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Home > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect > The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect: How Child Abuse And Neglect Is Defined
The Role of Mental Health Professionals in the Prevention and Treatment of Child Abuse and Neglect
User Manual Series (1993)
How Child Abuse And Neglect Is DefinedThe Child Abuse Prevention and Treatment Act (Public Law l02-295) defines child abuse and neglect as the physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment:
Legal definitions of child abuse and neglect and child abuse reporting law requirements vary from State to State. Because mental health professionals are mandated by all States to report child abuse and neglect, they must be knowledgeable about reporting law requirements. Information about reporting requirements can be obtained by calling State or county child protective services (CPS) or a local law enforcement agency. The NCCAN publication entitled Child Abuse and Neglect: A Shared Community Concern contains a list of State CPS agencies; how to access county agencies if a State's child protection services are organized by county, telephone number(s), address; and procedures on how to make a child abuse report. Operational Definitions The four types of abuse described below may occur alone or in combination. Physical and sexual abuse and neglect are not separate, discrete categories. They overlap in the experiences of many children and are linked to short- and long-term psychological sequelae. Physical Abuse Physical abuse is characterized by inflicting physical injury by hitting, punching, beating, kicking, throwing, biting, burning, or otherwise physically harming a child. The injury may be the result of a single episode or of repeated episodes. The physical trauma can range in severity from minor bruising, abrasions, lacerations, burns, eye injuries, and fractures to damage to the brain and internal organs (liver, spleen, abdomen, pancreas, and kidneys). Head and internal injuries are the leading causes of child abuse-related deaths. This form of abuse also includes extreme or bizarre forms of punishment such as torture or confinement of children in dark closets, boxes, or rooms for days, months, or even years at a time. Sexual Abuse Child sexual abuse includes a wide range of conduct: genital exposure; masturbation between adult and child; fondling breasts, genitals, buttocks, and thighs; oral copulation; vaginal or anal penetration by finger, penis, or foreign object; dry intercourse (rubbing penis between child's thighs or anal-genital area); and commercial exploitation through prostitution or the production of pornographic materials. Children are more often sexually abused by someone responsible for their care than by strangers. The most commonly reported cases involve incest (sexual abuse occurring among nuclear family members) between father or stepfather and daughter. Motherson, fatherson, motherdaughter, and brothersister incest also occurs. Sexual abuse may be committed by other relatives such as grandfathers, grandmothers, cousins, aunts, and uncles or by nonrelatives such as babysitters and day care providers, teachers, children's activity group leaders, neighbors, and friends of the family. Sexual abuse may also involve multiple child victims by a group of offenders, sometimes involving satanic or ritualistic practices. Client histories of ritualistic abuse may include reports of torture, animal and human sacrifice, and homicide. Similar reports have surfaced in many States and should not be dismissed because they sound unbelievable. Emotional/Psychological Abuse Emotional abuse includes acts or omissions by the parents or other persons responsible for the child's care that have caused, or could cause, serious emotional, behavioral, cognitive, or mental disorders. Emotional/ psychological abuse exists on a continuum of habitual behavioral interactions such as belittling through comments, comparisons, and name-calling; scapegoating; humiliating; isolating; screaming and raging; and psychological inaccessibility or rejecting treatment. Child Neglect Child neglect is characterized by failure to provide for the child's basic needs. Neglect can be physical, educational, or emotional.
