research paper on childhood abuse

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• June 01, 2024 | VOL. 181, NO. 6 CURRENT ISSUE pp.461-564
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The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

• Elizabeth T.C. Lippard , Ph.D. ,
• Charles B. Nemeroff , M.D., Ph.D.

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A large body of evidence has demonstrated that exposure to childhood maltreatment at any stage of development can have long-lasting consequences. It is associated with a marked increase in risk for psychiatric and medical disorders. This review summarizes the literature investigating the effects of childhood maltreatment on disease vulnerability for mood disorders, specifically summarizing cross-sectional and more recent longitudinal studies demonstrating that childhood maltreatment is more prevalent and is associated with increased risk for first mood episode, episode recurrence, greater comorbidities, and increased risk for suicidal ideation and attempts in individuals with mood disorders. It summarizes the persistent alterations associated with childhood maltreatment, including alterations in the hypothalamic-pituitary-adrenal axis and inflammatory cytokines, which may contribute to disease vulnerability and a more pernicious disease course. The authors discuss several candidate genes and environmental factors (for example, substance use) that may alter disease vulnerability and illness course and neurobiological associations that may mediate these relationships following childhood maltreatment. Studies provide insight into modifiable mechanisms and provide direction to improve both treatment and prevention strategies.

“It is not the bruises on the body that hurt. It is the wounds of the heart and the scars on the mind.” —Aisha Mirza

“We can deny our experience but our body remembers.” —Jeanne McElvaney, Spirit Unbroken: Abby’s Story

It is now well established that childhood maltreatment, or exposure to abuse and neglect in children under the age of 18, has devastating consequences. Over the past two decades, research has begun not only to define the consequences in the context of health and disease but also to elucidate mechanisms underlying the link between childhood maltreatment and medical, including psychiatric, outcomes. Research has begun to shed light on how childhood maltreatment mediates disease risk and course. Childhood maltreatment increases risk for developing psychiatric disorders (e.g., mood and anxiety disorders, posttraumatic stress disorder [PTSD], antisocial and borderline personality disorders, and substance use disorders). It is associated with an earlier age at onset and a more severe clinical course (i.e., greater symptom severity) and poorer treatment response to pharmacotherapy or psychotherapy. Early-life adversity is also associated with increased vulnerability to several major medical disorders, including coronary artery disease and myocardial infarction, cerebrovascular disease and stroke, type 2 diabetes, asthma, and certain forms of cancer. The net effect is a significant reduction in life expectancy in victims of child abuse and neglect. The focus of this review is to expand on previous reviews by synthesizing the literature and integrating much recent data, with a focus on investigating childhood maltreatment interactions with risk for mood disorders, disease onset, and early disease heterogeneity, as well as emerging data suggesting modifiable mechanisms that could be targeted for early intervention and prevention strategies. A major emphasis of this review is to provide a clinically relevant update to practicing mental health practitioners.

Prevalence and Consequences of Childhood Maltreatment

It is estimated that one in four children will experience child abuse or neglect at some point in their lifetime, and one in seven children have experienced abuse over the past year. In 2016, 676,000 children were reported to child protective services in the United States and identified as victims of child abuse or neglect ( 1 ). However, it is widely accepted that statistics on such reports represent a significant underestimate of the prevalence of childhood maltreatment, because the majority of abuse and neglect goes unreported. This is especially true for certain types of childhood maltreatment (notably emotional abuse and neglect), which may never come to clinical attention but have devastating consequences on health independently of physical abuse and neglect or sexual abuse. Although rates of children being reported to child protective services have remained relatively consistent over recent decades ( Figure 1 ), our understanding of the devastating medical and clinical consequences of childhood maltreatment has grown, and childhood maltreatment is now well established as a major risk factor for adult psychopathology. In this review, we seek to summarize the burgeoning literature on childhood maltreatment, specifically focusing on the link between childhood maltreatment and mood disorders (depression and bipolar disorder). The data converge to point toward future directions for education, prevention, and treatment to decrease the consequences of childhood maltreatment, especially in regard to mood disorders.

FIGURE 1. National estimates of childhood maltreatment in the United States a

a Panel A graphs the prevalence of maltreatment (calculated national estimate/rounded number of victims by year, and panel B graphs rates of victimization per 1,000 children, between 1999 and 2016, as reported by the Children’s Bureau, which produces an annual Child Maltreatment report including data provided by the United States to the National Child Abuse and Neglect Data Systems. Estimated rates of maltreatment have remained high over the past two decades. The asterisk calls attention to the fact that before 2007, the national estimates were based on counting a child each time he or she was the subject of a child protective services investigation. In 2007, unique counts started to be reported. The unique estimates are based on counting a child only once regardless of the number of times he or she is found to be a victim during a reporting year. (Information obtained from https://www.acf.hhs.gov/cb/research-data-technology/statistics-research/child-maltreatment .)

Childhood Maltreatment Increases Risk for Illness Severity and Poor Treatment Response in Mood Disorders

The link between childhood maltreatment and risk for mood disorders and differences in disease course following illness onset has been well documented ( 2 – 8 ). Multiple studies have demonstrated greater rates of childhood maltreatment in patients with major depression and bipolar disorder ( 9 – 11 ). Indeed, a recent meta-analysis revealed that 46% of individuals with depression report childhood maltreatment ( 12 ). Patients with bipolar disorder also report high levels of childhood maltreatment ( 13 , 14 ), with estimates as high as 57% ( 15 ). Childhood maltreatment is associated with an increased risk and earlier onset of unipolar depression, with syndromal depression occurring on average 4 years earlier in individuals with a history of childhood maltreatment compared with those without such a history ( 12 ). Childhood maltreatment is also associated with a more pernicious disease course, including a greater number of lifetime depressive episodes and greater depression severity, with the majority of studies showing more recurrence and greater persistence of depressive episodes ( 16 – 18 ). For example, Wiersma et al. ( 19 ), in an analysis of 1,230 adults with major depressive disorder drawn from the Netherlands Study of Depression and Anxiety, found that childhood maltreatment (measured with the Childhood Trauma Interview) was associated with chronicity of depression, defined as being depressed for ≥24 months over the past 4 years, independent of comorbid anxiety disorders, severity of depressive symptoms, or age at onset. Increased risk for suicide attempts and comorbidities, including increased rates of anxiety disorders, PTSD, and substance use disorders, are reported in individuals with depression who experience childhood maltreatment. Individuals with major depressive disorder and atypical features report significantly more traumatic life events (including physical abuse, sexual abuse, and other forms of trauma) both before and after their first depressive episode, independently of sex, age at onset, or duration of depression ( 20 ). Additionally, childhood maltreatment has consistently been shown to be associated with poor treatment outcome (after psychotherapy, pharmacotherapy, and combined treatment) in depression, as assessed by lack of remission or response or longer time to remission ( 12 , 18 , 21 , 22 ).

Although the studies cited above describe a link between childhood maltreatment and a more pernicious depression course, most studies have been cross-sectional, and the possibility of recall bias and mood effects (owing to the retrospective investigation of childhood maltreatment in individuals who are currently depressed) cannot be ruled out. However, studies over the past few years comparing retrospective and prospective measurement of childhood maltreatment suggest consistency between retrospective reports and prospective designs ( 23 , 24 ), although a recent meta-analysis ( 25 ) suggested poor agreement between these measures, with better agreement observed when retrospective measures were based on interviews and in studies with smaller samples. Longitudinal and prospective studies are emerging that have further confirmed and extended our understanding of the devastating consequences of childhood maltreatment on illness course ( 5 , 7 ). Ellis et al. ( 26 ) recently reported that childhood maltreatment increased risk for more severe trajectories of depressive symptoms during a 7-year longitudinal study in 243 adolescents in the Orygen Adolescent Development Study. Gilman et al. ( 27 ) reported that childhood maltreatment increased the risk for recurrent depressive episodes and suicidal ideation by 20%−30% during a 3-year follow-up of 2,497 participants diagnosed with major depressive disorder in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Additionally, Widom et al. ( 7 ), in a study that followed a cohort of 676 children with documented childhood maltreatment and compared risk for major depression in adulthood between them and a cohort of 520 children matched on age, race, sex, and family social class who were not exposed to childhood maltreatment, found a clear association between childhood maltreatment and both increased risk for depression and earlier onset of the disorder.

Although more research has been reported investigating the link between childhood maltreatment and disease onset and course in unipolar depression, more recent evidence supports the link between childhood maltreatment and disease onset and course in bipolar disorder ( 28 ). Childhood maltreatment is associated with increased disease vulnerability and earlier age at onset of bipolar disorder ( 29 ). Jansen et al. ( 30 ) sought to determine whether childhood maltreatment mediated the effect of family history on diagnosis of a mood disorder. The findings indicated that one-third of the effect of family history on risk for mood disorders was mediated by childhood maltreatment. As with depression, studies on bipolar disorder with a prospective or longitudinal approach are few, but they are informative. Using data from the NESARC (N=33,375), Gilman et al. ( 31 ) found that childhood physical and sexual abuse were associated with increased risk for first-onset and recurrent mania independently of recent life stress. An association between childhood maltreatment and prodromal symptoms has also been reported in bipolar disorder ( 32 ), suggesting that childhood maltreatment may contribute to disease vulnerability before onset of the first manic episode. Childhood maltreatment in the context of bipolar disorder is also associated with a more pernicious disease course, including greater frequency and severity of mood episodes (both depressive and manic), greater severity of psychosis symptoms, and greater risk for comorbidities (i.e., anxiety disorders, PTSD, substance use disorders), rapid cycling, inpatient hospitalizations, and suicide attempts ( 28 , 33 – 41 ). Studies are beginning to emerge investigating treatment response in bipolar disorder following childhood maltreatment. Such studies remain few, but they suggest that childhood maltreatment is associated with a poor response to benzodiazepines ( 42 ) and anticonvulsants ( 41 ) in bipolar disorder. The concatenation of findings in depression and bipolar disorder are concordant in that childhood maltreatment increases risk for, and early onset of, first mood episode and episode recurrence. Childhood maltreatment affects disease trajectories, including in its association with more insidious mood episodes, poor treatment response, a greater risk for comorbidities, and a greater risk for suicide ideation, attempts, and completion. The link between childhood maltreatment and increased prevalence of suicide-related behaviors is of particular importance given the high rate of suicide ideation, attempts, and completion in depression and bipolar disorder. Despite many prevention strategies (e.g., education and outreach and clinical studies to identify risk factors for impending suicide attempts in individuals with mood disorders), suicide rates have not decreased but in fact have increased in the United States. The link between childhood maltreatment and suicide-related behavior has been reviewed by several groups ( 21 , 33 , 43 – 47 ). Dube et al. ( 48 ) reported that adverse childhood experiences, including childhood maltreatment, increased the risk for suicide attempts twofold to fivefold in 17,337 adults in the now classic Adverse Childhood Experiences Study. Gomez et al. ( 49 ) reported that physical or sexual abuse increased the odds of suicide ideation, planning, and attempts among the 9,272 adolescents in the U.S. National Comorbidity Survey Adolescent Supplement. Miller et al. ( 50 ) examined the relationship between childhood maltreatment and prospective suicidal ideation in a cohort of 682 youths followed over a 3-year period. Emotional maltreatment predicted suicidal ideation, independently of previous suicidal ideation and depressive symptom severity. Childhood maltreatment is also associated with earlier age at first suicide attempt ( 51 ). Additionally, an association between childhood maltreatment and suicide risk in 449 individuals age 60 or older was recently reported from the Multidimensional Study of the Elderly, in the Family Health Strategy in Porto Alegre, Brazil ( 52 ). The effect was independent of depressive symptom severity. These findings suggest that childhood maltreatment increases risk for suicide-related behavior across the lifespan. More work is warranted in investigating the biological mechanisms that may mediate the association between childhood maltreatment and suicide-related behaviors.

Timing of Childhood Maltreatment: Are There Periods of Heightened Sensitivity?

Although childhood maltreatment at any age can result in long-lasting consequences ( 53 ), there is evidence that the timing, duration, and severity of maltreatment mediate the risk for later psychopathology ( 54 ). Childhood maltreatment that occurs earlier in life and continues for a longer duration is associated with the worst outcomes ( 55 ). This is supported by preclinical models (rodent and nonhuman primate) that investigated maternal separation ( 56 , 57 ), a paradigm more similar to neglect in humans. One study in rodents found that maternal separation during the early postnatal period (days 2–15) but not the later postnatal period (days 7–20) is associated with anxious and depressive-like behaviors in adulthood ( 57 ). Although this postnatal period coincides with in utero development in humans, there is evidence that in utero insults in the form of stress can have consequences similar to early-life trauma ( 58 , 59 ), supporting the translational validity of these models. Clinical studies also support the importance of timing of childhood maltreatment in moderating risk for psychopathology. Cowell et al. ( 60 ) investigated the timing and duration of childhood maltreatment in 223 maltreated children between the ages of 3 and 9 and found that children who were maltreated during infancy and those who experienced chronic maltreatment had poorer inhibitory control and working memory. Dunn et al. ( 61 ) investigated the relationship between timing of childhood maltreatment and depression and suicidal ideation in early adulthood among 15,701 participants in the National Longitudinal Study of Adolescent Health, and found that exposure to early maltreatment, especially during the preschool years (between ages 3 and 5), was most strongly associated with depression. Additionally, sexual abuse occurring during early childhood, compared with adolescence, was reported to be more strongly associated with suicidal ideation ( 61 ). While these studies suggest that childhood maltreatment that occurs earlier in development may further increase risk for developing mood disorders and associated behaviors in adulthood, it is important to emphasize that evidence suggests that exposure to maltreatment during later childhood and adolescence also independently increases risk for mood disorders. Emotional abuse and neglect, especially if it occurs between ages 8 and 9, increases depressive symptoms ( 62 ). Emotional abuse during adolescence also increases risk for depression ( 63 ).

More work is emerging investigating the negative consequences of bullying. A study of 1,420 participants (ages 9–16) revealed that victims of bullying showed an increased prevalence of generalized anxiety disorder, depression, and suicide-related behavior ( 64 ). A recent study of more than 5,000 children that comprised a longitudinal data set (the Avon Longitudinal Study of Parents and Children in England and the Great Smoky Mountains Study in the United States) ( 65 ) found an increased risk for mental health problems, including anxiety, depression, and self-harm, in individuals who experienced bullying, but not other maltreatment. Additionally, an association between childhood bullying by peers and risk for suicide-related behaviors (ideation, planning, attempting, and onset of plan among ideators), independent of childhood maltreatment by adults, was reported in a sample of U.S. Army soldiers ( 66 ).

