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Home > Treatment for Abused and Neglected Children: Infancy to Age 18 > Treatment for Abused and Neglected Children: Infancy to Age 18: Consequences of Abuse and Neglect
Treatment for Abused and Neglected Children: Infancy to Age 18
User Manual Series (1994)
Consequences of Abuse and NeglectChild maltreatment is a multidimensional and interactive problem involving the child and the multiple environments in which the child exists. Garbarino presents the "Ecological System" (see Figure 1), which provides a means to identify and describe the environments in which the child exists.10 The first context is identified as the microsystem and is composed of individuals or structures that have ongoing and daily contact with the child. "For children, microsystems are the places they inhabit, the people who live there with them, and the things they do together."11 Therefore, common microsystems for the developing child might include home and family, school, neighborhood friends, and peer groups. The next system, the mesosystem, is defined as the relationships between microsystems. It is optimal for a child's development to live within an environment in which there are many mesosystem connections, such as parental involvement in school and church functions, multiple child and sibling social contacts within the neighborhood, etc. In contrast, the deprived child's environment might have relatively few mesosystem connections and consist of problems that may detract from the child's life, such as parents' chronic complaints about school and the child's teacher, neighborhood suspicion and distrust, and few neighborhood peer relationships. The last system, the macrosystem, consists of the broad ideological or institutional patterns within a particular culture or subculture. These patterns may be easily identified by common factors, such as ethnicity or religion, or they may be more difficult to determine, but still important, factors within the culture such as attitudes toward corporal punishment, the value of education, gender-based perceptions of family roles, etc. Garbarino's model also views the child as an active part of his/her environment, facilitating change while being responsive to external stimuli. This model addresses the ever-changing and developing environments of the child, rather than viewing the child as a static organism. Finally, this model enables clinicians to identify those factors that increase the likelihood of abuse occurring (i.e., risk factors) and decrease the likelihood of abuse occurring (i.e., compensatory factors). (See Table 1.) The following sections describe consequences of each form of child maltreatment (i.e., physical abuse, child sexual abuse, and neglect). The previously described categories of intrapersonal, interpersonal, physical, sexual, and behavioral conduct are used to describe the consequences of maltreatment. Physical Abuse Salter, Richardson, and Kairys state that, "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." 12 Consequences Within the Intrapersonal Category Our knowledge of child development tells us that the most significant factor within a child's life is his/her relationship (i.e., attachment) to his/her parents. Within our society, this attachment is typically a mother- infant/child relationship, because most fathers have not yet taken equal responsibility for the caretaking of young children. Given the significance of this relationship, much has been written about the consequence for the intrapersonal development of a child when his/her parent is physically abusive.13 14 Crittenden and Ainsworth argue that it is the need and goal of the human infant to establish and maintain an ongoing relationship with an adult caretaker.15 Through this relationship, the infant is able to meet his/her physical needs (warmth, nutritional sustenance, protection, etc.) and begin to develop predictable patterns of behavior that influence later aspects of his/her development. Typically, this relationship is very predictable and responsive (e.g., as in parents reacting to the cries of their infant). This relationship leads to a subjective perception of security on the part of the infant. In the case of a physically abusive parent, the infant's attachment to the parent disrupts the child's internal beliefs of him/herself and his/her world. As a result, a child develops a perception of him/herself as incompetent, feels bad about him/herself, and considers him/herself unworthy of the love of another. Additionally, a pattern may develop of expecting pain or injury from others, distrusting closeness, and being wary or suspicious of others. Older children who have been abused often demonstrate some type of affective problem (e.g., depression, sadness, anxiety). Lynch reported that maltreated children look unhappy and take little pleasure from their environment.16 This reaction may be related to alterations in the abused child's ability to interpret his/her own as well as others' emotional and social actions. Some research has found that abused children are limited in their ability to perceive their own and other children's intentions and actions, and they may have difficulty interpreting the emotional expressions of others. This finding suggests that abused children may develop a pattern of denying certain emotional responses (i.e., conflicting