenagers who experienced sexual trauma (Hébert, M., Lavoie, F., & Blais, M. (2014). However, many factors are measured when speaking of the severity of PTSD in a victim of sexual abuse, such as the duration of the traumatic event, and the severity/ relationship to the perpetrator. One of the few things that can help the severity of the trauma the victim has faced is their parents. Non-offending parents serve as a potential factor, support from the parents may serve as a buffer against outcomes following disclosure (Hébert, M., Lavoie, F., & Blais, M. (2014). A non-offending parent may play a crucial role in how the victim copes with the trauma they have experienced. A parent can help their child mentally and emotionally by simply believing their child, and taking action to protect their child so that the abuse may never occur again. Peers are often a considerable support system, for many victims, often confined in their peers. It was also found that the most common recipient of disclosure was a friend and nearly 40% had only disclosed to the same age peer (Hébert, M., Lavoie, F., & Blais, M. (2014).

In this study, there was a sample size of 6540, in which participants had to fill out a questionnaire which took forty minutes to complete. Participants completed a series of self-report measures related to sexual abuse, PTSD symptoms and protective factors. According to the results of (Hébert, M., Lavoie, F., & Blais, M. (2014) 14.9% of sexually abused boys and 27.8% sexually abused girls achieved a clinical score of PTSD symptoms. Their results revealed that the gravity of the abuse was significantly associated with post-traumatic stress disorder. Results in the study of (Hébert, M., Lavoie, F., & Blais, M. (2014) confirmed that there is a significant difference in the portion of boys being sexually abused (4%) and girls which are (15%), they also found that the prevalence rate for PTSD among girls between 12 and 17 years is 6.2% meanwhile boys is 3.7%. When dealing with a victim of child sexual abuse, there have to be certain precautions, because victims of abuse are more sensitive to questions being asked than to individuals who were never sexually abused. There was a study conducted in which it included 106 female adolescence, in which all participants were victims of child sexual abuse, 63.3% were sexually abused without penetration and 37.7% with penetration. Nonetheless 67.9% had been abused by a family member, meanwhile, 27.4% were abused by a person who is outside of the family however the perpetrator was known to the victim (Guerra, C., Farkas, C., & Moncada, L. (2018). In this study that was conducted, none of the participants were taking medication to control their symptoms. There was no relationship observed between the symptoms of mental illness in CSA victims and the severity of the abuse, frequency or violence of the abuse (Guerra, C., Farkas, C., & Moncada, L. (2018). This study indicated that throughout their research, the only significance that was proven was the symptoms of post-traumatic stress disorder and the relationship with the perpetrator. However, there were limitations to this study in which it was the use of a single questionnaire.

Many victims of traumatic childhood avoid traumatic or distressing memories so that they could prevent further psychological discomfort (L. S. Harris Et Al). A victim of any abuse will try to cope with the trauma they have faced in many different ways, however, they are usually strategic coping methods in which they are problem-focused and approach-oriented. You may find that avoidance has been one of the poorer outcomes in dealing with traumatic events. Often children who faced traumatic events grow up with a specific memory called RAMS, which means this individual is unable to recall detailed memories or specific actions. It was indicated that retrieving memories of sexual abuse is psychologically painful than retrieving memories of neglect, so it is possible that victims of child sexual abuse may develop rAMS given those feelings of shame, guilt, and self-blame are involved (L. S. Harris Et Al). However, (L. S. Harris Et Al) also stated that often individuals who faced CSA develop depression and PTSD, which in its way forces the individual to develop autobiographical memory. This study focused directly on how victims of abuse cope, and recall the abuse. Therefore the conducted study included 48 individuals with the history of child sexual abuse and 45 individuals who were never sexually abused. The study examined the relationship between coping styles, trauma-related psychopathology, and autobiographical memory specifically in adolescence who faced CSA (L. S. Harris Et Al). The minimum age of the participants in this study was 14 years old. The study required the participants to go through multiple testing, such as the dissociation measure, in which the participants were required to complete a self-report questionnaire that included 28 questions designed to measure pathological dissociative experiences. Nonetheless, throughout the study, the participants were tested through a self-report measure of PTSD that diagnoses them according to the Diagnostic and statistical manual of mental disorders. Also, they were required to complete a study in which their trauma symptoms and trauma exposure was evaluated. Once they were done with their examination, they analyzed their results and discovered that there was a strong correlation between age and autobiographical memory, however, adults showed they were able to recall more clearly than adolescence. However, it was also discovered that their hypothesis was correct in which distancing coping is associated with rAMS. Furthermore, the study associated trauma-related psychopathology with rAMS, however, they were wrong in the sense that trauma-related psychopathology is associated with autobiographical memory (L. S. Harris Et Al). Memory plays a significant role when associated with child sexual abuse, a child has to grow up recalling the incidents that have taken place. However, certain individuals choose to repress what they remember and to bury it as if it never happened deep within them, those are very few. The majority of CSA victims tend to seek medical attention for depression and PTSD, causing them to vividly recall the events that have taken place. Victims of child sexual abuse grow up unable to trust anyone properly and have troubles in their relationships, victims often tend to choose abusers as their partners. Furthermore, many studies have shown that victims tend to hide their stories for fear of being targeted in the new surroundings that they have built for themselves. Victims of child abuse face many psychological disorders, and if they were to be treated at an earlier stage in their life, or if they had a healthy coping mechanism they would have a sense of ease transitioning from one stage of their life to the next.

​ Physical Abuse

Child physical abuse is the most noticeable from all child abuse. Physical abuse is the most effective one because it occurs when one person uses physical pain or threat of physical force to intimidate another person. Physical abuse is defined as a physical injury that results in substantial harm from physical injury to the child. Physical abuse includes numerous things, for instance, an all-out physical beating total with punching, kicking, hair pulling, scratching, and genuine physical harm adequate at times to require hospitalization. According to National Statistics on Child Abuse, 44.2% of the children die from physical abuse. This means two in every four death is due to physical abuse. This makes it the number one cause of death in the United States; also one of the leading causes of death worldwide. Even though adults are the cause of the physical abuse to children, youth are the victims. That is the time to step up to prevent it before it is too late.

​There are so many articles, which discuss the issue of child physical abuse and how it is so dangerous. Also, in those articles, the writers discuss what is child physical abuse is and what it does to the child when they grow up. In the article​  Neighborhood effects on physical child abuse, and outcomes of mental illness and delinquency analysis, ​ the authors say that family violence is the most common form of physical child abuse. They did a study showing family violence by trying to examine physical child abuse in the neighborhood. Moreover, they did a project on Human Development in Chicago Neighborhoods (PHDCN). They brought 2,000 children to examine the effect of physical child abuse within the models. The first model was to to study effects on the neighborhood with physical child abuse. The second models were used to show mental illness measures of the effect of neighborhoods. The last models were delinquency measures. The results for the physical child abuse were effective both in externalizing mental illness outcomes and internalizing them. Therefore, this study provides further information about the connection between family violence and mental illness.

Child abuse includes physical mistreatment and neglect and happens everywhere throughout the world. These poor little kids are being hit, kicked, poisoned, burned, slapped, or having objects thrown at them. At the point when a child encounters physical child abuse, the wounds run genuinely deep. In the article​  Breaking the mold: Socio-ecological factors to influence the development of non-harsh parenting strategies to reduce the risk for child physical abuse,  ​the authors say physical punishment keeps on being a typical type of control in the U. S regardless of signs of its long-term damage to youngsters, including solid hazard for kid physical maltreatment. The study shows that the analyzing of child-rearing practices significant to anticipating child physical abuse, Positive Deviance identifies with those parents who pick

compelling, positive child rearing procedures to teach their kids, notwithstanding being presented to physical punishment and physical abuse in youth. After doing the study, the authors discovered that the short term effects of physical abuse are typically obvious and treatable by an emergency room physician or another healthcare provider. They can range from cuts, bruises, broken bones, and other physical maltreatment. Also, the article showed the long term physical abuse effects from these injuries as well.

It has been found that most people who struggle with drug addiction began from their experience since they were a child. Teenage drug abuse is one of the biggest issues in society today and the problem grows and is larger every year. Drugs are an inescapable power in our way of life today. In the article​  Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention,  ​the authors discussed that “drug exposure is an important consideration in the evaluation of suspected child maltreatment.” This shows that constrained information is accessible on the recurrence of drug introduction in children with suspected physical abuse. They did a study to examine occult drug to show the pharmaceutical effect in young children with suspected physical abuse. They brought in children of ages 2 weeks –59 months evaluated for physical abuse by a tertiary referral center Child Protection Team. “Results Occult drug exposures were found in 5.1% (CI 3.6–7.8) of 453 children tested: 6.0% (CI 3.6–10.0) of 232 children with high concern for physical abuse, 5.0% (CI 2.7–9.3) of 179 children with intermediate concern, and 0% of 42 children with low concern”, this shows that Up to 7.9% of young children suspected of being physically abused also had an occult drug Exposure. Given the adverse health consequences associated with exposure to a drug-endangered environment, screening for occult drug exposure should be considered in the evaluation of young children with intermediate or high concern for physical abuse. Also, the emotional effects of physical abuse can last a long time after physical wounds heal. Massive studies have revealed that many psychological problems develop as a result of physical abuse of the child. These children experience more problems at home, at school, and in dealing with peers.

After further research, researchers found out that many children die from physical abuse, and we still are not trying to fix it. In the article ​ Negative/unrealistic parent descriptors of infant attributes associated with physical abuse?, ​ the authors show that in the United States, about 7% of children suffer from physical abuse by their parent, and many children under the age of 15 die of physical abuse. They did a study of an infants 12 months of age who were described with negative development or have been physically abused. They asked the parents to describe their child’s personality and list at least three words to describe their child. The article states, “Of 185 children enrolled, 147 cases (79%) were categorized as accident and 38 (21%) as abuse. Parents used at least one negative/unrealistic descriptor in 35/185 cases (19%), while the remaining 150 cases (81%) included only positive or neutral descriptors. Of the infants described with negative/unrealistic words, 60% were abused, compared to 11% of those described with positive or neutral words.” This shows that the study informs future work to create a screening tool utilizing negative/unrealistic descriptors in combination with other predictive factors to identify infants at high risk for physical child abuse.

The United States has been fighting against child abuse but still many ​families ​think beating children is a way of the teaching them the right way. Many people are wrong in thinking of this abuse. In the article​  The relation of abuse to physical and psychological health in adults with developmental disabilities, ​ the authors say that child physical abuse is considered as a global public health problem. Individuals with developmental disabilities are at excessively high danger of maltreatment. Most developmental disabilities occur from physical child abuse. According to the article, ​ “Abuse experience was reflected by five-factor scores consisting of three child abuse factors (childhood sexual abuse, childhood physical abuse, childhood disability-related abuse) and two adult abuse factors (adult sexual abuse, adult mixed abuse)”, this demonstrates youth disability-related maltreatment and grown-up blended maltreatment altogether anticipated lower dimensions of mental and physical wellbeing in an example of grown-ups with formative inabilities and how people discoveries feature the significance of tending to mishandle and its sequelae in the developmental disabilities community. Many children these days have mental problems from their environment or their parents. When parents treat the child very bad when he is young the kid begins to be on his own and not trusting anyone or loving anyone, and these conditions create disability. Many families rely on beatings to raise their children, believing that they are advising them and teaching them the difference between right and wrong. From these studies that we read about the educational studies have shown that children do not know or understand why their parents beat them. They did not have the necessary growth to realize that beatings were caused by punishment for the wrong behavior they had done. The beatings reinforce the child’s violent behavior, and he may think if his parents have the right to hit him, he has the right to hit them back and that your child may be used to beating you every time he behaves badly. Also, the beating of children in schools is legally prohibited in many countries and it is not right to hit the children. The beating may lead to the isolation of the student from the others. The student is afraid to go to school and to integrate with his peers because of embarrassment because of teacher beating him in front of his friends. The child may be an outstanding student, but his level of study takes a decline due to the negative impact on his personality.

Finally, it may be concluded that child physical abuse is the most common abuse in our lives, and the effects of physical abuse on the child may last a lifetime and may include brain damage, loss of vision and hearing leading to disability, even minor injuries may cause the child who has been abused to have delayed learning, behavior, and emotions. Knowledge and great emotional problems affect his development in life. Some of the effects of physical abuse on children may lead to significant behavioral problems. Children who are suffering from anxiety and depression as a result of the abuse they have been exposed to often tend to smoke, drink alcohol, and other dangerous and unhealthy behaviors have to do with adapting to emotional and behavioral problems. Emotional abuse

A therapist from ​ Psychology Today  ​states that emotional abuse, also known as psychological abuse, characterizes an individual exposing another individual to behavior that may result in many effects to a person’s future (LPC, Matthews). A person who experiences emotional abuse at a young age can have a destructive effect on their self-esteem and relationship with others. Emotional abuse turns an individual against themselves due to the fact that they are being manipulated through harsh words. For example, if someone is utilizing derogatory terms repetitively, the victim is bound to believe it. Having this scenario constantly occurring can lead to self-harm and self-hatred. Other behaviors that define emotional abuse is when an adult reject, isolates, corrupts, ignores, terrorizes, overpressures, and verbally assaults a kid to make them feel less worthy of their selves. Emotional abuse may damage children of all ages but may be dangerous with infants and toddlers leaving them with permanent developmental deficits.

Childhood abuse is generally known as a major public health problem with many effects on adult mental health, such as suicidal behaviors and mood and anxiety disorders (Christ, 2019). Studies have shown that childhood abuse has been constantly linked to depressive disorders in adulthood. According to a research article from ​ PLOS, ​ childhood emotional abuse has been linked to depressive symptoms (Christ, 2019). While every type of childhood abuse is linked to depressive symptoms, most studies have shown that emotional abuse is more strongly related to depression. In the article “Linking childhood emotional abuse and depressive symptoms: The role of emotion dysregulation and interpersonal problems” it states “CEA refers to an aggressive attitude towards a child, which is not physical in nature, and may include verbal assaults on one’s sense of worth or wellbeing, or any humiliating or demeaning behavior” (Christ, 2019). The article also explains that CEA can lead to an increase risk of adult depression. Therefore, the main focus of this study is to determine the psychological processes that may act like a negotiator in this relationship. Also another main focus of this study is two see whether emotional dysregulation and interpersonal problems associated with childhood abuse and depression. The aim of this study was three things. First, we inspected the impact of childhood emotional abuse, sexual abuse, physical abuse on depressive symptoms in a European sample of female colleges students. Based on this, we hypothesized that only on emotional abuse would be independently associated with depressive symptoms. Second, if evidence for the relationship between childhood emotional abuse and depression were evident, we hypothesized to examine whether this relationship would it be mediated by of emotional dysregulation and interpersonal problems. Finally, we aimed to identify whether specific interpersonal problems could be identified as particularly important explaining the relationship between childhood emotional abuse and depressive symptoms.

For this study the participant that were used were females that are currently studying in the Netherlands. The study sample consisted of 276 female college students with the mean age of 21.7 years. The participants were born in the Netherlands, many were single, living with their parents or with roommates, and studying psychology. The age, country of birth, country of birth of parent, relationship status, living situation were also collected.

The results were as shown and the tables and charts provided of the research study. The highest relation was found between childhood emotional abuse and childhood physical abuse whereas the lower correlation was found between childhood emotional abuse and childhood sexual abuse. 59.8% of the participants were reported with no depressive symptoms, however, 30.1% were reported with some mild depressive symptoms, 8% were reported moderate depressive symptoms and 2.1% was reported with severe depressive symptoms. The first aim of the study was to examine which childhood abuse was associated with depressive symptoms, emotional dysregulation, and interpersonal problems in female college students. And as hypothesized childhood emotional abuse was independently associated with depressive symptoms and emotional dysregulation, whereas the other kind of childhood abuses were not. These results proved that childhood emotional abuse was a more strongly related to depression then childhood physical abuse and childhood sexual abuse. The reasoning behind this could possibly be because of the children’s development of emotion regulation skills, which is highly influenced by the interactions with the primary caregiver and the family emotional feelings.

