Introduction

Child abuse and neglect is the mixed consensus about what represents unacceptable child rearing/care, combined with what children have a right to be free from. This latter element is made explicit in the United Nations Convention on the Rights of the Child, (!) which sets out basic rights and standards for judging the welfare of children, including, but not limited to, child maltreatment. It incorporates both the maltreatment of children within family settings and that occurring through group processes and social forces within countries leading to child labour, sexual exploitation, and children in war zones. (2)

Child maltreatment affects the healthy and normal course of development. It causes deviation from an expected trajectory, preventing the developing child's negotiation of sequential tasks and disrupting the normal transaction between different facets of development. (3) Therefore child maltreatment is the very antithesis of adequate child care and rearing, posing a major threat to human development.

Adequate rearing of the young is such a fundamental activity that the state must be concerned with the overall welfare of children within its society; in family settings where they are normally brought up, and in schools, hospitals, and residential settings. While the Convention articulates a fundamental framework, several states have initiated a children's Ombudsman, to oversee the status of children's welfare and to tackle obstacles to it. There are laws within each society to regulate the care and welfare of children, specifying the consequences if children are maltreated. In the United Kingdom, the Children Act 1989 incorporates both the broad welfare of children within England and Wales, including those children deemed to be in need of extra help and support, as well as those children who are at risk of, or are actually being, significantly harmed (child maltreatment).(4)

Countries vary in their approach to the problem of child maltreatment. In the United States, any professional who has reason to suspect that a child is being maltreated is legally required to inform the local child welfare agency (mandatory reporting). Some countries in Europe (e.g. Belgium and Holland) have a system whereby child-maltreatment concerns are dealt with confidentially, through health and social care supportive systems, rather than through primarily legal methods. The United Kingdom lies between these extremes, but relatively closer to the United States model than to the 'confidential doctor' system. Whatever system is in place, it is clear from the scope of the problem of child maltreatment that multidisciplinary working is a core requirement.

The developmental-ecological model is the most useful theoretical framework, which draws together the various factors known to contribute or be associated with the occurrence, predisposition, precipitation, or perpetuation of child maltreatment. (5,6and It draws together individual and interpersonal factors, the influences of the family and immediate neighbourhood, together with broader social influences on child rearing and care, all of which have the potential to affect the developing person. However, these layers of increasing social complexity, which surround the individual child, are not static. In addition to the transactions, there are important influences historically, and subsequent to any maltreatment, which have an impact on the course of human development. These temporal and ecological perspectives are drawn together in Fig 1. This broad perspective on child abuse is useful for the psychiatrist to bear in mind while identifying their role and responsibilities.

Fig. 1 Goya's A developmental and ecological perspective on child maltreatment.

Different types of maltreatment have been identified and, although there is much overlap, we will consider each in turn before reviewing intervention and treatment for all forms of maltreatment, together.

Child sexual abuse Definition and clinical features

This is defined as sexual activities which involve a child and an adult, or a significantly older child. There are two elements: the sexual activities and the abusive condition/8) Contact sexual activities include penetrative acts (e.g. penile, digital, or object penetration of the vagina, mouth, or anus) and non-penetrative acts (e.g. touching or sexual kissing of sexual parts of the child's body, or through the child touching sexual parts of the abuser's body). Non-contact sexual activities include exhibitionism, involving the child in making or consuming pornographic material, or encouraging two children to have sex together.

The abusive condition is founded on the premise that children cannot generally give consent to sex, because of their dependent condition. Consent can be difficult to assess in older children or if there is a small age gap between abuser and abused. Considering whether exploitation has occurred can aid this decision: it comprises misuse of authority or age differentials through deceit, unreasonable persuasion, coercion, or overt force.

Half the sexual abuse cases coming to the attention of welfare agencies involve penetration or orogenital contact. The proportion is less in community samples, because reported cases tend to be more serious in nature. Positive physical findings from paediatric examinations are only confirmatory in less than half of corroborated penetrative cases. This is because of the elasticity of the child's tissues, combined with the abuser's care to avoid detection.

Abuse perpetrated by a caretaking adult normally consists of increasingly severe sexual contact over time, with parallel increases in coercion and threats to the child if the 'secret' is disclosed. As the physical acts and psychological climate worsen, so the child's reluctance to disclose the predicament deepens.

Diagnosis

The most common presentation is through a statement from the child.(9) Unless the child is responded to sympathetically at this point, they may be reluctant to reveal the full nature of their plight. More than half of those who are abused do not disclose the fact, especially if they are male.

Less commonly the child's behaviour can draw attention to abuse, particularly if the child shows sexual behaviour problems, either directed towards themselves or towards other children. However, behaviour and emotional difficulties are normally non-specific, occurring in about two-thirds of children. Older children and adolescents show behaviour difficulties which are unexpected for themselves or their peer group, including substance abuse, suicide attempts, running away from home, or becoming unpredictably out of control. Not surprisingly, high rates of prior sexual abuse are noted among young people involved in prostitution.

