Friday, July 6, 2012

ABUSE


Child abuse is the physical, sexual or emotional mistreatment or neglect of a child or children.[1] In the United States, the Centers for Disease Control and Prevention (CDC) and the Department for Children And Families (DCF) define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.[2] Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. There are four major categories of child abuse: neglect, physical abuse, psychological/emotional abuse, and child sexual abuse.
Neglect is a passive form of abuse in which a perpetrator is responsible to provide care for a victim who is unable to care for himself or herself, but fails to provide adequate care.

Neglect may include the failure to provide sufficient supervision, nourishment, or medical care, or the failure to fulfill other needs for which the victim is helpless to provide for himself or herself. The term is also applied when necessary care is withheld by those responsible for providing it from animals, plants, and even inanimate objects. Neglect can carry on in a child's life falling into many long-term side effects such as: physical injuries, low self-esteem, attention disorders, violent behavior, and can even cause death.[1]

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[edit]Consequences

There are many different types of neglect but they all have consequences whether it be physically or mentally. Neglect can affect the body physically by effecting a child's development which can lead to chronic medical problems. Children experiencing neglect often suffer from malnutrition, which causes abnormal patterns for development. When not given the proper nutrients at certain growth periods it can result in stunted growth, and inadequate bone and muscle growth. Brain functioning and information processing may also be affected by neglect. This may lead to difficulty in understanding directions, poor understanding of social relationships, or the inability to complete academic tasks without assistance.[2] Neglected children or adults can have physical injuries like fractures or severe burns that go untreated, or infections, lice or other signs of lack of care. Not being treated for health problems can lead to chronic disorders when children get older. There are many physical effects neglect can have on a person.[3]
Not only is neglect associated with physical problems; it also has an effect on a person mentally, ranging from poor peer relationships to violent behavior. Not only is behavior affected, but the way a person looks at themself, which can lead to low self-esteem and the feeling of not being wanted. Neglect is more severe in younger children when it comes to psychological consequences. Parental detachment can harm the child's development of bonding and attachment to the parents, causing the child's expectations to be the same when they get older (like an unending cycle). Too little parental availability can result in difficulties in problem solving, coping with stressful situations and social relationships. Studies of neglected children show heighten levels of depression and hopelessness, and higher incidents of suicide attempts.[4]

Physical abuse is an act of another party involving contact intended to cause feelings of physical pain, injury, or other physical suffering or bodily harm.[1][2] Physical abuse has been described among animals too, for example among the Adélie penguins.[3]

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[edit]Forms of physical abuse



Psychological abuse, also referred to as emotional abuse or mental abuse, is a form of abuse characterized by a person subjecting or exposing another to behavior that may result in psychological trauma, including anxiety, chronic depression, or post-traumatic stress disorder.[1][2][3] Such abuse is often associated with situations of power imbalance, such as abusive relationships, bullying, child abuse and in the workplace.[2][3] there were "no consensus views about the definition of emotional abuse”. As such, clinicians and researchers have offered sometimes divergent definitions of emotional abuse. However, the widely used Conflict Tactics Scale measures roughly twenty distinct acts of "psychological aggression" in three different categories:
  1. Verbal aggression (e.g., "Your partner has said something to upset/annoy you");
  2. Dominant behaviours (e.g., "Your partner has tried to prevent you from seeing/speaking to your family");
  3. Jealous behaviors (e.g., "Your partner has accused you of maintaining other parallel relations").
The U.S. Department of Justice defines emotionally abusive traits as including causing fear by intimidation, threatening physical harm to self, partner, children, or partner's family or friends, destruction of pets and property, forcing isolation from family, friends, or school or work.[4]
In 1996, Health Canada argued that emotional abuse is motivated by urges for "power and discontrol",[3] and defines emotional abuse as including rejecting, degrading, terrorizing, isolating, corrupting/exploiting and "denying emotional responsiveness" as characteristic of emotional abuse.
Several studies have argued that, unlike physical and sexual maltreatment, an isolated incident does not constitute emotional abuse. Tomison and Tucci write, "emotional abuse is characterised by a climate or pattern of behaviour(s) occurring over time [...] Thus, 'sustained' and 'repetitive' are the crucial components of any definition of emotional abuse."[5] Andrew Vachss, an author, attorney and former sex crimes investigator, defines emotional abuse as "the systematic diminishment of another. It may be intentional or subconscious (or both), but it is always a course of conduct, not a single event."[6]
Subtler emotionally abusive tactics include insults, putdowns, arbitrary and unpredictable inconsistency, and gaslighting (the denial that previous abusive incidents occurred). Modern technology has led to new forms of abuse, by text messaging and online cyber-bullying.

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[edit]Pathology

[edit]Prevalence

[edit]In intimate relationships

Main article: Domestic abuse
Domestic abuse—defined as chronic mistreatment in marriage, families, dating and other intimate relationships —- can include emotionally abusive behavior. Psychological abuse does not always lead to physical abuse, but physical abuse in domestic relationships is nearly always preceded and accompanied by psychological abuse.[2][7] report that psychological aggression by one partner is the most reliable predictor of the other partner's likelihood of first exhibiting physical aggression.
A 2005 study by Hamel[8] reports that "men and women physically and emotionally abuse each other at equal rates". Basile[9] found that psychological aggression was effectively bidirectional in cases where heterosexual and homosexual couples went to court for domestic disturbances. A 2007 study of Spanish college students (n = 1,886) aged 18–27 [10] found that psychological aggression (as measured by the Conflict Tactics Scale) is so pervasive in dating relationships that it can be regarded as a normalized element of dating, and that women are substantially more likely to exhibit psychological aggression. Similar findings have been reported in other studies.[11] Strauss et al.[12] found that female intimate partners in heterosexual relationships were more likely than males to use psychological aggression, including threats to hit or throw an object. A study of young adults (N = 721) by Giordano et al.[13] found that females in intimate heterosexual relationships were more likely than males to threaten to use a knife or gun against their partner.
Numerous studies done between the 1980 and 1994[1][14][15][16][17][18] report that lesbian relationships have higher overall rates of interpersonal aggression (including psychological aggression/emotional abuse) than heterosexual or gay male relationships. Furthermore, women who have been involved with both men and women reported higher rates of abuse from their female partners.[19]
In 1996, the National Clearinghouse on Family Violence,[3] for Health Canada, reported that 39% of married women or common-law wives suffered emotional abuse by husbands/partners; and a 1995 survey of women 15 and over (n = 1000) 36-43% reported emotional abuse during childhood or adolescence, and 39% experienced emotional abuse in marriage/dating; this report does not address boys or men suffering emotional abuse from families or intimate partners. A BBC radio documentary on domestic abuse, including emotional maltreatment, reports that 20% of men and 30% of women have been abused by a spouse or other intimate partner.[20]
Straus and Field [21] report that psychological aggression is a pervasive trait of American families: "verbal attacks on children, like physical attacks, are so prevalent as to be just about universal". A 2008 study by English, et al.[22] found that fathers and mothers were equally likely to be verbally aggressive towards their children.

