An Overview of Child Maltreatment

Few topics are more emotive than child maltreatment. Children under the age of 18 may be exposed to abuse and neglect by a parent, caregiver, or another person in a custodial role (e.g. guardian, clergy, coach, teacher).

In this article:
What is child maltreatment?
Key facts about child maltreatment
Scope of the problem
Types and forms of child maltreatment
Causes and risk factors
Symptoms and signs
Diagnosing child maltreatment
Treatment of child maltreatment
Consequences of child maltreatment
Prevention of child maltreatment

What is child maltreatment?

Child maltreatment is the abuse and neglect that occurs to children under 18 years of age. It includes all types of physical and/or emotional ill-treatment, sexual abuse, neglect, negligence and commercial or other exploitation, which results in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power. Such relationships include guardians, clergy, coach, teacher, or other similar.

Key facts about child maltreatment

According to the World Health Organization (WHO), the following key facts and figures are true for child maltreatment:

• Nearly 3 in 4 children - or 300 million children - aged 2–4 years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers
• 1 in 5 women and 1 in 13 men report having been sexually abused as a child aged 0-17 years.
• 120 million girls and young women under 20 years of age have suffered some form of forced sexual contact.
• Consequences of child maltreatment include impaired lifelong physical and mental health, and the social and occupational outcomes can ultimately slow a country's economic and social development.
• A child who is abused is more likely to abuse others as an adult so that violence is passed down from one generation to the next. It is therefore critical to break this cycle of violence, and in so doing create positive multi-generational impacts.
• Preventing child maltreatment before it starts is possible and requires a multisectoral approach.
• Effective prevention approaches include supporting parents and teaching positive parenting skills, and enhancing laws to prohibit violent punishment.
• Ongoing care of children and families can reduce the risk of maltreatment reoccurring and can minimize its consequences.

Scope of child maltreatment

Child maltreatment is a global problem with serious life-long consequences. Although child maltreatment is complex and difficult to study with current estimates varying widely depending on the country and the method of research used, yet international studies reveal that nearly 3 in 4 children aged 2-4 years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers, and 1 in 5 women and 1 in 13 men report having been sexually abused as a child.

Every year, there are an estimated 40 150 homicide deaths in children under 18 years of age, some of which are likely due to child maltreatment. This number almost certainly underestimates the true extent of the problem, since a significant proportion of deaths due to child maltreatment are incorrectly attributed to falls, burns, drowning and other causes.

In armed conflict and refugee settings, girls are particularly vulnerable to sexual violence, exploitation and abuse by combatants, security forces, members of their communities, aid workers and others.

A Christian girl who was bruised and burnt during the Orissa violence in August 2008. This girl was injured with burns bruises during anti Christian violence by Hindu nationalists. Credit: All India Christian Council / CC BY-SA

Types and forms of child maltreatment

Although there are four common types of child abuse and neglect, other forms exist; and the different forms of maltreatment often coexist, and overlap is considerable. The common types are:

• Physical Abuse. This is the intentional use of physical force that can result in physical injury to the child. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual Abuse. This involves all activities associated with pressuring, forcing, deceiving or convincing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities, including activities over the internet.
• Emotional Abuse. This covers all behaviors that harm a child’s self-worth or emotional well-being. Examples include name calling, shaming, rejection, withholding love, and threatening a child.
• Neglect. This is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, and access to medical care.

Other less common, but nonetheless serious and important forms of child maltreatment include:

• Abuse in a medical setting (fabricated or induced illness). Previously called Munchausen syndrome by proxy (MSP), but now referred to as factitious disorder imposed on another (FDIO), or also fabricated or induced illness (FII). This occurs when caregivers, for example parents, guardian or caretakers, intentionally produce or falsify physical or psychologic symptoms or signs in a child. Caregivers may injure the child with drugs or other agents or add blood or bacterial contaminants to urine specimens to simulate disease. Many children receive unnecessary and harmful or potentially harmful tests and treatments because of this.
• Cultural factors. Severe corporal punishment (eg, whipping, burning, scalding) clearly constitutes physical abuse, but for lesser degrees of physical and emotional chastisement, the boundary between socially accepted behavior and abuse varies among different cultures. Likewise, certain cultural practices are so extreme as to constitute abuse (eg, female genital mutilation, FGM -- see image below). However, certain folk remedies (eg, coining, cupping, irritant poultices) often create lesions (eg, bruises, petechiae, minor burns) that can blur the line between acceptable cultural practices and abuse.
  
  Members of certain religious and cultural groups have sometimes failed to obtain life-saving treatment (eg, for malaria, diabetic ketoacidosis, meningitis), resulting in a child's death. Such failure is typically considered neglect regardless of the parents’ or caregivers’ intent. Additionally, some people and cultural groups have increasingly been declining to have their children vaccinated, citing safety concerns. It is not clear whether this refusal of vaccination is true medical neglect. However, in the face of illness, refusal of scientifically and medically accepted treatment often requires further investigation and sometimes legal intervention.

Female genital mutilation (FGM) is a form of child abuse.
Image in Public Domain

Causes and risk factors

Several risk factors for child maltreatment have been identified. Not all risk factors are present in all social and cultural contexts, and the list here provides an overview when attempting to understand the causes of child maltreatment.