This study had many strengths and limitations. Some strengths were that this was the first study to explore the mediating role of interpersonal problems between childhood emotional abuse and depressive symptoms. It was also the first to confirm previous research in identifying whether emotional dysregulation was the mediator between childhood emotional abuse and depressive symptoms in college students. Some limitations where that the results had to be taken with caution due to the fact that it was a cross-sectional study. Also the study relied a lot on self-report measures, however all measures have a good psychometric properties and are widely used. Lastly the prevalence of some a B childhood abuses were relatively low, which limited to statistical power to detect possible week associations between other types of uses.

Child maltreatment is a major public health concern. Many studies have compared it to all types of childhood abuse, however it has been proved that the long-term impact of emotional maltreatment under mental health is more related to emotional abuse. In the study “Childhood emotional maltreatment and mental disorders: Results from a nationally representative adult sample from the United States” the purpose of the research was to examine the relationship of emotional abuse, emotional neglect, and both with other types of child maltreatment (Taillieu, 2014). The data was from the National Epidemiological Survey on Alcohol and Related Conditions. The measures of this study were taken from emotional maltreatment, other childhood maltreatment, family history of dysfunction, and mental disorders.

The data collected from the NESARC were taken from the general US population and the results are as follows (Taillieu 2014). Childhood emotional maltreatment was 14.1%; the most widespread form was emotional neglect be 6.2%, followed by emotional abuse being 4.8%. The least common pattern of childhood emotional maltreatment was experiencing both emotional neglect and emotional abuse at 3.1%. Experiencing both emotional neglect and emotional abuse was more prevalent among females compared to males being a 4% versus 2%, and the categories of all emotional maltreatment were more dominant among divorced, separated, and widowed individuals (Taillieu, 2016). Participants with a higher household income and a higher level of education were less likely to report childhood emotional maltreatment then participants with a low household income and a lower level of education.

The effects of emotional abuse can be both devastating and extensive from childhood into adolescence and adulthood. Children who experience emotional abuse develop many chronic health problems when they become adults. Some of these problems are heart diseases, obesity, mental health issues, eating disorders, headaches, etc. If left untreated, these health problems can develop into more serious conditions in the future leaving you susceptible to more harm. Not only can it lead to health problems, but it can also cause damage to a child’s brain development. This can lead to problematic behaviors, increased occurrences of physical and mental health issue, and long-term learning difficulties. Kids won’t be able to focus in school and be on the same track as their other classmates. They will have a slower pace in learning which will lead them to being behind in school. Thinking that it is okay for a child to be treated this way, the child may start to participate in bad behavior towards other kids. Many children have been at risk of harm from emotional abuse. Statistics show that 1 in 14 children have experienced emotional abuse by a parent or guardian. In 2017, over 19,000 children were identified as needing protection from emotional abuse. Report shows that girls show a higher percentage of maltreatment among boys. When it comes to racial and ethnic groups, black children are the highest percentage of maltreated kids, with 1 in 5 children. In today’s society, people don’t acknowledge that they are emotionally abusing a child and how it can affect them in the long run. Therefore, this leads to children continuously getting abused. Today’s society tend to not look at what’s being done to their kids rather just focusing on themselves more than their kids. All children have particular needs that must be met. That is receiving love and attention, being protected from harm, to have their needs heard, etc. On top of all that, kids also struggle with challenges such as sensitivity and emotional regulation. Child Neglect

A really common type of child abuse is child neglect. According to Child Welfare Information Gateway (2018), there is a higher number of children who suffer from neglect abuse than there are for physical and sexual abuse combined. Yet, victims are not often identified, for the most part, it is because neglect is a type of child abuse that is an act of others not doing something. There might be some overlap between emotional abuse and emotional neglect definitions. But neglect is a pattern of failure to deliver the basic needs of a child. A particular act of neglect may not be regarded as child abuse, but a constantly repeated action is definitely child abuse. There are three fundamental types of neglect; physical neglect, neglect of education, and neglect of emotion (Tudoran, 2015). To begin with, physical neglect is the failure to provide food, clothing appropriate for the weather, supervision, a home that is secured and safe, and/or medical care, as needed for the child. Tudoran (2015) stated that “Physical neglect and the safety of the child by Insufficient care which leads to underdevelopment of the children (not motivated by organic causes), malnutrition and mental underdevelopment.’’ This demonstrates that physical neglect means not having a secure place to sleep, starvation and no medical support for a child or teenager. It is also essential for human (for young children) growth and development to have a safe, supervised environment to grow up and live in. This neglects affects child physical appearances and health throughout his life. Once children are in school, school staff often notice child neglect markers such as poor hygiene, poor weight gain, poor medical care, or frequent school absences. Many excuses can be heard for parental neglect, such as “They lost their jobs and have no money,” “They’re young and they didn’t know,” and “They couldn’t find a babysitter, and they had to go to work, or they would have lost the job.” As illustrated by these examples, neglect is still regarded as a less harmful form of child abuse, but according to Bagley, “neglect is not only the most frequent type of abuse; it can be just as lethal as physical abuse.” Neglect may be physical, educational, or emotional as well. Then, educational neglect. is the failure to enroll a school-age child in school or to provide necessary special education. This includes allowing excessive absences from school. In most cases, this refers to younger children who still demand as dependents of the parent because of that one of their rights as children (Angela, 2015). Although, parents are primarily responsible for meeting their children’s needs; however, we can’t blame the parents for every failure. There is many cases, such as schools that fail to meet the educational needs of a child, is beyond parental control. Educational neglect may cause the child to fail to develop basic life skills, drop out of school, or display disruptive behavior. It may pose a significant threat to the child’s emotional well-being, physical health, or normal psychological growth and development, especially if the child has unmet special educational needs (Dubowitz, 2013). Also, Child Protection Services (CPS) who protects children from caregivers that may be harm them are typically only involved in parental inaction that is considered to be the major contributor to the need of the child (Dubowitz, 2013).

Lastly, emotional neglect is the falling to provide emotional support, love, and affection. This includes neglecting the emotional needs of the child and then failing to provide psychological treatment as needed. When someone does not provide emotional support, especially when the kid need it, or when they are supposed to be provided, it means that the child is still emotionally neglected (Angela, 2015). The most common cause of emotional neglect is an overworked and/or overly-ambitious parent who places the needs and desires of their own ambition, and their company’s demands ahead of those of their family. In most of those instances, it is the children who suffer from having none of their emotional needs met. In this case, they are being neglected emotionally. Parental behaviors that are considered emotional child abuse when they ignore the child consistently by declining to respond to the child’s need for stimulation, nursing, encouragement, and protection or failure to recognize the presence of the child (M. Sperry, 2013). As of now, child neglect is considered as the largest part of child abuse in the United States, and nearly two-thirds of all reported cases in child protection is about neglect abuse (Dubowitz, 2015). Statistically speaking, according to the United States. Children’s Bureau, “Neglect is the most common form of maltreatment. Of the children who experienced maltreatment or abuse, three-quarters suffered neglect.” While physical abuse might be the most visible, other types of abuse such as emotional abuse and neglect, also leave deep, lasting scars on the children (Smith, M.A, Segal). Child neglect has become a major social issue and a primary cause for many people that are suffering and having personal problems. According to M. Sperry, Widom, studies have shown that “Adjusting for age, sex, and race, individuals with documented histories of child abuse and neglect reported significantly lower levels of social support in adulthood [total (p < .001), appraisal (p < .001), belonging (p < .001), tangible (p < .001), and self-esteem support (p < .01)] than controls.” With the adjusting for age, sex, race, and previous psychiatric diagnosis, social support proved the strong connection in the relationship between child abuse and neglect and anxiety and depression in adulthood.

Neglect is not a little thing. It can be extreme, as in failing to provide adequate food, shelter, and clothing for the most basic needs of a child. Or it might be less apparent but still quite traumatic. It can leave kids traumatized, living on the verge of terror (which becomes integrated into normal everyday life and the child really doesn’t feel the fear anymore but stuffs it back behind walls of denial). Later, when it is safe the fear surfaces as panic attacks, anxiety disorders, nightmares, fear of rejection. Long-term neglect leaves children with horrendous problems of abandonment, depending on your age and how long it lasted and whether someone else was in charge of you; and if you had at least one person to trust or show you love (like a grandparent cousin or aunt). Perhaps a teacher? You may have less severe consequences and difficulties if there was someone to help, and you may recover quickly. As a matter of fact, religions and culture play a role in infusing the parent-child relationship and allow for neglect to show up. It is important to understand and recognize that neglect often involves continuous intervention with support and monitoring. Humility is essential with regard to different cultural and religious traditions. We should prevent the ethnocentric attitude (i.e., thinking that “my way is the correct way”). Alternatively, while respecting different cultural practices, those traditions that clearly harm the children should not be accepted. Parents and religious and cultural leaders have to work together in order to find a satisfactory compromise; however, an agreement cannot be reached if the child is either harmed or in danger. Regarding that neglect is a deliberate act to harm a child. Most children are not neglected even if their “parents” ignore them or forget them. A lot of parents are negligent in an innocent way because not all the parents are taught the good skills to raise children or have the experience to deal with kids. So, this lack of resources and information lead to how the parent’s behavior with their children. It might be because that’s what the parents are capable of at that time. For instance, the parent job or professional play a role in the way they treat their children while growing up which ultimately contribute to neglect because poor communication with parents may lead to a lack to of understanding of the treatment plan (Dubowitz, 2013) However, parents have a duty and they are primarily responsible to meet their children’s basic needs, and the show of neglect toward their kids means that they had failed in their duty to take care of them.

Neglect may have long lasting consequences. Based on the U.S. Department of Health and Human Services, nearly two-thirds of all child abuse – related deaths involve neglect. So, some of the consequences a neglected child may experience are problems with health and development, emotions, behavior toward other and even death. These consequences are most likely to occur with young children. Also, most often neglect fatalities are caused by lack of supervision, chronic physical neglect, or medical neglect. Malnutrition can affect brain development. A lack of adequate immunizations and medical issues could result in a variety of health conditions. The National Survey of Child and Adolescent Well – Being (​NSCAW​) found that 3 years after being removed from a negligent situation, 28 percent of children suffered from chronic health conditions. Neglect can cause problems of attachment, self – esteem, and difficulty of trusting others. Neglected children may struggle to develop healthy relationships and may experience behavior disorders or disorder social involvement disorder. NSCAW data showed that over half of those mistreated in younger age were at risk of substance abuse, delinquency, truancy, or pregnancy.

When the teenager has been abused or neglected as a child, it can leave him feeling wounded, deprived, and wronged by those who he loves and trust. The hurt can be particularly profound if our own parents were the ones that caused the pain to us. These hurts will continue to affect us and our subsequent relationships if they are not resolved. The child will need psychiatric and psychological care (​Viswalingam​,​ 2018). Medicine can help when the severe symptoms show up when the child gets in touch with their feelings and emotions again. Recovery takes time and is a slow process. Expect some setbacks and tough times (Sathiadas, 2018). The first step in a neglected child’s treatment is to ensure his safety. By providing resources and education to the family, providers maybe able to reduce the neglect. On the other hand, some psychiatrists may fail to follow recommended approaches and to identify the medical or psychological social needs, which can be responsible for the continues of the neglect.

Finally, neglecting children can have devastating effects on children’s intellectual, physical, social, and psychological development. Neglected and abused infants and toddlers fail to develop a secure connection with their neglecting and/or abusive carrier provide. They develop anxious, insecure, or disorganized/disoriented connection with that carrier provide. Neglected children appear to be more generally passive and socially withdrawn in their interactions with others. Neglect comes in all forms and levels of severity, but it is a hard concept to nail down. It remains important to point out to the public that child abuse and neglect are serious threats to the healthy growth of the child and that opening violence against children and persistent lack of care and supervision are unacceptable. People have the capacity to take personal responsibility for reducing child abuse and neglect by providing mutual support and protecting to all the children within their family and community. Prevention is better than healing. Child abuse leads to numerous bathing effects not only for abused children, but also for the abuser. We should avoid it getting worse because today’s kids will be tomorrow’s leader.

It may be concluded that the child abuse is the most dangerous thing in our society because children are the future of our world. If we abuse the children by one of these things child abuse; physical abuse, sexual abuse, emotional abuse, and neglect, There will be no future in our life. Children are the ones who makes our life smile, they are the happiness in this world and many people called them angels but if we human been change the way they think and they the way see the world in their eyes, there will be no longer angels. Throughout this literature review, we have also mentioned Child abuse cases developmental disabilities and many children die from it. In most cases, these children that their family abuses them or the environment abuse them such with child abuse; physical abuse, sexual abuse, emotional abuse, and neglect which were discussed. Some of these disorders people still don’t think that they are the cause of negative things in our society. However, these abuses do have their own effects on the child. As well, these abuses can lead to there being physical health problems. Especially when children get abused by their environment and they do not have anyone to reach out. By bringing awareness to this child abuse we can reduce the possibilities of children getting child abuse.

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2. Dubowitz, Howard. “Neglect in Children.” Pediatric Annals, U.S. National Library of Medicine, Apr. 2013,​ www.ncbi.nlm.nih.gov/pmc/articles/PMC4288037/​.

3. Gateway, Child Welfare Information. “Acts of Omission: An Overview of Child Neglect.” Acts of Omission: An Overview of Child Neglect -Child Welfare Information Gateway, 2018,​ www.childwelfare.gov/pubs/focus/acts/​.

4. Guerra, C., & Pereda, N. (2015). Research With Adolescent Victims of Child Sexual Abuse: Evaluation of Emotional Impact on Participants. Journal of Child Sexual Abuse,24(8), 943-958. doi:10.1080/10538712.2015.1092006

5. Guerra, C., Farkas, C., & Moncada, L. (2018). Depression, anxiety, and PTSD in sexually abused adolescents: Association with self-efficacy, coping and family support. Child Abuse & Neglect,76, 310-320. doi:10.1016/j.chiabu.2017.11.013

6. Harris, L. S., Block, S. D., Ogle, C. M., Goodman, G. S., Augusti, E., Larson, R. P., . . . Urquiza, A. (2015). Coping style and memory specificity in adolescents and adults with histories of child sexual abuse. Memory,24(8), 1078-1090. doi:10.1080/09658211.2015.1068812

7. Hébert, M., Lavoie, F., & Blais, M. (2014). Post Traumatic Stress Disorder/PTSD in adolescent victims of sexual abuse: Resilience and social support as protection factors.

Ciência & Saúde Coletiva,19(3), 685-694. doi:10.1590/1413-81232014193.15972013 8. Hughes, R. B., Robinson-Whelen, S., Raymaker, D., Lund, E. M., Oschwald, M., Katz, M., … Nicolaidis, C. (2019). The relation of abuse to physical and psychological health in adults with developmental disabilities. Disability and Health Journal.