[edit]In the workplace

Main article: Workplace bullying
Rates of reported emotional abuse in the workplace vary, with studies showing 10%[23] 24%[24] and 36%[25] of respondents indicating persistent and substantial emotional abuse from coworkers.
Keashly and Jagatic [26] found that males and females commit “emotionally abusive behaviors” in the workplace at roughly similar rates. In a web-based survey, Namie[27] found that women were more likely to engage in workplace bullying, such as name-calling, and that the average length of abuse was 16.5 months

[edit]Characteristics of abusers

In their review of data from the Dunedin Multidisciplinary Health and Development Study (a longitudinal birth cohort study; n = 941) Moffitt et al.[28] report that while men exhibit more aggression overall, gender is not a reliable predictor of interpersonal aggression, including psychological aggression. The study found that whether male or female, aggressive people share a cluster of traits, including high rates of suspicion and jealousy; sudden and drastic mood swings; poor self-control; and higher than average rates of approval of violence and aggression. Moffitt et al. also argue that antisocial men exhibit two distinct types of interpersonal aggression (one against strangers, the other against intimate female partners), while antisocial women are rarely aggressive against anyone other than intimate male partners.
Male and female perpetrators of emotional and physical abuse exhibit high rates of personality disorders.[29][30][31] Rates of personality disorder in the general population are roughly 15%-20%, while roughly 80% of abusive men in court-ordered treatment programmes have personality disorders.[1]
Abusers may aim to avoid household chores or exercise total control of family finances. Abusers can be very manipulative, often recruiting friends, law officers and court officials, even the victim's family to their side, while shifting blame to the victim.[32][33]

[edit]Effects

English, et al.[34] report that children whose families are characterized by interpersonal violence, including psychological aggression and verbal aggression, may exhibit a range of serious disorders, including chronic depression, anxiety, post-traumatic stress disorder, dissociation and anger. Additionally, English et al. report that the impact of emotional abuse "did not differ significantly" from that of physical abuse. Johnson et al.[35] report that, in a survey of female patients (n = 825), 24% suffered emotional abuse, and this group experienced higher rates of gynecological problems. In their study of men emotionally abused by a wife/partner or parent (n = 116), Hines and Malley-Morrison[36] report that victims exhibit high rates of post traumatic stress disorder, drug addiction and alcoholism.
Namie's study[27] of workplace emotional abuse found that 31% of women and 21% of men who reported workplace emotional abuse exhibited three key symptoms of post-traumatic stress disorder (hypervigilance, intrusive imagery, and avoidance behaviors). A 1998 study of male college students (n = 70) by Simonelli & Ingram[37] found that men who were emotionally abused by their female partners exhibited higher rates of chronic depression than the general population.
A study of college students (N = 80) by Goldsmith and Freyd[38] report that many who have experienced emotional abuse do not characterize the mistreatment as abusive. Additionally, Goldsmith and Freyd show that these people also tend to exhibit higher than average rates of alexithymia (difficulty identifying and processing their own emotions).
Jacobson et al.[39] found that women report markedly higher rates of fear during marital conflicts. However, a rejoinder[40] argued that Jacobson's results were invalid due to men and women's drastically differing interpretations of questionnaires. Coker et al.[41] found that the effects of mental abuse were similar whether the victim was male or female. Pimlott-Kubiak and Cortina[42] found that severity and duration of abuse were the only accurate predictors of aftereffects of abuse; sex of perpetrator or victim were not reliable predictors.
Analysis of large survey (N = 25,876) by LaRoche[43] found that women abused by men were slightly more likely to seek psychological help than were men abused by women (63% vs. 62%).
In a 2007 study, Laurent, et al.,[44] report that psychological aggression in young couples (n = 47) is associated with decreased satisfaction for both partners: "psychological aggression may serve as an impediment to couples development because it reflects less mature coercive tactics and an inability to balance self/other needs effectively". A 2008 study by Walsh and Shulman[11] reports that relationship dissatisfaction for both partners is more likely to be associated with, in women, psychological aggression and, in men, with withdrawal.

[edit]Popular and clinical perception

Several studies found double-standards in how people tend to view emotional abuse by men versus emotional abuse by women. Follingstad et al. found that,[45] when rating hypothetical vignettes of psychological abuse in marriages, professional psychologists tend to rate male abuse of females as more serious than identical scenarios describing female abuse of males: "the stereotypical association between physical aggression and males appears to extend to an association of psychological abuse and males" (Follingstad et al., p. 446) Similarly, Sorenson and Taylor randomly surveyed a group of Los Angeles, California residents for their opinions of hypothetical vignettes of abuse in heterosexual relationships.[46] Their study found that abuse committed by women, including emotional and psychological abuse such as controlling or humiliating behavior, was typically viewed as less serious or detrimental than identical abuse committed by men. Additionally, Sorenson and Taylor found that respondents had a broader range of opinions about female perpetrators, representing a lack of clearly defined mores when compared to responses about male perpetrators.
According to Walsh and Shluman, "The higher rates of female initiated aggression [including psychological aggression] may result, in part, from adolescents' attitudes about the unacceptability of male aggression and the relatively less negative attitudes toward female aggression".[11]
Hamel's 2007 study found that "prevailing patriarchal conception of intimate partner violence" led to a systematic reluctance to study women who psychologically and physically abuse their male partners.[47]
Dutton found that men who are emotionally or physically abused often encounter victim blaming that erroneously presumes the man either provoked or deserved the mistreatment of their female partners.[48] Similarly, domestic violence victims will often blame their own behavior, rather than the violent actions of the abuser. Victims may try continually to alter their behavior and circumstances in order to please the abuser.[49]