Incidence In 1990, States received an estimated 1.7 million reports of alleged child abuse and neglect of an estimated 2.7 million children. After investigation, more than 618,200 allegations involving more than 846,000 children were substantiated or indicated. Because definitions and criteria vary from State to State and data collection methods differ, it is difficult to obtain representative statistics. States do provide their annual data on child abuse and neglect cases to NCCAN, which publishes them as reports and working papers of the National Child Abuse and Neglect Data System. A commonly asked question is whether the incidence of child abuse is actually increasing or whether public awareness has caused more people to report abuse and neglect. No one knows for sure; however, many of the causative factors in child abuse have not been ameliorated but have worsened. Social indicators include poverty and unemployment rates; drug and alcohol abuse; school dropout rates; high incidence of low birthweight babies; stress; poor or inadequate housing; high divorce rates and resulting increase in single-parent households headed by women; teen pregnancy; and increased social isolation caused by decline of influence by the nuclear and extended family; by reduced participation in school, community or church activities; and the gradual disenfranchisement or dissociation of individuals from the community. For more information on the definitions and extent of child maltreatment, the reader is referred to another manual in this series entitled A Coordinated Response to Child Abuse and Neglect: A Basic Manual. Effects Of Child Abuse Child abuse and neglect have been found to be intergenerational in families, although not all maltreated children mature to become parents who abuse and neglect their children. In many families, however, models of parenting are passed on through the generations, and victims internalize or adapt the patterns of their victimizers. These parenting and intergenerational patterns can be changed or modified through education and effective treatment interventions with children and parents. Child maltreatment by parents and caretakers has a significant impact on the organization and development of personality. The child development literature is clear that the most significant factor in children's lives is their relationship to their parents. Interactions from birth form this relationship, and the result is a continuum of high- or low-degree bonding, attachment, and family cohesiveness. Disruption and impairment of bonding and attachment directly affect the child's formation of internal beliefs about him/herself and others. The child's self-perception and subsequent responses and adaptations to the maltreatment affect personality development and how the child relates to others. Contextual and Developmental Factors Contextual (environmental) and developmental factors are important to consider in evaluating the impact of child abuse and neglect because they affect the variability in the experience of abuse by the child and the family's response to the abuse. These mediating variables prevent a simple cause-and-effect response to victimization. It is possible to identify certain maladaptive responses that occur with high frequency (sexualized behavior, aggressive behavior, or passive or withdrawn behavior) in studies of sexually and physically abused or neglected children. Despite the frequency, the mediating variables make it impossible to predict that the behavioral indicators listed below will be present in every abused and neglected child. Examples of contextual variables include:
Examples of developmental considerations are:
This section will present a brief summary of intrapersonal and interpersonal problems reported in the literature about maltreated children--and issues that adults abused as children experience. Each form of maltreatment is presented separately; however, it is important to emphasize that neglect and emotional, physical, and sexual abuse can overlap in families. Physical Abuse The consequences of physical abuse on the developing child have been well documented. Salter, Richardson, and Kairys state, "Abused children have learned that their world is an unpredictable, often hurtful place. The adults who care for them may be angry, impatient, depressed, and distant. Further, they can be transformed without warning, into hostile, violent persons."8 With a physically abusive parent, the child's attachment is affected in a manner that causes the young child to develop a perception of himself as incompetent, unloved, and unlovable. This experience can result in a pattern of expecting the infliction of pain or injury from others, of behaving in ways to incite pain and injury, of distrusting closeness, of feeling helpless and powerless, and of developing wariness or suspicion of others. Older children often demonstrate some type of affective problem (e.g., depression, sadness, anxiety). They numb themselves to abuse, become limited in their ability to perceive their own feelings, and have difficulty interpreting and responding to the emotional expressions of others. As a result of abuse, children and adults may develop a pattern of denying or limiting certain emotional responses (i.e., feelings that may be conflictual) which, in turn, limit their ability to be expressive or spontaneous in other contexts. Although this blunted affective ability and response may be useful in coping with the