9. Petska, H. W., Porada, K., Nugent, M., Simpson, P., & Sheets, L. K. (2019). Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention. Child Abuse & Neglect, 88, 412–419.https://doi-org.ccny-proxy1.libr.ccny.cuny.edu/10.1016/j.chiabu.2018.12.015

10. Rosner, R., König, H.-H., Neuner, F., Schmidt, U., & Steil, R. (2014). Developmentally adapted cognitive processing therapy for adolescents and young adults with PTSD symptoms after physical and sexual abuse: study protocol for a randomized controlled trial. Trials, 15(1), 1–18.https://doi-org.ccny-proxy1.libr.ccny.cuny.edu/10.1186/1745-6215-15-195

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• Published: 04 May 2024

Early identification and awareness of child abuse and neglect among physicians and teachers

• M. Roeders 1 , 2 ,
• J. Pauschek 2 ,
• R. Lehbrink 2 , 3 ,
• L. Schlicht 2 ,
• S. Jeschke   ORCID: orcid.org/0009-0007-1479-1367 1 , 2 ,
• M.P. Neininger   ORCID: orcid.org/0000-0002-5208-0888 4 &
• A. Bertsche   ORCID: orcid.org/0000-0003-2832-0156 1 , 2  

BMC Pediatrics volume  24 , Article number:  302 ( 2024 ) Cite this article

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Metrics details

Child abuse and neglect (CAN) causes enormous suffering for those affected.

The study investigated the current state of knowledge concerning the recognition of CAN and protocols for suspected cases amongst physicians and teachers.

In a pilot study conducted in Mecklenburg-Western Pomerania from May 2020 to June 2021, we invited teachers and physicians working with children to complete an online questionnaire containing mainly multiple-choice-questions.

In total, 45 physicians and 57 teachers responded. Altogether, 84% of physicians and 44% of teachers were aware of cases in which CAN had occurred in the context of their professional activity. Further, 31% of physicians and 23% of teachers stated that specific instructions on CAN did not exist in their professional institution or that they were not aware of them. All physicians and 98% of teachers were in favor of mandatory training on CAN for pediatric residents and trainee teachers. Although 13% of physicians and 49% of teachers considered a discussion of a suspected case of CAN to constitute a breach of confidentiality, 87% of physicians and 60% of teachers stated that they would discuss a suspected case with colleagues.

Despite the fact that a large proportion of respondents had already been confronted with suspected cases of CAN, further guidelines for reporting procedures and training seem necessary. There is still uncertainty in both professions on dealing with cases of suspected CAN.

Peer Review reports

Introduction

Child abuse and neglect (CAN) is a global problem [ 1 ]. It is estimated that incidents of different types of sexual abuse vary from 8 to 31% for girls and from 3 to 17% for boys throughout the world [ 2 ]. In Germany, more than 59,900 children and adolescents were identified as being at risk of neglect, and psychological, physical, or sexual violence in the year 2021 [ 3 ]. Child abuse and neglect are a widespread problem. The number of unreported cases is estimated to be high. The officially reported cases of CAN are below the 1% limit. However, retrospective surveys of young people and adults indicate a lifetime prevalence of more than 10% [ 4 ].

CAN is a problem on several levels. It is well known that the long-term consequences of CAN are severe and often persistent [ 5 ]. For example, affected children have a higher risk for developing an internalizing and externalizing mental disorder, drug abuse, suicide attempts, sexually transmitted infections, and risky sexual behavior, or, once they are adults, to abuse their own children [ 6 , 7 , 8 , 9 ].

In addition to the enormous burden for the individual, there are economic consequences for society. The annual costs of CAN are estimated to range from 11.1 to 29.8 billion Euros in Germany per year [ 10 ] and up to 124 billion US Dollars in the US [ 11 ]. Studies suggest that a 10 per cent decrease of CAN prevalence in America and Europe could lead to annual savings of 105 billion dollars [ 12 ]. Thus, CAN carries burdens both for the affected individual and society.

Despite the high prevalence and resulting consequences, studies regarding early identification and action procedures are rare [ 13 ]. In addition, some issues have not been adequately addressed in professional groups such as teachers and physicians. Members of these professions are usually the adults outside the family who are in closest and most frequent contact with children. They therefore have the potential to play an essential part in the identification of CAN [ 14 ] and should be adequately trained [ 15 ]. Nevertheless, even for those professionals the detection of CAN often remains difficult [ 16 ]. As both physicians and teachers play an important role in child protection, it is essential to investigate their current level of understanding of CAN and their strategies for dealing with suspected cases. In this way, an accurate baseline for training can be established, in order that these professions be adequately qualified to intervene early in cases of CAN. We therefore performed a pilot study in Mecklenburg-Western Pomerania surveying teachers and physicians about their current knowledge of CAN, actions taken in case of a CAN, existing protocols in their institutions, training on the topic in the past and their individual need for further training. We aimed to compare the knowledge and information needs of those two professional groups, which both can act as key players in the detection of CAN. In the long term, those insights will enable the development of new training programs, or the improvement of those that already exist.

Materials and methods

Setting and participants.

After approval of the ethics committee of the Medical Faculty of Rostock University and the Rostock school authority, we conducted this pilot study with physicians and teachers from May 2020 to June 2021. In total, three hospitals as well as eight schools in Mecklenburg-Western Pomerania agreed to participate in the pilot survey. Two university hospitals and one primary care hospital were included in the study. In total, these hospitals reflect around 30% of the bed capacity for pediatric and adolescent medicine in Mecklenburg-Western Pomerania. It can be assumed that the number of physicians in the departments contacted was around 70, resulting in a response rate of around 65%. Clinic directors and principals of schools received an e-mail containing an information sheet and a link to access the questionnaire and were asked to spread the e-mail in their teams.

The survey was accessible without registration or a password. The link provided in the invitation e-mails led directly to the questionnaire. For data collection we used EvaSys, a software for conducting surveys [evasys V9.0 (2404), EvaSy GmbH]. Participants were informed about the study objectives, voluntary participation, and anonymization in the questionnaire introduction. The participants were informed that by filling in the questionnaire they agreed to participate in the study.

Questionnaire

A study team consisting of pediatricians and medical students interested in the topic of CAN designed the questionnaire. Current literature was researched during the development of the questionnaire. To improve comprehensibility, clarity, and readability, the questionnaire was pre-tested with 10 physicians and 10 teachers. After the pre-test, the physicians and teachers were interviewed about the questionnaire. This was followed by further adjustments to optimize the questionnaire.

The questionnaire consisted of single-choice, multiple-choice, and Likert-scale answering options. After a short introduction, the participants were asked questions on the following topics (Supplement 1 ):

Personal experiences of physicians and teachers regarding the topic of CAN.

Knowledge about the topic of CAN, including bruising patterns.

Actions taken in case of a CAN and existing protocols in their institutions in cases of suspected CAN.

Confidentiality and associated difficulties in reporting procedures.

Training on the topic of CAN.

Additionally, sociodemographic data were collected at the end of the questionnaire.

With regard to the question of bruising patterns, the body parts were adapted to the TEN-4-FACESp Bruising Rule [ 17 ].

Calculations were performed using SPSS (Statistical Package for the Social Sciences, Version 26, IBM Corporation, Armonk, New York, USA). Frequencies are reported as numbers and percentages. For further statistical analysis, we applied Chi-square tests, Fisher’s exact tests and Mann-Whitney-U-tests as appropriate. A p -value ≤ 0.05 was considered to indicate significance.

Participants

In total, 45 physicians and 57 teachers took part in the survey. Sociodemographic data summarized in Table  1 .

Of teachers, 13/57 (23%) reported working at an elementary school, 10/57 (18%) at a school for children with special needs, 24/57 (42%) at a grammar school, and 10/57 (18%) at an other secondary school.

Personal experiences of physicians and teachers regarding child abuse and neglect

Of the participants, 38/45 (84%) physicians and 25/57 (44%) teachers reported that they had been confronted with cases of CAN in the past. None of the physicians, and 10/57 (18%) of teachers stated that they were unsure about whether they had witnessed a case of CAN before. Of physicians, 7/45 (14%) and of teachers, 22/57 (38%) reported that they had not been involved in any cases of CAN so far.

Physicians (32/45; 71%) reported more frequently having already encountered a case of physical abuse compared to teachers (15/57; 26%, p  < 0.001). Also, experiences with cases of physical neglect were reported more frequently by physicians (32/45; 71%) than by teachers (13/57; 23%; p  < 0.001). More details are shown in Table  2 .

Knowledge about child abuse and neglect

Knowledge of typical signs and behavior patterns.

Of the participants, 40/45 (89%) physicians and 51/57 teachers (89%; n.s.) correctly assumed that the back and bottom are very likely body sites for signs of CAN. In addition, 35/45 (78%) physicians and 24/57 (42%; p  < 0.001) teachers correctly indicated that injuries to the chin and nose were unlikely indicators of possible CAN. Further information is presented in Fig.  1 .

Legend to Fig.  1 : Respondents’ answers on the probability of child abuse if the respective body parts were affected. Respondents could indicate probabilities on a Likert scale ranging from very probable to very unlikely

Correct answers are marked with *. Total respondents: Physicians n  = 45, Teachers n  = 57

Asked for their opinions on what emotional abnormalities could occur in the context of CAN, 41/45 (91%) physicians and 43/57 (75%; p  = 0.039) teachers indicated that verbal and socioemotional developmental delays might occur. More details are shown in Table  3 .

When asked which parental behavior could most likely indicate CAN, 41/45 (91%) physicians and 44/57 (77%; n.s.) teachers responded slight irritability and overwhelming demands. Further, 40/45 (89%) physicians and 31/57 (54%; p  < 0.001) teachers reported inappropriate reactions (exaggerated or underexaggerated) as indicators for CAN (Table  4 ).

Estimated long-term effects

Of physicians, 37/45 (82%) and 42/57 (74%; n.s.) teachers assumed that children who have had experiences of abuse and/or neglect might behave similarly towards their own children in the future.

42/45 (93%) physicians and 52/57 (91%; n.s.) teachers anticipated long-term consequences for affected children due to a failure to report CAN.

Actions and instruction procedures in cases of suspected child abuse and neglect

Where CAN was suspected, physicians (39/45; 87%) would discuss the case with colleagues more frequently than teachers (34/57, 60%; p  = 0.003). More details on actions physicians and teachers would consider are shown in Table  5 .

To the question whether specific instructions regarding responses to suspected CAN were in place, 31/45 (67%) physicians and 44/57 (77%) teachers answered, “yes, there are specific instructions in my institution”; 5/45 (11%) physicians and 1/57 (2%) teachers answered, “no, there are no specific instructions in my institution”; and 9/45 (20%) physicians and 12/57 (21%) teachers answered, “I am not aware of specific instructions in my institution”. 42/45 (93%) of physicians and 48/57 (84%; n.s.) of teachers said that a generally applicable guideline for dealing with suspected cases of CAN could have a positive effect.

Impact of confidentially

When asked whether the duty of confidentiality influenced the respondents in their actions, 14/45 (31%) physicians and 23/57 (40%; n.s.) teachers agreed.

When asked in which scenarios a breach of confidentiality occurs according to the participants, 6/45 (13%) physicians and 28/57 (49%; p  < 0.001) teachers assumed that sharing information with colleagues constituted a breach. 17/45 (38%) of physicians, and 7/57 (12%; p  = 0.003) of teachers, assumed that passing on information to the police would be a breach of confidentiality. Multiple answers were possible. Further results are displayed in Table  6 .

Training on the topic of child abuse and neglect

2/45 (4%) of physicians reported that they felt that CAN was a taboo subject in the professional setting, compared to 10/57 (18%; p  = 0.041) of teachers. However, both professional groups (physicians: 34/45, 76%; teachers: 46/57, 81%; n.s.) supported the importance of increasing public awareness of the issue.

In terms of training, 43/45 (96%) of physicians and 40/57 (70%; p  = 0.001) of teachers reported that they had already attended training on CAN during or after their studies (multiple answers were possible). 43/45 (96%) of physicians, and 53/57 (93%; n.s.) of teachers, confirmed the importance of continuous education to deepen knowledge, including after the completion of their studies.

The idea that the topic of CAN should be a mandatory part of the training for pediatricians and teachers was supported by 45/45 (100%) of physicians and 56/57 (98%; n.s.) of teachers.

Among physicians, 32/45 (71%) reported feeling adequately informed about the topic compared to 21/57 (37%; p  < 0.001) of teachers. 34/45 (76%) of physicians, and 22/57 (39%; p  < 0.001) of teachers, still required more information regarding CAN.

When asked by whom the information should be provided, the following professional groups were mentioned: psychologists (physicians: 11/45, 24%; teachers: 30/57, 53%; p  = 0.004), the youth welfare office (physicians: 1/45, 2%; teachers: 12/57, 21%; p  = 0.005), physicians (physicians: 22/45, 49%; teachers: 7/57, 12%; p  < 0.001), authorities such as the health department (physicians: 1/45, 2%; teachers: 0/57, 0%; n.s.), schools (physicians: 1/45, 2%; teachers: 2/57, 3%; n.s.), and others (physicians: 5/45, 11%; teachers: 3/57, 5%; n.s.).

This study gives insights into the awareness and handling of CAN among physicians and teachers. An overall majority of respondents reported previous experiences with cases of CAN. Remarkably, both professional groups reported uncertainty in dealing with cases of CAN and did not feel sufficiently prepared to report such cases.

In this study, 84% of the physicians and 44% of the teachers reported previous experiences with CAN.

It is noteworthy that none of the physicians interviewed was unsure whether he or she had ever been confronted with a case of CAN. In contrast, some teachers were unsure. Teachers experience the children and families in many sometimes contradictory facets over long periods of time and thus have more opportunities to reflect on and question their own judgements.

The higher level of exposure of physicians compared to teachers may explain why, in this questionnaire, they tended to show greater theoretical and practical knowledge than teachers regarding the forms and signs of CAN. A large proportion of physicians was exposed to suspected cases of physical abuse and neglect. Those teachers who reported having been confronted with CAN were more likely to have exposure to suspected cases involving emotional abuse and neglect. Those results might be explained by the different professional activities of physicians and teachers. Both physical and emotional types of CAN can have long-term consequences such as mental disorders, drug abuse, suicide attempts, sexually transmitted infections, and risky sexual behavior [ 8 ]. Further, children whose mothers were abused as children are at high risk of being abused themselves, thus creating a vicious cycle [ 9 ]. For this reason, it is important to identify CAN as early as possible in order to be able to intervene and reduce the risk of long-term consequences. The majority of both professions were aware of long-term consequences as well as possible early warning signs, especially in specific patterns of parental behavior. This result can be seen as very positive since in both groups theoretical knowledge is present to identify not only CAN but also to detect early warning signs of CAN. Our study shows that physicians generally feel better informed than teachers. It is therefore surprising that a higher percentage of physicians than teachers would still like to have more information on the topic of CAN. It can be assumed that their wider direct experience with cases of CAN makes them aware of gaps in knowledge and thus leads to the demand for a guideline with concrete instructions for action and further training.

Nevertheless, both professions agreed that the topic of CAN should be a mandatory part of training which should also be regularly refreshed. Mandatory courses designed to train in the early identification and intervention of CAN significantly increase knowledge and self-awareness of this topic [ 15 ] and thus increase the detection and encourage the reporting of cases of CAN.

