Blue diaper syndrome

Definition

Child abuse is the blanket term for four types of child mistreatment: physical abuse, sexual abuse, emotional abuse, and neglect. In many cases children are the victims of more than one type of abuse. The abusers can be parents or other family members, caretakers such as teachers and babysitters, acquaintances (including other children), and (in rare instances) strangers.

Description

Prevalence of abuse

Child abuse was once viewed as a minor social problem affecting only a handful of U.S. children. However, in recent years it has received close attention from the media, law enforcement, and the helping professions, and with increased public and professional awareness has come a sharp rise in the number of reported cases. But because abuse is often hidden from view and its victims too young or fearful to speak out, experts suggest that its true prevalence is possibly much greater than the official data indicate. In 1996, more than three million victims of alleged abuse were reported to child protective services (CPS) agencies in the United States, and the reports were substantiated in more than one million cases. Put another way, 1.5% of the country's children were confirmed victims of abuse in 1996. Parents were the abusers in 77% of the confirmed cases, other relatives in 11%. Sexual abuse was more likely to be committed by males, whereas females were responsible for the majority of neglect cases. More than 1,000 U.S. children died from abuse in 1996.

Although experts are quick to point out that abuse occurs among all social, ethnic, and income groups, reported cases usually involve poor families with little education. Young mothers, single-parent families, and parental alcohol or drug abuse are also common in reported cases. Charles F. Johnson remarks that "More than 90% of abusing parents have neither psychotic nor criminal personalities. Rather they tend to be lonely, unhappy, angry, young, and single parents who do not plan their pregnancies, have little or no knowledge of child development, and have unrealistic expectations for child behavior." About 10%, or perhaps as many as 40%, of abusive parents were themselves physically abused as children, but most abused children do not grow up to be abusive parents.

Types of abuse

Physical abuse is the nonaccidental infliction of physical injury to a child. The abuser is usually a family member or other caretaker, and is more likely to be male. In 1996, 24% of the confirmed cases of U.S. child abuse involved physical abuse.

A rare form of physical abuse is Munchausen syndrome by proxy, in which a caretaker (most often the mother) seeks attention by making the child sick or appear to be sick.

Charles F. Johnson defines child sexual abuse as "any activity with a child, before the age of legal consent, that is for the sexual gratification of an adult or a significantly older child." It includes, among other things, sexual touching and penetration, persuading a child to expose his or her sexual organs, and allowing a child to view pornography. In most cases the child is related to or knows the abuser, and about one in five abusers are themselves underage. Sexual abuse was present in 12% of the confirmed 1996 abuse cases. An estimated 20-25% of females and 10-15% of males report that they were sexually abused by age 18.

Emotional abuse

Emotional abuse, according to Richard D. Krugman, "has been defined as the rejection, ignoring, criticizing, isolation, or terrorizing of children, all of which have the effect of eroding their self-esteem." Emotional abuse usually expresses itself in verbal attacks involving rejection, scapegoating, belittlement, and so forth. Because it often accompanies other types of abuse and is difficult to prove, it is rarely reported, and accounted for only 6% of the confirmed 1996 cases.

Neglect--failure to satisfy a child's basic needs--can assume many forms. Physical neglect is the failure (beyond the constraints imposed by poverty) to provide adequate food, clothing, shelter, or supervision. Emotional neglect is the failure to satisfy a child's normal emotional needs, or behavior that damages a child's normal emotional and psychological development (such as permitting drug abuse in the home). Failing to see that a child receives proper schooling or medical care is also considered neglect. In 1996 neglect was the finding in 52% of the confirmed abuse cases.

Causes & symptoms

Physical abuse

The usual physical abuse scenario involves a parent who loses control and lashes out at a child. The trigger may be normal child behavior such as crying or dirtying a diaper. Unlike nonabusive parents, who may become angry at or upset with their children from time to time but are genuinely loving, abusive parents tend to harbor deep-rooted negative feelings toward their children.

Unexplained or suspicious bruises or other marks on the skin are typical signs of physical abuse, as are burns. Skull and other bone fractures are often seen in young abused children, and in fact, head injuries are the leading cause of death from abuse. Children less than one year old are particularly vulnerable to injury from shaking. This is called shaken baby syndrome or shaken impact syndrome. Not surprisingly, physical abuse also causes a wide variety of behavioral changes in children.

Sexual abuse

John M. Leventhal observes that "The two prerequisites for this form of maltreatment include sexual arousal to children and the willingness to act on this arousal. Factors that may contribute to this willingness include alcohol or drug abuse, poor impulse control, and a belief that the sexual behaviors are acceptable and not harmful to the child." The chances of abuse are higher if the child is developmentally handicapped or vulnerable in some other way.