psychic pain of being abused, it may inhibit the range of emotional responses and impairs an important part of a child's development. Older physically abused children also have a tendency to become caretakers for their abusive parents.9 These children often engage in caregiving actions that serve to meet the needs of their parents and reduce parents' stress. The children may also provide similar caregiving behavior to younger children within the family to provide assistance to their parents, meet the needs of the siblings, and reduce stress within the family. A further explanation of this caregiver role reversal is the need to counteract feelings of powerlessness and acquire positive meaning and appreciation within their life as a way of maintaining closeness to their attachment figure. Both verbally and physically aggressive behavior and passive compliance and avoidant behavior have been reported by studies investigating physically abused children. Green suggests that aggressiveness is an effort by abused children to avoid feelings of helplessness and anxiety.10 Helfer suggests that being raised in an environment where physical abuse is a common response to problems, feelings, and conflicts impairs several important developmental behaviors such as problem solving, accepting delayed gratification, and impulse control.11 Without the opportunity to learn these behaviors, a child responds in ways that are modeled within the family. In response to conflict, negative affect, or a problem, abused children resort to some type of verbal or physical hostility or passive compliance to resolve the problem or to meet their unmet needs. Physically abused children frequently have significant problems in their ability to develop and sustain peer relationships. In their review, Mueller and Silverman state that "the very heart of peer relations, a felt equality between partners, involves developing a working model of relationships that is based on sharing, equality, and non-exploitation. The experiences of abuse and neglect seem antithetical to developing such a model."12 Sexual Abuse In reviewing the empirical research on child sexual victimization, some type of intrapersonal disturbance in children, adolescents, and adults has been consistently reported. A sexual abuse victim feels a sense of shame unlike that from other forms of abuse. Even the youngest children drop their voices to barely audible during interviews when describing the details of sexual abuse. The shame is in response to both the misuse of the child and the abuse of the sexuality that is both a physical and psychological aspect of human beings. Sexual abuse victims experience a loss of power and control over their lives. They report symptoms of fear, anxiety, isolation, vulnerability, feeling different from others, and feelings of low self-esteem. With intrafamilial abuse, they also feel a sense of betrayal toward the abusive parent, grandparent, or sibling and anger toward the nonabusive parent if they failed to believe or protect them. Porter, Block, and Sgroi describe sexual abuse victims perceiving themselves as "damaged goods," a characterization to describe an overall sense of poor self-image.13 Finkelhor describes the dynamic of betrayal as shown through distrust in others14 15 and conflicted relationships with others as shown through reactions of fear and hostility. 16 17 Despite this sense of distrust or wariness towards others, research regarding victims of sexual abuse has shown that they have an increased risk of being revictimized.18 A consistent finding in research describing consequences of child sexual abuse is the increase in sexualized behavior in many children and promiscuity in adolescents and adults. Two studies using standardized measures of assessment have indicated that sexually abused children tend to be more involved with sexual ideation and behavior.19 20 One study reported that nearly three-fourths of the boys and slightly more than two-fifths of the girls exhibited some type of sexual problem (e.g., preoccupation with masturbating, masturbating in public, talks about sex too much).21 In a second study, approximately one-fourth of the younger age group (46 years) and one-third of the older age group (713 years) were elevated on a sexual behavior scale (which included items about excessive sexual curiosity, open masturbation).22 In a smaller sample of 14 boys referred to therapy for sexual aggression, Friedrich and Leucke identified 11 of them with a history of being sexually victimized.23 Several clinical case studies report a variety of sexual behavior problems in children with a history of sexual abuse, including problems with sexual acting-out, an exaggerated interest in sexuality, and an increased interest in sexual material.24 25 26 Finally, several researchers have suggested that having a history of sexual abuse may contribute to becoming a sexual offender (either as a juvenile, adult, or both). 