Some studies suggest that differential periods of sensitivity to different subtypes of maltreatment are distinctly associated with an increased risk for mood disorders. Recently, a stronger relationship was reported between adult depression and early childhood sexual abuse (occurring at age 5 or earlier) and later childhood physical abuse (occurring at age 13 or later), compared with maltreatment that occurred during other developmental periods ( 67 ). Harpur et al. ( 68 ) reported that early childhood maltreatment (between birth and age 4) predicted more anxiety symptoms, and maltreatment that occurred in late childhood or early adolescence (between ages 10 and 12) predicted more depressive symptoms in adolescence. Taken together, these studies suggest that maltreatment at any age and across different contexts (physical and emotional, familial- and peer-induced) often result in long-lasting and severe consequences and that there may be specific sensitive periods in development when exposure to distinct types of maltreatment may differentially increase risk for affective disorders in adulthood. To date, the majority of research investigating the impact of childhood maltreatment timing on illness risk and course in mood disorders has focused on depression. One study ( 69 ) reported that early sexual or physical abuse (before age 11) in 225 early psychosis patients (6.7% with a bipolar disorder diagnosis) coincided with lower scores on the Global Assessment of Functioning Scale and the Social and Occupational Functioning Assessment Scale during a 3-year follow-up period, whereas late sexual or physical abuse (between ages 12 and 15) did not. More work investigating timing of maltreatment and associated clinical outcomes is warranted.

Experiencing Single Subtypes of Abuse and Neglect Versus Experiencing Multiple Types

Several groups have sought to determine the impact of single types of childhood maltreatment on mood disorders. Although all types of childhood maltreatment (physical, emotional, and sexual) increase disease vulnerability and risk for more severe illness course in mood disorders, including increased risk for suicide ( 52 ), there may be some distinctions between individual subtypes and associated outcomes ( 70 ). An association between sexual abuse and lifetime risk for anxiety disorders, depression, and suicide attempts independent of other types of maltreatment has been reported ( 2 , 71 , 72 ). In bipolar disorder, physical abuse and sexual abuse independently increase risk for illness vulnerability and more severe course ( 13 ). One study of 446 youths (ages 7 to 17) found that physical abuse was independently associated with a longer duration of illness in bipolar disorder, a greater prevalence of comorbid PTSD and psychosis, and a greater prevalence of family history of a mood disorder when compared with sexual abuse, which was only associated with a greater prevalence of PTSD ( 13 ). Recent life stress in adulthood was found to increase risk for first-onset mania in individuals with a history of childhood physical maltreatment, but not individuals with a history of sexual maltreatment ( 31 ). However, it should be noted that early-life sexual abuse in the study was a strong risk factor for mania even in the absence of recent life stress.

Neglect is the least studied form of early-life adversity, and emerging data suggest differential consequences following neglect as compared with abuse ( 73 ). Similarly, long-lasting consequences following emotional maltreatment, independently of other forms of maltreatment, have also been reported ( 47 , 74 , 75 ). In a 2015 meta-analysis, emotional abuse showed the strongest association with depression, followed by neglect and sexual abuse ( 76 ), a finding supported by another recent meta-analysis ( 77 ). Spertus et al. ( 78 ) reported that emotional abuse and neglect predicted depressive symptoms even after controlling for physical and sexual abuse, further suggesting emotional abuse and neglect to be independently related to illness severity in depression. Parental “verbal aggression” was found to increase risk for depression and anxiety in adolescents, with risk suggested to be greater following verbal aggression compared with physical abuse ( 79 ). Khan et al. ( 63 ) recently reported that nonverbal emotional abuse in males and peer emotional abuse in females are important predictors of lifetime history of major depression and are more predictive than number of types of maltreatment experienced. Another recent meta-analysis ( 12 ) reported that in individuals with depression, emotional neglect was the most common reported form of childhood maltreatment, and emotional abuse was most closely related to symptom severity. High prevalence of emotional maltreatment is also reported in bipolar disorder (approximately 40%), with emotional maltreatment associated with disease vulnerability and more severe illness course, including rapid cycling, comorbid anxiety or stress disorders, suicide attempts or ideation, and cannabis use ( 80 ).

Although studies on subtypes of maltreatment are only now burgeoning, they are concordant in implicating emotional maltreatment, in addition to physical and sexual maltreatment, in increasing risk for, and differences in disease course of, mood disorders. Emotional maltreatment and neglect are clearly the least studied of all forms of childhood adversity. This is in part because they are often overlooked and least likely to come to clinical attention, as compared with physical and sexual abuse, which can, of course, result in physical injury. Because emotional maltreatment and neglect are likely the most prevalent forms of childhood maltreatment in psychiatric populations ( 81 ), and given findings suggesting that independent of other forms of maltreatment, emotional maltreatment has long-lasting consequences that increase risk for mood disorders and illness outcome ( 74 , 75 ), more research on the role of emotional maltreatment and neglect are urgently needed.

Although the findings described above suggest the hypothesis that different subtypes of early-life adversity may independently increase risk for mood disorders and that some subtypes may be more closely related to specific differences in illness course and severity, it is clear that subtypes of abuse and neglect, as a rule, do not occur in isolation but instead occur together in the same individuals. For example, individuals experiencing physical or sexual abuse likely also experience emotional maltreatment. Some studies have investigated the impact of multiple types of childhood maltreatment. A recent meta-analysis reported that 19% of individuals with major depression report more than one form of childhood maltreatment and, while all childhood maltreatment subtypes have been shown to increase the risk of depression, experiencing multiple forms of childhood maltreatment further elevates this risk ( 12 ). The Adverse Childhood Experiences study provided evidence of an additive effect of eight early-life stress events (including abuse but also other early-life stressors, such as divorce, domestic violence, household substance abuse, and parental loss) on adult psychopathology. Specifically, individuals with four or more early-life stress events had significantly increased risk for depression, anxiety, suicide attempts, substance use disorders, and other detrimental outcomes ( 82 , 83 ). An additive or cumulative effect of early-life stress on increased risk for mood, anxiety, and substance use disorders has also been reported by others ( 5 , 6 ). Multiple adverse childhood experiences (maltreatment plus other forms of stressful events) also result in higher rates of comorbidities ( 7 , 82 ). Likewise, a dose-response relationship between number of types of childhood maltreatment and illness severity in bipolar disorder has been suggested, including increased risk for comorbid anxiety disorders and substance use disorders ( 84 ).

Underlying Mechanisms by Which Childhood Maltreatment Increases Risk for Mood Disorders and Contributes to Disease Course

As depicted in Figure 2 , several putative biological mechanisms by which childhood maltreatment may increase the risk for mood disorders and disease progression have been described ( 21 , 85 ). These include, but are not limited to, inflammation and other immune system perturbations, alterations in the hypothalamic-pituitary-adrenal (HPA) axis, and genetic and epigenetic processes as well as structural and functional brain imaging changes. These studies provide insight into modifiable targets and provide direction to improve both treatment and prevention strategies.

FIGURE 2. Child maltreatment, its consequences, and windows for intervention across development a

a The gray arrow represents the development of disease vulnerability, disease onset, and variations in disease course and treatment. Exposure to childhood maltreatment at any point during development (red bar) can result in long-lasting consequences, including increasing disease vulnerability and illness severity in mood disorders. There may be optimal windows (black arrows) across development when interventions could decrease disease burden by decreasing disease vulnerability and improving illness course; these include before and after birth (parenting classes and parenting support groups), at the time of maltreatment, when prodromal symptoms begin to emerge, immediately following disease onset, and during disease course (e.g., improving treatment response). Modifiable targets are beginning to emerge (green arrows and text) and point to behavioral and environmental factors, as well as genetic and other molecular factors, that could be focused on for interventions.

Biological Abnormalities Associated With Childhood Maltreatment

Several persistent biological alterations associated with childhood maltreatment may mediate the increased risk for development of mood and other disorders. Childhood maltreatment is associated with systemic inflammation ( 86 , 87 ) as assessed by measurements of C-reactive protein (CRP) and inflammatory cytokines including tumor necrosis factor-alpha and interleukin-6. Childhood maltreatment was found to be associated with increased plasma CRP levels and increased body mass index in 483 participants identified as being on the psychosis spectrum ( 88 ). Patients with depression and bipolar disorder have also been reported to exhibit increased levels of inflammatory markers ( 89 – 92 ). It is unclear whether childhood maltreatment–associated inflammation is responsible for the observations in patients with mood disorders. Anti-inflammatory drugs are a promising novel therapeutic strategy in the subgroup of depressed patients with elevated inflammation ( 93 ), although the findings thus far are preliminary, and further study on inflammation as a modifiable target is warranted.

Another mechanism through which childhood maltreatment may increase risk for mood disorders is through alterations of the HPA axis and corticotropin-releasing factor (CRF) circuits that regulate endocrine, behavioral, immune, and autonomic responses to stress. Research documenting how childhood maltreatment contributes to altered HPA axis and CRF circuit activity in preclinical and clinical studies has been reviewed in detail elsewhere ( 21 ). Childhood adversity likely increases sensitivity to the effects of recent life stress on the course of both unipolar and bipolar disorder. Soldiers exposed to childhood maltreatment have a greater risk for depression or anxiety following recent life stressors ( 94 ). Likewise, individuals exposed to childhood maltreatment have a greater risk of mania following recent life stressors compared with individuals without childhood maltreatment ( 31 , 34 ). Individuals with depression or bipolar disorder and early-life stress report lower levels of stress prior to recurrence of a mood episode compared with individuals with depression or bipolar disorder without early-life stress ( 34 , 95 ); this suggests that less stress is required to induce a mood episode in individuals who were exposed to childhood maltreatment. These findings support theoretical sensitization frameworks on the role of stress in unipolar depression and bipolar disorder ( 96 – 99 ). Alterations in the HPA axis and CRF circuits following childhood maltreatment are mechanisms that likely contribute to increased risk for mood episodes following stressful life events and may be modifiable targets. Indeed, Abercrombie et al. ( 100 ) recently reported that therapeutics targeting cortisol signaling may show promise in the treatment of depression in adults with a history of emotional abuse.

In addition to the biological mechanisms noted above, genetic predisposition undoubtedly also plays a role in the pathogenesis of mood disorders following early-life stress. As previously reviewed ( 21 ), studies support the interaction of genetic predisposition and childhood maltreatment in increasing risk for mood disorders and affecting disease course. Indeed, this is now considered a prototype of how gene-by-environment interactions influence disease vulnerability. Polymorphisms in genes comprising components of the HPA axis and CRF circuits increase the risk for adult mood disorders in adults exposed to childhood maltreatment. For example, polymorphisms in the FK506 binding protein 5 (FKBP5) gene interact with childhood maltreatment to increase risk for major depression, suicide attempts, and PTSD ( 101 – 105 ). Caspi et al. ( 106 ) found that adults exposed to childhood maltreatment who carried the short arm allele of the serotonin transporter promoter polymorphism (heterozygotes and homozygotes) exhibited an increased risk for a depressed episode, greater depressive symptoms, and greater risk for suicidal ideation and attempts compared with homozygotes with two long arm alleles. A large number of studies now support the interaction between early-life stress, the serotonin transporter promoter, and other serotonergic gene polymorphisms and disease vulnerability and illness course in depression and bipolar disorder ( 107 – 111 ), although conflicting findings have also been reported ( 112 ). Childhood maltreatment has also been reported to interact with corticotropin-releasing hormone receptor 1 gene (CRHR1) polymorphisms to predict syndromal depression and increase risk for suicide attempts in adults ( 113 – 115 ). Early-life stress interactions with other genetic polymorphisms to influence risk for mood disorders and illness course include, but are not limited to, brain-derived neurotrophic factor (BDNF) Val66Met polymorphism ( 116 , 117 ), toll-like receptors ( 118 ), the oxytocin receptor ( 119 ), inflammation pathway genes ( 120 ), and methylenetetrahydrofolate reductase ( 121 ), although negative findings have also been reported ( 122 ). Studies employing polygenic risk score (PRS) analyses, an approach assessing the combined impact of multiple genotyped single-nucleotide polymorphisms, have reported that PRS is differentially related to risk for depression in individuals with a history of childhood maltreatment compared with those without maltreatment ( 123 , 124 ), although negative findings have also been reported ( 125 ).

Studies investigating the role of epigenetics (e.g., the modification of gene expression through DNA methylation and acetylation) in mediating detrimental outcomes following early-life stress have recently appeared ( 126 ). For example, a recent study reported that hypermethylation of the first exon of a monoamine oxidase A (MAOA) gene region of interest mediated the association between sexual abuse and depression ( 127 ). Childhood maltreatment is also associated with epigenetic modifications of the glucocorticoid receptor ( 128 ), the FKBP5 gene ( 101 ), and the serotonin 3A receptor ( 129 ), with these modifications associated with suicide completion, altered stress hormone systems, and illness severity, respectively. Childhood maltreatment–associated epigenetic changes in individuals who died by suicide have been identified in human postmortem studies ( 130 ). These studies, and others not cited here, support gene–by–childhood maltreatment interactions, including epigenetic modifications, in risk for mood disorders and in illness course.

Epigenetics may also be one mechanism that contributes to the intergenerational transmission of trauma ( 131 – 133 ), although it is important to note that nongenomic mechanisms are also implicated in the intergenerational transmission of behavior ( 134 ). There is a robust literature in rodent models supporting the intergenerational transmission of maternal behavior—maternal traits being passed to offspring—including abuse-related phenotypes ( 132 , 135 ). Intergenerational transmission of behavior is also implicated in humans. Yehuda et al. ( 136 , 137 ) investigated risk for psychopathology in offspring of Holocaust survivors. These pivotal studies identified increased risk for PTSD, mood disorders, and substance use disorders in offspring. These offspring also reported having higher levels of emotional abuse and neglect, which correlated with severity of PTSD in the parent ( 136 , 137 ), implicating early-life stress in transmission of psychopathology. While there is evidence that children with developmental disabilities are at a higher risk for neglect ( 138 – 140 ), there is a paucity of studies investigating whether offspring of individuals with mental illness are more liable to abuse. However, as discussed above, higher rates of maltreatment are reported in individuals with mood disorders, but whether and what familial factors may drive these elevated rates, or whether these interactions contribute to the intergenerational transmission of psychopathology, are not known. In light of the emerging data on intergenerational transmission of trauma, this is an important, complex area in need of further study. There have not been many genetic studies in this area. In a study investigating early-life maltreatment in a rodent model, early-life abuse (defined as stepping on, dropping, or dragging offspring, and active avoidance) was associated with altered BDNF expression and methylation in the prefrontal cortex in adult offspring, with adult offspring also showing poorer maternal care patterns when rearing their own offspring ( 135 ). Altered expression and methylation of BDNF is reported in individuals with mood disorders ( 141 , 142 ). These studies highlight the importance of understanding the intergenerational transmission of trauma and psychopathology to identify modifiable targets to improve outcomes, for example, the family unit and interpersonal relationships. It is noteworthy that while the majority of research has focused on intergenerational transmission of maternal traits, research is also emerging that supports the important role of paternal care on intergenerational transmission of behavior ( 131 ). More study on intergenerational transmission of trauma is needed.