Instructions and legal frameworks can make it easier for physicians and teachers to identify CAN and to deal with reporting procedures. Thus, those measures are amongst the most important interventions to prevent CAN [ 18 ]. When asked if their facilities had specific instructions for suspected CAN, our study shows that many physicians and teachers were not adequately informed. A survey showed that the majority of healthcare professionals in Germany did not feel confident in applying the Child Welfare Law [ 19 ], and felt insecure about the legal framework and its application [ 19 ]. Similar results were also seen in this study, although most physicians stated to have received training on this topic during their university studies or pediatric training. Consequently, the share of physicians who received training is much higher than in other studies. However, as many physicians still report uncertainties the current standard training is insufficient. Respondents were uncertain in which cases a breach of confidentiality occurs. This creates a barrier that can lead to delayed reporting or even non-reporting behavior [ 20 ]. Significantly more teachers than physicians assumed that disclosure to colleagues is associated with a breach of confidentiality. Most physicians would discuss a possible suspicion with colleagues; significantly fewer teachers would do so. This contradicts a guideline issued in Germany in 2019 that provides recommendations for diagnostics and management in child protective services [ 21 ]. This guideline states that physicians and other professionals are strongly advised to seek the help of experienced professionals when CAN is suspected. This indicates that the guideline is not yet sufficiently known and not routinely applied. In addition, it is important to make counselling and support services for professionals even better known. Professionals and private individuals have the opportunity to obtain low-threshold help from the Mecklenburg-Western Pomerania child protection hotline, child and youth welfare professionals, forensic medicine institutes and the federal medical child protection hotline, for example.

Overall, it can be concluded that an obligation to participate in further training is necessary, or that these trainings must be more attractive. Mandatory and recurring courses for example using case studies and simplified checklists should therefore be discussed. Tools such as screening instruments also need to be further investigated and established. Recent studies show that such implementations, combined with adequate training and concise action procedures, can increase the early identification of CAN [ 22 ].

Since child protection is a multi-professional task, the training should also be carried out by different professional groups as they have different resources and contact points with affected families at different times [ 23 ]. In many cases of CAN it is important to work together systematically and interdisciplinary, and to use different expertise, skills and resources. It is therefore important that interdisciplinary work is practiced in training and that opportunities for networking between different professional groups are encouraged.

Limitations

As participation was voluntary, it can be assumed that motivated professionals with a connection to the topic of child protection, both among physicians and teachers, are more likely to have responded. Thus, uncertainty in dealing with CAN may be greater than reported.

Due to the high workload caused by the Covid-19 pandemic, only eight schools and three hospitals agreed to participate. In order to address the important issue of CAN nonetheless, we decided to start a pilot survey in these schools and hospitals. As another consequence of the Covid-19 pandemic, the surveys could not be conducted in person as originally planned. Due to the lack of personal visits, a lower response rate is assumed.Although different results of the professional groups in the survey on physical abnormalities were to be expected, the same questions were asked in each case for better comparability. This made it possible to confirm the different expertise and emphasize the indispensability of both professions for the identification of CAN.

In summary, although most physicians and teachers report professional experience with cases of CAN, many of them display uncertainty in dealing with suspected cases. Clear, concise institutional guidelines for dealing with CAN are needed as well as support for teachers and physicians confronted with suspected cases of CAN.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

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Acknowledgements

We thank the senior physicians and school administrators who shared the survey with their colleagues, as well as physicians and teachers for participating in the survey. Besides, we thank Dr. Verena Kolbe for support in the preparation of the questionnaire from a forensic point of view, and Dr. Phoebe Makiello for language editing of the manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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R.L. and A.B. developed the study protocol. M.R., R.L. L.S. and A.B designed the questionnaire. M.R. and A.B. distributed the questionnaire. M.R., J.P., S.J., M.P.N. and A.B. performed the data analysis and interpretation of data. M.R. and M.P.N. conducted the statistical analyses. M.R. wrote the first draft of the manuscript. M.R., J.P., S.J., M.P.N. and A.B.edited the manuscript. All authors proofread the final version of the manuscript.

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Roeders, M., Pauschek, J., Lehbrink, R. et al. Early identification and awareness of child abuse and neglect among physicians and teachers. BMC Pediatr 24 , 302 (2024). https://doi.org/10.1186/s12887-024-04782-3

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4 Consequences of Child Abuse and Neglect

Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods—the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions.

• CASCADING CONSEQUENCES

Newborns are almost fully dependent upon parents to help them regulate physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as “co-regulators” of behavior and physiology ( Hertsgaard et al., 1995 ; Hofer, 1994 , 2006 ). Over time, children raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers.

For some children, parents cannot fill these roles as buffer and co-regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences.

Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulating behavior and physiology ( Moriceau et al., 2010 ). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an extended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children's health and social, psychological, cognitive, and brain development.

Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., problems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defiant disorder, conduct disorder, aggression), and posttraumatic stress disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity.

This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and neglect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic outcomes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that distinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6 , the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course.

Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of a child's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child's development. Therefore, the most rigorous research on this topic attempts to account for the many factors that may be confounded with abuse or neglect.

Ecological Framework

Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect ( Belsky, 1993 ; Cicchetti and Lynch, 1993 ; Cicchetti and Toth, 1998 ). Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by characteristics of the individual, parents and family, and neighborhood and/or community and their interactions.

In examining the role of contextual factors in the onset of consequences due to child abuse and neglect, Cicchetti and Lynch's (1993) ecological/transactional model is particularly useful because it successfully incorporates multiple etiological frameworks ( Lynch and Cicchetti, 1998 ). This model is based on Belsky's (1980 , 1993 ) ecological model and Cicchetti and Rizley's (1981) transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The ecological/transactional model describes four interrelated, mutually embedded categories that contribute to abuse and neglect and the potential associated consequences:

• Ontogenic development—Reflects factors within the individual that influence the achievement of competence and adaptation.
• Microsystem—Defined as the “immediate context” (i.e., the family) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child interactions directly or indirectly.
• Exosystem—The exo- and macrosystemic levels reflect social or cultural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning.
• Macrosystem—Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a “larger cultural fabric,” that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children).

The model is based on the fact that a child's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes. Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children.

At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment. These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur.

The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect.

Types of Evidence

Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible.

Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006 ; Suomi, 1997 ). One salient human study involved random assignment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) ( Nelson, 2007 ). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were extensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013 ; Nelson et al., 2007a , b ; Zeanah et al., 2003 ). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature.

The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999) , which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999 , 2000 ), Noll and colleagues (2007) , and Jonson-Reidz and colleagues (2012) . Retrospective designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases ( Briere, 1992 ; Offer et al., 2000 ; Ross, 1989 ; Widom, 1988 ). Results of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment ( Widom et al., 2007a ). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting ( Gilbert et al., 2009a ).

The federal government has supported an effort, launched since the 1993 NRC report was issued—the National Survey of Child and Adolescent Well-Being (NSCAW)—to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5 .

This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor.

Despite recent methodological advances, researchers face many challenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect (e.g., physical abuse, sexual abuse, neglect from caregivers) for child functioning and development. One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a number of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others ( Dubowitz et al., 1987 ; Lyons et al., 2005 ; McCurdy, 2005 ). These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children's functioning, but need to be disentangled from the specific effects of abuse and neglect ( Widom et al., 2007a ). Controlling for other relevant variables becomes vital, since failure to take such family variables into account may result in reporting spurious relationships ( Widom et al., 2007a ). Some studies consider and covary other risk factors, and some do not. Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues (2012) found that the number of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains.

Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning. These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect.

• NEUROBIOLOGICAL OUTCOMES

An adequate caregiver is needed to support developing brain architecture and the developing ability to regulate behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise development. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discussion begins, however, with a brief overview of brain development.

Overview of Neurobiological Development

The construction of the brain.

Brain development begins just a few weeks after conception, starting with the construction of the neural tube. This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter , whereas most of the rest of the brain is referred to as grey matter .

Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development—is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience ( Nelson et al., 2011 ).

Neural Plasticity and Sensitive Periods

Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experiences occur), development can go awry. This leads to the concept that plasticity “cuts both ways,” meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experiences or inadequate input, the brain may suffer ( Nelson et al., 2011 ). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation.

The Time Course of Development

In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion regulation—have a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive period for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1 .

The time course of key aspects of brain development. SOURCE: Thompson and Nelson, 2001 (reprinted with the permission of American Psychologist ).

These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience considerable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., neglect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed.

Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation

There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect (e.g., Bruce et al., 2009 ; Gunnar and Vazquez, 2001 ; Levine et al., 1993 ; Shonkoff et al., 2012 ). Glucocorticoids (cortisol in humans, corticosterone in rodents) are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintaining a diurnal rhythm. A cascade of events is designed to promote survival behavior by directing energy to processes that are critical to immediate survival (e.g., metabolism of glucose) and away from processes that are less critical to immediate survival, such as immune functioning, growth, digestion, and reproduction ( Gunnar and Cheatham, 2003 ).

Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation ( Gunnar and Cheatham, 2003 ). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime ( Gunnar and Donzella, 2002 ). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work ( Larson et al., 1991 ; Watamura et al., 2002 ). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children ( Bernard et al., 2010 ; Bruce et al., 2009 ; Dozier et al., 2006 ; Fisher et al., 2007 ; Gunnar and Vazquez, 2001 ). Similar flattened diurnal rhythms have been found in institutionalized children ( Bruce et al., 2000 ; Carlson and Earls, 1997 ). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation ( Carpenter et al., 2009 ; Fries et al., 2005 ).

Cicchetti and colleagues ( Cicchetti and Rogosch, 2001a , b ) examined changes across the day among abused and neglected children attending summer camp. The time points included when children first arrived at camp (at about 9 AM) and before they left camp for the day (at about 4 PM), likely tapping diurnal change within a challenging environment. The authors report complex findings regarding cortisol in this setting. Differences were found in some studies related to subtype and/or psychopathology and/or aggression ( Cicchetti and Rogosch, 2001b ; Murray-Close et al., 2008 ).

Animal models have been used to study experimentally the effects of neglect and abuse on HPA functioning (e.g., Levine et al., 1993 ). Experiences of abuse or neglect, depending on age of pup/infant, duration, chronicity, and subsequent response of dam/mother differentially affect short- and long-term effects on the HPA axis ( Sanchez, 2006 ). Under naturally occurring conditions (about 10 percent of rhesus monkeys abuse their infants), a 1-year-old rhesus monkey that was abused (primarily in the first month of life) showed higher cortisol levels under basal and stress conditions than a 1-year-old that had not been abused. These effects were not seen at older ages. (The age translation from rhesus to human is about 1 to 4, so a 1-year-old rhesus is developmentally similar to about a 4-year-old human child.) In other studies that have manipulated rearing conditions (such as isolation rearing), differences between conditions of abuse or neglect have been inconsistent. In some studies, higher cortisol values were observed in basal and/or stress conditions; in some, lower basal and/or stress conditions; and in some, no differences between the monkeys that had undergone deprivation and those that had not ( Champoux et al., 1989 ; Clarke, 1993 ; Higley et al., 1992 ; Shannon et al., 1998 ).

Disrupted HPA axis regulation may have negative effects on a number of other biological systems. High levels of circulating cortisol resulting from early life stress may cause damage to developing brain regions ( Teicher et al., 2003 ; Twardosz and Lutzker, 2010 ). Several brain regions, including limbic regions such as the amygdala and hippocampus and prefrontal regions, may be particularly susceptible to the effects of high levels of circulating cortisol because of the high number of glucocorticoid receptors in these areas ( Brake et al., 2000 ; Schatzberg and Lindley, 2008 ; Wellman, 2001 ).

High levels of circulating cortisol may affect telomere length as well. Telomeres are the repeated sequences of DNA that cap the ends of chromosomes. Telomeres shorten each time cells divide, a process generally associated with aging, but also with stress ( Epel et al., 2004 ). If telomeres become too short, the cell may become senescent (grow old) or may become malfunctional, for example, triggering inflammation or tumor development. Children who have been exposed to neglect show shortened telomeres ( Asok et al., 2013 ; Drury et al., 2011 ). Drury and colleagues (2011) found shorter telomeres among children in institutional care. Similarly, Asok and colleagues (2013) found that children living in highly challenging environments showed shorter telomeres than comparison children, but that mothers could buffer children from the environment challenge. When mothers of neglected children were sensitive to challenging environments, their children's telomeres were as long as those of low-risk children, but when mothers were insensitive, children's telomeres were shorter. Clearly, then, sensitive caregiving serves as a protective factor even under difficult conditions of adversity.

There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to affect brain development adversely, leaving these arguments speculative. Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems ( McEwen, 1998 ; Yehuda et al., 2002 ).

Studies (e.g., McGowan et al., 2008 , 2009 , 2011 ; Meaney and Szyf, 2005 ; Weaver et al., 2004 ) have found that the effects of abuse on the stress response are mediated by epigenetic programming of glucocorticoid receptor expression. Differential methylation of the glucocorticoid receptor gene promoter in the hippocampus was found to be associated with different rearing conditions in rodents, and was reversed by changes in caregiving conditions ( McGowan et al., 2008 ). Paralleling these findings among rodents are nonexperimental findings among humans examined in postmortem analyses ( McGowan et al., 2009 ; Szyf and Bick, 2013 ). Adult suicide victims who had experienced abuse as children differed in glucocorticoid receptor mRNA from adult suicide victims who had not experienced abuse as children and from controls. These findings are consistent with the experimental rodent findings, and suggest that methylation of receptor sites mediates the association between early care and stress responsiveness.

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity (e.g., Chareyron et al., 2012 ). Relative to low-risk children, abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity ( Ellis et al., 2004 ; Kaplow and Widom, 2007 ; Tottenham et al., 2009 ; van Ijzendoorn and Juffer, 2006 ; Zeanah et al., 2009 ) and deficits in emotional processing ( Dalgeish et al., 2001 ; Pollak et al., 2000 ; Vorria et al., 2006 ). Figure 4-2 illustrates structures in the medial temporal lobe critically involved in emotion (amygdala) and learning and memory (hippocampus).

Illustration of brain structures.

Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect ( De Bellis et al., 2001b ; Tottenham and Sheridan, 2010 ; Woon and Hedges, 2008 ). However, Tottenham and colleagues (2010) and Mehta and colleagues (2009) found that amygdala volume was enlarged among children following institutionalized care, although this finding was not replicated by Sheridan and colleagues (2012) among a similar population. Importantly, both the Mehta et al. and Sheridan et al. studies did find a dramatic reduction in total brain volume, meaning that these children had physically smaller brains.

Functional magnetic resonance imaging (fMRI) studies have shown that early adversity leads to a sensitized amygdala. Relative to comparison children, previously institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces ( Tottenham et al., 2011 ). Similarly, Maheu and colleagues (2010) found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces.

Hippocampus, Learning, and Memory

The hippocampus (see Figure 4-2 ) plays an important role in learning and memory ( Andersen et al., 2007 ; Ghetti et al., 2010 ; Otto and Eichenbaum, 1992 ) and, like the amygdala, matures rapidly over the first months and years of life ( Lavenex et al., 2007 ). The hippocampus appears to be particularly susceptible to stress early in life ( Gould and Tanapat, 1999 ; Sapolsky et al., 1990 ) and plays a role in modulating the response of the HPA axis to stressors, as binding of cortisol to hippocampal receptors serves to turn off the HPA axis response ( Kim and Yoon, 1998 ). Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation ( de Quervain et al., 1998 ; Sheridan et al., 2012 ).

Most studies have found no evidence of hippocampal volume deficits among abused children compared with healthy, nonabused control children ( De Bellis et al., 1999 , 2001a , 2002 ). Among adults, however, decreased hippocampal volume has been linked with the experience of childhood physical and sexual abuse ( Andersen and Teicher, 2004 ; Andersen et al., 2008 ; Schmahl et al., 2003 ; Woon and Hedges, 2008 ). Nonetheless, relatively smaller hippocampal volumes in abused adults may be specific to PTSD rather than abuse itself ( Kitayama et al., 2005 ).