[edit]Cultural causes

Some scholars argue that hundreds or thousands of years of male dominated societies have created negative attitudes towards women among many men, and that wife abuse stems from "normal psychological and behavioral patterns of most men ... feminists seek to understand why men in general use physical force against their partners and what functions this serves for a society in a given historical context".[50] Similarly, Dobash and Dobash claim that "Men who assault their wives are actually living up to cultural prescriptions that are cherished in Western society--aggressiveness, male dominance and female subordination--and they are using physical force as a means to enforce that dominance", while Walker claims that men exhibit a "socialized androcentric need for power".[51][52]
While some women are aggressive and dominating to male partners the majority of abuse in heterosexual partnerships, at about 80% in the USA, is by men.[53] (Note that critics[54] stress that this Department of Justice study examines crime figures, and does not specifically address domestic abuse figures. While the categories of crime and domestic abuse may cross-over, most instances of domestic abuse are not regarded as crimes or reported to police—critics thus argue that it's inaccurate to regard the DOJ study as a comprehensive statement on domestic abuse because compelling evidence shows that men and women tend to commit emotional and physical abuse in roughly equal rates.) A 2002 study reports that ten percent of violence in the UK, overall, is by females against males.[55] However, more recent data specifically regarding domestic abuse (including emotional abuse) report that 3 in 10 women, and 2 in 10 men, have experienced domestic abuse.[20]
Some argue that fundamentalist views of religions, which have developed in male-dominated cultures, tend to reinforce emotional abuse, citing the Book of Genesis as an example of a text that has been used to justify men abusing women: "in sorrow thou shalt bring forth children: and thy desire shall be to thy husband, and he shall rule over thee".[56] Critics also suggest that fundamentalist religious prohibitions against divorce make it more difficult for religious men or women to leave an abusive marriage: A 1985 survey of Protestant clergy in the United States by Jim M Alsdurf found that 21% of them agreed that "no amount of abuse would justify a woman's leaving her husband ever", and 26% agreed with the statement that "a wife should submit to her husband and trust that God would honour her action by either stopping the abuse or giving her the strength to endure it." [57]
Many older and some not so old children's stories contain gender stereotyping, and music videos and computer games for children and teenagers have been criticised for continuing to portray men as aggressive and in control, while the females are there only for their sexual allure; women are portrayed as wanting to be chased and caught when they run away.[32]
Critics argue that legal systems have in the past endorsed these traditions of male domination and it is only in recent years that abusers have begun to be punished for their behaviour.[32] Some laws in past centuries have however specifically prohibited punitive wife-beating: "The Body of Liberties adopted in 1641 by the Massachusetts Bay colonists states, 'Every married woman shall be free from bodily correction or stripes by her husband, unless it be in his own defense from her assault.'[58] In 1879, Harvard University law scholar wrote, "The cases in the American courts are uniform against the right of the husband to use any chastisement, moderate or otherwise, toward the wife, for any purpose."[59]
While recognizing that feminist researchers have done valuable work and highlighted neglected topics[60] critics suggest that the male cultural domination hypothesis for abuse is untenable as a generalized explanation for numerous reasons:
Many variables (racial, ethnic, cultural and subcultural, nationality, religion, family dynamics, mental illness, etc.) make it difficult or impossible to define male and female roles in any meaningful way that apply to the entire population.[61]
Studies show that disagreements about power-sharing in relationships are more strongly associated with abuse than are imbalances of power.[62]
Research has not discovered that male privilege is a necessary and sufficient sole cause of abuse of women. On the contrary, peer-reviewed studies have produced inconsistent results when directly examining patriarchal beliefs and wife abuse. Yllo and Straus[63] argued that "low status" women in the United States suffered higher rates of spousal abuse; however, a rejoinder argued that Yllo and Straus's interpretive conclusions were "confusing and contradictory".[64] Smith[65] estimated that patriarchal beliefs were a causative factor for only 20% of wife abuse. Other studies failed to find a causal link between spouse abuse and traditionalist/conservative cultural beliefs. Campbell[66] writes that "there is not a simple linear correlation between female status and rates of wife assault". Other studies had similar findings.[67][68] Additionally, a study of Hispanic Americans revealed that traditionalist men exhibited lower rates of abuse towards women.[69]
Studies show that treatment programs based on the patriarchal privilege model are flawed due to a weak connection between abusiveness and one's cultural or social attitudes.[70][71][72]
Numerous empirical studies challenge the concept that male abuse or control of women is culturally sanctioned. Such studies show that abusive men are widely viewed as unsuitable partners for dating or marriage.[73] A minority of abusive men qualify as pervasively misogynistic.[74] The majority of men who commit spousal abuse agree that their behavior was inappropriate.[75] A minority of men approve of spousal abuse under even limited circumstances.[76] Furthermore, the majority of men are non-abusive towards girlfriends or wives for the duration of relationships, contrary to predictions that aggression or abuse towards women is an innate element of masculine culture.[77][78][79][80]
Dutton[1] argues that the numerous studies establishing that heterosexual and gay male relationships have lower rates of abuse than lesbian relationships, and the fact that women who've been involved with both men and women were more likely to have been abused by a woman "are difficult to explain in terms of male domination". Additionally, Dutton suggests that "patriarchy must interact with psychological variables in order to account for the great variation in power-violence data. It is suggested that some forms of psychopathology lead to some men adopting patriarchal ideology to justify and rationalize their own pathology".


Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. According to the Journal of Child Abuse and Neglect, child abuse is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation, an act or failure to act which presents an imminent risk of serious harm".[3] A person who feels the need to abuse or neglect a child may be described as a "pedopath".[4]
Child sexual abuse is a form of child abuse in which an adult or older adolescent uses a child for sexual stimulation.[1][2] Forms of child sexual abuse include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure (of the genitals, female nipples, etc.) with intent to gratify their own sexual desires or to intimidate or groom the child, physical sexual contact with a child, or using a child to produce child pornography.[1][3][4]
The effects of child sexual abuse can include depression,[5] post-traumatic stress disorder,[6] anxiety,[7] propensity to further victimization in adulthood,[8] and physical injury to the child, among other problems.[9] Sexual abuse by a family member is a form of incest, and can result in more serious and long-term psychological trauma, especially in the case of parental incest.[10]
The global prevalence of child sexual abuse has been estimated at 19.7% for females and 7.9% for males, according to a 2009 study published in Clinical Psychology Review that examined 65 studies from 22 countries. Using the available data, the highest prevalence rate of child sexual abuse geographically was found in Africa (34.4%), primarily because of high rates in South Africa; Europe showed the lowest prevalence rate (9.2%); America and Asia had prevalence rates between 10.1% and 23.9%.[11] In the past, other research has concluded similarly that in North America, for example, approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.[12][13][14] Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, uncles or cousins; around 60% are other acquaintances such as 'friends' of the family, babysitters, or neighbors; strangers are the offenders in approximately 10% of child sexual abuse cases.[12] Most child sexual abuse is committed by men; studies show that women commit 14% to 40% of offenses reported against boys and 6% of offenses reported against girls.[12][13][15] Most offenders who sexually abuse prepubescent children are pedophiles,[16][17] although some offenders do not meet the clinical diagnosis standards for pedophilia.[18][19]
Under the law, "child sexual abuse" is an umbrella term describing criminal and civil offenses in which an adult engages in sexual activity with a minor or exploits a minor for the purpose of sexual gratification.[4][20] The American Psychiatric Association states that "children cannot consent to sexual activity with adults", and condemns any such action by an adult: "An adult who engages in sexual activity with a child is performing a criminal and immoral act which never can be considered normal or socially acceptable behavior."[21]