Pathways to Mood Disorder Outcomes

More work on mechanisms and pathways by which childhood maltreatment increases risk for and ultimately results in adult mood disorders is essential for early intervention. Childhood maltreatment is associated with a marked increase in medical morbidities and an array of physical symptoms, and in general it predicts poor health and a shorter lifespan ( 143 , 144 ). Higher rates of comorbid substance use disorders in individuals with mood disorders who report experiencing childhood maltreatment is of particular interest. Childhood maltreatment has consistently been associated with a number of high-risk health behaviors, including smoking and alcohol and drug use—behaviors thought to contribute to the association between childhood maltreatment and poor health ( 145 – 148 ). These behaviors on their own increase risk for, and alter disease course in, mood disorders ( 149 – 153 ). More study on the relationship between early-life adversity, substance use disorders, and mood disorders is therefore warranted. For example, childhood maltreatment is associated with increased risky alcohol use, alcohol-related problems, and alcohol use disorders ( 154 , 155 ), and alcohol use disorders are an established risk factor for both depression and bipolar disorder ( 149 – 151 ) in addition to increasing risk for a more severe clinical course, such as further increasing risk for suicide ( 152 , 153 ). A recent study reported that depression mediates the relationship between childhood maltreatment and alcohol abuse ( 156 ). Another study recently reported that sexual abuse increased risk of alcohol use and depression in adolescence, which then influenced risk for adult depression, anxiety, and substance abuse ( 157 ). In a longitudinal study investigating changes in patterns of substance use over time in 937 adolescents, childhood maltreatment was associated with an increased progression toward heavy polysubstance use ( 158 ). More research is needed looking at the interactions between childhood maltreatment and other drugs of abuse. This is especially true in light of the current opioid epidemic, as increased rates of childhood maltreatment are also reported in individuals with opioid use disorders ( 159 – 161 ), and greater reported childhood maltreatment is associated with faster transmission from use to dependence ( 162 ) and with higher rates of suicide attempts in this population ( 163 ).

Interestingly, certain genes described above that exhibit gene–by–childhood maltreatment interactions on risk for mood disorders, including FKBP5 and the serotonin transporter promoter polymorphisms, also exhibit gene-by-childhood maltreatment interactions on risk for alcohol use disorders ( 164 – 168 ). Alterations in the stress hormone system are also associated with an increased risk for alcohol use disorders in individuals with a history of childhood maltreatment ( 169 ), and past-year negative life events have been reported to increase drinking and drug use, an effect that is dependent on genetic variation in the serotonin transporter gene ( 170 ). Childhood maltreatment has been found to be associated with an earlier age at initiation of alcohol and marijuana use, with this association mediated by externalizing behaviors ( 171 ). Impulsivity may mediate the relationship between childhood maltreatment and increased risk for developing alcohol or cannabis abuse ( 172 ). Etain et al. ( 173 ) conducted a path analysis in 485 euthymic patients with bipolar disorder and uncovered a significant association between impulsivity and emotional abuse, and impulsivity was associated with an increased risk for substance use disorders. These studies suggest that in some individuals with a history of childhood maltreatment, although not all, interventions that focus on alcohol or drug use problems, and specifically externalizing behaviors that may mediate the link between childhood maltreatment and alcohol or drug use problems (e.g., impulsivity), could decrease disease burden by decreasing risk for developing mood disorders or by improving illness course (e.g., decreasing symptom severity and risk for suicide).

Substance use disorders are also associated with increases in inflammatory markers ( 174 , 175 ). Inflammation is suggested to contribute to comorbid alcohol use disorders and mood disorders ( 176 ), and it contributes to a variety of medical morbidities ( 177 ), and these in turn are associated with an increased risk for mood disorders ( 177 ). Speculatively, inflammation may be one mechanism by which childhood maltreatment increases risk for medical morbidity and through that pathway increases risk for mood disorders. While there is a paucity of studies on the pathways described above, the associations between childhood maltreatment, risky health behaviors, inflammation, and medical morbidities warrant more study, as identifying pathways (mediators and moderators) to illness outcomes could foster the development of more effective interventions and treatment strategies.

It should be noted that not all individuals who experience childhood maltreatment develop mood disorders. This may be related in part to genetics. However, other resiliency factors are likely of importance. In a recent meta-analysis, Braithwaite et al. ( 178 ) identified interpersonal relationships, cognitive vulnerabilities, and behavioral difficulties as modifiable predictors of depression following childhood maltreatment. Specifically, social support and secure attachments were reported to exert a buffering effect on risk for depression, brooding was suggested to be a cognitive marker of risk, and externalizing behavior was suggested to be a behavioral marker of risk. Other researchers have also reported that social support may be protective and that interventions directed toward enhancing social support may decrease disease vulnerability and improve illness course ( 179 ). Metacognitive beliefs, or beliefs about one’s own cognition, are suggested to mediate the relationship between childhood maltreatment and mood-related and positive symptoms in individuals with psychotic or bipolar disorders ( 180 ). Specifically, beliefs about thoughts being uncontrollable or dangerous mediated the relationship between emotional abuse and depression or anxiety and positive symptom subscale score on the Positive and Negative Syndrome Scale. Affective lability was found to mediate the relationship between childhood maltreatment and several clinical features in bipolar disorder, including suicide attempts, anxiety, and mixed episodes ( 181 ), and social cognition was suggested to moderate the relationship between physical abuse and clinical outcome in an inpatient psychiatric rehabilitation program ( 182 ).

Childhood Maltreatment and Associated Alterations in Neural Structure and Function

Research on neurobiological consequences that may mediate the relationship between childhood maltreatment and risk for, and affect disease course in, mood disorders is clearly integral to addressing the question of whether the consequences of early-life stress are reversible. Although a comprehensive review of neuroimaging findings is beyond the scope of this review, over the past 5 years, review articles summarizing the neurobiological associations with childhood maltreatment have emphasized the long-lasting neurobiological structural and functional changes in the brain following maltreatment ( 21 , 83 , 183 , 184 ). In brief, while null and conflicting findings have been reported, data are converging to suggest that childhood maltreatment is associated with lower gray matter volumes and thickness in the ventral and dorsal prefrontal cortex, including the orbitofrontal and anterior cingulate cortices, hippocampus, insula, and striatum, with more recent studies also suggesting an association with decreased white matter structural integrity within and between these regions ( 185 – 194 ). Smaller hippocampal and prefrontal cortical volumes following childhood maltreatment are consistently reported in unipolar depression and other psychiatric disorders ( 189 , 195 – 199 ), with gene-by-environment interactions suggested ( 200 – 202 ). These studies suggest mechanisms that may cross diagnostic boundaries in conferring risk for psychopathology and genetic variation that may link neurobiology, childhood maltreatment, and vulnerability for detrimental outcomes.

Studies investigating differences in function within, and functional connectivity between, these regions following childhood maltreatment are emerging, with more recent results suggesting that these changes may relate to risk for psychopathology. It was recently reported that decreased prefrontal responses during a verbal working memory task mediated the relationship between childhood maltreatment and trait impulsivity in young adult women ( 203 ). In a study investigating functional responses to emotional faces in 182 adults with a range of anxiety symptoms ( 204 ), the authors found that increased amygdala and decreased dorsolateral prefrontal activity to fearful and angry faces—as well as increased insula activity to fearful and increased ventral but decreased dorsal and anterior cingulate activity to angry faces—mediated the relationship between childhood maltreatment and anxiety symptoms. Differences in functional connectivity, measured with multivariate network-based approaches, within the dorsal attention network and between task-positive networks and sensory systems have been reported in unipolar depression following childhood maltreatment ( 205 ). Altered reward-related functional connectivity between the striatum and the medial prefrontal cortex has also been reported in individuals with greater recent life stress and higher levels of childhood maltreatment, with increased connectivity associated with greater depressive symptom severity ( 206 ). Childhood maltreatment–associated changes in functional connectivity between the amygdala and the dorsolateral and rostral prefrontal cortex have been suggested to contribute to altered stress response and mood in adults ( 207 ). Additionally, childhood maltreatment has been reported to moderate the association between inhibitory control, measured with a Stroop color-word task, and activation in the anterior cingulate cortex while listening to personalized stress cues, an individual’s recounting of his or her own stressful events ( 208 ). As discussed above, it has been hypothesized that childhood maltreatment may increase risk for mood disorders through alterations of the HPA axis and CRF circuits in the brain. Therefore, research aimed at identifying neurobiological changes in function of CRF circuits in the brain that may mediate the relationship between childhood maltreatment and risk for mood disorders and affect disease course, including interactions with recent life stress, is a promising area of investigation.

Recent studies investigating altered function could suggest neurobiological mechanisms of risk but may also suggest possible mechanisms underlying resilience ( 183 ). Functional studies, such as those discussed above, that link functional changes in the brain following childhood maltreatment to mood-related symptoms can provide some clues to help identify mechanisms underlying risk. However, in the absence of longitudinal study of outcomes, these results must still be interpreted with caution. While the majority of studies have been cross-sectional, longitudinal studies are beginning to emerge. Opel et al. ( 209 ) recently reported that reduced insula surface area mediated the association between childhood maltreatment and relapse of depression among 110 patients with unipolar depression followed prospectively. A longitudinal study incorporating structural MRI in 51 adolescents (37% of whom had a history of childhood maltreatment) found that reduced cortical thickness in prefrontal and temporal cortices was associated with psychiatric symptoms at follow-up ( 210 ). Swartz et al. ( 211 ) followed 157 adolescents over a 2-year period and reported results suggesting that early-life stress is associated with amygdala hyperactivity during threat processing, with this finding preceding syndromal mood or anxiety. Longitudinal study of outcomes following childhood maltreatment and underlying neurobiology (predictors and trajectories) is critically needed to identify modifiable targets that confer risk and disentangle mechanisms of risk and resilience.

Only recently have studies investigating childhood maltreatment in bipolar disorder and neurobiological associations begun to emerge. Similar to unipolar depression and other psychiatric disorders, decreased ventral and dorsolateral prefrontal, insula, and hippocampal gray matter volume are reported in individuals with bipolar disorder with a history of childhood maltreatment compared with individuals with bipolar disorder without childhood maltreatment ( 202 , 212 , 213 ). Decreased white matter structural integrity across the whole brain, including lower structural integrity in the corpus callosum and uncinate fasciculus, have been reported in individuals with bipolar disorder who reported having experienced child abuse compared with those who did not and a healthy comparison group ( 214 , 215 ). Interestingly, one study ( 214 ) found that the effects of childhood maltreatment on white matter structural integrity were specific to individuals with bipolar disorder; decreased structural integrity was not observed in healthy comparison individuals with a history of childhood maltreatment compared with healthy individuals without maltreatment. In light of this finding, along with recently published data from other groups ( 216 – 218 ), it is possible that some consequences following childhood maltreatment may be more robust or distinct in some individuals—or that perhaps individuals with a genetic predisposition for mood disorders may be more vulnerable to the detrimental effects of childhood maltreatment.

Altered amygdala and hippocampal volumes are suggested to be differentially modulated following childhood maltreatment in patients with bipolar disorder compared with a healthy comparison group ( 216 ), although interactions with history of treatment (e.g., duration of lithium exposure) cannot be ruled out, as this was not investigated. Souza-Queiroz et al. ( 217 ) found that childhood maltreatment was associated with decreased amygdala volume, decreased ventromedial prefrontal connectivity with the amygdala and hippocampus, and decreased structural integrity in the uncinate fasciculus—the main white matter fiber tract connecting these regions. The bipolar group primarily drove these effects, with only smaller amygdala volume associated with childhood maltreatment in the healthy comparison group. While these findings could be driven by higher rates of maltreatment reported in the bipolar disorder group, or other clinical factors such as medication exposure and history of depressed or manic episodes, they could also suggest interactions between genetic vulnerability to bipolar disorder (or other environmental factors) and neurobiological consequences following childhood maltreatment.

More research is needed to identify genes that may influence neurobiological vulnerability following childhood maltreatment. An example of a potential gene that may mediate this relationship is the serotonin transporter promoter. Genetic variation in the serotonin transporter promoter is associated with differences in structural integrity of white matter in bipolar disorder ( 219 ). Because a large number of studies support the interaction between early-life stress, the serotonin transporter promoter, and disease vulnerability and illness course in depression and bipolar disorder ( 106 – 111 ), this example highlights the potential of genes to contribute to long-lasting structural consequences in the brain following childhood maltreatment in mood disorders. Genetic imaging studies are emerging and suggest gene-by-environment interactions on structural and functional alterations following childhood maltreatment. For example, one study found that hippocampal volume differences following childhood maltreatment are mediated by genetic variation in bipolar disorder ( 202 ). Additionally, polymorphisms in stress system genes, including FKBP5 and NR3C1, are suggested to moderate the effects of childhood maltreatment on amygdala reactivity ( 220 – 222 ) and hippocampal volumes ( 223 ). Studies investigating interactions between familial risk for mood disorders and childhood maltreatment and associated structural and functional changes in the brain would be useful to test whether familial factors (genetic and environmental vulnerability) may interact with childhood maltreatment to alter brain structure and function while avoiding confounders such as medication exposure.

Limitations and Future Directions

A sizable percentage of patients with mood disorders have a history of childhood maltreatment. While the devastating consequences of childhood maltreatment cannot be disavowed, several limitations in research should be noted. Research groups often assess childhood maltreatment differently, and this can result in a measurement bias. Demographic characteristics and differences in assessments (age and sex ratio of participants; clinical versus nonclinical populations being studied; observer-rated versus self-rated depression measures) are all suggested to contribute to differences in prevalence of childhood maltreatment and relation with illness severity ( 12 ). For example, studies using the Childhood Trauma Questionnaire report higher rates of emotional abuse compared with studies using other measures to investigate childhood maltreatment ( 12 ). Further study is warranted investigating the neurobiological mechanisms, underlying genetics, familial factors, and modifiable targets that may drive development of mood disorders following childhood maltreatment. A promising area is network-based approaches to understand this link ( 224 ). Additionally, consequences following different types of maltreatment require further investigation, as different forms of childhood maltreatment may be associated with distinct neural consequences, and a better understanding of these relations is critical for the development of more effective interventions and prevention strategies. For example, Heim et al. ( 225 ) reported that victims of sexual abuse exhibit more alterations in the somatosensory area, whereas victims of emotional abuse exhibit differences in areas mediating emotional processing and self-awareness, including the anterior cingulate and parahippocampal gyrus. More work is needed to investigate whether there are sensitive periods in development when maltreatment has more robust consequences on neurobiology. Humphreys et al. ( 226 ) recently reported that hippocampal volume differences were associated with stress severity during early childhood (≤5 years of age), but there was no association between hippocampal volumes and stress occurring during later childhood. Studies investigating interactions between childhood maltreatment and genetic variation or familial risk for mood disorders could identify mechanisms underlying risk and resiliency in the absence of some study-related confounders (e.g., medication).