Prefrontal Cortex and Executive Functions

The prefrontal cortex (see Figure 4-2 ) is responsible for a variety of higher-order “executive” functions ( Miller and Cohen, 2001 ). The development of the prefrontal cortex is protracted, extending from birth into the third decade of life ( Gogtay et al., 2004 ; Rubia et al., 2006 ; Sowell et al., 2003 ). Prefrontal systems are especially sensitive to experiences of early adversity ( Hart and Rubia, 2012 ; McLaughlin et al., 2010 ).

Evidence is mixed with regard to structural changes in the prefrontal cortex following abuse and neglect, with some studies showing smaller volumes of the right orbitofrontal cortex, right ventral-medial prefrontal cortex, and dorsolateral prefrontal cortex ( Hanson et al., 2010 ); some showing decreased grey matter volume in the prefrontal cortex in children with interpersonal trauma and PTSD symptoms ( Carrion et al., 2008 ); some showing the opposite effect ( Carrion et al., 2009 ; Richert et al., 2006 ); and still others showing no effect after controlling for total brain volume ( De Bellis et al., 2002 ). Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and related brain regions. In particular, children with trauma experiences show patterns of neural activation during tasks requiring executive function that are similar to patterns observed in children with attention-deficit hyperactivity disorder (ADHD) (e.g., Carrion et al., 2008 ).

Consistent with these findings among abused and neglected children, previously institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues (2010) found that children with a history of neglect or institutional care showed greater activation in several regions of the prefrontal cortex (e.g., left inferior frontal cortex, anterior cingulate cortex) during response inhibition trials of a go/no-go task compared with children without a history of neglect. Similar findings have been reported by McDermott and colleagues (2012) and Loman and colleagues (2009) among currently and previously institutionalized children.

Corpus Callosum

The corpus callosum facilitates communication between the two hemispheres of the brain ( Giedd et al., 1996a , b ; Kitterle, 1995 ). The white matter fibers composing the corpus callosum are myelinated throughout childhood and adulthood ( Giedd et al., 1996a ; Teicher et al., 2004 ), which allows faster, more efficient transmission ( Bloom and Hynd, 2005 ). Myelinated regions such as the corpus callosum are susceptible to the impacts of early exposure to high levels of cortisol, which suppress the glial cell division critical for myelination.

Retrospective/cross-sectional studies have found abuse and neglect to be associated with structural changes in the corpus callosum. Teicher and colleagues (2004) compared corpus callosum volume in adults with different abuse and neglect experiences. The total corpus callosum area of the abused children was smaller than that of both healthy control children and children with psychiatric disorders and no abuse or neglect. Other findings suggest that gender may moderate these effects, with the effects being more pronounced among males than females ( De Bellis and Keshavan, 2003 ; De Bellis et al., 1999 , 2002 ; Teicher et al., 1997). Sheridan and colleagues (2012) performed structural MRIs on children enrolled in the Bucharest Early Intervention Project, described previously in this chapter. In a follow-up of 8- to 11-year-olds, Sheridan and colleagues (2012) found smaller total white and gray matter volume and smaller posterior corpus callosum volume among children who had been institutionalized relative to those who had never been institutionalized. By middle childhood, however, there were no significant differences in total white matter volume or posterior corpus callosum volume between the never-institutionalized (community) children and the foster care children. These early differences in corpus callosum may be associated with less efficient cognitive functioning among children who experience early adversity.

Influence of Early Profound Neglect on Brain Electrical Activity

The influence of profound neglect early in life has been examined using electroencephalography (EEG) and event-related potentials (ERPs).

Electroencephalography

EEG measurements of the brain's electrical activity can serve as a coarse metric for brain development. Most work on EEG in the context of neglect has been performed on children with a history of institutional care. The most extensive study of brain electrical activity among children with a history of institutional care was conducted with the children enrolled in the prospective, longitudinal Bucharest Early Intervention Project. At baseline (mean age 20 months), prior to random assignment to continued institutional care or foster care, institutionalized children showed higher levels of theta power (low-frequency brain activity) and lower levels of alpha and beta power (high-frequency activity) compared with children who were not institutionalized ( Marshall et al., 2004 ). The pattern of activity observed in institutionalized children suggests a maturational delay or deficit in cortical development associated with an extreme form of neglect ( Marshall et al., 2004 ). The profiles are similar to patterns found among children with ADHD ( Barry et al., 2003 ; Harmony et al., 1990 ).

At follow-up, as a group, children assigned to foster care did not differ from the care-as-usual group ( Marshall et al., 2008 ). However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely resembled that of the never-institutionalized group than the care-as-usual group. Overall, then, “institutionalization led to dramatic reductions in brain activity (as reflected in the EEG), whereas placement in foster care before 2 years of age led to a more normal pattern of EEG activity” ( Nelson et al., 2011 , p. 139). This last finding was replicated when the children were 8 years old ( Vanderwert et al., 2010 ). Specifically, previously institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly assigned to institutional care.

Event-Related Potentials

ERPs measure changes in the brain's electrical activity in response to an internal or external stimulus or event. The components of the ERP (i.e., positive and negative deflections) can be quantified in terms of latency, amplitude, and location/distribution on the scalp. The P300 (i.e., positive deflection occurring approximately 300 ms after a stimulus) is associated with attention to emotionally evocative visual stimuli, such as emotional faces ( Eimer and Holmes, 2007 ; Olofsson et al., 2008 ). Whereas nonabused children show similar P300 activity across emotional expressions, abused children show larger P300s to angry target faces ( Pollak et al., 1997 , 2001 ), a finding consistent with behavioral evidence of enhanced attention to angry faces among abused children.

Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a number of factors and seen at some ages and not others. Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior. Finding: Abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional processing. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity leads to a sensitized amygdala. Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

• COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES

Cognitive Development

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement.

Executive Functioning and Attention

As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior ( Lewis-Morrarty et al., 2012 ). Included among executive functions are “holding information in working memory, inhibiting impulses, planning, sustaining attention amid distraction, and flexibly shifting attention to achieve goals” ( Lewis-Morrarty et al., 2012 , p. 2). Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop through at least the second decade of life.

Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a number of studies conducted by the Bucharest Early Intervention Project team ( McDermott et al., 2012 ). For example, McDermott and colleagues (2012) found that children who were randomly assigned to foster care showed better performance on an executive functioning task (i.e., a go/no-go task requiring inhibitory control) than children who were randomly assigned to treatment as usual. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children (with histories of institutionalization) have been reported (e.g., Loman et al., 2013 ). These findings suggest that extreme forms of neglect may interfere with the development of executive functioning.

Problems in regulating attention represent one of the most striking deficits seen among children who have experienced severe early deprivation in institutional settings ( Gunnar et al., 2007 ; Kreppner et al., 2001 ). Gunnar and colleagues (2007) found that problems with inattention or overactivity were more pronounced among children who had experienced early institutional care than among those who had been adopted internationally without early institutional care. Kreppner and colleagues (2007) found that many children who had been adopted following institutional care showed problems with inattention or overactivity, but that such problems were usually seen in combination with reactive attachment disorder, quasi-autistic behaviors, or severe cognitive impairment.

Using NSCAW data, Heneghan and colleagues (2013) examined mental health problems in teens older than age 12 who were the subject of a child welfare agency investigation. They found that 18.6 percent of abused and neglected teens scored positively for ADHD, compared with 5 percent of children and 2.5 percent of adults in the general U.S. population ( APA, 2013c ). Likewise, Briscoe-Smith and Hinshaw (2006) studied a sample of 228 girls with and without ADHD and with and without a history of abuse and neglect, finding that the girls with ADHD had a statistically significant heightened risk of having a documented history of abuse or neglect, as indicated by substantiated child protective services, parental, or school report. Some studies have found preliminary differences in the characteristics of ADHD displayed by children with and without a history of abuse or neglect ( Webb, 2013 ). For example, Becker-Blease and Freyd (2008) studied a small community sample of 8- to 11-year-old children in which ADHD and abuse history were assessed by parent report. They found that children with a history of abuse displayed more severe impulsivity and inattention than nonabused children with ADHD, but the groups did not differ on measures of hyperactivity ( Becker-Blease and Freyd, 2008 ).

A number of studies have found evidence that children who experience abuse and neglect show deficits in executive functioning and attention ( Arseneault et al., 2011 ; De Bellis et al., 2009 ; Fisher et al., 2011 ; Lewis et al., 2007 ; Spann et al., 2012 ). Pears and colleagues (2008) found that abuse and neglect were associated with generally lower cognitive functioning among preschoolers. Lewis and colleagues (2007) found that 4-year-old children who had experienced abuse or neglect and were in foster care showed poorer inhibitory control on a Stroop-like task relative to comparison children, despite similar levels of performance on a control task. Spann and colleagues (2012) found that physical abuse and neglect were associated with diminished cognitive flexibility on the Wisconsin Card Sorting Task among adolescents.

Academic Achievement

Abuse and neglect increase children's risk for experiencing academic problems. Several studies suggest that abuse versus neglect matters, with neglect being especially predictive of academic underachievement ( Briere et al., 1996 ; Jonson-Reid et al., 2004 ; Nikulina et al., 2011 ). Other studies failed to find differences between abuse and neglect, with both predicting achievement problems (e.g., Barnett et al., 1996 ; Crozier and Barth, 2005 ; Eckenrode et al., 1993 ; Jaffee and Gallop, 2007 ; Kurtz et al., 1993 ; Leiter and Johnsen, 1997 ). On balance, the evidence suggests that both abuse and neglect are predictive of academic problems. Perez and Widom (1994) found that child abuse and neglect had a significant impact on reading ability, IQ scores, and academic achievement. For example, 42 percent of abused and neglected children completed high school, compared with two-thirds of the matched comparison group without histories of abuse and neglect. The average IQ score for the abused and neglected children was about one standard deviation below the average for the control group; this association was significant after controlling for age, race, gender, and social class ( Perez and Widom, 1994 ). Using NSCAW data, Jaffee and Maikovich-Fong (2011) found that chronically abused or neglected children had lower IQ scores than situationally abused or neglected children. The effect of chronic abuse or neglect on IQ scores remained significant after controlling for the effects of caregiver educational level on IQ. Leiter and Johnsen (1997) found that effects of abuse and neglect on school performance were cumulative, with more episodes of abuse and neglect being associated with poorer outcomes. Abuse and neglect predicted entry into special education after controlling for early medical conditions ( Jonson-Reid et al., 2004 ). Jonson-Reid and colleagues (2004) found that 24 percent of the abused and neglected children entered special education, compared with 14 percent of those with no record of abuse or neglect. Further, every additional report of abuse or neglect before the age of 8 led to an increase of 7 percent in entry into special education. Thompson and colleagues (2012) found that expectations of future academic success were adversely affected by previous experiences of abuse and neglect, with these expectations having powerful self-fulfilling possibilities ( Ross and Hill, 2002 ).

Psychosocial and Behavioral Outcomes

Given that child abuse and neglect are social experiences that undermine the ability to trust in caregivers, either because caregivers are frightening (as in cases of abuse) or because they fail to protect or provide care (as in cases of neglect), it makes sense that children who experience abuse and neglect are at risk for interpersonal problems. At the most proximal level, problems are seen in children's ability to form trusting attachments to their parents. But not surprisingly, the effects also are seen in such areas as children's processing of emotion (e.g., overly vigilant of angry faces), their attributions of others' intent (e.g., assuming that intentions are malevolent when they are ambiguous), and difficulties with peers (e.g., being the victim or perpetrator of bullying or violence). Problems also are seen in internalizing symptoms, such as anxiety and depression, and externalizing symptoms, such as conduct disorder and substance use.

Children develop secure attachments to parents who are responsive to them when they are distressed ( Ainsworth, 1978 ). Children typically develop insecure (avoidant or resistant) attachments when parents are unresponsive or inconsistent in responsiveness, but not frightening or bizarre (e.g., Lyons-Ruth et al., 1993 ; Schuengel et al., 1998 ). Secure, avoidant, and resistant attachments are referred to as organized attachment strategies because they are organized around the caregiver's availability and provide a child a template for dealing with distress. On the other hand, disorganized attachment represents a breakdown in or a lack of strategy for dealing with distress when in the parent's presence ( Main and Solomon, 1990 ). Disorganized attachments are the most problematic in terms of outcomes for children. Relative to organized attachment, disorganized attachment is most predictive of long-term problems, especially externalizing symptoms ( Fearon et al., 2010 ). Fearon and colleagues (2010) found strong evidence for a link between disorganized attachment and later externalizing symptoms through a meta-analysis of 34 studies involving 3,778 participants.

Child abuse and neglect are predictive of disorganized attachment, as well as insecure attachment more generally. A meta-analysis conducted by Cyr and colleagues (2010) included the 10 studies that have examined attachment quality with samples of children who have experienced abuse and neglect. The effect size was large for both disorganized and insecure attachment. Although abuse was more strongly related to disorganized attachment and neglect to insecure attachment, both abuse and neglect were associated with both types of attachment. These results are consistent with theory and with other empirical findings suggesting that when parents are either frightening or unavailable, children fail to develop a secure attachment to them. Nonetheless, the effects of having more than five socioeconomic risk factors were comparable to those of child abuse and neglect, indicating that multiple challenges to parental functioning had significant effects on attachment regardless of whether these effects were seen in child abuse and neglect.

In early childhood, abused or neglected children may develop attachment disorders resulting from and following pathogenic care that inhibits a young child's ability to form selective attachments ( Hornor, 2008 ). Childhood attachment disorders are phenomena distinct from insecure, disorganized, or nonexistent attachment types; they have been redefined in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-V) to include two distinct disorders: reactive attachment disorder and disinhibited social engagement disorder ( APA, 2013a , b ). Reactive attachment disorder involves inhibited or emotionally withdrawn behavior, including rarely seeking and responding to comforting; it results from a lack of or incompletely formed selective attachments to adult caregivers ( APA, 2013a ). Disinhibited social engagement disorder is marked by a pattern of overly familiar behavior with strangers; it may occur even in children with established or secure attachments. Previously, each attachment disorder was considered the inhibited or disinhibited type of reactive attachment disorder, respectively.

Zeanah and colleagues (2004) studied the prevalence of attachment disorders among 94 toddlers in foster care whose abuse or neglect cases had been substantiated and who were enrolled in an intervention program; they found that the prevalence of attachment disorders reached 38-40 percent. Lyons-Ruth and colleagues (2009) examined socially indiscriminate attachment behavior in a sample of mother-child dyads that included pairs referred to a clinical service because of problematic caregiving and comparison pairs matched on socioeconomic status. They found that 18-month-olds displayed socially indiscriminate attachment behavior only if they had a history of abuse or neglect, or their mother had a history of psychiatric hospitalizations. Both disorders also have been identified in children exposed to neglectful institutional care in Romania who were later adopted into middle-class families in the United Kingdom ( Smyke et al., 2002 ; Zeanah et al., 2002 ), although the disinhibited type of reactive attachment disorder (as defined in DSM-IV) has been found to be much more prevalent than the inhibited type ( O'Connor et al., 2003 ). Furthermore, findings from the Bucharest Early Intervention Project study indicate that the inhibited type of reactive attachment disorder declined significantly once institutionalized children were placed in foster care, but the disinhibited type proved more persistent ( Smyke et al., 2002 ; Zeanah and Gleason, 2010 ).