Medical presentations do occur, for instance venereal diseases, evidence of acute assault, or an otherwise unexplained pregnancy.

Prior to investigation, one-third of reported cases are already known to child welfare agencies for other reasons. Children are more likely to disclose their predicament if they have first made a spontaneous statement to someone before being interviewed by professionals.

Child psychiatric services may assist social workers interviewing children and young people with a psychiatric disorder, or very young children. Other specialists should be enlisted for those with communication problems and learning difficulties. The aim of interviewing is to help a child to describe their predicament whilst avoiding suggestion/!0) Child psychiatry also has a role to play in providing psychological treatments for symptomatic children and working with disturbed families. (11)

Screening for the possibility of child sexual abuse increases recognition in both adult and child populations, revealing information that can be essential for psychiatric management.^ Adult services have a role to play in addressing psychiatric problems in family members, including treatment for paraphilias, often in conjunction with the probation service or other specialized provision.

Epidemiology

Annual incidence in the United States is 3.2 per 1000 children each year. (12) The equivalent United Kingdom figure is 0.6 per 1000 children. (13> The United Kingdom figures in this chapter are for registered cases only, whereas the United States figures include all cases known to the agency. Childhood prevalence derived from adult retrospective recall is 20 per cent for females, and between 5 and 10 per cent for males. ^i!5) Between 20 and 25 per cent of this abuse is penetrative or involves orogenital contact, contrasting with 50 per cent among cases reported to welfare authorities during childhood. Men perpetrate 90 per cent of the abuse, while among victims the ratio is 2.5 girls to 1 boy. Of the abusers, 70 to 90 per cent are known to the child, with family members comprising between a third and a half of the abusers of girls, and between 10 and 20 per cent of the abusers of boys. Child sexual abuse comprises 15 per cent of the cases of abuse and neglect known to child welfare agencies.

Aetiological and background factors Characteristics of abused children

Sexual abuse affects children of both sexes and all ages. The most common age when children are abused is between the ages of 7 and 13 years, but up to one-quarter of reported cases comprise the under-fives. Race and socio-economic status are not major risk factors, but there are increased rates of sexual abuse among children living with parents who are emotionally unavailable, psychiatrically disturbed, violent, or who abuse alcohol or drugs. (1 ID Children from lower socio-economic groups are over-represented in child protection samples, but in adult retrospective surveys there is less of a link with economic status. Children who have been in substitute care are at higher risk.

Boys are less likely to be reported or discovered to have been abused during their childhood. Compared with girls, boys are more likely to be older when first victimized and to be abused by someone from outside the immediate family, and more likely to be abused by women or by offenders who are known to have abused other children.

In the United States, African-American children are more likely to be penetrated and to be abused when younger than Caucasian or Asian children. Asian victims are more likely to be abused by a male relative than other racial groups, whereas Caucasian children are more likely to be abused by an acquaintance. The risk of sexual abuse is almost doubled for children with a disability. (18)

Characteristics of abusers

Most abusers are male, but up to 10 per cent of children are abused by a female, though this figure is higher when the victim is male. Up to one-third of children are abused by a person who is under 18 years of age. (lZ» Young abusers are, on average, 14 years old, while their victims are 7 years old and usually known to them/1. ,2.9 The abusers lack social skills and assertiveness, and show impulse-control problems, learning difficulties, and clinical depression. Their home environments are characterized by instability, family violence, and sexual problems in their parents. Parental loss or separation is common among adolescent abusers. Between 20 and 50 per cent of abusers have a history of childhood sexual abuse themselves. Physical abuse histories are even more common, together with deprivation and periods of substitute care in childhood. These characteristics are common among other offenders for non-sexual abuse offences, and thus do not explain the aetiological pathways through which some young people and adults develop a pathway of sexual attraction or desire to sexually assault a child. Marshall and Barbareek1 have drawn together psychological, biological, and social factors into an integrated theory of aetiology.

Abusers typically deny sexual abuse allegations. Even measures of penile tumescence in response to childhood imagery are unlikely to discriminate a denying abuser from a falsely accused man. Some psychological features are common among abusers but are unlikely to be definitive, prior to any admission of guilt. (19) The demarcation between intrafamilial and extrafamilial abusers is less sharp than originally thought, and mixed abusers are relatively common. Family aspects

Up to half of all cases are abused by someone outside the family. In the majority of these extrafamilial cases the abuser is known to the child and in a position of trust, either providing care or supervision, or involved in an educational or recreational activity with the child. Among within-family cases, the original stereotype—of a closed family with a controlling abusive father and mother who is collusive with her husband's abuse of her child—has been demonstrated to be inaccurate. Although such a pattern may be seen, a variety of family styles of functioning occur. However, investigators have found that families containing sexual abuse victims are less cohesive, more disorganized, and permit less healthy expression of emotion than comparison families. (22) These differences may pre-date the onset of sexual abuse or be a consequence of its occurrence/!6' Nonetheless, the observations are important for intervention purposes.