Longitudinal studies are critically needed to distinguish what behaviors and mechanisms (genetic and neurobiological) may contribute to risk and whether alterations in behaviors or neurobiology are secondary to mood disorder onset. It is important to emphasize that sex differences likely contribute to outcomes following childhood maltreatment ( 227 ). These include females, compared with males, having a higher risk for internalizing disorders (depression and anxiety) ( 228 , 229 ), greater deficits in neural systems underlying emotional regulation ( 187 , 230 ), and being more susceptible to stress-induced changes in the HPA axis ( 231 ) following maltreatment. Males, compared with females, may be more vulnerable to developing externalizing disorders (conduct disorders and substance use disorders) ( 232 ). However, few studies have investigated sex differences following childhood maltreatment. More research on sex differences is critically needed, including on the underlying neurobiology. As previously reviewed ( 21 ), early-life adversity is associated with increased vulnerability to several major medical disorders, including coronary artery disease and myocardial infarction, cerebrovascular disease and stroke, type 2 diabetes, asthma, and certain forms of cancer. More work is needed on medical morbidities that may increase risk for early mortality following early-life adversity. Additionally, more research is needed on disparities that contribute to, and minority communities that show, elevated rates of early-life adversity. As discussed above, rates of early-life adversity are higher among individuals with developmental disabilities ( 138 – 140 ). Rates of trauma are also higher in youths in the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community ( 233 ). Few studies have been published in this area. Youths in the LGBTQ community show higher rates of mood disorders, anxiety, suicide, and alcohol and drug use ( 234 ). In a recent study, Rhoades et al. ( 235 ) investigated the relationship between parental rejection, homelessness, and mental health outcomes in LGBTQ youths. Parental rejection was associated with higher rates of homelessness, with experience of homelessness associated with greater feelings of hopelessness, PTSD and depressive symptoms, and greater prevalence of past suicide attempts and more individuals saying they are likely to attempt suicide in the future. More work is critically needed in vulnerable populations, including work focused on interventions that may improve mental health outcomes, for example, interventions that focus on the family unit and interpersonal relationships to foster support and educational interventions, which may decrease peer victimization and cyberbullying ( 236 , 237 ).

In summary, studies converge on and consistently support the finding that childhood maltreatment increases disease vulnerability for mood disorders, as well as a more pernicious disease course. A reduction in the prevalence of childhood maltreatment would have a substantial impact on decreasing disease burden ( 238 ). Studies suggesting modifiable targets are only just beginning to emerge and point to behavioral and environmental factors that could be focused on for early interventions.

Dr. Nemeroff has served as a consultant for Bracket (Clintara), Fortress Biotech, EMA Wellness, Gerson Lehrman Group, Intra-Cellular Therapies, Janssen Research and Development, Magstim, Navitor Pharmaceuticals, Sunovion Pharmaceuticals, Taisho Pharmaceutical, Takeda, TC MSO, and Xhale; he holds stock in AbbVie, Antares, BI Gen Holdings, Celgene, Corcept Therapeutics Pharmaceuticals Company, EMA Wellness, OPKO Health, Seattle Genetics, TC MSO, Trends in Pharma Development, and Xhale; he is a member of the scientific advisory boards of the Anxiety Disorder Association of America (ADAA), the American Foundation for Suicide Prevention (AFSP), Bracket (Clintara), the Brain and Behavior Research Foundation, the Laureate Institute for Brain Research, Skyland Trail, and Xhale and on the boards of directors of ADAA, AFSP, Gratitude America, and Xhale Smart; he has had income sources or equity of $10,000 or more from American Psychiatric Publishing, Bracket (Clintara), CME Outfitters, EMA Wellness, Intra-Cellular Therapies, Magstim, Takeda, TC-MSO, and Xhale; he holds patents on a method and devices for transdermal delivery of lithium (US 6,375,990B1), a method of assessing antidepressant drug therapy via transport inhibition of monoamine neurotransmitter by ex vivo assay (US 7,148,027B2), and compounds, compositions, methods of synthesis, and methods of treatment (CRF receptor binding ligand) (US 8,551,996 B2). Dr. Lippard reports no financial relationships with commercial interests.

Dr. Lippard’s research is supported by NIH grant K01AA027573. Dr. Nemeroff’s research is supported by NIH grants MH117293 and AA-024933.

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• Maltreatment
• Posttraumatic Stress

Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central nexus of more comprehensive research activity.

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment.

The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own typology and framework of reference terms, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom mal-

treatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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127 Captivating Child Abuse Essay Ideas, Research Questions & Essay Examples

Child abuse is one of the crucial problems that has been overlooked for many centuries. At the same time, it is an extremely sensitive issue and should be recognized and reduced as much as possible.

In this article, you will find child abuse research topics and ideas to use in your essay.

Let’s start!

📝 The Child Abuse Essay Structure

🏆 best child abuse topics & essay examples, 👍 good essay topics on child abuse, 📌 simple research topics about child abuse, 💡 interesting topics on child abuse, ❓ child abuse research questions.

Child abuse is one of the most problematic topics in today’s society. Writing child abuse essays may be challenging because it requires analyzing sensitive issues.

The problem refers to physical, psychological, or sexual mistreatment of children. It is vital to discuss this acute issue in studies and essays on child abuse.

Before working on your essay, you should select a topic for discussion. Here are some child abuse essay topics that we can suggest:

• The problem of child abuse in the US (Canada, the UK)
• Child abuse: Types and definitions
• Child neglect crimes and their causes
• Current solutions to the problem of sexual abuse of children
• The importance of child maltreatment prevention programs
• Child abuse: Legal implications
• Consequences of child abuse and neglect

If you are looking for other possible titles for your paper, you can check out child abuse essays samples online. Remember to only use them as examples to guide your work, and do not copy the information you will find.

One of the most important features of an outstanding essay is its structure. Here are some tips on how you can organize your essay effectively:

• Do preliminary research before writing your paper. It will help you to understand the issues you will want to discuss and outline which of them you will include in the essay. Remember to keep in mind the type of essay you should write, too.
• An introductory paragraph is necessary. In this paragraph, you will present background information on the issue and the aspects that you will cover in the paper. Remember to include a thesis statement at the end of this section.
• Think of the main arguments of your paper. You will present them in the body paragraphs of the essay. What child abuse issues do you want your reader to know about? Dedicate a separate section for each of the arguments. Remember to make smooth transitions between the paragraphs.
• Remember to dedicate a paragraph to identifying the problem of the essay and explaining the main terms. For example, if you are writing a child labor essay, you can discuss the countries in which this practice is present. You can also reflect on the outcomes of this problem.
• Include a refutation section if you are writing an argumentative essay. Discuss an alternative perspective on each of your arguments and prove that your opinion is more reliable than the alternative ones.
• Remember that you should not make paragraphs and sentences too long. It is easier for the reader to comprehend shorter sentences compared to complex ones. You can write between 65 and 190 words per paragraph and include at least 10 words in a sentence. It is a good idea to make all sections of the body paragraphs of similar length.
• A concluding paragraph or a summary is also very important. In this paragraph, you will discuss the arguments and counter-arguments of your paper.
• Do not forget to add a reference page in which you will include the sources used in the paper. Ask your professor whether you need a title page and an outline too.
• If you are not sure that the selected structure is good, check out child abuse essay examples online. Pay attention to how they are organized but do not copy the facts you will find in them.

For extra help, see our free samples and get some ideas for your paper!

• Ethical Dilemma of Child Abuse In the above example, a nurse has to apply rational judgment to analyze the extent and threats when making decisions in the best interest of the victim of child abuse.
• Daniel Valerio Child Abuse In the end, it was an electrician who identified the typical signs of abuse in Daniel that finally led police to investigate, thereby exposing the weakness and ineffectiveness of the Dual Track System; the child […]
• Child Abuse: Preventive Measures My artifact is an infographic that communicates the various forms of child abuse and how to report them to the necessary authorities.
• Child Abuse in the Victorian Era in Great Britain This was unacceptable in the eyes of the factory owners resulting in the implementation of the practice of children being sent into the mechanisms of machines while they were still operating since they were supposedly […]
• Physical Child Abuse Usually the child is unaware of the abuse due to the na ve state of mind or innocence. Physical abuse also lowers the social-economic status and thus high chances of neglect or abuse due to […]
• Problem of Child Abuse The most common form of child abuse in America and in most parts of the world is child abuse. The cost of child abuse is dire to both the children, healthcare organizations, parents, and the […]
• Child Abuse Problem The study of the problem of child abuse has begun in the 60s with focusing attention to children problems. In such a case the early recognition of child abuse is of great importance.
• The Prevention of Child Abuse From the interview conducted with the school administrator of the local elementary school and the director of a local preschool, it is clear that both institutions have some advocacy plans for the prevention of child […]
• Child Abuse: History and Causes The purpose of this paper is to explore the history, and causes of child abuse as well as the legislation implemented to address its cases.
• The Causes and Effects of Child Abuse The main problem of the project is the presence of a number of effects of child abuse and parental neglect on children, their development, and communication with the world.
• Effects of Child Abuse and Neglect Antisocial behaviour is one of the outcomes of child abuse and parental neglect that may be disclosed in a variety of forms.
• Child Abuse: A Case for Imposing Harsher Punishments to Child Abusers While harsh punishments appear to offer a solution to the problem, this measure may be detrimental to the welfare of the child in the case where the abuser is its guardian.
• Child Abuse Versus Elder Abuse The second distinction is that older people frequently encounter issues that might lead to abuse or neglect, particularly in nursing homes, such as mental disability, loneliness, and physical limitation.
• The Relationship Between Child Abuse and Embitterment Disorder Some emotions, like the dread of tests in school or sibling rivalry and conflicts, are a regular part of growing up.
• Trafficking Causes Child Abuse and Neglect The dissociation of children from their families and the exposure to intense trauma they are subjected to during and after trafficking may cause the minors to have attachment problems.
• Child Abuse and Maltreatment Discussion Additionally, this may cause a child’s behavior to change, such as making a sad or melancholy face or becoming furious with parents or other adults. When it comes to emotional abuse, a child may feel […]
• Impact of Child Abuse on Adulthood: An Idea Worth Spreading A frequent argument of those who do not want to recognize the scale of the problem of abuse in the world is “Beating is a sign of love!”.
• Effects of Child Abuse on Adults Second, she was so irrationally averse to the idea of having children that I knew immediately that it would be a contentious point in her future relationships.
• Domestic Violence, Child Abuse, or Elder Abuse In every health facility, a nurse who notices the signs of abuse and domestic violence must report them to the relevant authorities.
• Child Abuse: Screening Methods and Creating Financial Programs When the reporting is mandatory, it is easy to follow its guidelines which should be carefully elaborated not to be harsh on parents and at the same time offer protection to a child.
• Child Abuse Allegations: Multidisciplinary Team Approach In children with allegations of child abuse, what is the effectiveness of the multidisciplinary team approach compared to the non-multidisciplinary team approach on prosecution rates, mental health referrals, and provision of medical examinations?
• Hidden Epidemic of Child Abuse and Neglect Child abuse should be perceived as a form of deviant behavior to which researchers give different explanations: biological, psychological, socio-cultural.
• Criminal Justice System: Child Abuse During the consideration of cases as part of a grand jury, citizens perform some functions of the preliminary investigation bodies.
• Promoting Child Abuse Prevention Services in Oahu, Hawaii, and the US The primary goal the Hui Hawaii organization is trying to achieve is to improve the well-being of American children by preventing abuse, neglect, and depression.
• Child Abuse in Singapore The second reason for child abuse in Singapore to continue being one of the most underreported illegal offenses is the country’s collectivist culture.
• Protocol for Pre-Testing the Child Abuse and Neglect Public Health Policy Based on the above, it is necessary to identify the conditions of child abuse like the quality of family relations and improper upbringing.
• Child Abuse: Term Definition However, there is a component that is not so clearly represented in other crimes: a third party, who has observed the abuse or the consequences of abuse has the legal obligation and reasonable cause of […]
• Discipline and Child Abuse: Motivation and Goals The first proof of the justice and reasonableness of discipline is that it is permitted by law to be considered to be the most authoritative source to consult.
• Sociological Perspective on “Punishment” as a Major Contributor to Child Abuse This is done with the aim of ensuring that the child is disciplined and is perceived as a legitimate punishment. This has offered a loophole to parents to abuse the child in the name of […]
• Critical Statistical Data Regarding the Issues Related to Child Abuse Due to acts of abuse children suffer greatly and it will not be wrong to say that these experiences are definitely engraved into the child’s personality.
• Child Abuse and Culture: Juan’s Case Analysis The following is the list of reflective insights that I came to while getting myself familiarized with Juan’s case and analyzing this case’s discursive implications: When addressing the issue of children being suspected to have […]
• Child Abuse: Altruistic Behavior Intervention plays a crucial role in the prevention of child abuse, as it helps to eliminate the possibility of the recurrence of events.
• New Jersey’s Bill on Child Abuse and Neglect The legislation’s impact is expected to be large because it is targeted at raising awareness of the pervasive issue of child abuse and encouraging the public to stay active and not to disregard any signs […]
• Child Abuse in the UAE and Explaining Theories The interest of carrying out the study on child abuse is based on the fact that it is a critical issue in any society, especially due to the actual and possible consequences on the child […]
• Child Abuse and Neglect and Family Practice Model Also, psychological violence can be either the only form of violence or the consequence of psychological or sexual abuse or neglect. Inadequate evaluation of the child’s capabilities and overstated requirements can also be a form […]
• Child Abuse and Protective Act in Idaho Also, abandonment is recognized in Idaho’s definition of child abuse, and, according to the Act, it means the failure of the parent or the guardian to foster a normal relationship with the child.
• Child Abuse and Neglect: Drug and Alcohol Problems The families of individuals who have committed a drug related offense should be investigated in order to ensure the practice is acceptable and capable of supporting the needs of more societies.
• Child Abuse as a Result of Insufficient Policies According to Latzman and Latzman, child abuse may be manifested in the use of excessive physical force when disciplining a child or an adolescent.
• Child Abuse and Neglect A church/synagogue/mosque retreat activity for parents and they children can be beneficial in strengthening parents to deal with the issues of child abuse and neglect.
• A True Nature of the Effects of Child Abuse and Neglect in a Society The outcomes of child abuse usually depend on a variety of factors like the age of a child, the type of relation between a child and a perpetrator, and, of course, the type of maltreatment.
• A True Nature of the Effects of Child Abuse A society is in need of powerful and effective research that can prove the necessity to introduce the issue of child abuse and its effects as a leading problem the solution of which requires the […]
• Child Abuse Problems and Its Effects on a Future Child’s Life In fact, there were the three main challenges in writing the literature review just completed that were overcome due to the ability to organize the work, follow the suggestions of the experts, and keep in […]
• Effects of Child Abuse The nature of the effects of child abuse, their consequences in a society, and the most appropriate preventive methods should be considered.
• Child Abuse Issues and Its Effects The recognition of child abuse signs is a very important step as it is wrong to believe that child maltreatment takes place because of the presence of a single sing or poor understanding of child […]
• Child Abuse and Capstone Project This is why the problem of child abuse remains to be crucial for analysis, as people have to understand its urgency and effects on human behavior.
• The Effects of Child Abuse: Capstone Project Time Line The development of a Capstone Project will become a new step in solving the problem and thinking about the possible ways of improvement the situation and creation the most appropriate living conditions for children.
• Introducing Improvements to Children Abuse Reporting System The paper is connected with the analysis of the quality of the current child abuse report systems because of the serious problems in the sphere of childcare.
• Biological Underpinnings Behind Child Abuse The dimension of the baby’s head is also seen to decrease in quantity from on third of the whole body at birth, to a quarter at the age of two years and to an eighth […]
• Cause and Effect of Child Abuse Parental response to the children is also presented in a form of abuse of the rights of the children, as they feel neglected or disowned.
• Abuse in Childhood Common Among Alcohol Addicts Dwelling upon the impact of the violence and abuse during childhood, the connection with the further disabilities and disorders is obvious.
• Child Abuse and Neglect Children in Court The objective of this paper was to determine the level of knowledge and nature of attitudes among maltreated children who appeared in court during their detention case hearings.
• Randomized Trial of Cognitive-Behavioral Therapy for Chronic Post-Traumatic Stress Disorders in Adult Female Survivors of Childhood Sexual Abuse However, in spite of the fact that there exist a wealth of clinical literature on treatment methodologies of victims of sexual abuse, the evidence base concerning the treatment of victims of childhood sexual abuse exhibiting […]
• Child Sexual Abuse: Impact and Consequences Due to the adverse consequences of sexual abuse, efforts to have Jody share her ordeal and get immediate help would be my priority.
• Educational Program on Child Abuse The report “Initial reliability and validity of a new retrospective measure of child abuse and neglect” by Bernstein, Fink and Handelsman provides the findings of the consistency and validity of some of the conservative measures […]
• Public Health Media Campaign Proposal for Child Abuse
• Child Abuse and Lack of Communication in Marriages the Main Factors of Failed Family
• The Reasons and Three Most Common Factors Contributing to Child Abuse in Our Society
• Child Abuse and Its Effects on Social and Personality Development
• Neo-Liberal and Neo-Conservative Perspectives on Child Abuse
• Physical and Behavioural Indicators of Possible Child Abuse
• Defining Child Abuse and Its Different Forms in the 21st Century
• Child Abuse and Neglect: Recognizing the Signs and Symptoms
• Behind Closed Doors: The Correlation Between Multiple Personality Disorder and Child Abuse
• Child Abuse and Later Maladjustment in Adulthood
• Modern Beliefs Regarding the Treatment of Child Abuse Victims
• Neighborhood Poverty and Child Abuse and Neglect: The Mediating Role of Social Cohesion
• The Connection Between Child Abuse, Child Discipline, and Adult Behavior
• State the Possible Types, Signs and Symptoms of Child Abuse and Why It Is Important to Follow the Policies and Procedures of the Work Place
• Child Abuse and Its Effects on the Physical, Mental, and Emotional State of a Child
• Child Abuse, and Neglect and Speech and Language Development
• Social Issue: Child Abuse and How It Affects Early Childhood Development
• Child Abuse Scandal Publicity and Catholic School Enrollment
• Physical Abuse: The Different Types of Child Abuse
• Promoting Help for Victims of Child Abuse: Which Emotions Are Most Appropriate to Motivate Donation Behavior
• Describing Child Abuse, Its Different Forms, and Solutions to the Problem
• Child Abuse: The Four Major Types of Abuse, Statistics, Prevention, and Treatment
• Causes and Risk Factors Behind Child Abuse
• Child Abuse, Cause, and Effect on the Rest of Their Lives
• Child Abuse Has Severe Negative Psychological Effects on Children
• Child Abuse and the Professional Network Working Within the Child Protec
• Child Abuse Prevention and Control: Can Physical, Sexual or Psychological Abuse Be Controlled Within the Household?
• Child Abuse and the Effect on Development Into Adulthood
• Child Abuse: Victim Rights & the Role of Legal Representative
• Child Abuse and the Legal System – Developmental Forensic Psychology: Unveiling Four Common Misconceptions
• Parent Stress Factors and Child Abuse: A Tutoring Proposal
• Approaching Child Abuse From a Multi-Dimensional Perspective
• Child Abuse, Alcoholism, and Proactive Treatment
• Adverse Effects and Prevention of Child Abuse
• Suspected Child Abuse and the Teacher´S Role in Reporting It
• Child Abuse and Its Correlation to Poverty
• Sexual Child Abuse Exploring the Mind of the Perpetrator
• Relationship Between Domestic Violence and Child Abuse and How to Protect the Children From It
• Child Abuse Saddest and Most Tragic Problem Today
• Child Abuse and Academic Performance of Children
• Why Should People Care About Child Abuse?
• Why Should Child Abuse Be Addressed as a Social Problem?
• How Child Abuse and Neglect Affect Childhood?
• How Has Child Abuse Been Conceptualised and Addressed in Policy and Law?
• How to Protect Children From Abuse and Neglect?
• What Are the Negative Effects of Child Abuse?
• How Is the United States Dealing With Child Abuse Problem?
• How Can Therapy Help Victims of Child Abuse?
• How Can the Community Stop Child Abuse and Neglect?
• When Should Teachers Report Child Abuse?
• What Cause Child Abuse?
• Does Child Abuse and Neglect Lead To Bullying?
• How Do the Government and Society Have a Responsibility to Help Child Abuse Victims?
• Parent Support Groups Can Reduce Child Abuse?
• When Child Abuse Overlaps With Domestic Violence: The Factors Influencing Child Protection Workers’ Beliefs?
• How Can Spanking Lead to Child Abuse?
• How the Government and Society Have a Responsibility to Help Child Abuse Victims
• What Does Victimology Say About Child Abuse Data?
• Are There Any Biomarkers for Pedophilia and Sexual Child Abuse?
• When Does Discipline Cross the Line to Child Abuse?
• How Child Abuse Affects a Hero, a God, and a Monster in Greek Mythology?
• Does Child Abuse Create a Psychopath?
• Does Not Get Noticed Enough Around the World Is Child Abuse?
• How Can Sexual Child Abuse Affect the Child’s Psychological Development?
• How Child Abuse Effects Students Education?
• How Do Abuse and Neglect Impact a Child’s Whole Life?
• Should Pregnant Drug Abusers Be Charged With Child Abuse?
• How Children Carry the Weight of Child Abuse?
• Does Child Abuse Cause Crime?
• Childhood Essay Topics
• Attachment Theory Essay Topics
• Child Development Research Ideas
• Mental Health Essay Ideas
• Child Welfare Essay Ideas
• Childcare Research Topics
• Alcohol Abuse Paper Topics
• Foster Care Titles
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Whoa! This looks different. Meet the new DoSomething.