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Effects

Psychological harm

Child sexual abuse can result in both short-term and long-term harm, including psychopathology in later life.[9][22] Psychological, emotional, physical, and social effects include depression,[5][23][24]post-traumatic stress disorder,[6][25] anxiety,[7] eating disorders, poor self-esteem, dissociative and anxiety disorders; general psychological distress and disorders such as somatization, neurosis,chronic pain,[24] sexualized behavior,[26] school/learning problems; and behavior problems including substance abuse,[27][28] self-destructive behaviour, animal cruelty,[29][30][31] crime in adulthood andsuicide.[12][32][33][34][35][36] A specific characteristic pattern of symptoms has not been identified[37] and there are several hypotheses about the causality of these associations.[5][38][39]
A study funded by the USA National Institute of Drug Abuse found that "Among more than 1,400 adult females, childhood sexual abuse was associated with increased likelihood of drug dependence, alcohol dependence, and psychiatric disorders. The associations are expressed as odds ratios: for example, women who experienced nongenital sexual abuse in childhood were 2.83 times more likely to suffer drug dependence as adults than were women who were not abused."[28]
Long term negative effects on development leading to repeated or additional victimization in adulthood are also associated with child sexual abuse.[8][27] Studies have established a causal relationship between childhood sexual abuse and certain specific areas of adult psychopathology, including suicidality, antisocial behavior, PTSD, anxiety and alcoholism.[40] Adults with a history of abuse as a child, especially sexual abuse, are more likely than people with no history of abuse to become frequent users of emergency and medical care services.[24] A study comparing middle-aged women who were abused as children with non-abused counterparts found significantly higher health care costs for the former.[41]
Sexually abused children suffer from more psychological symptoms than children who have not been abused; studies have found symptoms in 51% to 79% of sexually abused children.[34][42][43][44][45] The risk of harm is greater if the abuser is a relative, if the abuse involves intercourse or attempted intercourse, or if threats or force are used.[46] The level of harm may also be affected by various factors such as penetration, duration and frequency of abuse, and use of force.[9][22][47][48] The social stigma of child sexual abuse may compound the psychological harm to children,[48][49] and adverse outcomes are less likely for abused children who have supportive family environments.[50][51]

Dissociation and posttraumatic stress disorder (PTSD)

Main articles: Dissociation (psychology) and Posttraumatic stress disorder
Child abuse, including sexual abuse, especially chronic abuse starting at early ages, has been found to be related to the development of high levels of dissociative symptoms, which includes amnesia for abuse memories.[52] The level of dissociation has been found to be related to reported overwhelming sexual and physical abuse.[53] When severe sexual abuse (penetration, several perpetrators, lasting more than one year) had occurred, dissociative symptoms were even more prominent.[53]
Child sexual abuse independently predicts the number of symptoms for PTSD a person displays, after controlling for possible confounding variables, according to Widom (1999), who wrote "sexual abuse, perhaps more than other forms of childhood trauma, leads to dissociative problems ... these PTSD findings represent only part of the picture of the long-term psychiatric sequelae associated with early childhood victimization ... antisocial personality disorder, alcohol abuse, and other forms of psychopathology."[6] Children may develop symptoms of post traumatic stress disorder resulting from child sexual abuse, even without actual or threatened injury or violence.[54]

Research factors

Because child sexual abuse often occurs alongside other possibly confounding variables, such as poor family environment and physical abuse,[55] some scholars argue it is important to control for those variables in studies which measure the effects of sexual abuse.[22][38][56][57] In a 1998 review of related literature, Martin and Fleming state "The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is due to the child's developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects."[58] Other studies have found an independent association of child sexual abuse with adverse psychological outcomes.[7][22][38]
Kendler et al. (2000) found that most of the relationship between severe forms of child sexual abuse and adult psychopathology in their sample could not be explained by family discord, because theeffect size of this association decreased only slightly after they controlled for possible confounding variables. Their examination of a small sample of CSA-discordant twins also supported a causal link between child sexual abuse and adult psychopathology; the CSA-exposed subjects had a consistently higher risk for psychopathologic disorders than their CSA non-exposed twins.[38]
A 1998 meta-analysis by Rind et al. generated controversy by suggesting that child sexual abuse does not always cause pervasive harm, that some college students reported such encounters as positive experiences and that the extent of psychological damage depends on whether or not the child described the encounter as "consensual."[59] The study was criticized for flawed methodology and conclusions.[60][61] The US Congress condemned the study for its conclusions and for providing material used by pedophile organizations to justify their activities.[62]

Physical harm

Injury

Depending on the age and size of the child, and the degree of force used, child sexual abuse may cause internal lacerations and bleeding. In severe cases, damage to internal organs may occur, which, in some cases, may cause death.[63] Herman-Giddens et al. found six certain and six probable cases of death due to child sexual abuse in North Carolina between 1985 and 1994. The victims ranged in age from 2 months to 10 years. Causes of death included trauma to the genitalia or rectum and sexual mutilation.[64]

Infections

Child sexual abuse may cause infections and sexually transmitted diseases.[65] Depending on the age of the child, due to a lack of sufficient vaginal fluid, chances of infections are higher. Vaginitis has also been reported.[65]

Neurological damage

Research has shown that traumatic stress, including stress caused by sexual abuse, causes notable changes in brain functioning and development.[66][67] Various studies have suggested that severe child sexual abuse may have a deleterious effect on brain development. Ito et al. (1998) found "reversed hemispheric asymmetry and greater left hemisphere coherence in abused subjects;"[68] Teicher et al. (1993) found that an increased likelihood of "ictal temporal lobe epilepsy-like symptoms" in abused subjects;[69] Anderson et al. (2002) recorded abnormal transverse relaxation time in the cerebellar vermis of adults sexually abused in childhood;[70] Teicher et al. (1993) found that child sexual abuse was associated with a reduced corpus callosum area; various studies have found an association of reduced volume of the left hippocampus with child sexual abuse;[71] and Ito et al. (1993) found increased electrophysiological abnormalities in sexually abused children.[72]
Some studies indicate that sexual or physical abuse in children can lead to the overexcitation of an undeveloped limbic system.[71] Teicher et al. (1993)[69] used the "Limbic System Checklist-33" to measure ictal temporal lobe epilepsy-like symptoms in 253 adults. Reports of child sexual abuse were associated with a 49% increase to LSCL-33 scores, 11% higher than the associated increase of self-reported physical abuse. Reports of both physical and sexual abuse were associated with a 113% increase. Male and female victims were similarly affected.[69][73]
Navalta et al. (2006) found that the self-reported math Scholastic Aptitude Test scores of their sample of women with a history of repeated child sexual abuse were significantly lower than the self-reported math SAT scores of their non-abused sample. Because the abused subjects verbal SAT scores were high, they hypothesized that the low math SAT scores could "stem from a defect in hemispheric integration." They also found a strong association between short term memory impairments for all categories tested (verbal, visual, and global) and the duration of the abuse.[74]