The support of the non-abusive adult carer (usually the mother) in terms of belief, protection, and help for the child to understand the abuse, is linked with the child's ability to cope in positive ways with their experience.(23) This is important for assessment and intervention purposes, because there is a significant link between sexual abuse and markers of parent-child relationship difficulties, such as emotional unavailability, interparental conflict, parental mental health, and substance abuse problems.

Course and prognosis

A wide range of psychological sequelae in childhood and adult life are associated with prior childhood sexual abuse ( Table !) (! However, these are linked with the effects of both the quality of the family environment at the time of abuse, and the nature of subsequent life events. (232 2 26 and 27> In particular, factors such as family disharmony and violence, existence of other forms of abuse and neglect, and parental mental health difficulties in addition to subsequent events, such as losses through death or separation, combined with the child's own method of coping with the abuse and ameliorative effects of positive school or social relationships all contribute to outcome.

Table 1 Impairments and problems associated with childhood sexual abuse

About one-third of children are symptom free. Approximately 10 per cent of children show worsening symptoms over time, including depression and post-traumatic symptoms. While effects on personality and social relationships can be disabling during development, other children are unaffected. (26)

Physical abuse Definition and clinical features

Physical abuse is the physical assault of a child by any person having custody, care, or charge of that child. It includes hitting, throwing, biting, inducing burns or scalds, poisoning, suffocating, and drowning. (28) In the United States and United Kingdom physical chastisement of children is commonplace, leading to problems of definition. In other parts of Europe and in some Eastern cultures physical chastisement is regarded as unacceptable. Legal definitions in the United States and Western Europe normally link physical acts to observable harm. However, for research and clinical purposes an endangerment-based definition appears preferable, because of the widely different sequelae resulting from similar assaults. (7) Failure to prevent injury or suffering is preferably considered a manifestation of physical neglect. Other definition problems include the frequency or repetitiveness of the acts, their severity, and whether intent to harm should be included. In addition, developmental factors affect the recognition of abuse and possibly its definition also—a smack to the head of an 8-year-old, although unacceptable, will have significantly different consequences from that to an 8-month-old. (29)

The distinction between accidental injury, non-accidental injury, and specific medical diseases is sometimes straightforward (e.g. particular types of fractures, burns, or bruising) but difficult diagnostic dilemmas do occur. It is important to resolve these dilemmas so that the way forward for psychiatric assessment and treatment can be clarified. (2,30)

The 'battered child syndrome' refers to young children with multiple bruises, skeletal injuries, and head injuries, often accompanied by neglect, malnutrition, and fearfulness, whose parents deny responsibility. (3D Diagnosis and recognition

Physical abuse is detected through the observation of physical injuries without an alternative non-abusive explanation. (2 2 and 3,9 Less commonly, a direct account comes from a child or a witness, or through confession by a parent or carer. Usually, the diagnosis is based upon a discrepancy between the physical findings and the history provided. The history may be insufficient or simply improbable. When an explanation is forthcoming, trigger events or developmental challenges are common—for example, persistent crying in infancy, problems of toileting or feeding among toddlers, or issues of discipline in later childhood. In adolescents, conflict surrounding independence may coincide with parental midlife crises. Not all physical abuse can be related to loss of control, however, and the assessor has to consider planned or even sadistic activities, such as scalding, burning, or torture.

There may have been previous episodes of similar or lesser concern, for which adequate explanations were unavailable at the time. Delay in presenting the child for medical attention is not a reliable diagnostic feature; neither is the apparent absence of parental concern nor their unreasonable behaviour at presentation.

Epidemiology

The annual incidence of physical abuse is estimated at 5.7 per 1000 children in the United States (!2> and 0.8 per 1000 children in the United Kingdom. (!3) Girls are more commonly abused than boys, although male infants are more likely to be abused. Population-based surveys reveal higher rates. Mortality has been estimated at 1.94 per 100 000 children in the United States, 50 per cent of whom are children under the age of 1 year. Physical abuse comprises 29 per cent of child protection service cases in the United Kingdom, and a similar proportion in the United States.

Aetiology and background factors

Child characteristics

Physical abuse occurs at all ages, although biological sequelae are more severe in infancy. There is no association with ethnic group, but a strong one with low socio-economic status among the under-fives, becoming weaker throughout childhood and disappearing by adolescence. (3 33) Children with developmental disabilities have a raised risk. (18) Associations with low birth weight, prematurity, or physical ill health disappear once parental and social variables are controlled for. Boys under 5 years of age are more likely to be abused, whereas girls are at greater risk in childhood overall.