feelings), which often generalize to a broader range of affective responses. Although this blunted affective ability and response may be useful in coping with the psychic pain of being abused, it inhibits the range of emotional responses, and hence, impairs an important part of a child's development. Consequences Within the Interpersonal Category Physically abused infants appear to respond adversely to maltreatment and then begin to adapt to their environment. Crittenden found that when in interaction with their mothers, abused infants were more difficult (e.g., crying more often, more irritable) than other infants and that this pattern of behavior was related to the immediate interpersonal behavior, rather than the infant's innate temperament.17 Crittenden further suggests that during the first year of life, abused infants learn to accommodate their mother's behavior without complaint.18 By establishing a pattern of behavior that transforms anger to superficial cooperation, many infants and older children become passive, fearful, vigilant, and compliant. This finding complements research using the "Strange Situation" paradigm, in which physically abused infants and young children demonstrate a pattern of anxious/avoidant attachment to their abusive parent. Such infants are described as rejecting or being angry toward their mothers, although this pattern of behavior is not always consistent. Therefore, the infant may be angry and rejecting at one time while appearing superficially cooperative at another time. An example of this behavior is demonstrated by an infant who alternates between wanting to be held and nurtured and then resists attempts by his/her caretaker to hold or cuddle the child. This pattern of behavior becomes a means of adapting and coping with his/her attachment relationship. An interpersonal characteristic observed in many older physically abused children is their tendency to care for their abusive parents.19 That is, these children often engage in actions that serve to meet the needs of their parents and result in the child providing some caregiving. Additionally, these children may also provide similar caregiving to younger children within the family and thus demonstrate secondary assistance to their parents (by fulfilling a parental role). Role reversal offers a means for the child to acquire positive meaning and appreciation within his/her life and yet maintain closeness to the attachment figure. Studies have shown that physically abused children tend to interact with their peers either by being overly hostile and aggressive or by exhibiting excessive withdrawal and avoidance of other children. The reasons why one child responds in one way while another child responds in a different way are not yet clear. Galdston suggests that abused children have a need for recognition and attention from adults.20 Green argues that heightened aggressiveness may reflect an identification with the child's abusive parent in an attempt to avoid anxiety and feelings of helplessness.21 Also, aggressiveness may be a result of parental modeling, with the abused child demonstrating a pattern of behavior that he/she has learned from the abusive parent(s). Whether aggressive or avoidant, it appears that 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, involved developing a working model of relationships that was based on sharing, equality, and non-exploitation. The experiences of abuse and neglect seem antithetical to developing such a model." 22 Consequences Within the Physical Category In an extensive 5-year study, Martin reported that slightly more than half of the 58 physically abused children he studied had some type of neurological impairment.23 Additionally, approximately one-third of the children studied had an impairment that was significant enough to handicap everyday functioning. Similar neurological, sensory, and/or psychomotor problems have also been identified by other researchers investigating the consequences of physical abuse.24 25 26 There are some delays in motor skills development in young children exposed to physical abuse. Martin reported some gross motor skills deficits.27 It is difficult to determine if these motor delays are the direct result of actions related to the abuse (e.g., hitting, pushing, or punching) such as might result from neurological impairment, or if these motor delays are the result of a home environment that does not provide sufficient opportunity to use and master these skills. Martin suggests that physically abused children come from a home environment in which exploration and normal risk taking are discouraged, thus impairing their development in this area.28 Consequences Within the Sexual Category Little is known about the sexual problems of children who have been physically abused. As adults, these children may have difficulty developing trust in relationships involving sexual intimacy. Some children who have been physically abused have also been sexually abused.29 Those children may demonstrate negative consequences of both types of abuse. Physically abused children who have also been sexually abused may possess some type of sexual behavior problem. Ryan presents a model of cognitive factors that may develop as sexual offending behavior.30 In reviewing this model, some of these factors (e.g., denial, minimalization, and retaliation fantasies) may also be present in victims of