Emotion Regulation

Infants have limited capacities to regulate their own emotions and are dependent on caregivers to help them deal effectively with distress ( Tronick, 1989 ). Indeed, infants and young children are highly attuned and responsive to their parents' emotions and use parental emotional signals to guide their behavior ( Klinnert et al., 1983 ; Malatesta and Izard, 1984 ). The scaffolding important for the development of emotion regulation is challenged in abusing or neglecting families. When children feel upset or distressed, parents' availability and soothing presence can help them feel that they can cope with the strong negative affect, such that they are able to develop autonomous and effective means of regulating emotions over time. When children regulate their emotions well, they react to challenge with flexible and socially acceptable responses ( Cole et al., 1994 ; Kim and Cicchetti, 2010 ). Abused and neglected children, however, may not have such scaffolding experiences. It is likely that abused and neglected children experience not only a lack of modeling and support and an absence of positive affect but also harsh, inconsistent, and insensitive parenting ( Shipman and Zeman, 2001 ). In the case of abuse, parents often respond in threatening or unpredictable ways to children's distress ( Milner, 2000 ). In the case of neglect, parents may be unresponsive or nonempathic. As a result of either response, children are at risk of failing to develop effective strategies for regulating emotions ( Cicchetti et al., 1995 ; Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ).

An initial, key task in regulating emotions is processing of cues. Studies have examined differences among children who have experienced abuse and neglect in how readily they identify angry, sad, and happy faces ( Pollak and Sinha, 2002 ; Pollak and Tolley-Schell, 2003 ; Pollak et al., 2000 ; Shackman et al., 2007 ). Pollak and Sinha (2002) found that the threshold for detecting anger in the face was lower among abused than nonabused children; there were no differences in processing happy faces. Thus, these children appear to have a bias toward angry faces rather than a general deficit in processing faces. Pollak and Sinha (2002) point out that it is useful to identify emotions in others based on less than full information. Abused children's bias toward attributing angry or sad affect may be adaptive when living with parents whose anger may be an important threat cue ( Belsky et al., 2012 ); nonetheless, it comes at the cost of assuming hostile intent too readily under benign conditions, leading to aggressive responses that would not have been evoked had attributions been different ( Dodge et al., 1995 ). Neglected children, on the other hand, generally are not as good as nonneglected children at identifying facial expressions, showing a general deficit ( Pollak et al., 2000 ).

Emotion regulation can be seen as key to a number of the constructs considered in this chapter. Problems in regulating emotion are associated with externalizing behaviors, such as aggression and behavior problems ( Eisenberg et al., 2001 ; Kim and Cicchetti, 2010 ); internalizing behaviors, such as depression ( Cole et al., 2008 ; Maughan and Cicchetti, 2002 ); and challenges in peer relations ( Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ). Emotion regulation can be seen, then, to have effects both on children's own affect and on their behavioral reactions, which then have implications for their relationships with others.

Peer Relations

Children's relationships with their peers are critical to their sense of well-being. Abused and neglected children have problematic peer relations at disproportionately high rates ( Kim and Cicchetti, 2010 ), as do children with a history of institutional care ( Almas et al., 2012 ). Chronicity of child abuse and neglect predict peer relations, as reported by teachers, at age 8 ( Graham et al., 2010 ). Problematic emotion regulation ( Shields and Cicchetti, 2001 ) and higher levels of aggression and withdrawal ( Rogosch et al., 1995 ) found in abused and neglected children can become apparent to peers when frustrations and challenges arise in school and playground environments.

Externalizing Problems

Externalizing behavior refers to problem behaviors that are manifested externally (rather than internally, as in the case of depression and anxiety). Findings from several studies indicate that children who have experienced abuse and neglect are at greater risk for a number of externalizing behaviors, including conduct disorders, aggression, and delinquency ( Lansford et al., 2002 , 2009 ; Lynch and Cicchetti, 1998 ; Stouthamer-Loeber et al., 2001 ; Thornberry et al., 2010 ).

Oppositional defiant disorder and conduct disorder Studies have reported significant associations between a history of childhood abuse or neglect and various conduct problems, including those classified as oppositional defiant disorder or conduct disorder. Oppositional defiant disorder is indicated by a frequent or persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness ( APA, 2013a ). Its symptoms usually first appear during early childhood, and it often precedes conduct disorder, anxiety disorders, or major depressive disorder. Conduct disorder is indicated by a repetitive or persistent pattern of behavior that violates the basic rights of others or major societal norms or rules, including aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules ( APA, 2013a ). Conduct disorder can begin in childhood or adolescence; however, childhood-onset conduct disorder is more often preceded by oppositional defiant disorder, more persistent into adulthood, and more likely to include aggressive behavior than adolescence-onset conduct disorder. Both disorders also frequently co-occur with ADHD.

In a study using a community sample, Dodge and colleagues (1995) found that children who were physically abused before age 5 were 4 times more likely than nonabused children to display externalizing conduct problems in grade 3 and 4. Likewise, Kaplan and colleagues (1998) found that adolescents (aged 12-18) with substantiated cases of physical abuse were more likely to display conduct disorder or oppositional defiant disorder at the time of the study (odds ratio = 5.98) than the matched nonabused comparison group. Fergusson and colleagues (2008) found that childhood sexual abuse was associated with higher rates of conduct disorder in young adulthood. Furthermore, they found that childhood physical abuse was not associated with conduct disorder when sexual abuse was included in the model. Additional environmental and individual factors that interact with abuse or neglect to increase the likelihood of conduct disorder or oppositional defiant disorder include exposure to parental divorce ( Afifi et al., 2009 ), interparental violence ( Boden et al., 2010 ), and community violence ( McCabe et al., 2005 ), as well as gender, with males more likely to display conduct disorder ( Boden et al., 2010 ).

Aggression Manly and colleagues (2001) found that children who had experienced severe emotional abuse only as infants or severe physical abuse only as toddlers were more aggressive and showed more externalizing symptoms as school-aged children than children without a history of abuse or neglect. The severity of abuse experienced predicted aggressiveness and externalizing symptoms in middle childhood. Although abuse experienced only in early childhood had lasting effects, abuse experienced beyond early childhood also had effects on aggression and externalizing symptoms, and the most problematic effects were seen for children subjected to chronic, severe abuse ( Manly et al., 2001 ). Rogosch and colleagues (1995) found that physically abused children showed both aggressive behaviors and social withdrawal during peer interactions. Along these lines, abused and neglected children were disproportionately likely to be both bullies and victims of aggression, effects that were mediated by emotion dysregulation ( Shields and Cicchetti, 2001 ). At odds with these findings, Kotch and colleagues (2008) found that children who experienced neglect in their first 2 years of life showed more aggression toward peers at ages 4, 6, and 8 relative to children without a history of abuse or neglect. Indeed, in that study, other subgroups (children who were abused or who were neglected at older ages) did not show an increased likelihood of aggression.

Hostile attributional bias refers to the tendency to assume that someone intended harm when circumstances were ambiguous but a negative outcome was experienced. For example, if a peer spilled milk on a child, the child could assume that the action was benign (unintentional) or intentional, with the latter representing a hostile attributional bias. When children assume that such an action was intentional, they are likely to act aggressively in response ( Dodge et al., 1995 ). Physically abused children are more likely than other children to show such attributional biases ( Dodge et al., 1995 ). Price and Glad (2003) found that these effects were seen in boys only and were associated with frequency of abuse. Such biases can lead to a self-fulfilling prophecy whereby children anticipate that someone intends them harm and react in a hostile way, which then elicits a hostile response ( Dodge et al., 1995 ).

Internalizing Problems

Internalizing problems—problems that are manifested internally—include symptoms of depression and anxiety. Child abuse and neglect have been found to put children at increased risk of internalizing symptoms from early childhood through adolescence and adulthood ( Dubowitz et al., 2002 ; Thornberry et al., 2001 ; Widom et al., 2007a ).

Dubowitz and colleagues (2002) found that neglect was associated with internalizing problems for 3- and 5-year-old children. Swanston and colleagues (1997) found that sexually abused children had a significantly higher average score on depression measures than a control group just 5 years after the abuse occurred, after adjusting for individual differences in age and sex, as well as contextual factors such as socioeconomic status, family functioning, mother's mental health, and number of negative life events. Trickett and colleagues (2001) found that a sample of sexually abused girls had significantly higher rates of self-reported depression than a comparison group of nonabused females. At follow-up, approximately 7 years later, rates of depression were found to be significantly higher among the sexually abused group, excluding a subset whose experience of abuse was characterized chiefly by multiple perpetrators and a relatively short duration.

The heightened risk of depression extends beyond childhood to adolescence and adulthood. Multiple studies have found clear links between child abuse and neglect and depression in adolescence (e.g., Fergusson et al., 2008 ; Heneghan et al., 2013 ; Lansford et al., 2002 ). Brown and colleagues (1999) found that child abuse and neglect were associated with a nearly threefold increase in the rate of depression in adolescence, although this risk was diminished after controlling for other adverse conditions. Gilbert and colleagues (2009b) cite a body of studies reporting adjusted odds ratios ranging from 1.3 to 2.4 for depression after childhood among those subjected to abuse and neglect as children. Among adults, Brown and colleagues (1999) found that the increased risk of depression associated with child abuse and neglect remained when other factors were covaried, consistent with findings that more than one-third of abused or neglected children show symptoms of major depressive disorder by their late 20s ( Gilbert et al., 2009b ). Likewise, Widom and colleagues (2007a) followed a group of individuals who had experienced abuse and/or neglect in childhood and a matched comparison group into young adulthood and found that experiencing childhood physical abuse and multiple types of abuse increased the lifetime risk for a diagnosis of major depressive disorder.

A growing body of research examines whether different types and combinations of abuse or neglect in childhood result in different levels of risk for the development of depressive symptoms. The results in this domain are mixed, with strong evidence that sexual and physical abuse in childhood are associated with depression later in life (e.g., Heneghan et al., 2013 ), but mixed evidence that neglect increases risk for depression independent of contextual factors. Many studies have found child sexual abuse to have large and independent effects on risk for depression later in life. For example, Fergusson and colleagues (2008) found that young adults who reported a history of childhood sexual abuse had mental health disorders, including depression, at a rate 2.4 times higher than that among those not exposed to such abuse. By contrast, Widom and colleagues (2007a) found that child sexual abuse was not associated with an elevated risk of major depressive disorder relative to matched controls, although physical abuse or multiple kinds of abuse did increase the risk for lifetime major depressive disorder. Additional studies have found that physical abuse increased the risk for adult depression (e.g., Brown et al., 1999 ). Some studies have found that neglect did not increase the risk for depression when statistical models included contextual factors ( Nikulina et al., 2011 ), although Widom and colleagues (2007a) found that neglect increased risk for current major depressive disorder relative to matched controls in adulthood.

As discussed in the section on individual differences later in this chapter, researchers also have examined how the timing ( Dunn et al., 2013 ; Thornberry et al., 2001 ) and severity ( Fergusson et al., 2008 ) of abuse and neglect affect the risk of developing depression. Other factors throughout the life course, such as the presence or absence of social support ( Sperry and Widom, 2013 ) and exposure to multiple traumas ( Banyard et al., 2001 ) or stressful life events in adulthood ( Power et al., 2013 ), have been found to interact with childhood experiences of abuse and neglect to influence the risk of developing depression later in life.

Dissociation

Dissociation is defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including—but not limited to—memory, identity, consciousness, perception, and motor control” ( Spiegel et al., 2011 , p. 19). Dissociation can be measured reliably and validly in children, adolescents, and adults ( Briere et al., 2001 ; Keck Seeley et al., 2004 ; Lanktree et al., 2008 ; van Ijzendoorn and Schuengel, 1996 ; Wherry et al., 2009 ).

Child abuse and neglect have been associated with dissociation among both preschool-aged and elementary-aged children ( Hulette et al., 2008 , 2011 ; Macfie et al., 2001 ), as well as among adults ( van Ikzendoorn and Schuengel, 1996 ). The existence of a subgroup of PTSD patients with high levels of dissociation has been demonstrated in clinical ( Lanius et al., 2013 ; Putnam, 1997 ), psychophysiological ( Griffin et al., 1997 ), neuroimaging ( Lanius et al., 2013 ), and epidemiological ( Stein et al., 2013 ) research. As a result, DSM-V is adding a dissociative subtype to the PTSD diagnosis ( Spiegel et al., 2011 a) (see the discussion of PTSD on p. 139).

High scores on dissociation measures have proven to be a predictor of externalizing behavior in children ( Kisiel and Lyons, 2001 ; Shapiro et al., 2012 ; Yates et al., 2008 ). In adults, high levels of dissociation are associated with refractoriness to standard treatments for a number of psychiatric conditions, as well as increased comorbidity ( Jans et al., 2008 ; Kleindienst et al., 2011 ; Wolf et al., 2012 ; Zanarini et al., 2011 ).

A meta-analysis of 55 studies ( Cyr et al., 2010 ) links abuse with disorganized attachment. Grienenberger and colleagues (2005) found that mothers who engaged in disrupted affective communication with their infants at 4 months (as measured using the AMBIANCE scale) were more likely to have toddlers who were classified as disorganized at 14 months. In turn, disorganized attachment at 14 months predicted high dissociation scores at age 20 years ( Lyons-Ruth, 2008 ). Disorganized attachment assessed during the child's second year predicted elevated levels of self-reported dissociation in mid-adolescence (age 16 years) ( Carlson, 1998 ) and early adulthood (age 19) ( Ogawa et al., 1997 ).

Based on findings from the Minnesota Mother-Child Project, Egeland and Susman-Stillman (1996) propose that dissociation may act as a mediator of child abuse across generations. In a longitudinal study of sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, a tentative generational loop can be hypothesized in which harsh and abusive parenting increases the risk for higher levels of dissociation in childhood and adolescence, which in turn increases the risk for impulsive behavior and harsh parenting of offspring. Further research, especially with a longitudinal design, is warranted to determine whether this hypothesized generational pattern of transmission represents an early opportunity for prevention of abuse in the next generation.

Posttraumatic Stress Disorder

In DSM-V, PTSD is classified as a trauma- and stressor-related disorder, a change from its previous classification as an anxiety disorder. PTSD develops following “exposure to actual or threatened death, serious injury, or sexual violation,” including directly experiencing the traumatic event, witnessing the event firsthand, learning that an actual or threatened violent or accidental death occurred to a family member or close friend, and experiencing repeated or extreme firsthand exposure to the details of the traumatic event ( APA, 2013c ). Behavioral symptoms of PTSD are divided into four categories: intrusion or reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity ( National Center for PTSD, 2013 ). Experiences of child abuse and neglect involve traumatic events that are often violent, invasive, and coercive ( Kearney et al., 2010 ). Furthermore, secondary trauma may result from experiences of child abuse and neglect, including separation from family or homelessness, which may also trigger a PTSD response ( Wechsler-Zimring et al., 2012 ).

A number of prospective and retrospective studies have found elevated rates of PTSD among individuals with a history of abuse and neglect ( Chen et al., 2010 ; Kearney et al., 2010 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Numerous studies have found that PTSD was preceded by abuse and neglect; links with sexual abuse were especially strong ( Chen et al., 2010 ; Gregg and Parks, 1995 ; Kendall-Tackett et al., 1993 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Kearney and colleagues (2010) report PTSD rates of 20-50 percent among youth who had been sexually abused, 50 percent among youth who had been physically abused, and 33-50 percent among youth who had experienced neglect combined with exposure to domestic violence. Kolko (2010) found that nearly 20 percent of youth in out-of-home care showed posttraumatic symptoms. Widom (1999) found increased risk for PTSD among adults who had experienced abuse and neglect as children, with 23 percent of those who had been sexually abused, 19 percent of those who had been physically abused, and 17 percent of those who had been neglected meeting criteria for PTSD at age 29, compared with 10 percent of the comparison group.