Abuser characteristics

Young maternal age at the time of the child's birth is linked with abuse, but generally the effect of age is overshadowed by low socio-economic status and high social stress/32,33) Physical abusers of young children are likely to be female, but male abusers predominate during adolescence. They are more likely to be single parents and to have large numbers of closely spaced children. Their educational level, but not necessarily their intelligence, is lower; they are, however, more likely to be unemployed. Most physical abuse is perpetrated by parents, but others who adopt a caretaking role become increasingly significant in the abuse of older children.

Abusive parents are more likely to have had a childhood history of abuse themselves. However, regarded prospectively, 70 per cent of abused children do not abuse their own children/34) Non-repeaters are more likely to have enjoyed social support from a partner, had a positive relationship with an adult during childhood, and to have received psychological help during adolescence. In addition, they have a more balanced and coherent perspective about their childhood experiences than those who show intergenerational continuity of parenting problems. The quality of attachment relationships between parents and children shows continuity, rather than the specific type of abuse. Hence, physically abused children have an increased risk of perpetrating both physical and sexual abuse when they become parents themselves.

Frank psychiatric disorder is relatively infrequent among abusers, but recent studies of physical abuse fatalities underline their importance in a minority of cases. (35) Personality difficulties and disorders are more common, however. Hostile adults with poor impulse control, low self-esteem, antisocial and aggressive personalities, with accompanying mood disorder are more likely to abuse. These abusers have disrupted social relationships and inadequate coping responses in a wide range of domains. They are frequently socially isolated, alienated, and have disharmonious relationships with neighbours and relatives. For these adults, potentially protective supportive relationships with friends and relatives are inhibited. (3 33)

Abusive parents have maladaptive ideas about their children. They tend to have high expectations for their children's development and behaviour, perceiving it to be deviant when objectively it is not. They are more likely to believe in the appropriateness of strict physical discipline, and to hold negative views and perceptions about their children. They show limited attention to their children, less positive affect, and respond with aversion, anger, or irritation to their children's bids for care or attention, as well as to their positive behaviours, when compared with non-maltreating parents. Physically, abusers show heightened arousal to both child stimuli and non-child-related stressors. (32,33)

Family aspects

Families in which physical abuse occurs are more likely to support mutually abusive coercive communications and interactions than controls. Partner abuse and domestic violence is relatively more common, combined with evasive hostility and decreased cohesion. Discussion, positive displays of affection, and encouragement of prosocial behaviours are less common than in non-maltreating families.(3 33)

The quality of the attachment between parent and child is significantly linked with physical abuse, especially when combined with high levels of social stress, low socio-economic status, and negative parental family attitudes and behaviours. Although infant temperament can be associated with maltreatment it probably only does so if combined with other risk factors, such as parent-child attachment problems, parental attitudes, and family difficulties of the sort described above. Clinicians have long observed that individual children can be perceived negatively by parents, without objective evidence, particularly if the child represents a particular issue or problem for the parent.

Course and prognosis

Some physically abused children have neurological and other physical sequelae as a result of their injuries. (5) Educational difficulties are consistently found on follow-up. The children are less attentive to social cues and less skilful at managing personal problems and more likely to attribute a hostile motivation to their peers, compared with non-abused children, at the age of 5. Their capacity for empathic concern with the everyday problems of their peers becomes blunted. Not surprisingly therefore, chronic oppositional and aggressive behaviour is the most consistently documented childhood outcome. These children range from the socially withdrawn and avoidant, to those who demonstrate fear, anger, and aggression. These features are linked both to the physical abuse and the family context of pervasive aggression and conflict/3 33)

The children's attachments to their caretakers are anxious and insecure. Children view themselves negatively, and show increased rates of both depression and anxiety throughout childhood. Long-term exposure results in a constellation of reactions characterized by pervasive denial by the child, an apparent repression or dissociation of memories, relative indifference to pain or distress, episodes of rage directed towards self or others, and an unremitting sadness. The boy victims may develop a characteristic hypervigilance.(33)

Approximately 20 to 30 per cent of physically abused children become delinquent in their teenage years, starting earlier and displaying more violence than their non-abused counterparts. They are at increased risk of running away from home and are over-represented among the young homeless populations of inner cities. There are links with alcohol and illicit drug use, self-destructive behaviour, suicide, and teenage pregnancy, which are difficult to discriminate from the associations with disturbed and violent family environments, and disruptions in caretaking. The combination and transaction between these multiple influences are associated with the negative outcomes in teenage years and young adulthood. (32,33) However, early intervention and management of hostile coercive family environments is associated with an improved outcome.

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