physical abuse. Individuals who perceive sexual offending behavior as an assertion of power rather than solely as a deviant sexual behavior might argue that factors that contribute to the need for a demonstration of force and power also contribute to the development of sexual offenders.31 32 If this is the case, physical abuse may make such a contribution. Consequences Within the Behavioral Conduct Category Salter, Richardson, and Kairys argue that physically abused children do not behave any differently than other children under another type of stress.33 These researchers also report that children's reactions to distress can be described "in one of two ways: 'internalizing' or 'overcontrolled' (i.e., inhibited, shy, anxious) behaviors and 'externalizing' or 'undercontrolled' (i.e., acting out, aggressive) behaviors." 34 Although this finding may be true, children have a developmentally limited verbal capacity; they must rely on a specific set of symptoms to express distress. Therefore, they may engage in internalizing behaviors, in externalizing behaviors or in both. What is of interest are those behaviors that are unique to, or more likely to occur with, physically abused children. One such symptom or behavior that is commonly reported as a consequence of physical abuse is the increase in aggressive behavior. Both verbal and physically aggressive behavior have been reported by studies investigating physically abused children. The process of being raised in an environment in which physical abuse is used as a common response to problems, feelings, and conflicts impairs several important developmental functions (e.g., problem-solving, accepting delayed gratification, and impulse control).35 Without the opportunity to learn these functions, children use methods or respond in ways that utilize mechanisms modeled for them within their family (i.e., aggression). Therefore, when placed in a situation in which he/she experiences conflict, negative affect, or a problem, an abused child resorts to some type of verbal or physical hostility as a means to a resolution or to fulfill his/her unmet needs. It appears from reviewing their behavior, that there are two primary response patterns that children use in coping with the distress of living with an abusive parent. The first response is a negative, resistant, verbally and behaviorally hostile pattern. The second response is a fearful, passive, and compliant pattern. However, it has not yet been shown that abused children adopt these patterns across all daily interpersonal situations. For example, while an abused child may adopt these patterns of behavior in relation to his/her abusive parent, he/she may react differently (outside the bounds of these patterns) when interacting with peers or other adults. Again, the common interpersonal response and action appears to center on the relatively quick move toward aggression and hostility. The specific reasons for this response are unclear, but they may include displaced parental anger, increased vigilance and the expectation of aggression from others, social modeling of aggressive problem-solving, and a limited range of conflict resolution abilities. Child Sexual Abuse Consequences Within the Intrapersonal Category In reviewing the empirical research on the responses of children who have been sexually victimized, some type of intrapersonal disturbance is consistently reported. The reasons may be related to Finkelhor's traumagenic dynamics of powerlessness, betrayal, and/or stigmatization.36 A victimized child may feel unable to protect him/herself, vulnerable to invasion from others, different from others (which may lead to a sense of isolation), and may develop a sense of low self-esteem. If the abuse is intrafamilial, he/she may also feel a sense of betrayal from the abusive parent or sibling or betrayal on the part of nonabusive parents for failing to provide adequate protection. Victims of child sexual abuse also report symptoms of fear, anxiety, isolation, and a perception of low self-esteem. Porter, Blick, and Sgroi suggest that these symptoms may result from the child perceiving him/herself as "damaged goods," which is characterized by an overall sense of poor self-image.37 Though these symptoms have been supported with female victims, the evidence is less clear with male victims. Some studies appear to support similar responses with boys, but their findings remain inconclusive. Consequences Within the Interpersonal Category Many problems within the realm of social functioning and interpersonal relationships have also been noted in victims of child sexual abuse. Some of these problems include using illegal drugs and alcohol, having difficulty in school, and running away from home. Such problems are often associated with attempts to avoid an abusive home environment.38 Finkelhor's traumatic dynamic of betrayal is described as manifesting itself through a sense of distrust in others and conflicted relationships with others as shown through reactions of fear and hostility.39 40 41 Many victims of sexual abuse possess this sense of distrust or wariness toward others, perhaps as a reaction to fear of being victimized in the past, not trusting their decision-making abilities regarding dangerous sexual situations, and/or attempting to avoid revictimization. Interestingly, research examining victims of abuse has shown that past victims of sexual