Child

It is important to emphasize that children are the victims and are never to blame for maltreatment. Characteristics of an individual child that may increase the likelihood of being maltreated include:

• being either under four years old or an adolescent
• being unwanted, or failing to fulfill the expectations of parents
• having special needs, crying persistently or having abnormal physical features
• having an intellectual disability or neurological disorder
• identifying as or being identified as lesbian, gay, bisexual or transgender.

Parent or caregiver

Characteristics of a parent or caregiver that may increase the risk of child maltreatment include:

• difficulty bonding with a newborn
• not nurturing the child
• having been maltreated themselves as a child
• lacking awareness of child development or having unrealistic expectations from their children
• misusing alcohol or drugs, including during pregnancy
• having low self-esteem
• suffering from poor impulse control
• having a mental or neurological disorder
• being involved in criminal activity
• experiencing financial difficulties.

Relationship

Characteristics of the relationships within families or among intimate partners, friends and peers that may increase the risk of child maltreatment include:

• family breakdown or violence between other family members
• being isolated in the community or lacking a support network
• a breakdown of support in child rearing from the extended family.

Community and societal factors

Characteristics of communities and societies that may increase the risk of child maltreatment include:

• gender and social inequality;
• lack of adequate housing or services to support families and institutions;
• high levels of unemployment or poverty;
• the easy availability of alcohol and drugs;
• inadequate policies and programmes to prevent child maltreatment, child pornography, child prostitution and child labour;
• social and cultural norms that promote or glorify violence towards others, support the use of corporal punishment, demand rigid gender roles, or diminish the status of the child in parent–child relationships;
• social, economic, health and education policies that lead to poor living standards, or to socioeconomic inequality or instability.

Symptoms and signs

Symptoms and signs which suggest child maltreatment depends on the nature and duration of the child abuse or neglect.

Physical abuse

• Skin lesions are common and may include handprints or oval fingertip marks caused by slapping or grabbing and shaking, bleeding into the skin (bruises and ecchymoses) caused by belt or cord whipping, multiple small round burns caused by cigarettes, patchy bald hair (alopecia) with varying hair lengths caused by hair pulling and similar other signs. However, more commonly, skin findings are subtle for example a small bruise on the face and/or neck.
• Fractures
• Confusion and other abnormalities, like fussiness and vomiting, indicative of injury to the brain and spinal cord can occur. For example infants who become comatose or stuporous due to traumatic brain injury from violent shaking. It is worthwhile to note that such babies may have no bodily injuries.
• Fear and/or irritability with or without poor sleep. 
• There may also be depression, posttraumatic stress reactions, or anxiety. 
• Sometimes victims of abuse display symptoms similar to those of attention-deficit/hyperactivity disorder (ADHD) and are mistakenly diagnosed with that disorder. 
• Violent or suicidal behavior may occur.

Sexual abuse

Children do not spontaneously disclose sexual abuse and rarely exhibit behavioral or physical signs of sexual abuse. If a disclosure is made, it is generally delayed, sometimes days to years. In some cases, abrupt or extreme changes in behavior may occur. Aggressiveness or withdrawal may develop, as may phobias or sleep disturbances. Some sexually abused children act in ways that are sexually inappropriate for their age.

Physical signs of sexual abuse that involves penetration may include

• Difficulty in walking or sitting
• Bruises or tears around the genitals, anus, or mouth
• Vaginal discharge, bleeding, or pruritus

Other manifestations include a sexually transmitted infection and pregnancy. Within a few days of the abuse, examination of the genitals, anus, and mouth will likely be normal, but the examiner may find healed lesions or subtle changes.

See separate article, Adolescent Pregnancy for more on that topic.

Emotional abuse

In early infancy, emotional abuse may blunt emotional expressiveness and decrease interest in the environment. Emotional abuse commonly results in failure to thrive and is often misdiagnosed as intellectual disability or physical illness. Inadequate parental stimulation and interaction often causes delayed development of social and language skills. Emotionally abused children may be insecure, anxious, distrustful, superficial in interpersonal relationships, passive, and overly concerned with pleasing adults. Children who are spurned may have very low self-esteem. Children who are terrorized or threatened may seem fearful and withdrawn.

The emotional effects of maltreatment on children usually becomes obvious at school age, when difficulties develop in forming relationships with teachers and peers. Often, emotional effects are appreciated only after the child has been placed in another environment or after aberrant behaviors abate and are replaced by more acceptable behaviors. Children who are exploited may commit crimes or abuse alcohol and/or drugs.

Neglect

Undernutrition, fatigue, poor hygiene, lack of appropriate clothing, and failure to thrive are common signs of inadequate provision of food, clothing, or shelter. Stunted growth and death resulting from starvation or exposure to extremes in temperature or weather may occur. Neglect that involves inadequate supervision may result in preventable illness or injury.