Genital or anal injuries or abnormalities (including the presence of sexually transmitted diseases) can be signs of sexual abuse, but often there is no physical evidence for a doctor to find. In fact, physical examinations of children in cases of suspected sexual abuse supply grounds for further suspicion only 15-20% of the time. Anxiety, poor academic performance, and suicidal conduct are some of the behavioral signs of sexual abuse, but are also found in children suffering other kinds of stress. Excessive masturbation and other unusually sexualized kinds of behavior are more closely associated with sexual abuse itself.

Emotional abuse

Emotional abuse can happen in many settings: at home, at school, on sports teams, and so on. Some of the possible symptoms include loss of self-esteem, sleep disturbances, headaches or stomach aches, school avoidance, and running away from home.

Neglect

Many cases of neglect occur because the parent experiences strong negative feelings toward the child. At other times, the parent may truly care about the child, but lack the ability or strength to adequately provide for the child's needs because handicapped by depression, drug abuse, mental retardation, or some other problem.

Neglected children often do not receive adequate nourishment or emotional and mental stimulation. As a result, their physical, social, emotional, and mental development is hindered. They may, for instance, be underweight, develop language skills less quickly than other children, and seem emotionally needy.

Diagnosis

Doctors and many other professionals who work with children are required by law to report suspected abuse to their state's Child Protective Services (CPS) agency. Abuse investigations are often a group effort involving medical personnel, social workers, police officers, and others. Some hospitals and communities maintain child protection teams that respond to cases of possible abuse. Careful questioning of the parents is crucial, as is interviewing the child (if he or she is capable of being interviewed). The investigators must ensure, however, that their questioning does not further traumatize the child. A physical examination for signs of abuse or neglect is, of course, always necessary, and may include x rays, blood tests, and other procedures.

Treatment

Notification of the appropriate authorities, treatment of the child's injuries, and protecting the child from further harm are the immediate priorities in abuse cases. If the child does not require hospital treatment, protection often involves placing him or her with relatives or in foster care. Once the immediate concerns are dealt with, it becomes essential to determine how the child's long-term medical, psychological, educational, and other needs can best be met, a process that involves evaluating not only the child's needs but also the family's (such as for drug abuse counseling or parental skills training). If the child has brothers or sisters, the authorities must determine whether they have been abused as well. On investigation, signs of physical abuse are discovered in about 20% of the brothers and sisters of abused children.

Prognosis

Child abuse can have lifelong consequences. Research shows that abused children and adolescents are more likely, for instance, to do poorly in school, suffer emotional problems, develop an antisocial personality, become promiscuous, abuse drugs and alcohol, and attempt suicide. As adults they often have trouble establishing intimate relationships. Whether professional treatment is able to moderate the long-term psychological effects of abuse is a question that remains unanswered.

Prevention

Government efforts to prevent abuse include home-visitor programs aimed at high-risk families and school-based efforts to teach children how to respond to attempted sexual abuse. Emotional abuse prevention has been promoted through the media.

When children reach age three, parents should begin teaching them about "bad touches" and about confiding in a suitable adult if they are touched or treated in a way that makes them uneasy. Parents also need to exercise caution in hiring babysitters and other caretakers. Anyone who suspects abuse should immediately report those suspicions to the police or his or her local CPS agency, which will usually be listed in the blue pages of the telephone book under Rehabilitative Services or Child and Family Services, or in the yellow pages. Round-the-clock crisis counseling for children and adults is offered by the Childhelp USA/IOF Foresters National Child Abuse Hotline. The National Committee to Prevent Child Abuse is an excellent source of information on the many support groups and other organizations that help abused and at-risk children and their families. One of these organizations, National Parents Anonymous, sponsors 2,100 local self-help groups throughout the United States, Canada, and Europe. Telephone numbers for its local groups are listed in the white pages of the telephone book under Parents Anonymous or can be obtained by calling the national headquarters.

Further Reading

For Your Information

Books

• Johnson, Charles F. "Abuse and Neglect of Children." In Nelson Textbook of Pediatrics, edited by Waldo E. Nelson, et al. Philadelphia: W.B. Saunders, 1996.
• Krugman, Richard D. "Child Abuse & Neglect." In Pediatric Diagnosis & Treatment, edited by William W. Hay, Jr., et al. Stamford, CT: Appleton & Lange, 1997.
• Leventhal, John M. "Child Maltreatment: Neglect to Abuse." In Rudolph's Pediatrics, edited by Abraham M. Rudolph, et al. Stamford, CT: Appleton & Lange, 1996.

  Organizations

• Childhelp USA/IOF Foresters National Child Abuse Hotline. (800) 422-4453.
• National Clearinghouse on Child Abuse and Neglect Information. PO Box 1182, Washington, DC 20013-1182. (800) 394-3366. http://www.calib.com/nccanch.
• National Committee to Prevent Child Abuse. 200 S. Michigan Avenue, 17th Floor, Chicago, IL 60604. (312) 663-3520. http://www.childabuse.org.
• National Parents Anonymous. 675 W. Foothill Blvd., Suite 220, Claremont, CA 91711. (909) 621-6184.

Gale Encyclopedia of Medicine. Gale Research, 1999.