abuse are at increased risk of revictimization.42 43 44 Consequences Within the Physical Category Many studies that have examined the physical consequences to children as a result of sexual abuse indicate that for both female and male victims there are an array of injuries including some type of injury to the genital area that can result from sexual abuse.45 46 47 As a result of their abuse, certain children acquire some type of direct injury (e.g., vaginal or anal laceration or tear or acquisition of a sexually transmitted disease) that requires medical attention or, they develop a secondary problem associated with this initial injury. Examples include the onset of enuresis or encopresis and/or recurrent problems with urinary tract infections. In addition to the direct injuries resulting from their abuse, many children develop some type of somatic or psychophysiological problem that may be related to their abuse. Spencer and Dunklee describe a sample of boys who reported somatic complaints including sleep disturbance, nightmares, or bedwetting.48 Similarly, the Tufts New England Medical Center study reported significantly more somatic complaints in the children they assessed.49 In the second study, common problems identified included sleep disturbance, nightmares, and phobias. During the past few years there has been an increase in research attempting to link child sexual abuse and post-traumatic stress disorder (PTSD).50 Many abuse victims exhibit symptoms such as dissociation, nervousness, anxiety, and flashbacks commonly associated with PTSD. However, a clear relationship has yet to be established between child sexual abuse and PTSD. Because of the wide range of responses to abuse, some children present some symptoms of PTSD; others may present most or all of the PTSD symptoms (and be diagnosed as having PTSD), and other children exhibit no symptoms. Consequences Within the Sexual Category A consistent finding in research describing consequences of child sexual abuse is the increase in sexualized behavior in children. Two studies using standardized measures of assessment have indicated that abused children tend to be more involved with sexual ideation and behavior. The Friedrich et al. study reported nearly three-fourths of the boys and slightly more than two-fifths of the girls exhibited some type of sexual problem (e.g., masturbating too much, masturbating in public, talking about sex too much).51 In a Tufts' New England Medical Center study, approximately one-fourth of the younger age group (4-6-year-olds) and one-third of the older age group (7-13-year-olds) were elevated on a sexual behavior scale (which included items about excessive sexual curiosity and open masturbation).52 In a smaller sample of 14 boys referred to therapy for sexual aggression, Friedrich and Leucke identified 11 of these boys as having a history of being sexually victimized.53 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.54 55 56 Finally, several researchers have argued that having a history of being sexually abused may contribute to the development of being a sexual offender (either as a juvenile, adult, or both).57 58 59 It is important to note that although sex offenders may possess a relatively high prevalence of child sexual abuse, this does not mean that every child who has been sexually abused will become a sex offender. Making such an assertion fails to account for the fact that most victimized children have no later sexual interest in children or that there are sexual offenders without a history of having been sexually abused as a child. Furthermore, such an assertion oversimplifies the broad range of factors that lead to the development of sexual offending behavior. For example, Ryan states that victim responses such as "patterns of denial and minimalization, power and control behaviors, irrational thinking, irresponsible decision making, retaliation fantasies, deviant sexual arousal, aggression, secrecy, and preoccupation with or reenactment of one's own victimization" may influence the child's development from being a victim to being a victimizer.60 In summary, both empirical research and clinical case studies indicate that one consequence of being sexually victimized is an increase in sexualized behavior. This behavioral sequela has been reported in both male and female victims and includes an increase in sexual ideation and fantasies as well as an increase in sexualized behavior. Although research with sex offenders suggests that there may be a relationship between being sexually abused and being a sexual offender, conclusions suggesting a causal relationship are faulty. Consequences Within the Behavioral Conduct Category One of the most common findings for male victims is a wide array of behavioral disturbances. Although this same range of behavioral disturbances is not as pronounced with girls, this does not reflect an absence of behavioral problems for girls. Psychological research shows that boys tend to express distress through externalization and girls through internalization. Numerous studies provide empirical support for the presence of some type of behavioral disturbance (e.g., aggression, delinquency, hyperactivity) with sexually abused children.61 62 63 An extensive study conducted by the Tufts' New England Medical Center was one of the first to use standardized measures in examining sexually abused boys and