Incest

Main article: Incest
Incest between a child or adolescent and a related adult has been identified as the most widespread form of child sexual abuse with a huge capacity for damage to a child.[10] One researcher stated that more than 70% of abusers are immediate family members or someone very close to the family.[75] Another researcher stated that about 30% of all perpetrators of sexual abuse are related to their victim, 60% of the perpetrators are family acquaintances, like a neighbor, babysitter or friend and 10% of the perpetrators in child sexual abuse cases are strangers.[12] A child sexual abuse offense where the perpetrator is related to the child, either by blood or marriage, is a form of incest described as intrafamilial child sexual abuse.[76]
The most-often reported form of incest is father-daughter and stepfather-daughter incest, with most of the remaining reports consisting of mother/stepmother-daughter/son incest.[77] Father-son incest is reported less often, however it is not known if the prevalence is less, because it is under-reported by a greater margin.[78][79] Similarly, some argue that sibling incest may be as common, or more common, than other types of incest: Goldman and Goldman[80] reported that 57% of incest involved siblings; Finkelhor reported that over 90% of nuclear family incest involved siblings;[81] while Cawson et al. show that sibling incest was reported twice as often as incest perpetrated by fathers/stepfathers.[82]
Prevalence of parental child sexual abuse is difficult to assess due to secrecy and privacy; some estimates show 20 million Americans have been victimized by parental incest as children.[77]

Types

Child sexual abuse includes a variety of sexual offenses, including:
  • sexual assault – a term defining offenses in which an adult touches a minor for the purpose of sexual gratification; for example, rape (including sodomy), and sexual penetration with an object.[83]Most U.S. states include, in their definitions of sexual assault, any penetrative contact of a minor’s body, however slight, if the contact is performed for the purpose of sexual gratification.[84]
  • sexual exploitation – a term defining offenses in which an adult victimizes a minor for advancement, sexual gratification, or profit; for example, prostituting a child,[85] and creating or trafficking in child pornography.[86]
  • sexual grooming – defines the social conduct of a potential child sex offender who seeks to make a minor more accepting of their advances, for example in an online chat room.[87]

Disclosure

Children who received supportive responses following disclosure had less traumatic symptoms and were abused for a shorter period of time than children who did not receive support.[88][89] In general, studies have found that children need support and stress-reducing resources after disclosure of sexual abuse.[90][91] Negative social reactions to disclosure have been found to be harmful to the survivor’s well being.[92] One study reported that children who received a bad reaction from the first person they told, especially if the person was a close family member, had worse scores as adults on general trauma symptoms, post traumatic stress disorder symptoms, and dissociation.[93] Another study found that in most cases when children did disclose abuse, the person they talked to did not respond effectively, blamed or rejected the child, and took little or no action to stop the abuse.[91] Non-validating and otherwise non-supportive responses to disclosure by the child's primary attachment figure may indicate a relational disturbance predating the sexual abuse that may have been a risk factor for the abuse, and which can remain a risk factor for its psychological consequences. [94]
The American Academy of Child and Adolescent Psychiatry provides guidelines for what to say to the victim and what to do following the disclosure.[95] Asa Don Brown has indicated: "A minimization of the trauma and its effects is commonly injected into the picture by parental caregivers to shelter and calm the child. It has been commonly assumed that focusing on children’s issues too long will negatively impact their recovery. Therefore, the parental caregiver teaches the child to mask his or her issues."[96]

Treatment

The initial approach to treating a person who has been a victim of sexual abuse is dependant upon several important factors:
  • Age at the time of presentation
  • Circumstances of presentation for treatment
  • Co-morbid conditions
The goal of treatment is not only to treat current mental health issues, but to prevent future ones.

Children and adolescents

Children often present for treatment in one of several circumstances, including criminal investigations, custody battles, problematic behaviors, and referrals from child welfare agencies.[97]
The three major modalities for therapy with children and teenagers are family therapy, group therapy, and individual therapy. Which course is used depends on a variety of factors that must be assessed on a case by case basis. For instance, treatment of young children generally requires strong parental involvement, and can benefit from family therapy. Adolescents tend to be more independent, and can benefit from individual or group therapy. The modality also shifts during the course of treatment, for example group therapy is rarely used in the initial stages, as the subject matter is very personal and/or embarrassing.[97]
Major factors that affect both the pathology and response to treatment include the type and severity of the sexual act, its frequency, the age at which it occurred, and the child’s family of origin.

Adults

Adults with a history of sexual abuse often present for treatment with a secondary mental health issue, which can include substance abuse, eating disorders, personality disorders, depression, and conflict in romantic or interpersonal relationships.[98]
Generally the approach is to the present problem, rather than the abuse itself. Treatment is highly varied and depends on the person’s specific issues. For instance, a person with a history of sexual abuse suffering from severe depression would be treated for depression. However, there is often an emphasis on cognitive restructuring due to the deep-seated nature of the trauma. Some newer techniques such as Eye Movement Desensitization and Reprocessing (EMDR) have been shown to be effective.[99]
Sexual abuse is associated with many sub-clinical behavioral issues as well, including re-victimization in the teenage years, a bipolar-like switching between sexual compulsion and shut-down, anddistorted thinking on the subject of sexual abuse (for instance, that it is common and happens to everyone). When first presenting for treatment, the patient can be fully aware of their abuse as an event, but their appraisal of it is often distorted, such as believing that the event was unremarkable (a form of isolation). Frequently, victims do not make the connection between their abuse and their present pathology.

Offenders

Demographics

Offenders are more likely to be relatives or acquaintances of their victim than strangers.[100] A 2006–2007 Idaho study of 430 cases found that 82% of juvenile sex offenders were known to the victims (acquaintances 46% or relatives 36%).[101][102]
More offenders are male than female, though the percentage varies between studies. The percentage of incidents of sexual abuse by female perpetrators that come to the attention of the legal system is usually reported to be between 1% and 4%.[103] Studies of sexual misconduct in US schools with female offenders have shown mixed results with rates between 4% to 43% of female offenders.[104]Maletzky (1993) found that, of his sample of 4,402 convicted pedophilic offenders, 0.4% were female.[105] Another study of a non-clinical population found that, among those in the their sample that had been molested, as much as a third were molested by women.[106]
In U.S. schools, educators who offend range in age from "21 to 75 years old, with an average age of 28" with teachers, coaches, substitute teachers, bus drivers and teacher's aides (in that order) totaling 69% of the offenders.[107]

Typology

Early research in the 1970s and 80s began to classify offenders based on their motivations and traits. Groth and Birnbaum (1978) categorized child sexual offenders into two groups, "fixated" and "regressed."[108] Fixated were described as having a primary attraction to children, whereas regressed had largely maintained relationships with other adults, and were even married. This study also showed that adult sexual orientation was not related to the sex of the victim targeted, e.g. men who molested boys often had adult relationships with women.[108]
Later work (Holmes and Holmes, 2002) expanded on the types of offenders and their psychological profiles. They are divided thus:[109]
  • Situational – does not prefer children, but offend under certain conditions.
    • Regressed – Typically has relationships with adults, but a stressor causes them to seek children as a substitute.
    • Morally Indiscriminate – All-around sexual deviant, who may commit other sexual offenses unrelated to children.
    • Naive/Inadequate – Often mentally disabled in some way, finds children less threatening.
  • Preferential – has true sexual interest in children.
    • Mysoped – Sadistic and violent, target strangers more often than acquaintances.
    • Fixated – Little or no activity with own age, described as an "overgrown child."