Welcome to DoSomething.org , a global movement of millions of young people making positive change, online and off. The 11 facts you want are below, and the sources for the facts are at the very bottom of the page. After you learn something, Do Something. Find out how to take action here .

For crisis intervention, information, referrals, and support, contact the Childhelp National Child Abuse Hotline at 1-800-422-4453 . For 24/7 crisis support at your fingertips, contact the Crisis Text Line by texting DS to 741741 . Additional resources can be found at the bottom of this page.

• It’s estimated that at least 1 in 7 children in the US has experienced child abuse and/or neglect in the past year.^[Centers for Disease Control and Prevention. “Child Abuse & Neglect: Fast Facts.” Accessed July 31, 2020. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html]
• Neglect is the most common form of child abuse, followed by physical abuse, sexual abuse, and psychological abuse.^[U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. “Child Maltreatment 2018.” Accessed July 31, 2020. https://www.acf.hhs.gov/cb/research-data-technology /statistics-research/child-maltreatment]
• In 2018, about 16% of children who were abused experienced more than one kind of maltreatment.^[U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. “Child Maltreatment 2018.” Accessed July 31, 2020. https://www.acf.hhs.gov/cb/research-data-technology /statistics-research/child-maltreatment]
• Boys and girls experience similar rates of childhood abuse (48.6% and 51% respectively).^[The National Resource Center for Reaching Victims. “Youth Victimization Fact Sheet.” Accessed July 31, 2020. https://education.victimsofcrime.org/?mdocs-file=360]
• Rates of child abuse and neglect are 5 times higher for children in families with low socio-economic status compared to children in families with higher socio-economic status.^[Centers for Disease Control and Prevention. “Child Abuse & Neglect: Fast Facts.” Accessed July 31, 2020. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html]
• Children younger than one year old are the most vulnerable to maltreatment, accounting for almost half of child fatalities from abuse in 2018.^[U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. “Child Maltreatment 2018.” Accessed July 31, 2020. https://www.acf.hhs.gov/cb/research-data-technology /statistics-research/child-maltreatment]
• In 2018, 76% of child abuse perpetrators were a parent to their victim.^[U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. “Child Maltreatment 2018.” Accessed July 31, 2020. https://www.acf.hhs.gov/cb/research-data-technology /statistics-research/child-maltreatment]
• In 2018, 62% of children placed in foster care were removed from their homes due to abusive neglect, totalling over 160,000 children.^[U.S. Department o fHealth and Human Services, Administration for Children and Families, Administrationon Children, Youth and Families, Children's Bureau. “The AFCARS Report #26”. Accessed August 3, 2020. https://www.acf.hhs.gov/sites/default/files/cb/afcarsreport26.pdf.]
• Children who experienced any form of violence in childhood have a 13% greater likelihood of not graduating from high school.^[World Health Organization. “Child Maltreatment.” Accessed July 31, 2020. https://www.who.int/news-room/fact-sheets/detail/child-maltreatment.]
• Adult survivors of childhood abuse are more likely to experience mental health difficulties, including depression, anxiety, bipolar disorder, PTSD, eating disorders, and substance use disorders.^[Cameranesi, Margherita et al. “Linking a History of Childhood Abuse to Adult Health Among Canadians: A Structural Equation Modelling Analysis” International Journal of Environmental Research and Public Health. May 31, 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6603908/.]
• Adult survivors of childhood abuse are more likely to engage in high-risk behaviors like smoking, alcohol and drug use, and unsafe sex. They’re also more likely to report overall lower health than those who haven’t experienced childhood abuse.^[Springer, Kristen et al. “The Long-term Health Outcomes of Childhood Abuse.” Journal of General Internal Medicine. October 18, 2003. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494926/.]

Additional Resources

National Child Abuse Hotline: 24/7 at 1-800-422-4453

National Domestic Violence Hotline: 24/7 at 1-800-799−7233

National Sexual Assault Hotline: 24/7 at 1-800-656-4673

National Suicide Prevention Lifeline : 24/7 at 1-800-273-8255

Substance Abuse and Mental Health Services Administration (SAMHSA) Helpline: 24/7 at 1-800-622-4357

Crisis Text Line: 24/7 text DS to 741741

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States fail to track abuses in foster care facilities housing thousands of children, US says

Victims are emotional during a news conference with survivors of abused and neglected youth at residential treatment facilities (RTFs) and advocates, on the need for Congress to act to protect children and reform RTFs, Wednesday, June 12, 2024, on Capitol Hill in Washington. (AP Photo/Mariam Zuhaib)

Caroline Cole speaks during a news conference with survivors of abused and neglected youth at residential treatment facilities (RTFs) and advocates, hold a news conference on the need for Congress to act to protect children and reform RTFs, Wednesday, June 12, 2024, on Capitol Hill in Washington. (AP Photo/Mariam Zuhaib)

Family members of abused and neglected youth at residential treatment facilities (RTFs) and advocates, attend a news conference on the need for Congress to act to protect children and reform RTFs, Wednesday, June 12, 2024, on Capitol Hill in Washington. (AP Photo/Mariam Zuhaib)

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WASHINGTON (AP) —

Many states are failing to track how frequently children in foster care facilities are abused, sexually assaulted or improperly restrained, leaving them vulnerable to mistreatment, the U.S. Health and Human Services Office of Inspector General said in a report Wednesday.

The findings come as hotel heiress Paris Hilton heads to Congress to lobby in person on the problem. The report follows a Senate committee investigation that revealed children are subjected to abuse in foster care facilities around the country that are operated by a handful of large, for-profit companies and financed by taxpayers.

States that are responsible for the nearly 50,000 children in these facilities are not doing enough to piece together which facilities or companies are problematic, according to the latest federal report.

More than a dozen states don’t track when multiple abuses happen at a single facility or across facilities owned by the same company, the HHS OIG report found.

“We found that many states did not have the information they would need to identify patterns of maltreatment in residential facilities,” the report said.

States are also not consistently sharing information about abuse, even when it occurs at facilities owned by companies that operate across the country.

Federal taxpayers spend billions of dollars on foster care for thousands of children around the country. Some children are placed with families in homes or with their relatives. The most expensive care, which can cost hundreds of dollars a day or more, involves a residential treatment facility — essentially a group home for children. Those children sometimes have complex medical or behavioral needs.

In recent years, those facilities have come under scrutiny. Hilton planned to address the House Ways and Means Committee about the abuse she endured at one of those facilities as a child, during a hearing that will look at strengthening oversight of the facilities.

In 2020, for example, 16-year-old Cornelius Fredericks died in a Michigan center after staffers physically restrained him for 12 minutes as punishment for throwing food. Michigan overhauled its care system, prohibiting the facilities from restraining children face down, like Fredericks was. A Philadelphia Inquirer investigation that same year uncovered more than 40 children who were abused at facilities across Pennsylvania.

Those public reports were detailed in the Senate Finance Committee’s investigation released earlier this month.

However, 32 states told the HHS Inspector General that they do not track the abuses that happen in facilities that are run in other states by companies they have contracts with.

HHS should help states track abuses at facilities, as well as ownership information, and create a location for states to share information about the problems occurring, the Inspector General recommended in its report.

“We found that many states lacked important information that could support enhanced oversight of residential facilities for children,” the report says.

HHS said it agreed with the recommendation, but it would not require states to gather such information.

Megachurch pastor resigns after admitting 'sexual behavior' with 'young lady.' She was 12.

Cindy clemishire says gateway church senior pastor robert morris was 21 when he began molesting her when she was 12. morris, who says he has 'walked in purity' since, has now resigned..

The pastor of a megachurch in Dallas resigned Tuesday, two days after admitting to "inappropriate sexual behavior with a young lady" 35 years ago. The "young lady" in question was 12 and the "behavior" as she described it would amount to criminal sexual abuse.

The now-former Pastor Robert Morris of Gateway Church was preaching to more than 100,000 active attendees and was once a spiritual adviser to former President Donald Trump. His resignation comes four days after 54-year-old Cindy Clemishire went public with allegations that Morris started molesting her when she was 12 and he was 21, telling USA TODAY on Tuesday that she was no longer afraid.

"It was kissing and petting and not intercourse, but it was wrong," Morris, 62, said Sunday in a statement to local Dallas news station WFAA-TV . "This behavior happened on several occasions over the next few years ... Since that time, I have walked in purity and accountability in this area." 

At first the church was standing behind Morris but announced his resignation following a wave of criticism.

In a statement issued to members of the news media, the church's board of elders said they previously understood that Morris had an "extramarital relationship" with a "young lady," citing the pastor's words − "not abuse of a 12-year-old child."

"We are heartbroken and appalled by what has come to light over the past few days, and we express our deep sympathy to the victim and her family," according to the statement, obtained by CBS News and NBC News .

Here's what we know.

Cindy Clemishire says Robert Morris sexually abused her at age 12

Allegations against Morris went public on Friday after Clemishire first shared her story with the Wartburg Watch , a blog about sexual abuse within the church.

Clemishire said in the blog post that she and her family met Morris at a youth revival in Tulsa, Oklahoma, when he was 20 and she was 11. Morris was a traveling evangelist with his wife, Debbie.

Morris would preach at Clemishire's church on Sundays, and sometimes he, Debbie, and their son would stay at her family's home. She viewed him as "safe and friendly," she said.

Things changed on Christmas in 1982 when Morris asked a 12-year-old Clemishire to "visit him in his room that night," and she thought nothing of it, she said in the post. Once in his room, she said he sexually abused her and warned her: "Never tell anyone about this because it will ruin everything."