27 28 It is important to note that, as a group, sex offenders may possess a relatively high prevalence of child sexual abuse in their childhoods, but this does not mean that children who have been sexually abused will become sexual offenders. An extensive study conducted by the Tufts' New England Medical Center, was one of the first research reports to use standardized measures in examining sexually abused boys and girls.29 This study reported that nearly half of the oldest age group (713 years of age) showed substantially elevated levels of hostility on scales of aggression and antisocial behavior on the Louisville Behavior Checklist. Similarly, approximately one-sixth of the younger age group (46 years of age) were reported as being elevated on these same scales of aggression and antisocial behavior. Neglect In neglectful families, the infant or child does not experience an actively involved, caring, responsible, and reliable caretaker. These children do not experience recognition of themselves or their needs. The consequences of this experience for overall personality development are profound. In contrast to physical and sexual abuse (where children experience visibility, albeit negative) with neglect, the child feels invisible. This childhood experience may manifest in symptoms of withdrawal, depression, passivity, and disorientation or confusion. Neglected children have been shown to become helpless and passive, and they tend to roam aimlessly when placed in a situation where they are temporarily separated from their parent.30 Howes and Espinoza report that the neglected children appeared to display less affect, either positive or negative, in their peer encounters.31 Helfer reports that being raised in such an abnormal environment results in several intrapersonal problems because the child's needs are not consistently met. Core self-esteem is pervasively damaged.32 The processes of decisionmaking and problem solving are rarely modeled adequately, and the child has limited opportunity to build and practice these skills. Some of these children do not fully develop the capacity to control their feelings and actions or develop delayed gratification, which results in impulsive behavior. It has been reported that many neglectful mothers have difficulty providing adequate care for their children because of their past history of maltreatment.33 As a result of dysfunctional interpersonal relationships, these mothers have difficulty coping with the demands of an intimate relationship and may not understand their children's cues and interactions because of their own emotional limits and instability. They may have limited capacity to engage in healthy attachment relationships with their children. Consequently, their children may never acquire the basic interpersonal skills and may grow up to perpetuate this intergenerational transmission of relationship dysfunction. When interacting with peers, neglected children tend to be withdrawn from schoolmates or relate to peers in a disorganized, active, or aggressive manner. They may exhibit fewer positive play behaviors, such as offering, sharing, showing, accepting, throwing, and following. This problem in peer relationships is supported by Hoffman-Plotkin and Twentyman,34 who report that neglected children tend to be more withdrawn than physically abused children and nonmaltreated children. Additionally, their research suggests that both physically abused and neglected children exhibit less prosocial behavior than nonmaltreated children. This is consistent with another study, which reports that neglected children directed fewer positive behaviors toward their peers, initiated fewer interactions, and were involved in simpler forms of play.35 In a related study, it was found that neglected children appeared resistant to approaches from a friendly playmate, confirming the researchers' assumption of problems related to prosocial abilities.36 Mental Health Evaluations Children and parents may be referred for evaluations for legal or forensic purposes or for case planning and treatment purposes. Clarifying the reasons for the evaluation referral is important. The mental health professional needs to identify the questions that need to be answered by this evaluation and the purposes for which this information will be used. Professionals from the fields of criminal justice and CPS making referrals may need information about mental health evaluations, what questions can be answered, the different objectives of forensic and clinical assessments, psychological testing, and consultation on how to interpret the results of psychological assessments. Mental health professionals must also understand the difference between forensic and clinical evaluations, clearly explain their role to the client(s), and clarify for clients such issues as client confidentiality and release of information as they relate to each type of evaluation. Forensic Evaluations Children are referred for evaluations by law enforcement investigators, attorneys for the defense or prosecution, or by CPS for help in determining whether abuse occurred. Sexually abused children are most commonly referred for this reason because the case is often entirely based on statements made by the child, and it has been determined that a specially trained clinician is needed to perform the interview. Physical findings from medical/evidentiary exams, which can support the case, are only present in about 28 percent of the cases.37 This is in contrast to physical abuse and neglect cases, in which the case is largely based on the physical evidence. Because child sexual abuse cases are mainly based on children's reports of what happened, children are frequently subjected to multiple interviews by multiple interviewers. The purposes of these various interviews are to obtain information for criminal investigations and make child protective custody decisions. Multiple interviews by multiple interviewers have been found to be emotionally damaging to children. Multidisciplinary