Causal factors

Causal factors of child sex offenders are not known conclusively.[110] The experience of sexual abuse as a child was previously thought to be a strong risk factor, but research does not show a causal relationship, as the vast majority of sexually abused children do not grow up to be adult offenders, nor do the majority of adult offenders report childhood sexual abuse. The US Government Accountability Office concluded, "the existence of a cycle of sexual abuse was not established." Prior to 1996, there was greater belief in the theory of a "cycle of violence," because most of the research done was retrospective—abusers were asked if they had experienced past abuse. Even the majority of studies found that most adult sex offenders said they had not been sexually abused during childhood, but studies varied in terms of their estimates of the percentage of such offenders who had been abused, from 0 to 79 percent. More recent prospective longitudinal research—studying children with documented cases of sexual abuse over time to determine what percentage become adult offenders—has demonstrated that the cycle of violence theory is not an adequate explanation for why people molest children.[111]
Offenses may be facilitated by cognitive distortions of the offender, such as minimization of the abuse, victim blaming, and excuses.[112]

Pedophilia

Main article: Pedophilia
The term "pedophilia" refers to persistent feelings of attraction in an adult or older adolescent toward prepubescent children, whether the attraction is acted upon or not.[113][114][115] A person with this attraction is called a "pedophile".[116]
According to the Mayo Clinic, approximately 95% of incidents of sexual abuse of children age 12 and younger are committed by offenders who meet the diagnostic criteria for pedophilia;[16] and that such persons make up 65% of child molestation offenders.[16] Pedophilic child molesters commit ten times more sexual acts against children than non-pedophilic child molesters.[16]
In law enforcement, the term "pedophile" is generally used to describe those accused or convicted of child sexual abuse under sociolegal definitions of child (including both prepubescent children and adolescents younger than the local age of consent);[17] however, not all child sexual offenders are pedophiles and not all pedophiles engage in sexual abuse of children.[18][117][118] Law enforcement and legal professionals have begun to use the term predatory pedophile,[119] a phrase coined by children's attorney Andrew Vachss, to refer specifically to pedophiles who engage in sexual activity with minors.[120] The term emphasizes that child sexual abuse consists of conduct chosen by the perpetrator.[121]

Recidivism

Recidivism rates for sex offenders are lower than for the general criminal population.[122] Estimated rates among child sex offenders vary. One study found that 42% of offenders re-offended (either a sex crime, violent crime, or both) after they were released. Risk for re-offense was highest in the first 6 years after release, but continued to be significant even 10–31 years later, with 23% offending during this time.[123] A study done in California in 1965 found an 18.2% recidivism rate for offenders targeting the opposite sex and a 34.5% recidivism rate for same-sex offenders after 5 years.[124]

Child and young adolescent offenders

Main article: Child-on-child sexual abuse
When a prepubescent child is sexually abused by one or more other children or adolescent youths, and no adult is directly involved, it is defined as child-on-child sexual abuse. The definition includes any sexual activity between children that occurs without consent, without equality, or as a result of coercion,[125] whether the offender uses physical force, threats, trickery or emotional manipulation to compel cooperation. When sexual abuse is perpetrated by one sibling upon another, it is known as "intersibling abuse", a form of incest.[126]
Unlike research on adult offenders, a strong causal relationship has been established between child and adolescent offenders and these offenders' own prior victimization, by either adults or other children.[127][128][129][130]

Contents

  [hide] 

[edit]Types

Child abuse can take several forms:[5] The four main types are physical, sexual, psychological, and neglect.[6] A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice], Office on Child Abuse and doctor). There are many effects of child neglect, such as children not being able to interact with other children around them.[7] The continuous refusal of a child's basic needs is considered chronic neglect.[8]

[edit]Physical abuse

Physical abuse involves physical aggression directed at a child by an adult. Most nations with child-abuse laws consider the deliberate infliction of serious injuries, or actions that place the child at obvious risk of serious injury or death, to be illegal. Beyond this, there is considerable variation. The distinction between child discipline and abuse is often poorly defined. Cultural norms about what constitutes abuse vary widely: among professionals as well as the wider public, people do not agree on what behaviors constitute abuse.[9] Some professionals claim that cultural norms that sanctionphysical punishment are one of the causes of child abuse, and have undertaken campaigns to redefine such norms.[10][11][12]

[edit]Child sexual abuse

Main articles: Child sexual abuse and child-on-child sexual abuse
Child sexual abuse (CSA) is a form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation.[13][14] Forms of CSA include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact with a child, physical contact with the child's genitals, viewing of the child's genitalia without physical contact, or using a child to produce child pornography.[13][15][16] Selling the sexual services of children may be viewed and treated as child abuse with services offered to the child rather than simple incarceration.[17]
Effects of child sexual abuse include guilt and self-blame, flashbacks, nightmares, insomnia, fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.), self-esteem issues, sexual dysfunction, chronic pain, addiction, self-injury, suicidal ideation, somatic complaints, depression,[18] post-traumatic stress disorder,[19] anxiety,[20] other mental illnesses(including borderline personality disorder[21] and dissociative identity disorder,[21] propensity to re-victimization in adulthood,[22] bulimia nervosa,[23] physical injury to the child, among other problems.[24]
Approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.[25][26][27][28][29] Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, mothers, uncles or cousins; around 60% are other acquaintances such as friends of the family, babysitters, or neighbours; strangers are the offenders in approximately 10% of child sexual abuse cases.[25] In over one-third of cases, the perpetrator is also a minor.[30]

[edit]Psychological/emotional abuse

Main article: Emotional abuse
Out of all the possible forms of abuse, emotional abuse is the hardest to define. It could include name-calling, ridicule, degradation, destruction of personal belongings, torture or killing of a pet, excessive criticism, inappropriate or excessive demands, withholding communication, and routine labeling or humiliation.[31]
Victims of emotional abuse may react by distancing themselves from the abuser, internalizing the abusive words, or fighting back by insulting the abuser. Emotional abuse can result in abnormal or disrupted attachment development, a tendency for victims to blame themselves (self-blame) for the abuse, learned helplessness, and overly passive behavior.[31]