She said the abuse continued in Oklahoma and Texas until 1987.

Eventually Clemishire told a good friend and her parents about the abuse, and Morris "reportedly stepped down from ministry for two years," she told the blog.

Church's initial support precedes Morris' resignation

Even as the church released a statement about his resignation, on Tuesday Morris was still listed as the senior pastor on Gateway Church's website, which says he has been married to his wife Debbie for 44 years and has three children with her.

Morris has a television program that airs in over 190 countries and his radio program airs in more than 6,800 cities, according to his biography on the Gateway Church website . Morris' YouTube page , which has 80,000 subscribers, includes videos with titles like "Freedom Through Forgiveness" and "Did You Know You're Made Perfect By God's Grace?"

In a previous statement issued to WFAA-TV, the church said that Morris has been "open and forthright about a moral failure he had over 35 years ago" and that "there have been no other moral failures."

In his own statement to the outlet on Sunday, Morris said that "this situation was brought to light, and it was confessed and repented of."

"I submitted myself to the Elders of Shady Grove Church and the young lady's father," he said. "They asked me to stop out of ministry and receive counseling and freedom ministry, which I did."

In the latest statement, the church elders said that "we regret that we did not have the information that we now have."

"For the sake of the victim, we are thankful this situation has been exposed," they said. "We know many have been affected by this, we understand that you are hurting, and we are very sorry. It is our prayer that, in time, healing for all those affected can occur."

Morris was also on Trump’s spiritual advisory board during the 2016 campaign and during the presidency. Trump's current campaign spokesman, Steven Cheung, said in a statement to NBC News that the former president hadn't been aware of the allegations and that Morris "does not have a role with the 2024 campaign.”

'Any and all victims, come forward'

Before Morris' resignation on Tuesday Clemishire told USA TODAY that she was "disappointed that they're basically lying and minimizing the crime."

USA TODAY does not typically name victims of sexual abuse but Clemishire said it was important to her.

She said that she has been sharing her story for decades with leadership in "very large and high-profile" churches and organizations, but no one took Morris out of ministry or the pulpit. Clemishire decided to come forward publicly to encourage others who may be victims to tell their stories, she said.

"Any and all victims, come forward ... I just don't believe that I'm the only person," she said.

At 54 years old, Clemishire said she has a "different confidence and a different understanding" that no longer makes her "feel intimidated."

"The courage is there," she said. "I just couldn't stay silent anymore."

Clemishire also included her name in the Wartburg Watch blog because she has "no shame."

"I've always just trusted that God's timing would take it wherever it needed to go," she said about Morris. "Why hide?"

Can Robert Morris be charged criminally?

Boz Tchividjian, Clemishire's attorney, told USA TODAY on Tuesday that Morris can't be charged criminally or civilly for the abuse because of the statute of limitations in place in the late 1980s, which was "fairly short."

Since 2017, the statute of limitations in Oklahoma for sex crimes involving children has been until the accuser turns 45. Before 2017, the statute of limitations was 12 years after the accuser turned 18.

"This just demonstrates the absolute importance of statute of limitations reform, both in criminal and civil cases," Tchvidijian said. "When somebody is traumatized as a child, for many it takes decades to process that trauma to even be ready to speak out or do something about it."

Tchividjian is advocating for "look-back windows," which allows states to reopen statutes of limitations that have previously expired so "survivors can now file their lawsuits."

Clemishire and Tchividjian are "currently evaluating all options" when it comes to legal action against Morris.

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Florida to Pay Millions to Victims of Abuses at Notorious Reform School

A $20 million program will give financial restitution to students who endured abuse and neglect at the hands of the state.

By Patricia Mazzei

Reporting from Miami

The horrors inflicted on hundreds of boys at a notorious reform school in the Florida Panhandle remain excruciating for survivors to recount, all these years later. Forced labor. Brutal floggings. Sexual abuse.

For more than 15 years, survivors of the Arthur G. Dozier School for Boys, who are now old men, have traveled to the State Capitol in Tallahassee to share their deeply painful memories and implore politicians for justice — for themselves and for the dozens of boys who died at the school.

In 2017, survivors, many of them Black, received an official apology . On Friday, Florida went further: Gov. Ron DeSantis signed legislation creating a $20 million program to give financial restitution to the victims who endured abuse and neglect at the hands of the state. Mr. DeSantis signed the bill in private, his office announced late on Friday.

The compensation program will allow applications from survivors who were “confined” to the Dozier school between 1940 and 1975 and who suffered from “mental, physical, or sexual abuse perpetrated by school personnel.” Survivors may also apply if they were sent to the Florida School for Boys at Okeechobee, known as the Okeechobee school, which was opened in 1955 to address overcrowding at Dozier.

Applications will be due by Dec. 31. Each approved applicant will receive an equal share of the funds and waive the right to seek any further state compensation related to their time at the schools.

Florida lawmakers approved the program unanimously this year. Several survivors testified at an emotional State Senate committee hearing in February that appeared to leave some lawmakers at a loss for words.

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First Person: Philippines ‘cyber cops’ tackle explosion of online child abuse

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Law enforcement officers in the Philippines are being informally supported by the United Nations as they deal with the emotional stress of chasing online child abusers.

The Southeast Asian country has been identified as one of many trouble spots for online child abuse on the internet, a phenomenon which has grown because of the COVID-19 pandemic.

Cheng Veniles works with law enforcement, prosecution and court officers as part of the UN Office on Drugs and Crime’s ( UNODC ) initiatives on online child protection.

She started a small informal network of dedicated men and women who lean on each other for support as they track down the abusers.

“Videos and images of children of a sexually exploitative nature or child sexual abuse material are being sold online for $15 to $20.

The incidence of online sexual abuse and exploitation of children boomed in the Philippines during the pandemic partly because many people lost their jobs and their livelihoods. And partly because of the misguided cultural notion of ‘No Touch, No Harm’.

Perpetrators, oftentimes, the children’s family members and relatives, would say that no harm is being done, that no abuse is taking place because no one is physically touching their children.

Do you want us to starve?

A recent trend in the Philippines is for a partner or boyfriend of the child’s parent who has the technical expertise to post the content on the dark web and then receive payment in crypto currency.

When asked to explain why they would allow children under their care to be abused online they would reply – Do you want us to starve?

It’s heartbreaking how some children don’t think of themselves as abused until after they have been rescued. They believe they are just helping the family, unaware that these photos and videos online could ruin their future when they grow up.

This is not just a Filipino problem born out of poverty. The consumers are overseas, so it is a global issue and UNODC is working with international police liaison officers and supporting engagement with the countries that consume the material to encourage cooperation among law enforcement agencies to act to shut down the abuse.

If there were no consumers, then the industry would not exist.

It’s heartbreaking how some children don’t think of themselves as abused until after they have been rescued. They believe they are just helping the family. — Cheng Veniles

Caring on the front-line of the response

In the Philippines, we have law enforcement officers who we call cybercops, prosecutors, special cybercrime and family courts who are all part of the ecosystem who hunt down the perpetrators of online child abuse and deal with this issue closely.

The emotional impact on both the victims and those working around its resolution from law enforcement to prosecutors to counselor to court staff can be deeply troubling.

We’ve been asked in workshops in the past, who cares for us?

Part of my role as a National Programme Officer for UNODC is to support these people and provide a means - informal though it may seem, to help them deal with the mental torture they endure because of being exposed to this heartbreaking content.

They are mothers and fathers themselves and so are deeply affected by what they see.

First, it was just WhatsApp and Viber groups and gradually we’ve come together for coffee, sometimes lunch to discuss the issues and in this way, we support each other through the shared trauma.

We also text each other regularly to check up on each other and to find out if there is an expert in the group that one can tap for a particular case. We’ve unintentionally built a strong professional and peer network in which the participants genuinely care for each other.

A safer Internet

There is an unwritten understanding that no one will leave this group or their job until there is an improvement in the situation. One of us resigned in April and the group chat was silent for about a week. But there were cases that needed to be dealt with, online undercover work that needed to be done, training events that had to be delivered and we’ve all been active again.

Maybe we are driven by some misplaced idealism, or maybe we just feed off on each other’s passion or maybe it’s just hope that we can at least make our children proud.

As a mother, I am motivated by UNODC’s goal to ensure that children can enjoy the Internet, free from any harm but I am also proud that my work here eases the misery of other people by bringing them together and reminding them that the work we all do of making the weird wild world of the internet a little safer, matters.” 

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Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25.

New Directions in Child Abuse and Neglect Research.

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4 Consequences of Child Abuse and Neglect

Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods—the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions.

• CASCADING CONSEQUENCES

Newborns are almost fully dependent upon parents to help them regulate physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as “co-regulators” of behavior and physiology ( Hertsgaard et al., 1995 ; Hofer, 1994 , 2006 ). Over time, children raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers.

For some children, parents cannot fill these roles as buffer and co-regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences.

Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulating behavior and physiology ( Moriceau et al., 2010 ). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an extended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children's health and social, psychological, cognitive, and brain development.

Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., problems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defiant disorder, conduct disorder, aggression), and posttraumatic stress disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity.

This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and neglect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic outcomes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that distinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6 , the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course.

Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of a child's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child's development. Therefore, the most rigorous research on this topic attempts to account for the many factors that may be confounded with abuse or neglect.

Ecological Framework

Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect ( Belsky, 1993 ; Cicchetti and Lynch, 1993 ; Cicchetti and Toth, 1998 ). Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by characteristics of the individual, parents and family, and neighborhood and/or community and their interactions.

In examining the role of contextual factors in the onset of consequences due to child abuse and neglect, Cicchetti and Lynch's (1993) ecological/transactional model is particularly useful because it successfully incorporates multiple etiological frameworks ( Lynch and Cicchetti, 1998 ). This model is based on Belsky's (1980 , 1993 ) ecological model and Cicchetti and Rizley's (1981) transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The ecological/transactional model describes four interrelated, mutually embedded categories that contribute to abuse and neglect and the potential associated consequences:

• Ontogenic development—Reflects factors within the individual that influence the achievement of competence and adaptation.
• Microsystem—Defined as the “immediate context” (i.e., the family) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child interactions directly or indirectly.
• Exosystem—The exo- and macrosystemic levels reflect social or cultural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning.
• Macrosystem—Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a “larger cultural fabric,” that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children).

The model is based on the fact that a child's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes. Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children.

At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment. These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur.

The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect.

Types of Evidence

Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible.

Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006 ; Suomi, 1997 ). One salient human study involved random assignment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) ( Nelson, 2007 ). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were extensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013 ; Nelson et al., 2007a , b ; Zeanah et al., 2003 ). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature.

The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999) , which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999 , 2000 ), Noll and colleagues (2007) , and Jonson-Reidz and colleagues (2012) . Retrospective designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases ( Briere, 1992 ; Offer et al., 2000 ; Ross, 1989 ; Widom, 1988 ). Results of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment ( Widom et al., 2007a ). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting ( Gilbert et al., 2009a ).

The federal government has supported an effort, launched since the 1993 NRC report was issued—the National Survey of Child and Adolescent Well-Being (NSCAW)—to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5 .

This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor.

Despite recent methodological advances, researchers face many challenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect (e.g., physical abuse, sexual abuse, neglect from caregivers) for child functioning and development. One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a number of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others ( Dubowitz et al., 1987 ; Lyons et al., 2005 ; McCurdy, 2005 ). These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children's functioning, but need to be disentangled from the specific effects of abuse and neglect ( Widom et al., 2007a ). Controlling for other relevant variables becomes vital, since failure to take such family variables into account may result in reporting spurious relationships ( Widom et al., 2007a ). Some studies consider and covary other risk factors, and some do not. Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues (2012) found that the number of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains.

Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning. These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect.

• NEUROBIOLOGICAL OUTCOMES

An adequate caregiver is needed to support developing brain architecture and the developing ability to regulate behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise development. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discussion begins, however, with a brief overview of brain development.

Overview of Neurobiological Development

The construction of the brain.

Brain development begins just a few weeks after conception, starting with the construction of the neural tube. This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter , whereas most of the rest of the brain is referred to as grey matter .

Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development—is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience ( Nelson et al., 2011 ).

Neural Plasticity and Sensitive Periods

Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experiences occur), development can go awry. This leads to the concept that plasticity “cuts both ways,” meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experiences or inadequate input, the brain may suffer ( Nelson et al., 2011 ). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation.

The Time Course of Development

In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion regulation—have a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive period for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1 .

The time course of key aspects of brain development. SOURCE: Thompson and Nelson, 2001 (reprinted with the permission of American Psychologist ).

These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience considerable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., neglect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed.

Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation

There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect (e.g., Bruce et al., 2009 ; Gunnar and Vazquez, 2001 ; Levine et al., 1993 ; Shonkoff et al., 2012 ). Glucocorticoids (cortisol in humans, corticosterone in rodents) are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintaining a diurnal rhythm. A cascade of events is designed to promote survival behavior by directing energy to processes that are critical to immediate survival (e.g., metabolism of glucose) and away from processes that are less critical to immediate survival, such as immune functioning, growth, digestion, and reproduction ( Gunnar and Cheatham, 2003 ).

Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation ( Gunnar and Cheatham, 2003 ). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime ( Gunnar and Donzella, 2002 ). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work ( Larson et al., 1991 ; Watamura et al., 2002 ). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children ( Bernard et al., 2010 ; Bruce et al., 2009 ; Dozier et al., 2006 ; Fisher et al., 2007 ; Gunnar and Vazquez, 2001 ). Similar flattened diurnal rhythms have been found in institutionalized children ( Bruce et al., 2000 ; Carlson and Earls, 1997 ). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation ( Carpenter et al., 2009 ; Fries et al., 2005 ).

Cicchetti and colleagues ( Cicchetti and Rogosch, 2001a , b ) examined changes across the day among abused and neglected children attending summer camp. The time points included when children first arrived at camp (at about 9 AM) and before they left camp for the day (at about 4 PM), likely tapping diurnal change within a challenging environment. The authors report complex findings regarding cortisol in this setting. Differences were found in some studies related to subtype and/or psychopathology and/or aggression ( Cicchetti and Rogosch, 2001b ; Murray-Close et al., 2008 ).

Animal models have been used to study experimentally the effects of neglect and abuse on HPA functioning (e.g., Levine et al., 1993 ). Experiences of abuse or neglect, depending on age of pup/infant, duration, chronicity, and subsequent response of dam/mother differentially affect short- and long-term effects on the HPA axis ( Sanchez, 2006 ). Under naturally occurring conditions (about 10 percent of rhesus monkeys abuse their infants), a 1-year-old rhesus monkey that was abused (primarily in the first month of life) showed higher cortisol levels under basal and stress conditions than a 1-year-old that had not been abused. These effects were not seen at older ages. (The age translation from rhesus to human is about 1 to 4, so a 1-year-old rhesus is developmentally similar to about a 4-year-old human child.) In other studies that have manipulated rearing conditions (such as isolation rearing), differences between conditions of abuse or neglect have been inconsistent. In some studies, higher cortisol values were observed in basal and/or stress conditions; in some, lower basal and/or stress conditions; and in some, no differences between the monkeys that had undergone deprivation and those that had not ( Champoux et al., 1989 ; Clarke, 1993 ; Higley et al., 1992 ; Shannon et al., 1998 ).

