ABUSE, CHILD

Child abuse and neglect are major sociological problems for this country. The number of alleged abuse incidents reported to state and local child protective services organizations has skyrocketed, and current statistics show that physical abuse is the leading cause of death for children younger than 1 year in the United States. As of the 1990 census figures, 160,000 children younger than 3 years were abused or neglected, representing 25% of all child abuse victims in the United States. The first year of life seems to have the highest incidence of child mistreatment in all years from birth to 18 years, and more than two third of child victims of physical abuse are younger than 6 years. Child abuse can take many forms; however, the so-called “shaken infant syndrome” is particularly disturbing and is associated with high death rates and physical injury. Most symptoms of child abuse result in such physical conditions as bleeding into the brain, blindness, and/or injuries to the different abdominal organs, and these injuries account for most of the deaths from child abuse. Another common form of child mistreatment in infancy is the familiar syndrome of failure to thrive. As many as 30% of all cases of failure to thrive are considered to be caused by parental neglect. Because severe malnutrition in the first 6 months of life can cause permanent brain damage, failure to thrive may be associated with
severe behavioral problems later in life. It is difficult to pinpoint an exact cause or predisposing factor to child abuse. However, child abuse and child mistreatment appear to be associated with poverty, unemployment, disability of a child, psychiatric problems in the parents, substance abuse by the parents, a history of the parents being abused as a children, antisocial behavior of the parents, and whether the pregnancy was planned or not. However, none of these factors alone seems to be sufficient to predict whether a child born into this environment will be abused. In some cases, the
parent-child problem may be more an example of child neglect than child abuse, and often depression or schizophrenia in the parent can lead to poor
bonding and a tendency to avoid the child, thereby leaving the child susceptible to any number of consequences of child neglect. Some parents, especially young, first-time parents, may be overwhelmed by the responsibility of having to care for a child, and become frustrated. Often, parents direct their feelings of anger and frustration toward their child, using their child as a scapegoat, when in fact their anger and frustration are related to difficulties at work or difficulties in other relationships. Thus not
caring for the usual needs of the child (neglect) may have different causes than deliberate mistreatment of the child (abuse). In particularly disturbing incidences of child abuse one or both parents may use the child for some form of sexual gratification. Certainly, there has been a significant rise in sexual abuse of children. However, merely witnessing the abuse of a sibling or of a mother or father by the other partner can have serious psychological consequences on a child. Not surprisingly, studies of children who have been abused show significant problems in their emotional, social, and behavioral functioning. These children seem to have difficulty accepting emotion and tenderness, and difficulty relating in a trusting way to others. They are often unfamiliar with the concept of unconditional love. Undeserved guilt may surface because many of these children later begin to feel that they in fact were responsible for the abuse, and that if they had been quieter or less obvious, or perhaps even not born, that their parent would not be facing consequences of abuse, or the family unit would not be disintegrating. Such doubts can lead to tremendous feelings of low selfesteem among children who have been abused. Abused children also tend to exhibit anger and aggression toward their playmates and schoolmates, so social behavior is often poor. These children are certainly more likely to have major psychiatric problems such as posttraumatic stress disorder, depression, anxiety, phobias, and personality disorders, and of course, they are more likely to become abusive parents. Treatment of child abuse is often initiated by the reporting or suspecting of the abuse by neighbors, other family members, or medical personnel. Most emergency departments that serve children are particularly wary of children who come in frequently, especially with frequent orthopedic injuries, and who have bruises or evidence of old fractures on xray. In all 50 states, physicians and other medical caregivers are obligated to report suspected child abuse and can face sanctions for not doing so. In most states, there is an organization similar to achild protective agency that investigates cases of child abuse and determines whether the child should be allowed to remain in the home. If the child is removed from the home, this will often lead to placement of the child in foster care and in some cases, legal charges being made against the parents. It is important to emphasize that in the treatment of child abuse, the primary and most important goal is the protection of the child. Obviously there is a need to evaluate and treat any medical consequences of the abuse, and to allow the child to engage in therapy for the abuse. Childhood therapy for abuse often involves the use of play therapy including puppets which provide a nonthreatening atmosphere for the child to discuss or demonstrate the abuse to the therapist by acting it out with dolls or puppets. This is especially helpful in cases of sexual abuse. If there are negative consequences, such as a parent being arrested or the child being taken from the home, often the child will blame himself for these consequences and may be reluctant to discuss the abuse. The abusing parent also requires treatment, regardless of whether they become involved in the criminal justice system. Support groups for parents have been very helpful, and parents should be treated. In addition, many states have a program for monitoring subsequent pregnancies to assess whether it is safe for those babies to return home with the new parents. Many adults have flashbacks to childhood physical and sexual abuse that they may have suppressed the memory of for years. Often these flashbacks are very intrusive and come at very inopportune times. It seems that childhood sexual abuse predisposes to a number of psychiatric disorders including borderline and multiple personality disorder, eating disorders, posttraumatic stress disorder, and alcohol and drug abuse. There are other peer support groups, many modeled along the lines of Adults Molested as Children (AMAC) or similar organizations. A more desirable approach to child abuse would be preventive. Evaluating the level of support and the support network for new parents, providing parenting classes, especially for young women who are having their first child, having mother’s day out days for the mothers of newborn infants, and encouraging new parents to talk about their concerns and fears about being new parents would all be helpful. Overwhelmed parents should not be ashamed or embarrassed to talk to their physicians or ministers. Of course, any episodes of abuse (even if by a family member) should be reported and investigated. Role playing between parent and child (What to Do If Approached by a Stranger, What to Do If Touched Inappropriately, etc.) can be very helpful. Unfortunately, most children are abused by someone they know. There are several commercial videos available through your local library or children’s hospital. The book entitled How to Raise a Street Smart Child is particularly helpful. In summary, the evaluation and treatment of child abuse involves both the awareness of the condition, the reporting of the condition by anyone who suspects it, and the rehabilitation of both the child and the parent.
Web sites:
Child Abuse Handbook Summary: http://www.fcbe.edu.on.ca/www/pubs/cah/cahsummary.htm
Sexual Abuse Information Page: http://www.cs.utk.edu/~bartley/salnfopage.htm/