[edit]Prevalence

According to the (American) National Committee to Prevent Child Abuse, in 1997 neglect represented 54% of confirmed cases of child abuse, physical abuse 22%, sexual abuse 8%, emotional maltreatment 4%, and other forms of maltreatment 12%.[32]
A UNICEF report on child wellbeing[33] stated that the United States and the United Kingdom ranked lowest among industrial nations with respect to the wellbeing of children. It also found that child neglect and child abuse were far more common in single-parent families than in families where both parents are present.[citation needed]
In the USA, neglect is defined as the failure to meet the basic needs of children including housing, clothing, food and access to medical care. Researchers found over 91,000 cases of neglect in one year (from October 2005 to 30 September 2006) using information from a database of cases verified by protective services agencies.[2]
Neglect could also take the form of financial abuse by not buying the child adequate materials for survival.[34]
The U.S. Department of Health and Human Services reports that for each year between 2000 and 2005, "female parents acting alone" were most likely to be perpetrators of child abuse.[35]
Race and ethnicity of victims in 2010: 44.8% of all victims were White, 21.9% were African American, and 21.4% were Hispanic.[36]

[edit]Fatalities

A child abuse fatality: when a child’s death is the result of abuse or neglect, or when abuse and/or neglect are contributing factors to a child’s death. In the United States, 1,730 children died in 2008 due to factors related to abuse; this is a rate of 2 per 100,000 U.S. children.[37] Child abuse fatalities are widely recognized as being under-counted; it is estimated that between 60–85% of child fatalities due to maltreatment are not recorded as such on death certificates. Younger children are at a much higher risk for being killed, as are African Americans. Girls and boys, however, are killed at similar rates. Caregivers, and specifically mothers, are more likely to be the perpetrators of a child abuse fatality, than anyone else, including strangers, relatives, and non-relative caregivers[citation needed]. Family situations which place children at risk include moving, unemployment, having non-family members living in the household. A number of policies and programs have been put into place to try to better understand and to prevent child abuse fatalities, including: safe-haven laws, child fatality review teams, training for investigators, shaken baby syndrome prevention programs, and child abuse death laws which mandate harsher sentencing for taking the life of a child.[38][unreliable source?][verification needed]

[edit]Causes

See also: Infanticide (zoology)
Child abuse is a complex phenomenon with multiple causes.[39] Understanding the causes of abuse is crucial to addressing the problem of child abuse.[40] Parents who physically abuse their spouses are more likely than others to physically abuse their children.[41] However, it is impossible to know whether marital strife is a cause of child abuse, or if both the marital strife and the abuse are caused by tendencies in the abuser.[41]
Children resulting from unintended pregnancies are more likely to be abused or neglected.[42][43] In addition, unintended pregnancies are more likely than intended pregnancies to be associated with abusive relationships,[44] and there is an increased risk of physical violence during pregnancy.[45] They also result in poorer maternal mental health,[45] and lower mother-child relationship quality.[45]
Substance abuse can be a major contributing factor to child abuse. One U.S. study found that parents with documented substance abuse, most commonly alcohol, cocaine, and heroin, were much more likely to mistreat their children, and were also much more likely to reject court-ordered services and treatments.[46] Another study found that over two thirds of cases of child maltreatment involved parents with substance abuse problems. This study specifically found relationships between alcohol and physical abuse, and between cocaine and sexual abuse.[47]
Unemployment and financial difficulties are associated with increased rates of child abuse.[48] In 2009 CBS News reported that child abuse in the United States had increased during the economic recession. It gave the example of a father who had never been the primary care-taker of the children. Now that the father was in that role, the children began to come in with injuries.[49]
A 1988 study of child murders in the US found that children are 100 times more often killed by a "non-biological parent (e.g. step-parent, co-habitee or boyfriend/girlfriend of a biological parent)" than by a biological parent.[50] An evolutionary psychology explanation for this is that using resources in order to take care of another person's biological child is likely not a good strategy for increasingreproductive success.[50] More generally, stepchildren have a much higher risk of being abused which is sometimes referred to as the Cinderella effect.

[edit]Effects

There are strong associations between exposure to child abuse in all its forms and higher rates of many chronic conditions. The strongest evidence comes from the Adverse Childhood Experiences (ACE's) series of studies which show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions, high-risk health behaviors and shortened lifespan.[51] A recent publication, Hidden Costs in Health Care: The Economic Impact of Violence and Abuse,[52] makes the case that such exposure represents a serious and costly public-health issue that should be addressed by the healthcare system. Child abuse is a major life stressor that has consequences involving the mental health of an adult but, the majority of studies examining the negative consequences of abuse have been focused on adolescences and young adults.[citation needed] It has been identified that childhood sexual abuse is a risk factor for the development of substance-related problems during adolescence and adulthood.[citation needed] The early experiences of child abuse can trigger the development of an internalizing disorder, such as anxiety and depression. For example, adults with a history of some form of child abuse, whether sexual abuse, physical abuse, or neglect, have more chances of developing depression then an adult who has never been abused.[citation needed] Child abuse can also cause problems with the neurodevelopment of a child.[citation needed] Research[by whom?] shows that abused children often develop deficits with language, deregulation of mood, behaviour and also social/emotional disturbances. These risks are elevated when child abuse is combined with traumatic events and/or fetal alcohol exposure.[citation needed]

[edit]Psychological effects

Children who have a history of neglect or physical abuse are at risk of developing psychiatric problems,[53][54] or a disorganized attachment style.[55][56][57] Disorganized attachment is associated with a number of developmental problems, including dissociative symptoms,[58] as well as anxiety, depressive, and acting out symptoms.[59][60] A study by Dante Cicchetti found that 80% of abused and maltreated infants exhibited symptoms of disorganized attachment.[61][62] When some of these children become parents, especially if they suffer from posttraumatic stress disorder (PTSD), dissociative symptoms, and other sequelae of child abuse, they may encounter difficulty when faced with their infant and young children's needs and normative distress, which may in turn lead to adverse consequences for their child's social-emotional development.[63][64] Despite these potential difficulties, psychosocial intervention can be effective, at least in some cases, in changing the ways maltreated parents think about their young children.[65]
Victims of childhood abuse, it is claimed, also suffer from different types of physical health problems later in life. Some reportedly suffer from some type of chronic head, abdominal, pelvic, or muscular pain with no identifiable reason.[66] Even though the majority of childhood abuse victims know or believe that their abuse is, or can be, the cause of different health problems in their adult life, for the great majority their abuse was not directly associated with those problems, indicating that sufferers were most likely diagnosed with other possible causes for their health problems, instead of their childhood abuse.[66]
The effects of child abuse vary, depending on the type of abuse. A 2006 study[which?] found that childhood emotional and sexual abuse were strongly related to adult depressive symptoms, while exposure to verbal abuse and witnessing of domestic violence had a moderately strong association, and physical abuse a moderate one. For depression, experiencing more than two kinds of abuse exerted synergetically stronger symptoms. Sexual abuse was particularly deleterious in its intrafamilial form, for symptoms of depression, anxiety, dissociation, and limbic irritability.[clarification needed]Childhood verbal abuse had a stronger association with anger-hostility than any other type of abuse studied, and was second only to emotional abuse in its relationship with dissociative symptoms.[citation needed] More generally, in the case of 23 of the 27 illnesses listed in the questionnaire of a French INSEE survey, some statistically significant correlations were found between repeated illness and family traumas encountered by the child before the age of 18 years.[67] According to Georges Menahem, the French sociologist who found out these correlations by studying health inequalities, these relationships show that inequalities in illness and suffering are not only social. Health inequality also has its origins in the family, where it is associated with the degrees of lasting affective problems (lack of affection, parental discord, the prolonged absence of a parent, or a serious illness affecting either the mother or father) that individuals report having experienced in childhood.[citation needed]