Disrupted HPA axis regulation may have negative effects on a number of other biological systems. High levels of circulating cortisol resulting from early life stress may cause damage to developing brain regions ( Teicher et al., 2003 ; Twardosz and Lutzker, 2010 ). Several brain regions, including limbic regions such as the amygdala and hippocampus and prefrontal regions, may be particularly susceptible to the effects of high levels of circulating cortisol because of the high number of glucocorticoid receptors in these areas ( Brake et al., 2000 ; Schatzberg and Lindley, 2008 ; Wellman, 2001 ).

High levels of circulating cortisol may affect telomere length as well. Telomeres are the repeated sequences of DNA that cap the ends of chromosomes. Telomeres shorten each time cells divide, a process generally associated with aging, but also with stress ( Epel et al., 2004 ). If telomeres become too short, the cell may become senescent (grow old) or may become malfunctional, for example, triggering inflammation or tumor development. Children who have been exposed to neglect show shortened telomeres ( Asok et al., 2013 ; Drury et al., 2011 ). Drury and colleagues (2011) found shorter telomeres among children in institutional care. Similarly, Asok and colleagues (2013) found that children living in highly challenging environments showed shorter telomeres than comparison children, but that mothers could buffer children from the environment challenge. When mothers of neglected children were sensitive to challenging environments, their children's telomeres were as long as those of low-risk children, but when mothers were insensitive, children's telomeres were shorter. Clearly, then, sensitive caregiving serves as a protective factor even under difficult conditions of adversity.

There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to affect brain development adversely, leaving these arguments speculative. Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems ( McEwen, 1998 ; Yehuda et al., 2002 ).

Studies (e.g., McGowan et al., 2008 , 2009 , 2011 ; Meaney and Szyf, 2005 ; Weaver et al., 2004 ) have found that the effects of abuse on the stress response are mediated by epigenetic programming of glucocorticoid receptor expression. Differential methylation of the glucocorticoid receptor gene promoter in the hippocampus was found to be associated with different rearing conditions in rodents, and was reversed by changes in caregiving conditions ( McGowan et al., 2008 ). Paralleling these findings among rodents are nonexperimental findings among humans examined in postmortem analyses ( McGowan et al., 2009 ; Szyf and Bick, 2013 ). Adult suicide victims who had experienced abuse as children differed in glucocorticoid receptor mRNA from adult suicide victims who had not experienced abuse as children and from controls. These findings are consistent with the experimental rodent findings, and suggest that methylation of receptor sites mediates the association between early care and stress responsiveness.

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity (e.g., Chareyron et al., 2012 ). Relative to low-risk children, abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity ( Ellis et al., 2004 ; Kaplow and Widom, 2007 ; Tottenham et al., 2009 ; van Ijzendoorn and Juffer, 2006 ; Zeanah et al., 2009 ) and deficits in emotional processing ( Dalgeish et al., 2001 ; Pollak et al., 2000 ; Vorria et al., 2006 ). Figure 4-2 illustrates structures in the medial temporal lobe critically involved in emotion (amygdala) and learning and memory (hippocampus).

Illustration of brain structures.

Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect ( De Bellis et al., 2001b ; Tottenham and Sheridan, 2010 ; Woon and Hedges, 2008 ). However, Tottenham and colleagues (2010) and Mehta and colleagues (2009) found that amygdala volume was enlarged among children following institutionalized care, although this finding was not replicated by Sheridan and colleagues (2012) among a similar population. Importantly, both the Mehta et al. and Sheridan et al. studies did find a dramatic reduction in total brain volume, meaning that these children had physically smaller brains.

Functional magnetic resonance imaging (fMRI) studies have shown that early adversity leads to a sensitized amygdala. Relative to comparison children, previously institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces ( Tottenham et al., 2011 ). Similarly, Maheu and colleagues (2010) found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces.

Hippocampus, Learning, and Memory

The hippocampus (see Figure 4-2 ) plays an important role in learning and memory ( Andersen et al., 2007 ; Ghetti et al., 2010 ; Otto and Eichenbaum, 1992 ) and, like the amygdala, matures rapidly over the first months and years of life ( Lavenex et al., 2007 ). The hippocampus appears to be particularly susceptible to stress early in life ( Gould and Tanapat, 1999 ; Sapolsky et al., 1990 ) and plays a role in modulating the response of the HPA axis to stressors, as binding of cortisol to hippocampal receptors serves to turn off the HPA axis response ( Kim and Yoon, 1998 ). Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation ( de Quervain et al., 1998 ; Sheridan et al., 2012 ).

Most studies have found no evidence of hippocampal volume deficits among abused children compared with healthy, nonabused control children ( De Bellis et al., 1999 , 2001a , 2002 ). Among adults, however, decreased hippocampal volume has been linked with the experience of childhood physical and sexual abuse ( Andersen and Teicher, 2004 ; Andersen et al., 2008 ; Schmahl et al., 2003 ; Woon and Hedges, 2008 ). Nonetheless, relatively smaller hippocampal volumes in abused adults may be specific to PTSD rather than abuse itself ( Kitayama et al., 2005 ).

Prefrontal Cortex and Executive Functions

The prefrontal cortex (see Figure 4-2 ) is responsible for a variety of higher-order “executive” functions ( Miller and Cohen, 2001 ). The development of the prefrontal cortex is protracted, extending from birth into the third decade of life ( Gogtay et al., 2004 ; Rubia et al., 2006 ; Sowell et al., 2003 ). Prefrontal systems are especially sensitive to experiences of early adversity ( Hart and Rubia, 2012 ; McLaughlin et al., 2010 ).

Evidence is mixed with regard to structural changes in the prefrontal cortex following abuse and neglect, with some studies showing smaller volumes of the right orbitofrontal cortex, right ventral-medial prefrontal cortex, and dorsolateral prefrontal cortex ( Hanson et al., 2010 ); some showing decreased grey matter volume in the prefrontal cortex in children with interpersonal trauma and PTSD symptoms ( Carrion et al., 2008 ); some showing the opposite effect ( Carrion et al., 2009 ; Richert et al., 2006 ); and still others showing no effect after controlling for total brain volume ( De Bellis et al., 2002 ). Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and related brain regions. In particular, children with trauma experiences show patterns of neural activation during tasks requiring executive function that are similar to patterns observed in children with attention-deficit hyperactivity disorder (ADHD) (e.g., Carrion et al., 2008 ).

Consistent with these findings among abused and neglected children, previously institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues (2010) found that children with a history of neglect or institutional care showed greater activation in several regions of the prefrontal cortex (e.g., left inferior frontal cortex, anterior cingulate cortex) during response inhibition trials of a go/no-go task compared with children without a history of neglect. Similar findings have been reported by McDermott and colleagues (2012) and Loman and colleagues (2009) among currently and previously institutionalized children.

Corpus Callosum

The corpus callosum facilitates communication between the two hemispheres of the brain ( Giedd et al., 1996a , b ; Kitterle, 1995 ). The white matter fibers composing the corpus callosum are myelinated throughout childhood and adulthood ( Giedd et al., 1996a ; Teicher et al., 2004 ), which allows faster, more efficient transmission ( Bloom and Hynd, 2005 ). Myelinated regions such as the corpus callosum are susceptible to the impacts of early exposure to high levels of cortisol, which suppress the glial cell division critical for myelination.

Retrospective/cross-sectional studies have found abuse and neglect to be associated with structural changes in the corpus callosum. Teicher and colleagues (2004) compared corpus callosum volume in adults with different abuse and neglect experiences. The total corpus callosum area of the abused children was smaller than that of both healthy control children and children with psychiatric disorders and no abuse or neglect. Other findings suggest that gender may moderate these effects, with the effects being more pronounced among males than females ( De Bellis and Keshavan, 2003 ; De Bellis et al., 1999 , 2002 ; Teicher et al., 1997). Sheridan and colleagues (2012) performed structural MRIs on children enrolled in the Bucharest Early Intervention Project, described previously in this chapter. In a follow-up of 8- to 11-year-olds, Sheridan and colleagues (2012) found smaller total white and gray matter volume and smaller posterior corpus callosum volume among children who had been institutionalized relative to those who had never been institutionalized. By middle childhood, however, there were no significant differences in total white matter volume or posterior corpus callosum volume between the never-institutionalized (community) children and the foster care children. These early differences in corpus callosum may be associated with less efficient cognitive functioning among children who experience early adversity.

Influence of Early Profound Neglect on Brain Electrical Activity

The influence of profound neglect early in life has been examined using electroencephalography (EEG) and event-related potentials (ERPs).

Electroencephalography

EEG measurements of the brain's electrical activity can serve as a coarse metric for brain development. Most work on EEG in the context of neglect has been performed on children with a history of institutional care. The most extensive study of brain electrical activity among children with a history of institutional care was conducted with the children enrolled in the prospective, longitudinal Bucharest Early Intervention Project. At baseline (mean age 20 months), prior to random assignment to continued institutional care or foster care, institutionalized children showed higher levels of theta power (low-frequency brain activity) and lower levels of alpha and beta power (high-frequency activity) compared with children who were not institutionalized ( Marshall et al., 2004 ). The pattern of activity observed in institutionalized children suggests a maturational delay or deficit in cortical development associated with an extreme form of neglect ( Marshall et al., 2004 ). The profiles are similar to patterns found among children with ADHD ( Barry et al., 2003 ; Harmony et al., 1990 ).

At follow-up, as a group, children assigned to foster care did not differ from the care-as-usual group ( Marshall et al., 2008 ). However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely resembled that of the never-institutionalized group than the care-as-usual group. Overall, then, “institutionalization led to dramatic reductions in brain activity (as reflected in the EEG), whereas placement in foster care before 2 years of age led to a more normal pattern of EEG activity” ( Nelson et al., 2011 , p. 139). This last finding was replicated when the children were 8 years old ( Vanderwert et al., 2010 ). Specifically, previously institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly assigned to institutional care.

Event-Related Potentials

ERPs measure changes in the brain's electrical activity in response to an internal or external stimulus or event. The components of the ERP (i.e., positive and negative deflections) can be quantified in terms of latency, amplitude, and location/distribution on the scalp. The P300 (i.e., positive deflection occurring approximately 300 ms after a stimulus) is associated with attention to emotionally evocative visual stimuli, such as emotional faces ( Eimer and Holmes, 2007 ; Olofsson et al., 2008 ). Whereas nonabused children show similar P300 activity across emotional expressions, abused children show larger P300s to angry target faces ( Pollak et al., 1997 , 2001 ), a finding consistent with behavioral evidence of enhanced attention to angry faces among abused children.

Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a number of factors and seen at some ages and not others. Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior. Finding: Abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional processing. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity leads to a sensitized amygdala. Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

• COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES

Cognitive Development

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement.

Executive Functioning and Attention

As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior ( Lewis-Morrarty et al., 2012 ). Included among executive functions are “holding information in working memory, inhibiting impulses, planning, sustaining attention amid distraction, and flexibly shifting attention to achieve goals” ( Lewis-Morrarty et al., 2012 , p. 2). Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop through at least the second decade of life.

Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a number of studies conducted by the Bucharest Early Intervention Project team ( McDermott et al., 2012 ). For example, McDermott and colleagues (2012) found that children who were randomly assigned to foster care showed better performance on an executive functioning task (i.e., a go/no-go task requiring inhibitory control) than children who were randomly assigned to treatment as usual. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children (with histories of institutionalization) have been reported (e.g., Loman et al., 2013 ). These findings suggest that extreme forms of neglect may interfere with the development of executive functioning.

Problems in regulating attention represent one of the most striking deficits seen among children who have experienced severe early deprivation in institutional settings ( Gunnar et al., 2007 ; Kreppner et al., 2001 ). Gunnar and colleagues (2007) found that problems with inattention or overactivity were more pronounced among children who had experienced early institutional care than among those who had been adopted internationally without early institutional care. Kreppner and colleagues (2007) found that many children who had been adopted following institutional care showed problems with inattention or overactivity, but that such problems were usually seen in combination with reactive attachment disorder, quasi-autistic behaviors, or severe cognitive impairment.

Using NSCAW data, Heneghan and colleagues (2013) examined mental health problems in teens older than age 12 who were the subject of a child welfare agency investigation. They found that 18.6 percent of abused and neglected teens scored positively for ADHD, compared with 5 percent of children and 2.5 percent of adults in the general U.S. population ( APA, 2013c ). Likewise, Briscoe-Smith and Hinshaw (2006) studied a sample of 228 girls with and without ADHD and with and without a history of abuse and neglect, finding that the girls with ADHD had a statistically significant heightened risk of having a documented history of abuse or neglect, as indicated by substantiated child protective services, parental, or school report. Some studies have found preliminary differences in the characteristics of ADHD displayed by children with and without a history of abuse or neglect ( Webb, 2013 ). For example, Becker-Blease and Freyd (2008) studied a small community sample of 8- to 11-year-old children in which ADHD and abuse history were assessed by parent report. They found that children with a history of abuse displayed more severe impulsivity and inattention than nonabused children with ADHD, but the groups did not differ on measures of hyperactivity ( Becker-Blease and Freyd, 2008 ).

A number of studies have found evidence that children who experience abuse and neglect show deficits in executive functioning and attention ( Arseneault et al., 2011 ; De Bellis et al., 2009 ; Fisher et al., 2011 ; Lewis et al., 2007 ; Spann et al., 2012 ). Pears and colleagues (2008) found that abuse and neglect were associated with generally lower cognitive functioning among preschoolers. Lewis and colleagues (2007) found that 4-year-old children who had experienced abuse or neglect and were in foster care showed poorer inhibitory control on a Stroop-like task relative to comparison children, despite similar levels of performance on a control task. Spann and colleagues (2012) found that physical abuse and neglect were associated with diminished cognitive flexibility on the Wisconsin Card Sorting Task among adolescents.

Academic Achievement

Abuse and neglect increase children's risk for experiencing academic problems. Several studies suggest that abuse versus neglect matters, with neglect being especially predictive of academic underachievement ( Briere et al., 1996 ; Jonson-Reid et al., 2004 ; Nikulina et al., 2011 ). Other studies failed to find differences between abuse and neglect, with both predicting achievement problems (e.g., Barnett et al., 1996 ; Crozier and Barth, 2005 ; Eckenrode et al., 1993 ; Jaffee and Gallop, 2007 ; Kurtz et al., 1993 ; Leiter and Johnsen, 1997 ). On balance, the evidence suggests that both abuse and neglect are predictive of academic problems. Perez and Widom (1994) found that child abuse and neglect had a significant impact on reading ability, IQ scores, and academic achievement. For example, 42 percent of abused and neglected children completed high school, compared with two-thirds of the matched comparison group without histories of abuse and neglect. The average IQ score for the abused and neglected children was about one standard deviation below the average for the control group; this association was significant after controlling for age, race, gender, and social class ( Perez and Widom, 1994 ). Using NSCAW data, Jaffee and Maikovich-Fong (2011) found that chronically abused or neglected children had lower IQ scores than situationally abused or neglected children. The effect of chronic abuse or neglect on IQ scores remained significant after controlling for the effects of caregiver educational level on IQ. Leiter and Johnsen (1997) found that effects of abuse and neglect on school performance were cumulative, with more episodes of abuse and neglect being associated with poorer outcomes. Abuse and neglect predicted entry into special education after controlling for early medical conditions ( Jonson-Reid et al., 2004 ). Jonson-Reid and colleagues (2004) found that 24 percent of the abused and neglected children entered special education, compared with 14 percent of those with no record of abuse or neglect. Further, every additional report of abuse or neglect before the age of 8 led to an increase of 7 percent in entry into special education. Thompson and colleagues (2012) found that expectations of future academic success were adversely affected by previous experiences of abuse and neglect, with these expectations having powerful self-fulfilling possibilities ( Ross and Hill, 2002 ).