Diagnosing child maltreatment

To properly diagnose child maltreatment, health professionals use the following essential tools:

1. High index of suspicion (eg, for history that does not match physical findings or for atypical injury patterns). Recognizing child abuse or maltreatment as the cause of injuries and nutritional deficiencies can be difficult, so the health professional usually maintains a high index of suspicion. Because of social biases, abuse is considered less often in children living in a 2-parent household with an at least median-level income. However, child abuse can occur regardless of family composition or socioeconomic status.
2. Supportive, open-ended questioning. Sometimes health professionals use direct questions to provide answers. Children who have been maltreated may describe the events and the perpetrator, but some children, particularly those who have been sexually abused, may be sworn to secrecy, threatened, or so traumatized that they are reluctant to speak about the abuse (and may even deny abuse when specifically questioned). Thus, the health professional obtains a medical history, including a chronological history of events from the child and their caregivers in a relaxed environment. Open-ended questions (eg, “Can you tell me what happened?”) are particularly important in these cases because yes-or-no questions (eg, “Did daddy do this?”, “Did he touch you here?”) can easily sculpt an untrue history in young children.
3. Sometimes imaging and laboratory tests. Health professionals carefully observe interactions between the child and their caregivers whenever possible noting how they interact. They then document the history and what they have observed (physical examination) as comprehensively and accurately as they can, including recording of exact quotes from the history and photographs of injuries.
4. Reporting to authorities for further investigation. Often it is unclear after the initial evaluation whether child abuse occurred. In such cases, the mandatory reporting requirement of suspected child abuse allows appropriate authorities and social agencies to investigate; if their evaluation confirms child abuse, appropriate legal and social interventions can be initiated.

Treatment of child maltreatment

Treatment of child abuse and neglect should consider a number of factors, including:

• Treatment of injuries
• Creation of a safety plan
• Family counseling and support
• Sometimes removal of the child from the home

Treatment first addresses urgent medical needs (including possible sexually transmitted infections) and the child’s immediate safety. Referral to a pediatrician specializing in child abuse should be considered. In all child maltreatment situations, both abuse and neglect, families should be approached in a helping rather than a punitive manner.

Consequences of child maltreatment

Child maltreatment causes suffering to children and families and can have long-term consequences. Maltreatment causes stress that is associated with disruption in early brain development. Extreme stress can impair the development of the nervous and immune systems. Consequently, as adults, maltreated children are at increased risk for behavioural, physical and mental health problems such as:

• perpetrating or being a victim of violence
• depression
• smoking
• obesity
• high-risk sexual behaviours
• unintended pregnancy
• alcohol and drug misuse.

Through these afore-mentioned behavioural and mental health consequences, maltreatment can contribute to heart disease, cancer, suicide and sexually transmitted infections. Violence against children is also a contributor to inequalities in education. Children who experienced any form of violence in childhood have a 13% greater likelihood of not graduating from school.

Beyond the health, social and educational consequences of child maltreatment, there is an economic impact, including costs of hospitalization, mental health treatment, child welfare, and longer-term health costs.

Prevention of child maltreatment

Preventing child abuse and neglect, and responding to child maltreatment requires a multisectoral approach.

The earlier such interventions occur in children's lives, the greater the benefits to the child (e.g. cognitive development, behavioural and social competence, educational attainment) and to society (e.g. reduced delinquency and crime).

Effective and promising interventions include:

• Parent and caregiver support: Information and skill-building sessions to support the development of nurturing, non-violent parenting delivered by nurses, social workers, or trained lay workers through a series of home visits or in a community setting.
• Education and life skills approaches:
  • Increasing enrolment in quality education to allow children acquire knowledge, skills and experiences that build resilience and reduce risk factors for violence
  • Programmes to prevent sexual abuse that build awareness and teach skills to help children and adolescents understand consent, avoid and prevent sexual abuse and exploitation, and to seek help and support
  • Interventions to build a positive school climate and violence-free environment, and strengthening relationships between students, teachers, and administrators
• Norms and values approaches: Programmes to transform restrictive and harmful gender and social norms around child-rearing, child discipline and gender equality and promote the nurturing role of fathers
• Implementation and enforcement of laws: laws to prohibit violent punishment and to protect children from sexual abuse and exploitation.
• Response and support services: Early case recognition coupled with ongoing care of child victims and families to help reduce reoccurrence of maltreatment and lessen its consequences.

To maximize the effects of prevention and care, WHO recommends that interventions are delivered as part of a four-step public health approach:

1. defining the problem;
2. identifying causes and risk factors;
3. designing and testing interventions aimed at minimizing the risk factors;
4. disseminating information about the effectiveness of interventions and increasing the scale of proven effective interventions.

Reference(s)
1). World Health Organization: Child maltreatment - WHO Fact Sheets. Accessed 01.08.20. Available online: https://www.who.int/news-room/fact-sheets/detail/child-maltreatment
2). Centers for Disease Control: Child Abuse and Neglect Prevention. Accessed 01.08.20. Available online: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html
3). MSDManuals: Overview of Child Maltreatment. Accessed 01.08.20. Available online: https://www.msdmanuals.com/en-gb/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment
4). NICE: Child maltreatment: when to suspect maltreatment in under 18s. Accessed 01.08.20. Available online: https://www.nice.org.uk/guidance/cg89/chapter/Introduction