[edit]Physical effects

Rib fractures in an infant secondary to child abuse
Children who are physically abused are likely to receive bone fractures, particularly rib fractures,[68] and may have a higher risk of developing cancer.[69]Children who experience child abuse & neglect are 59% more likely to be arrested as juveniles, 28% more likely to be arrested as adults, and 30% more likely to commit violent crime.[70]
The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. The long-term effects can be:
Shaken baby syndrome. Shaking a baby is a common form of child abuse that often results in permanent neurological damage (80% of cases) or death (30% of cases).[71] Damage results from intracranial hypertension (increased pressure in the skull) after bleeding in the brain, damage to the spinal cord and neck, and rib or bone fractures (Institute of Neurological Disorders and Stroke, 2007).
Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006). NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/OPRE, 2004a).
Poor physical health. Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).[72]
On the other hand, there are some children who are raised in child abuse, but who manage to do unexpectedly well later in life regarding the preconditions. Such children have been termed dandelion children, as inspired from the way that dandelions seem to prosper irrespective of soil, sun, drought, or rain.[73] Such children (or currently grown-ups) are of high interest in finding factors that mitigate the effects of child abuse.

[edit]Prevention

Unintended conception increases the risk of subsequent child abuse, and large family size increases the risk of child neglect.[43] Thus a comprehensive study for the National Academy of Sciences concluded that affordable contraceptive services should form the basis for child abuse prevention.[43][74] "The starting point for effective child abuse programming is pregnancy planning," according to an analysis for US Surgeon General C. Everett Koop.[43][75]
April has been designated Child Abuse Prevention Month in the United States since 1983.[76] U.S. President Barack Obama continued that tradition by declaring April 2009 Child Abuse Prevention Month.[77] One way the Federal government of the United States provides funding for child-abuse prevention is through Community-Based Grants for the Prevention of Child Abuse and Neglect (CBCAP).[78]
Resources for child-protection services are sometimes limited. According to Hosin (2007), "a considerable number of traumatized abused children do not gain access to protective child-protection strategies."[79] Briere (1992) argues that only when "lower-level violence" of children ceases to be culturally tolerated will there be changes in the victimization and police protection of children.[80]

[edit]Treatment

A number of treatments are available to victims of child abuse.[81] Trauma-focused cognitive behavioral therapy, first developed to treat sexually abused children, is now used for victims of any kind of trauma. It targets trauma-related symptoms in children including post-traumatic stress disorder (PTSD), clinical depression and anxiety. It also includes a component for non-offending parents. Several studies have found that sexually abused children undergoing TF-CBT improved more than children undergoing certain other therapies. Data on the effects of TF-CBT for children who experienced only non-sexual abuse was not available as of 2006.[81]
Abuse-focused cognitive behavioral therapy was designed for children who have experienced physical abuse. It targets externalizing behaviors and strengthens prosocial behaviors. Offending parents are included in the treatment, to improve parenting skills/practices. It is supported by one randomized study.[81]
Child-parent psychotherapy was designed to improve the child-parent relationship following the experience of domestic violence. It targets trauma-related symptoms in infants, toddlers, and preschoolers, including PTSD, aggression, defiance, and anxiety. It is supported by two studies of one sample.[81]
Other forms of treatment include group therapy, play therapy, and art therapy. Each of these types of treatment can be used to better assist the client, depending on the form of abuse they have experienced. Play therapy and art therapy are ways to get children more comfortable with therapy by working on something that they enjoy (coloring, drawing, painting, etc.). The design of a child's artwork can be a symbolic representation of what they are feeling, relationships with friends or family, and more. Being able to discuss and analyze a child's artwork can allow a professional to get a better insight of the child.[82]

[edit]Ethics

One of the most challenging ethical dilemmas arising from child abuse relates to the parental rights of abusive parents or caretakers with regard to their children, particularly in medical settings.[83] In the United States, the 2008 New Hampshire case of Andrew Bedner drew attention to this legal and moral conundrum. Bedner, accused of severely injuring his infant daughter, sued for the right to determine whether or not she remain on life support; keeping her alive, which would have prevented a murder charge, created a motive for Bedner to act that conflicted with the apparent interests of his child.[83][84][85] Bioethicists Jacob M. Appel and Thaddeus Mason Pope recently argued, in separate articles, that such cases justify the replacement of the accused parent with an alternative decision-maker.[83][86]
Child abuse also poses ethical concerns related to confidentiality, as victims may be physically or psychologically unable to report abuse to authorities. Accordingly, many jurisdictions and professional bodies have made exceptions to standard requirements for confidentiality and legal privileges in instances of child abuse. Medical professionals, including doctors, therapists, and other mental health workers typically owe a duty of confidentiality to their patients and clients, either by law and/or the standards of professional ethics, and cannot disclose personal information without the consent of the individual concerned. This duty conflicts with an ethical obligation to protect children from preventable harm. Accordingly, confidentiality is often waived when these professionals have a good faith suspicion that child abuse or neglect has occurred or is likely to occur and make a report to local child protection authorities. This exception allows professionals to breach confidentiality and make a report even when the child or his/her parent or guardian has specifically instructed to the contrary. Child abuse is also a common exception to Physician–patient privilege: a medical professional may be called upon to testify in court as to otherwise privileged evidence about suspected child abuse despite the wishes of the child and his/her family.[87]

[edit]Organizations

There are organizations at national, state, and county levels in the United States that provide community leadership in preventing child abuse and neglect. The National Alliance of Children's Trust Funds and Prevent Child Abuse America are two national organizations with member organizations at the state level.
Many investigations into child abuse are handled on the local level by Child Advocacy Centers. Started over 25 years ago at what is now known as the National Children's Advocacy Center[88] in Huntsville, Alabama by District Attorney Robert "Bud" Cramer these multi-disciplinary teams have met to coordinate their efforts so that cases of child abuse can be investigated quickly and efficiently, ultimately reducing trauma to the child and garnering better convictions.[89][90] These Child Advocacy Centers (known as CACs) have standards set by the National Children's Alliance.[91]
Other organizations focus on specific prevention strategies. The National Center on Shaken Baby Syndrome focuses its efforts on the specific issue of preventing child abuse that is manifested asshaken baby syndrome. Mandated reporter training is a program used to prevent ongoing child abuse.

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