interview centers are beginning to be established in some communities to reduce this trauma to children. At these sites, specially trained specialists conduct interviews that meet the needs of both criminal and CPS investigations. Law enforcement investigators, CPS social workers, and prosecutors observe the interviews behind a one-way glass. The interviews are also videotaped to reduce the need for repeated interviews. Because many communities have not yet established this practice, it is not uncommon for mental health professionals to receive referrals for forensic evaluations of children. Other reasons for these referrals are: the child shows behavioral symptoms of being sexually abused, but will not make any verbal statements; allegations in divorce/child custody disputes include abuse or neglect; confusion or conflict exists in the case, and an independent professional is needed to sort out the issues; and, recently, in physical abuse cases, mental health professionals have been called on to testify on "battered child syndrome" as a defense for homicide. These are cases in which adolescents have murdered their parents after years of physical and emotional abuse. Since nearly all of these types of evaluations require submitting a report to the court and testifying, mental health professionals must be prepared to defend their conclusions and recommendations, their education and credentials, and their knowledge of the literature. The primary purposes of the forensic evaluation are to determine if there is sufficient information to file charges related to child maltreatment and if the child is sufficiently capable of providing valid and reliable information. Typically, this involves determining the child's ability to recall information (i.e., developmental, intellectual, and affective functioning), acquiring basic information about the complaint, and documenting psychological and behavioral symptoms associated with abuse that support the allegation. This type of assessment requires knowledge of child development to enable the clinician to understand the abilities of a child to recall information at various ages, how to approach and interview children, and how to interpret the information provided by the child. A pitfall to avoid in interviewing young children for legal purposes is to ask leading questions that suggest the answer. Training with law enforcement investigators is recommended to distinguish between an appropriate question and a leading question that suggests or promotes an answer. Videotaping interviews may be helpful to preserve the child's answers to questions and document the manner in which they were asked. The following format can be used in these evaluations:
Parents Evaluations are performed of both abusive parents and nonoffending parents. The purpose of the evaluation of abusive parents is to assess their mental status; the presence of personality disorders, psychiatric problems, or psychopathology; character strengths and weaknesses; the precipitant of the abuse/neglect and whether the precipitants are chronic or situational; whether the person has a substance abuse problem; whether the parent admits or denies the abuse/neglect and can acknowledge the emotional or physical consequences to the child; whether the parent is amenable to treatment; the type of treatment recommended; whether incarceration is recommended; and the presence or absence of supportive family and friends. The purpose of the evaluation of nonabusive parents includes all of the issues listed above with the exception of recommendations for incarceration. The main focus of this evaluation is the nonabusive parent's ability to protect the child given the presence of any mental health, characterological, or substance abuse problems. This evaluation extends to the nonabusive parent's relationship to the abusive parent from the standpoint of whether they are intimidated by or dependent on the abuser and whether they are able and willing to protect the child and comply with court orders. Clinical Evaluations Of Children, Parents, And Families The purpose of the clinical evaluation is to assess the nature and extent of the presenting problem(s), the client's current level of functioning, the client's capabilities of improved functioning, and the client's willingness and motivation to participate in treatment. The primary objectives of the clinical evaluation are as follows:
Assessing Suicidal Risk Although suicidal ideation and attempts are less frequent with children than adults, a consistent number of children attempt suicide. According to the National Center on Health Statistics, the nationwide suicide rate among teenagers in 1983 was 8.7 per 100,000.38 Pfeffer provides a description of the demographic variables related to suicidal children.39 She states that suicidal ideation and attempts are far more frequent among boys than girls and that it is a much more frequent problem for teenage children than for younger children. There may be several reasons or motivations perceived by the child that lead to suicidal behavior. These include impulsive responses to aggressive or hostile situations; the influence of guilt and remorse; manipulation and punishment of the parents (i.e., "You'll be sorry when I'm dead"); or the need to join a deceased relative, decrease or end a sense of loneliness, or seek a solution or end to an unbearable situation. Behavioral Cues to Suicide
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