Some evidence indicates that PTSD may mediate the association between childhood abuse and neglect and later adverse outcomes. Wolfe and colleagues (2004) found that boys who had been abused or neglected in childhood and displayed a greater number of PTSD symptoms were at higher risk of perpetrating emotional abuse in a dating relationship compared with abused or neglected boys who displayed fewer trauma symptoms. Weierich and Nock (2008) found that the specific PTSD symptoms of reexperiencing, avoidance, and numbing mediated the relationship between childhood experiences of abuse and neglect and nonsuicidal self-injury. In a study of adult women survivors of childhood sexual abuse, Ginzburg and colleagues (2006) found that severe childhood maltreatment, including sexual abuse as well as other types of abuse or neglect, was significantly associated with experiencing high levels of dissociation in conjunction with PTSD, while less severe childhood maltreatment was not significantly associated with the dissociative subtype. Avery and colleagues (2000) examined PTSD and key areas of functioning based on interviews with sexually abused children and their nonoffending parents. Compared with sexually abused girls with low scores on the Child Posttraumatic Stress Reaction Index, sexually abused girls with higher scores expressed more worries; reported increased problems with sleep, appetite, headaches, and stomachaches; reported increased depression and suicidal ideation; displayed more problems in school functioning; and had higher levels of family disruption.

Personality Disorders

Evidence links child abuse and neglect with personality disorders. Johnson and colleagues (1999) found that adults with a history of abuse and neglect (as indicated by records and/or self-report) had a fourfold increase in personality disorders relative to those without a history of abuse or neglect. Physical abuse was associated with elevated antisocial and depressive personality disorder symptoms; sexual abuse was associated with elevated borderline personality disorder symptoms; and neglect was associated with elevated symptoms of antisocial, avoidant, borderline, narcissistic, and passive-aggressive personality disorders, as well as with attachment difficulties and other interpersonal and psychological problems. Widom (1998) reports an increase in risk for antisocial personality disorder for both males and females with a history of abuse and neglect. In a subsequent study, Widom and colleagues (2009) report an increase in risk for borderline personality disorder in males only, suggesting that there may be sex differences in the consequences of abuse and neglect. Natsuaki and colleagues (2009) found that personality problems, although not diagnosed personality disorders, worsened as adolescence progressed.

Finding: Abuse and neglect have profound effects on selected aspects of children's cognitive development. Although many attempts have been made to disentangle the effects of abuse and neglect, the balance of findings suggests that severe neglect may interfere with the development of executive functioning, and both neglect and abuse increase the risk for attention regulation problems and ADHD, lower IQ, and poorer school performance. Finding: As a result of abusive or neglectful responses from caregivers, children have a difficult time developing organized and secure attachments. As a result, abused and neglected children are at higher risk for the development of attachment disorders, particularly disinhibited social engagement disorder. Finding: Abused and neglected children often fail to develop effective strategies for emotion regulation, partly as a result of differences in processing of emotional cues. Difficulties with emotion regulation can lead to further problems, including externalizing and internalizing problems and challenges in peer relations. Finding: Children who experience abuse or neglect have been found to be at higher risk for the development of externalizing behavior problems, including oppositional defiant disorder, conduct disorder, and aggressive behaviors. Abused and neglected children also have been found to be at increased risk for internalizing problems, particularly depression, in childhood, adolescence, and adulthood. Finding: Among preschool- and elementary school–aged children, as well as adults, a history of childhood abuse and neglect has been associated with dissociation, which increases the risk for externalizing behavior in childhood and resistance to treatment for psychiatric conditions later in life. It has been suggested that dissociation may act as a mediator of harsh or abusive parenting across generations, although this hypothesis requires further research. Finding: A number of studies have found elevated rates of PTSD among individuals with a history of abuse and neglect. PTSD has been associated with physical, cognitive, psychological, social, and behavioral problems among youth who were abused or neglected in childhood.

• HEALTH OUTCOMES

Child abuse and neglect have effects on a number of health outcomes, from growth to illness to obesity. Connections have been found between problematic neurobiological outcomes of child abuse and neglect and health. One plausible mechanism for these effects relates to the purported frequent or chronic activation of the HPA axis. As discussed previously, the HPA axis is designed for responding in crises.

Growth and Motor Development

In their most extreme forms, abuse and neglect are associated with stunted growth. Children living in institutional environments ( Johnson et al., 2010 ) or adopted from highly neglecting institutional environments ( Johnson and Gunnar, 2011 ) sometimes show very delayed growth in height and head circumference. Olivan (2003) found that children placed in foster care between ages 24 and 48 months were significantly below normal for height, weight, and head circumference. Similarly, Chernoff and colleagues (1994) found that most children entering foster care had an abnormal physical screen involving at least one body system, and on average weighed less and were shorter than comparison children.

Gross motor development often is delayed among children with a history of institutional care who have then been adopted internationally ( Dobrova-Krol et al., 2008 ; Roeber et al., 2012 ). Roeber and colleagues (2012) found that children adopted from institutional settings showed motor system delays, with greater balance delays being predicted by length of time institutionalized and bilateral coordination delays being predicted by severity of deprivation. Rapid gains are seen after placement in adoptive homes, however ( Pomerleau et al., 2005 ). Although somewhat canalized (less responsive to genetic or environmental variations), the development of these gross motor abilities is dependent upon opportunities to engage in motor activities. Note that these findings regarding motor delays may be limited in their application to extreme cases of neglect in which young children are left alone in their cribs or otherwise neglected for extended periods of time.

Child abuse and neglect have been linked to various forms of physical illness as well as various indicators of physical health problems. Adolescents with a history of childhood abuse or neglect report a lower rating of their own health compared with low-risk peers ( Bonomi et al., 2008 ; Hussey et al., 2006 ). Likewise, more gastrointestinal symptoms were reported by adults who reported having been abused or neglected as children ( Walker et al., 1999 ). To examine whether this association resulted from shared method variance, van Tilburg and colleagues (2010) used data collected from multiple informants among a sample of 845 children enrolled in the longitudinal, prospective Longitudinal Studies of Child Abuse and Neglect. Across informants, youth who had experienced abuse or neglect had an increased likelihood of gastrointestinal symptoms, which often followed or coincided with sexual abuse.

In a longitudinal prospective study, childhood abuse and neglect predicted health indices among middle-aged adults ( Widom et al., 2012 ). Both physical abuse and neglect predicted hemoglobin A1C (a biomarker for diabetes) and albumin (a biomarker for liver and kidney function); physical abuse uniquely predicted malnutrition and blood urea nitrogen (a marker for kidney function); neglect uniquely predicted poor peak airflow; and sexual abuse uniquely predicted hepatitis C ( Widom et al., 2012 ).

Findings from the Adverse Childhood Experiences study indicate a heightened risk for liver disease, lung cancer, and ischemic heart disease among adults who report multiple adverse experiences in childhood ( Brown et al., 2010 ; Dong et al., 2003 , 2004 ). The adverse experiences measured in the study include emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, as well as indicators of household dysfunction, such as domestic violence, parental divorce or separation, household member mental illness, household member substance abuse, and household member incarceration. Dong and colleagues (2003) found that the adjusted odds ratio for ever having liver disease ranged from 1.4 to 1.6 for different types of abuse and neglect; among individuals with more than 6 adverse childhood experiences, the adjusted odds ratio was 2.6. Notably, the risk of liver disease was substantially mediated by risk behaviors for liver disease, such as alcohol and drug use and various sexual behaviors. Brown and colleagues (2010) found an association between adverse childhood experiences and an increased risk of lung cancer, which was partially mediated by smoking behavior. In particular, exposure to a large number of adverse childhood experiences was strongly associated with premature death from lung cancer; among individuals who died from lung cancer, those with 6 or more adverse childhood experiences died an average of 13 years earlier than those with no adverse childhood experiences. Likewise, Dong and colleagues (2004) found that adverse childhood experiences increased the likelihood of ischemic heart disease. The association was substantially mediated by both traditional (diabetes, hypertension, physical inactivity, smoking, and obesity) and psychological (anger and depressed affect) risk factors, but the psychological risk factors of anger (adjusted odds ratio of 2.1) and depression (adjusted odds ratio of 2.5) had stronger associations with heart disease than the traditional risk factors.

In various studies, different forms of child abuse and neglect have been linked with increased body mass index and higher rates of obesity in childhood, adolescence, and adulthood. Some studies link neglect but not abuse to obesity (e.g., Johnson et al., 2002 ; Lissau and Sorensen, 1994 ), and some link physical abuse but not neglect ( Bentley and Widom, 2009 ). These differences may be the result of differences in the time points at which obesity is assessed, in sample characteristics, or in the adequacy of controls, or other factors. Knutson and colleagues (2010) found that specific types of neglect (supervisory versus care) predicted obesity at different ages. Care neglect, defined as inattention to such things as provision of adequate food and clothing, predicted body mass index at younger ages, whereas supervisory neglect, defined as parental lack of availability, predicted body mass index at older ages.

Finding: Experiences of child abuse and neglect have effects on many health outcomes, including risks for long-term chronic and debilitating diseases and, in extreme cases, stunted growth.

• ADOLESCENT AND ADULT OUTCOMES

While a number of the consequences of child abuse and neglect discussed previously in this chapter can be present across childhood, adolescence, and adulthood, this section focuses on behavioral outcomes that manifest specifically in either adolescence or adulthood.

Delinquency and Violence

Maxfield and Widom (1996) found that abuse and neglect experienced in childhood predicted violence and arrests in early adulthood. Adults with a history of abuse and neglect were more likely than adults without such a history to have committed nontraffic offenses (49 percent versus 38 percent) and violent crimes (18 percent versus 14 percent). Victims of childhood physical abuse and neglect were more likely to be arrested for violence (odds ratios 1.9 and 1.6, respectively) after controlling for age, race, and sex. These authors also found that abused and neglected girls were at increased risk for being arrested for violence relative to girls who had not been abused and neglected, with an odds ratio of 1.9. Smith and colleagues (2005) also found that abuse and neglect increase the risk of violent offending in late adolescence and early adulthood. Jonson-Reid and colleagues (2012) found a powerful effect for the number of child abuse reports predicting violent delinquency, with the association being linear for up to three reports. Two of these prospective longitudinal studies also found that sexual abuse increased the risk for general offending, but not violent offending ( Smith et al., 2005 ). Physical abuse appears to be strongly related to violence in girls, as demonstrated in a meta-analysis ( Hubbard and Pratt, 2002 ).

There is evidence that childhood abuse increases the risk for crime and delinquency. A number of large prospective investigations in different parts of the United States have documented a relationship between childhood abuse and neglect and juvenile and/or young adult crime ( English et al., 2002 ; Lansford et al., 2007 ; Maxfield and Widom, 1996 ; Smith and Thornberry, 1995 ; Stouthamer-Loeber et al., 2001 ; Widom, 1989 ; Widom and Maxfield, 2001 ; Zingraff et al., 1993 ). Despite differences in geographic region, time period, youths' age and sex, definition of child maltreatment, and assessment technique, these prospective investigations provide evidence that childhood maltreatment increases later risk for delinquency and violence. Replication of this relationship across a number of well-designed studies supports the generalizability of and increases confidence in the results.

Alcohol and Substance Use

As adolescents and adults, those with a history of abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect ( Gilbert et al., 2009b ; Jonson-Reid et al., 2012 ). The effects tend to be stronger for women, being seen even when other factors are covaried ( Simpson and Miller, 2002 ; Widom et al., 1995 ). For example, Widom and colleagues (1995) found no association between a history of abuse and neglect and alcohol use by young men, but found an association for women even after controlling for parental substance use and other correlated variables. A similar pattern of results emerged in a follow-up with these participants about 10 years later, when they were approximately 40 years old. Women with a documented history of child abuse and/or neglect were more likely to drink excessively in middle adulthood than those without such a history ( Widom et al., 2007b ); again, this difference was not seen in men. Girls with a history of physical abuse tend to start using substances (including alcohol, marijuana, tobacco, etc.) at younger ages than youth without such a history ( Lansford et al., 2010 ). Work by Lansford and colleagues (2010) suggests that this early initiation serves as the mechanism for later substance use in adulthood.

Evidence linking abuse and neglect to substance abuse in adulthood is mixed ( Gilbert et al., 2009b ; Widom et al., 1999 ), with retrospective and prospective findings differing. For example, Widom and colleagues (1999) describe findings based on defining child abuse and neglect prospectively and retrospectively using self-reports (i.e., following their sample forward and asking adults whether they had been abused or neglected as children). The findings based on these two types of data differed dramatically. The prospective data showed no increase in risk of substance abuse at age 29, whereas the retrospective data showed significant differences. Interestingly, a later follow-up with this sample ( Widom et al., 2006 ) found that in middle adulthood, abused and neglected individuals compared with controls were about 1.5 times more likely to report using any illicit drug (in particular, marijuana) during the past year, and reported use of a greater number of illicit drugs and more substance use–related problems. Findings such as these provide support for the importance of longitudinal studies because without the subsequent follow-up, there would have appeared to be no increase in risk for adults who had experienced childhood abuse or neglect; these findings also illustrate the importance of contextual factors in understanding consequences.

Suicide Attempts

Experiences of abuse and neglect in childhood have a large effect on suicide attempts in adolescence and adulthood ( Brown et al., 1999 ; Fergusson et al., 2008 ; Gilbert et al., 2009b ; Widom, 1998 ). Among adults in their late 20s, Widom (1998) found that 19 percent of those with a history of abuse or neglect had made at least one suicide attempt, as compared with 8 percent of a matched community sample. Fergusson and colleagues (2008) found high rates of suicide among a New Zealand sample as well. These effects are seen for physical and sexual abuse even after accounting for other associated risk factors ( Fergusson et al., 2008 ). Trickett and colleagues (2011) found, through a prospective design, more incidents of self-harm and suicidal behaviors among women who had been sexually abused than among a control group of women who had not been sexually abused.

Sexual Behavior

Studies have investigated the association between child abuse and neglect and several aspects of sexual behavior, including early sexual initiation and sexual risk behavior, teen pregnancy, and prostitution and the risk for commercial sexual exploitation of children and adults.

Early Sexual Initiation and Sexual Risk Behavior

Children who experience abuse and neglect may initiate sexual activity at earlier ages than other children ( Lodico and DiClemente, 1994 ; Noll et al., 2003 ; Springs and Friedrich, 1992 ; Wilson and Widom, 2008 ). In addition, there is limited evidence of an association between child abuse and neglect and increased risky sexual behaviors ( Jones et al., 2010 ; Senn et al., 2008 ). This association has been studied most frequently for sexual abuse; however, Jones and colleagues (2010) found that physical and emotional abuse, but not neglect, contributed to risky behaviors over and above the effects of sexual abuse. Trickett and colleagues (2011) undertook one of the most extensive longitudinal studies of developmental outcomes for female victims of sexual abuse. The majority had experienced severe sexual abuse, defined by the type of abuse (with vaginal and anal penetrative abuse seen as most severe), the length of time over which the abuse occurred, and the relationship of the abuser to the victim. In addition to earlier initiation of sexual activity among women who had been sexually abused in childhood, the authors found less use of birth control ( Noll et al., 2003 ). For both abused and nonabused women, having a large number of male peers in childhood networks was associated with a lack of birth control use in adolescence ( Trickett et al., 2011 ). For abused females, however, having high-quality relationships with male peers and nonpeers in childhood was associated with greater birth control use in adolescence; in the comparison group, this association was not found.

Teen Pregnancy

Evidence linking childhood sexual abuse and increased risk for teen pregnancy has been mixed. Trickett and colleagues (2011) found that severely sexually abused females reported significantly higher rates of teen pregnancy and teen motherhood than nonabused females (abused = 39 percent, nonabused = 15 percent). In a meta-analysis of previously published studies of sequelae of child sexual abuse, Noll and colleagues (2009) found an increased risk for early pregnancy among girls who had been sexually abused. In contrast, using a prospective cohort design that followed children with documented cases of abuse and neglect into young adulthood, Widom and Kuhns (1996) found no evidence that childhood sexual abuse was a significant risk factor for multiple early sexual partners or teenage pregnancy.