girls. This study reported that nearly half of the oldest age group (7-13-year-olds) 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 (4-6-year-olds) were reported as having elevated scores on these same scales of aggression and antisocial behavior.64 Finally, DeFrancis reported that slightly more than half of the child victims showed behavioral disturbances such as defiance, disruptive behavior within the family, and fighting with siblings.65 In addition, there have been several clinical reports of aggressive behavior, including firesetting and destruction of property, delinquency, verbal explosiveness, and argumentativeness. In summary, although not all victims of sexual abuse demonstrate problems with behavioral disturbance, research suggests that some type of behavioral problem is a relatively common consequence. Furthermore, it appears that this behavioral response is more common in male victims than in female victims, with parents more likely to react to behaviors that are externally disruptive. Child Neglect Child neglect is the most frequently occurring type of child maltreatment and probably the least understood because of several definitional issues as well as difficulty in substantiating anything but severe neglect. Consequences Within the Intrapersonal Category By failing to recruit a consistent and adequate caretaker, the infant or young child will be unsuccessful in achieving the goal of establishing and maintaining an ongoing relationship with an adult caretaker. The consequences of such a failure may be profound. Typically, by relating to a caretaker through a repeated series of interactions, the infant or young child begins to develop a set of expectations regarding the nature of future interactions. These expectations become the basis for the internal representation of the caretaker and of him/ herself.66 That is, we construct ourselves, in part, from a series of interactions with individuals in our lives. Those closest to us usually have the most significant influence. As a child grows older, these series of interactions are integrated within beliefs about him/herself, his/her thoughts and activities in relation to others, and perceptions of his/her competency. Harter suggests that this self-evaluation of competency, originating in initial relationships with caretakers, becomes the source of stability for one's self-system. Without a stable initiating environment or consistent support from primary caretakers throughout childhood, the development of a child's sense of self is adversely affected.67 Neglected children often experience a loss of placement of themselves in relation to other people; this may manifest in symptoms of withdrawal, depression, passivity, and disorientation or confusion. Neglected children may become helpless and passive; they tend to roam aimlessly when placed in a situation in which they are temporarily separated from their parent(s).68 Additionally, in their study, Howes and Espinoza report that neglected children appeared to display less affect, either positive or negative, in their peer encounters, which suggests a blunted affect.69 Helfer argues that being raised in a neglected environment results in several intrapersonal problems, including living within an environment where needs are not consistently met. This type of environment disrupts the child's ability to develop the capacity for delayed gratification.70 Additionally, decision making and problem solving are rarely adequately modeled with the child having limited opportunities to practice these skills. Finally, a neglected child never fully develops the capacity for control over his/her feelings and actions. In other words, a neglected child never learns that he/she can control his/her behavior. This failure may lead to impulsive behavior in conjunction with a thought or feeling, Consequences Within the Interpersonal Category It is argued that many neglectful mothers have difficulty providing adequate care for their children because of their own past histories of maltreatment.71 These mothers have difficulty coping with the demands of an intimate relationship, and they may not understand the necessary cues and interactions because of their own emotional instability. Therefore, because of their inability to function effectively as well as their impaired relationships, these mothers do not have the capacity to engage in healthy attachment relationships with their children. Consequently, their children never acquire basic interpersonal skills and may grow up to perpetuate an intergenerational transmission of relationship dysfunction. Main and Goldwyn state that the dysfunctional characteristics identified with abusive mothers (e.g., poor or unsympathetic response to distress, self-isolation, or poor impulse control) are found in neglected children as young as 1 to 3 years of age.72 Further, women with histories of victimization in childhood, but who did not maltreat their own children, had strong marriages, positive self-esteem, and had made a conscious acknowledgment of their past maltreatment. This finding suggests that one road to recovery from maltreatment is the development and maintenance of intimate relationships in adulthood and the acknowledgment of past maltreatment. When interacting with peers, neglected children tend to be withdrawn from schoolmates or to relate to peers in a disorganized, active, or aggressive