Prostitution and Risk for Commercial Sexual Exploitation of Children and Adults

In a prospective study, Widom and Kuhns (1996) found that sexual abuse and neglect, but not physical abuse, were associated with later prostitution. In a subsequent study, Wilson and Widom (2010) examined the role of problem behaviors as a pathway to adult prostitution and found that adult victims who had experienced child abuse and neglect were more likely than nonvictims to report having been involved in prostitution as adults or prostituted as juveniles ( Wilson and Widom, 2008 ). Stoltz and colleagues (2007) found a significant relationship between child abuse and neglect (sexual, physical, and emotional) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada.

While an important topic, evidence that child abuse and neglect increase the risk for commercial sexual exploitation of children is very limited and comes primarily from retrospective studies of sexually exploited youth. Some older studies have reported that experiences of childhood sexual abuse influenced the decision of young women to become involved in commercial sex work ( Bagley and Young, 1987 ; Silbert and Pines, 1983 ). A comprehensive look at those issues will be presented in a forthcoming Institute of Medicine report from the Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States.

Finding: Experiences of abuse and neglect in childhood have a large effect on delinquency, violence, and suicide attempts in adolescence and adulthood. Finding: Adolescents and adults with a history of child abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect, although this relationship has been found most frequently in women. Finding: Children who experience abuse and neglect may initiate sexual activity at earlier ages than comparison groups. Childhood sexual abuse also has been found to be associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors. Finding: Studies seeking an association between child abuse and neglect and teen pregnancy or adult prostitution have reported mixed results.

• INDIVIDUAL DIFFERENCES IN OUTCOMES

This chapter has presented extensive evidence that children who are abused or neglected, as a group, are at increased risk for a variety of problematic outcomes. However, not all children who experience abuse or neglect experience these negative consequences. Not surprisingly (given what is known about typical development), children vary in the outcomes they experience even when exposed to the same type of abuse or neglect, with outcomes ranging from the most problematic to functioning well across domains. As discussed earlier in this chapter, an ecological-transactional model is helpful for understanding outcomes related to abuse and neglect as influenced by the interplay of risk and protective factors that occur at multiple levels of a child's ecology. Through examination of compensatory resources in children and their environment, an ecological-transactional framework can aid in understanding children who exhibit resilient outcomes despite having been abused or neglected ( Cicchetti and Toth, 2009 ; Luthar et al., 2000 ). Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. However, neither a child's individual strengths nor the surrounding environment alone can predict resilient outcomes. As noted by Jaffee and colleagues (2007 , p. 233), “the fit between the child and the environment is the best predictor of children's psychological well-being.” The following sections describe research examining explanatory factors for differences in outcomes related to child abuse and neglect.

Characteristics of Abuse or Neglect Experiences

Characteristics of a child's exposure to abuse or neglect have been shown to influence the risk for problematic outcomes. Such characteristics include the point within the course of a child's development at which an experience of abuse or neglect occurs; the chronicity of abuse or neglect experiences, taking into account their duration and frequency; the severity of the experiences; and the type of abuse or neglect ( Bulik et al., 2001 ; Collishaw et al., 2007 ; Keiley et al., 2001 ; Manly et al., 2001 ).

Among a sample of adult female twins, Bulik and colleagues (2001) found an association between characteristics of the abuse experience (e.g., a high level of severity of child sexual abuse, such as attempted or completed intercourse and the use of force or threats) and certain psychiatric disorders. In examining the effect of timing on outcomes related to child physical abuse, Keiley and colleagues (2001) found that children who experienced such abuse while under the age of 5 were at higher risk for negative outcomes than those who experienced the same type of abuse at age 5 or older. Jonson-Reid and colleagues (2012) found that nearly all children who experienced chronic, persisting abusing or neglect showed adverse outcomes in adulthood: 91.9 percent of children showed at least one negative outcome if they had 12 or more reports of abuse or neglect ( Jonson-Reid et al., 2012 ).

The concept of resilience serves as a useful lens for evaluating the differing outcomes of children exposed to abuse and neglect. By examining factors that contribute to whether children experience maladaptive outcomes in response to abuse or neglect, researchers can gain a better understanding of how better to prevent and treat these consequences. While resilience has been defined in various ways, it can be understood as “a good outcome in spite of high risk, sustained competence under stress, and recovery from trauma” ( McGloin and Widom, 2001 , p. 1022).

The study of resilience in the context of child abuse and neglect must take into account several factors. First, as shown throughout this chapter, consequences of child abuse and neglect can manifest in multiple domains of functioning. Therefore, a child's subsequent adaptation or maladaptation following abuse or neglect must be assessed in terms of multiple outcomes rather than a single indicator, such as depression ( Afifi and Macmillan, 2011 ; McGloin and Widom, 2001 ). Second, resilience is not a static construct, meaning that a child can exhibit resilient outcomes at a certain point in the course of development but may still experience problematic outcomes at a later time. It follows that analysis of resilience in abused and neglected children should include a temporal component ( McGloin and Widom, 2001 ). Third, many factors believed to promote resilience in response to child abuse and neglect can also serve to promote positive adaptation more generally in response to other childhood stressors, making it imperative for studies to include a comparison group that has not been abused or neglected ( Collishaw et al., 2007 ). Finally, resilience might usefully be considered from the perspective of allostatic load ( Danese and McEwen, 2012 ). That is, some children who experience abuse or neglect do not show problematic outcomes, but as abuse, neglect, and other adverse childhood experiences accumulate, they challenge children's ability to cope with the negotiation of life tasks.

Results from a study of adults who were the subjects of substantiated cases of child abuse or neglect as children indicate that 22 percent of abused and neglected individuals met the criteria for resilience, which required successful functioning in 6 of 8 domains ( McGloin and Widom, 2001 ). A study by Collishaw and colleagues (2007) examined resilience to adult psychopathology within a representative community sample, finding that 44 percent of adults who reported abuse during childhood reported no psychiatric problems in adulthood and demonstrated positive adaptation in other domains.

Protective factors supporting resilience have been examined at the levels of the individual, family, and social environment, with resilience being measured in childhood, adolescence, and early adulthood. In a review of protective factors for resilience following child abuse and neglect, Afifi and Macmillan (2011) identify three protective factors that are best supported by findings from longitudinal and cross-sectional studies: a stable family environment, supportive familial relationships, and personality traits that support social skills.

Individual-level protective factors identified among those displaying resilience following child abuse and neglect include personality traits (e.g., high ego control, high self-esteem, internal locus of control, external attributions of blame, and attribution of success to own efforts); gender (females more resilient than males); and relationship capabilities ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee and Gallop, 2007 ; Jaffee et al., 2007 ). There is some evidence that intelligence or cognitive ability functions as a protective factor ( Masten and Tellegen, 2012 ), but it has not always been found to be significant in supporting resilience ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ). Jaffee and colleagues (2007) found that children with protective individual-level characteristics were likely to be resilient in low-stress environments (59 percent), but children with the same protective individual-level characteristics were less likely to be resilient in highly challenging environments.

Family-level protective factors include a caring and safe home environment; positive changes in family structure (e.g., intervention, cessation of visiting rights, or removal to foster care); and supportive familial relationships at the time of abuse ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee et al., 2007 ). In a sample of sexually abused girls in foster care, family support was not found to be a protective factor, but peer influences, school plan certainty, and positive future orientation were ( Edmond et al., 2006 ). Other social-level protective factors include supportive relationships with non-family members, such as teachers or camp counselors, and supportive relationships with peers in adolescence ( Flores et al., 2005 ; Jaffee et al., 2007 ).

Gene x Environment Interactions

Historically, those working in the field of child abuse and neglect were unable to examine whether such adverse experiences interacted with biological risk or protective factors (e.g., so-called risk or protective genes)—specifically, whether experience interacted with underlying genetics. This situation has changed over the past 20 years as advances in molecular genetics have enabled a search for gene x environment (GxE) interactions. A number of such interactions have been studied in the last several decades in relation to early adversity generally and child abuse and neglect in particular. Critics of these approaches charge, among other things, that examining single gene and single environment combinations in interactions capitalizes on chance. In addition, some experts in genetics argue that the action of any single gene is likely to be very small, and to detect its effects will likely require very large sample sizes. Nonetheless, some GxE findings have emerged as robust and apparently replicable.

The 5-HTT gene is perhaps at the top of this list. This gene regulates reuptake of serotonin (a neurotransmitter that has various functions, including regulation of mood and sleep and some cognitive functions, such as memory and learning) at the synaptic cleft. The gene has long and short allelic variants that confer differential reuptake efficiency. Rodent, nonhuman primate, and human studies (e.g., Caspi et al., 2003 ) have shown that two alleles confer advantage among animals raised in stressful environments. Caspi and colleagues (2003) found that adults who had experienced stressful life events as children were more likely to have a major depressive disorder if they had one or two short alleles. Those who had two long alleles were no more likely to develop depression than individuals who had not experienced stressful life events.

A second genetic polymorphism that has received much attention is a functional polymorphism in the promoter region of the monoamine oxidase A (MAOA) gene. MAOA encodes the MAOA enzyme and selectively degrades serotonin, norepinephrine, and dopamine. Abused and neglected boys with the genotype conferring low levels of MAOA expression were found to be more likely to develop a range of externalizing behaviors, including conduct disorder, antisocial personality disorder, and violent criminality ( Caspi et al., 2002 ). However, subsequent studies have failed to replicate these findings or have demonstrated only partial replications ( Huizinga et al., 2006 ; Widom and Brzustowicz, 2006 ). For a recent review of the GxE literature concerned with child depression and abuse, see Dunn and colleagues (2011) .

Finding: Not all children who experience abuse or neglect show problematic outcomes. Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. These factors, along with risks and stressors at each level, interact with one another to predict resilient outcomes. Finding: There is a positive association between the number of risk factors for abuse and neglect to which a child is exposed and the likelihood of experiencing adverse outcomes. Finding: The timing, chronicity, and severity of child abuse and neglect, as well as the context in which they occur, have been shown to impact the associated outcomes.

• ECONOMIC BURDEN

Although the total costs of child abuse and neglect are difficult to gauge because much abuse is unreported ( Waters et al., 2004 ), a number of studies over the last few decades have attempted to document the economic burden of child abuse and neglect on society ( Corso and Fertig, 2010 ; Fang et al., 2012 ; Wang and Holton, 2007 ; Waters et al., 2004 ). Economic burden or economic impact analyses typically quantify burden by aggregating the direct medical expenditures resulting from a condition, the direct nonmedical expenditures associated with a condition, and the subsequent indirect losses in productivity potential for society. These analyses often are called cost of illness/injury analyses .

Examples of direct medical expenditures include inpatient and outpatient hospital care, mental health care, medical transport required in the event of an emergency, medications and medical devices, and the medical treatment of chronic conditions resulting from the abuse. Multiple studies since the 1993 NRC report was issued have assessed the direct medical costs associated with child abuse and neglect ( Brown et al., 2011 ), particularly the inpatient costs associated with severe abuse ( Courtney, 1999 ; Evasovich et al., 1998 ; Irazuzta et al., 1997 ; Libby et al., 2003 ; New and Berliner, 2000 ; Rovi et al., 2004 ).

Direct nonmedical expenditures include use of the child welfare system, law enforcement, and the criminal justice system. Studies have included nonmedical costs in their assessment of the economic burden of child abuse and neglect ( Staudt, 2003 ; Zagar et al., 2009 ).

Productivity losses include the child's missing school or performing at subpar levels in school because of the abuse, parents missing work or performing at subpar levels at work because of the abuse situation or having to deal with child welfare and criminal justice services, and permanent losses in lifetime productivity potential because of premature death. Productivity losses and economic well-being have been incorporated into a number of analyses of the economic burden of child abuse and neglect ( Brown et al., 2011 ; Corso and Fertig, 2010 ; Corso et al., 2011 ; Currie and Widom, 2010 ; Fang et al., 2012 ).

Gelles and Perlman (2012) estimate that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion each year—$33.3 billion in direct costs and $46.9 billion in indirect costs. An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to lost productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012 ). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity.

Currie and Widom (2010) found that adults who had experienced abuse and neglect in childhood had lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect. A higher percentage of adults who had been abused or neglected as children worked in menial, semiskilled positions at age 29 compared with adults who had not been abused or neglected—62 versus 45 percent, respectively. More of the abused and neglected group has been unemployed at some point during the previous 5 years (41 versus 58 percent, respectively). And fewer of those from the abused or neglected group were currently employed or had a bank account, owned a car, or owned their home. Larger effects were seen for women than for men.

Analyses of the economic burden of child abuse and neglect could be strengthened by greater transparency in the study methods, including a full accounting of all cost categories that may be impacted by abuse and neglect and transparency in the unit cost estimates for each cost category, as well as a methodologically sound choice of study design for estimating economic burden ( Corso and Fertig, 2010 ; Corso and Lutzker, 2006 ; Fang et al., 2012 ). Several approaches could be taken to estimate economic burden, each of which has advantages and disadvantages that could potentially result in overestimating or underestimating the true economic cost of child abuse and neglect. Options include using cross-sectional data to compare the medical costs for an abused/neglected population compared with a nonabused/nonneglected population, including only those health care costs that can be explicitly linked to diagnosis-specific health care utilization (and costs) through the use of diagnosis and external cause codes used in inpatient settings, and supplementing either of these two approaches by including the costs of the fraction of other health conditions attributed to child abuse and neglect.

Finding: Although the total costs of child abuse and neglect are difficult to gauge, a number of studies have attempted to document the economic burden of child abuse and neglect on society, including such measures as direct medical and nonmedical expenditures and productivity losses. One study estimates that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion annually ( Gelles and Perlman, 2012 ). Finding: Some studies have shown that adults who experienced abuse and neglect in childhood have lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect.

• CONCLUSIONS

Child abuse and neglect appear to influence the course of development by altering many elements of biological, cognitive, psychosocial, and behavioral development; in other words, child abuse and neglect “get under the skin” ( Hertzman and Boyce, 2010 ) to have a profound and often lasting impact on development. Brain development is affected, as is the ability to make decisions as carefully as one's peers, or executive functioning; the ability to regulate physiology, behavior, and emotions is impaired; and the trajectory toward more problematic outcomes is impacted. Effects are seen across domains, with the interplay across brain and behavioral systems being particularly striking.

Risk and protective factors across multiple levels of a child's ecology interact to influence outcomes related to child abuse and neglect. Factors that influence resilience across these domains are important to an understanding of how to protect children from the adverse outcomes discussed in this chapter. Evidence suggests that the timing, chronicity, and severity of the abuse or neglect matter in terms of outcomes. The more times children experience abuse or neglect, the worse are the outcomes ( Jonson-Reid et al., 2012 ). As Jonson-Reid and colleagues (2012) point out, it is not enough to know whether an event happened; one must also know how ongoing the problem is. The committee sees as hopeful the evidence that changing environments can change brain development, health, and behavioral outcomes. There is a window of opportunity, with developmental tasks becoming increasingly more challenging to negotiate with continued abuse and neglect over time.

Future research in this area needs to focus on disentangling the effects of child abuse and neglect from those of other conditions. There is a need to explore beneath the surface to understand the behavioral, neurobiological, social, and environmental mechanisms that mediate the association between exposure to abuse and neglect and their behavioral and neurobiological sequelae.

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• Cite this Page Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25. 4, Consequences of Child Abuse and Neglect.
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