manner. These children may exhibit fewer positive play behaviors such as offering, sharing, showing, accepting, throwing, and following. A problem in peer relationships is supported by Hoffman-Plotkin and Twentyman, who report that neglected children tend to be more withdrawn than physically abused children and nonmaltreated children.73 Additionally, their research suggests that both physically abused and neglected children exhibit less prosocial behavior than nonmaltreated children. Such findings are consistent with other research that reports that neglected children directed fewer positive behaviors toward their peers, initiated fewer interactions, and were involved in simpler forms of play.74 Problems in peer relationships are consistent with Helfer's description of what occurs when a child is raised in an abnormal environment. That is, if denied a healthy environment, a child never learns to trust others, has difficulty in selecting friends, and is often engaged in conflicts with others because of limited interactional skills. Consequences Within the Physical Category One obvious physical consequence of being neglected is deprivation of the fundamental nutritional needs required for healthy development. Very little has been written on the nutritional deficits associated with neglected children. Helfer discusses some of the consequences of malnutrition and growth retardation in the context of child abuse and neglect and identifies a variety of child and family problems associated with deprived backgrounds.75 Excluding diseases and medical problems, which are associated with some type of growth failure or malnutrition (e.g., metabolic disorders, intestinal disorders, or hepatic diseases), Helfer reports that many studies that identify physical problems associated with a significantly reduced caloric intake indicate that neglected children tend to make significant gains in both weight and nutritional status after identification and implementation of a medically related treatment regimen. However, throughout their childhood (and probably adulthood) their stature remains short and their physical health is identified as somewhat fragile. Secondary to malnutrition are the numerous developmental limitations and incapacities related to neglected children. Several studies indicate that the presence of severe neglect, usually associated with malnutrition, has major consequences for the achievement of many important early childhood developmental milestones as well as for intellectual and psychological functioning later in the child's development. Elmer, Gregg, and Ellison report that many of these children experienced behavioral disturbances and mental retardation.76 This finding is supported by other research that has identified school and academic problems, delays in the development of language abilities, and social immaturity as effects of child maltreatment. It appears that neglected children suffer long-term consequences if their neglect includes some type of malnutrition. These consequences appear to impair physical growth and development as well as intellectual and psychological functioning throughout childhood. Consequences Within the Sexual Category Finkelhor suggests that an important risk factor for child sexual abuse is parental absence and/or unavailability.77 He states that characteristics such as parental separation or divorce, mother's employment outside the home, and a disabled or ill parent may increase the risk for sexual victimization. This seems a reasonable assertion, given these characteristics play an important role in the parent's ability to act as a caretaker and supervisor of the child. Consequently, it may also mean that parents who fail to care adequately for their children (i.e., neglectful parents) may also place their children at risk for sexual abuse. Consequences Within the Behavioral Conduct Category As stated earlier, one set of behavioral responses that neglected children appear to possess is passivity, social withdrawal, and isolation. Helfer argues that many of the child's basic interpersonal characteristics/traits (developing interpersonal relations, controlling behavioral impulses, and reacting to feelings without consideration of the consequences) are affected by child abuse and neglect, and that as a result, these traits are impaired both at the time of the maltreatment and later in life.78 Problems with withdrawal and passivity are also suggested by Crittenden, although this research focused on mother-infant relations.79 The reasons for a pattern of passivity, withdrawal, and isolation are unclear. However, one possible reason is that neglected children do not have a strong sense that they can have a meaningful impact in obtaining the cooperation of others. As has been demonstrated in interactions with their neglecting caretaker, neglected children learn that individuals are nonresponsive to their needs. This realization leads the neglected child to believe that relationships with others are not an effective means to have his/her needs met or that his/her needs cannot be met by others. This results in a decrease in attempts to initiate or develop relationships and a perspective that such behavior may be futile. The final step in this process, then, becomes passivity and withdrawal characteristic of ineffective interpersonal relations.
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