Psychosocial and Behavioral Outcomes

Given that child abuse and neglect are social experiences that undermine the ability to trust in caregivers, either because caregivers are frightening (as in cases of abuse) or because they fail to protect or provide care (as in cases of neglect), it makes sense that children who experience abuse and neglect are at risk for interpersonal problems. At the most proximal level, problems are seen in children's ability to form trusting attachments to their parents. But not surprisingly, the effects also are seen in such areas as children's processing of emotion (e.g., overly vigilant of angry faces), their attributions of others' intent (e.g., assuming that intentions are malevolent when they are ambiguous), and difficulties with peers (e.g., being the victim or perpetrator of bullying or violence). Problems also are seen in internalizing symptoms, such as anxiety and depression, and externalizing symptoms, such as conduct disorder and substance use.

Children develop secure attachments to parents who are responsive to them when they are distressed ( Ainsworth, 1978 ). Children typically develop insecure (avoidant or resistant) attachments when parents are unresponsive or inconsistent in responsiveness, but not frightening or bizarre (e.g., Lyons-Ruth et al., 1993 ; Schuengel et al., 1998 ). Secure, avoidant, and resistant attachments are referred to as organized attachment strategies because they are organized around the caregiver's availability and provide a child a template for dealing with distress. On the other hand, disorganized attachment represents a breakdown in or a lack of strategy for dealing with distress when in the parent's presence ( Main and Solomon, 1990 ). Disorganized attachments are the most problematic in terms of outcomes for children. Relative to organized attachment, disorganized attachment is most predictive of long-term problems, especially externalizing symptoms ( Fearon et al., 2010 ). Fearon and colleagues (2010) found strong evidence for a link between disorganized attachment and later externalizing symptoms through a meta-analysis of 34 studies involving 3,778 participants.

Child abuse and neglect are predictive of disorganized attachment, as well as insecure attachment more generally. A meta-analysis conducted by Cyr and colleagues (2010) included the 10 studies that have examined attachment quality with samples of children who have experienced abuse and neglect. The effect size was large for both disorganized and insecure attachment. Although abuse was more strongly related to disorganized attachment and neglect to insecure attachment, both abuse and neglect were associated with both types of attachment. These results are consistent with theory and with other empirical findings suggesting that when parents are either frightening or unavailable, children fail to develop a secure attachment to them. Nonetheless, the effects of having more than five socioeconomic risk factors were comparable to those of child abuse and neglect, indicating that multiple challenges to parental functioning had significant effects on attachment regardless of whether these effects were seen in child abuse and neglect.

In early childhood, abused or neglected children may develop attachment disorders resulting from and following pathogenic care that inhibits a young child's ability to form selective attachments ( Hornor, 2008 ). Childhood attachment disorders are phenomena distinct from insecure, disorganized, or nonexistent attachment types; they have been redefined in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-V) to include two distinct disorders: reactive attachment disorder and disinhibited social engagement disorder ( APA, 2013a , b ). Reactive attachment disorder involves inhibited or emotionally withdrawn behavior, including rarely seeking and responding to comforting; it results from a lack of or incompletely formed selective attachments to adult caregivers ( APA, 2013a ). Disinhibited social engagement disorder is marked by a pattern of overly familiar behavior with strangers; it may occur even in children with established or secure attachments. Previously, each attachment disorder was considered the inhibited or disinhibited type of reactive attachment disorder, respectively.

Zeanah and colleagues (2004) studied the prevalence of attachment disorders among 94 toddlers in foster care whose abuse or neglect cases had been substantiated and who were enrolled in an intervention program; they found that the prevalence of attachment disorders reached 38-40 percent. Lyons-Ruth and colleagues (2009) examined socially indiscriminate attachment behavior in a sample of mother-child dyads that included pairs referred to a clinical service because of problematic caregiving and comparison pairs matched on socioeconomic status. They found that 18-month-olds displayed socially indiscriminate attachment behavior only if they had a history of abuse or neglect, or their mother had a history of psychiatric hospitalizations. Both disorders also have been identified in children exposed to neglectful institutional care in Romania who were later adopted into middle-class families in the United Kingdom ( Smyke et al., 2002 ; Zeanah et al., 2002 ), although the disinhibited type of reactive attachment disorder (as defined in DSM-IV) has been found to be much more prevalent than the inhibited type ( O'Connor et al., 2003 ). Furthermore, findings from the Bucharest Early Intervention Project study indicate that the inhibited type of reactive attachment disorder declined significantly once institutionalized children were placed in foster care, but the disinhibited type proved more persistent ( Smyke et al., 2002 ; Zeanah and Gleason, 2010 ).

Emotion Regulation

Infants have limited capacities to regulate their own emotions and are dependent on caregivers to help them deal effectively with distress ( Tronick, 1989 ). Indeed, infants and young children are highly attuned and responsive to their parents' emotions and use parental emotional signals to guide their behavior ( Klinnert et al., 1983 ; Malatesta and Izard, 1984 ). The scaffolding important for the development of emotion regulation is challenged in abusing or neglecting families. When children feel upset or distressed, parents' availability and soothing presence can help them feel that they can cope with the strong negative affect, such that they are able to develop autonomous and effective means of regulating emotions over time. When children regulate their emotions well, they react to challenge with flexible and socially acceptable responses ( Cole et al., 1994 ; Kim and Cicchetti, 2010 ). Abused and neglected children, however, may not have such scaffolding experiences. It is likely that abused and neglected children experience not only a lack of modeling and support and an absence of positive affect but also harsh, inconsistent, and insensitive parenting ( Shipman and Zeman, 2001 ). In the case of abuse, parents often respond in threatening or unpredictable ways to children's distress ( Milner, 2000 ). In the case of neglect, parents may be unresponsive or nonempathic. As a result of either response, children are at risk of failing to develop effective strategies for regulating emotions ( Cicchetti et al., 1995 ; Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ).

An initial, key task in regulating emotions is processing of cues. Studies have examined differences among children who have experienced abuse and neglect in how readily they identify angry, sad, and happy faces ( Pollak and Sinha, 2002 ; Pollak and Tolley-Schell, 2003 ; Pollak et al., 2000 ; Shackman et al., 2007 ). Pollak and Sinha (2002) found that the threshold for detecting anger in the face was lower among abused than nonabused children; there were no differences in processing happy faces. Thus, these children appear to have a bias toward angry faces rather than a general deficit in processing faces. Pollak and Sinha (2002) point out that it is useful to identify emotions in others based on less than full information. Abused children's bias toward attributing angry or sad affect may be adaptive when living with parents whose anger may be an important threat cue ( Belsky et al., 2012 ); nonetheless, it comes at the cost of assuming hostile intent too readily under benign conditions, leading to aggressive responses that would not have been evoked had attributions been different ( Dodge et al., 1995 ). Neglected children, on the other hand, generally are not as good as nonneglected children at identifying facial expressions, showing a general deficit ( Pollak et al., 2000 ).

Emotion regulation can be seen as key to a number of the constructs considered in this chapter. Problems in regulating emotion are associated with externalizing behaviors, such as aggression and behavior problems ( Eisenberg et al., 2001 ; Kim and Cicchetti, 2010 ); internalizing behaviors, such as depression ( Cole et al., 2008 ; Maughan and Cicchetti, 2002 ); and challenges in peer relations ( Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ). Emotion regulation can be seen, then, to have effects both on children's own affect and on their behavioral reactions, which then have implications for their relationships with others.

Peer Relations

Children's relationships with their peers are critical to their sense of well-being. Abused and neglected children have problematic peer relations at disproportionately high rates ( Kim and Cicchetti, 2010 ), as do children with a history of institutional care ( Almas et al., 2012 ). Chronicity of child abuse and neglect predict peer relations, as reported by teachers, at age 8 ( Graham et al., 2010 ). Problematic emotion regulation ( Shields and Cicchetti, 2001 ) and higher levels of aggression and withdrawal ( Rogosch et al., 1995 ) found in abused and neglected children can become apparent to peers when frustrations and challenges arise in school and playground environments.

Externalizing Problems

Externalizing behavior refers to problem behaviors that are manifested externally (rather than internally, as in the case of depression and anxiety). Findings from several studies indicate that children who have experienced abuse and neglect are at greater risk for a number of externalizing behaviors, including conduct disorders, aggression, and delinquency ( Lansford et al., 2002 , 2009 ; Lynch and Cicchetti, 1998 ; Stouthamer-Loeber et al., 2001 ; Thornberry et al., 2010 ).

Oppositional defiant disorder and conduct disorder Studies have reported significant associations between a history of childhood abuse or neglect and various conduct problems, including those classified as oppositional defiant disorder or conduct disorder. Oppositional defiant disorder is indicated by a frequent or persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness ( APA, 2013a ). Its symptoms usually first appear during early childhood, and it often precedes conduct disorder, anxiety disorders, or major depressive disorder. Conduct disorder is indicated by a repetitive or persistent pattern of behavior that violates the basic rights of others or major societal norms or rules, including aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules ( APA, 2013a ). Conduct disorder can begin in childhood or adolescence; however, childhood-onset conduct disorder is more often preceded by oppositional defiant disorder, more persistent into adulthood, and more likely to include aggressive behavior than adolescence-onset conduct disorder. Both disorders also frequently co-occur with ADHD.

In a study using a community sample, Dodge and colleagues (1995) found that children who were physically abused before age 5 were 4 times more likely than nonabused children to display externalizing conduct problems in grade 3 and 4. Likewise, Kaplan and colleagues (1998) found that adolescents (aged 12-18) with substantiated cases of physical abuse were more likely to display conduct disorder or oppositional defiant disorder at the time of the study (odds ratio = 5.98) than the matched nonabused comparison group. Fergusson and colleagues (2008) found that childhood sexual abuse was associated with higher rates of conduct disorder in young adulthood. Furthermore, they found that childhood physical abuse was not associated with conduct disorder when sexual abuse was included in the model. Additional environmental and individual factors that interact with abuse or neglect to increase the likelihood of conduct disorder or oppositional defiant disorder include exposure to parental divorce ( Afifi et al., 2009 ), interparental violence ( Boden et al., 2010 ), and community violence ( McCabe et al., 2005 ), as well as gender, with males more likely to display conduct disorder ( Boden et al., 2010 ).

Aggression Manly and colleagues (2001) found that children who had experienced severe emotional abuse only as infants or severe physical abuse only as toddlers were more aggressive and showed more externalizing symptoms as school-aged children than children without a history of abuse or neglect. The severity of abuse experienced predicted aggressiveness and externalizing symptoms in middle childhood. Although abuse experienced only in early childhood had lasting effects, abuse experienced beyond early childhood also had effects on aggression and externalizing symptoms, and the most problematic effects were seen for children subjected to chronic, severe abuse ( Manly et al., 2001 ). Rogosch and colleagues (1995) found that physically abused children showed both aggressive behaviors and social withdrawal during peer interactions. Along these lines, abused and neglected children were disproportionately likely to be both bullies and victims of aggression, effects that were mediated by emotion dysregulation ( Shields and Cicchetti, 2001 ). At odds with these findings, Kotch and colleagues (2008) found that children who experienced neglect in their first 2 years of life showed more aggression toward peers at ages 4, 6, and 8 relative to children without a history of abuse or neglect. Indeed, in that study, other subgroups (children who were abused or who were neglected at older ages) did not show an increased likelihood of aggression.

Hostile attributional bias refers to the tendency to assume that someone intended harm when circumstances were ambiguous but a negative outcome was experienced. For example, if a peer spilled milk on a child, the child could assume that the action was benign (unintentional) or intentional, with the latter representing a hostile attributional bias. When children assume that such an action was intentional, they are likely to act aggressively in response ( Dodge et al., 1995 ). Physically abused children are more likely than other children to show such attributional biases ( Dodge et al., 1995 ). Price and Glad (2003) found that these effects were seen in boys only and were associated with frequency of abuse. Such biases can lead to a self-fulfilling prophecy whereby children anticipate that someone intends them harm and react in a hostile way, which then elicits a hostile response ( Dodge et al., 1995 ).

Internalizing Problems

Internalizing problems—problems that are manifested internally—include symptoms of depression and anxiety. Child abuse and neglect have been found to put children at increased risk of internalizing symptoms from early childhood through adolescence and adulthood ( Dubowitz et al., 2002 ; Thornberry et al., 2001 ; Widom et al., 2007a ).

Dubowitz and colleagues (2002) found that neglect was associated with internalizing problems for 3- and 5-year-old children. Swanston and colleagues (1997) found that sexually abused children had a significantly higher average score on depression measures than a control group just 5 years after the abuse occurred, after adjusting for individual differences in age and sex, as well as contextual factors such as socioeconomic status, family functioning, mother's mental health, and number of negative life events. Trickett and colleagues (2001) found that a sample of sexually abused girls had significantly higher rates of self-reported depression than a comparison group of nonabused females. At follow-up, approximately 7 years later, rates of depression were found to be significantly higher among the sexually abused group, excluding a subset whose experience of abuse was characterized chiefly by multiple perpetrators and a relatively short duration.

The heightened risk of depression extends beyond childhood to adolescence and adulthood. Multiple studies have found clear links between child abuse and neglect and depression in adolescence (e.g., Fergusson et al., 2008 ; Heneghan et al., 2013 ; Lansford et al., 2002 ). Brown and colleagues (1999) found that child abuse and neglect were associated with a nearly threefold increase in the rate of depression in adolescence, although this risk was diminished after controlling for other adverse conditions. Gilbert and colleagues (2009b) cite a body of studies reporting adjusted odds ratios ranging from 1.3 to 2.4 for depression after childhood among those subjected to abuse and neglect as children. Among adults, Brown and colleagues (1999) found that the increased risk of depression associated with child abuse and neglect remained when other factors were covaried, consistent with findings that more than one-third of abused or neglected children show symptoms of major depressive disorder by their late 20s ( Gilbert et al., 2009b ). Likewise, Widom and colleagues (2007a) followed a group of individuals who had experienced abuse and/or neglect in childhood and a matched comparison group into young adulthood and found that experiencing childhood physical abuse and multiple types of abuse increased the lifetime risk for a diagnosis of major depressive disorder.

A growing body of research examines whether different types and combinations of abuse or neglect in childhood result in different levels of risk for the development of depressive symptoms. The results in this domain are mixed, with strong evidence that sexual and physical abuse in childhood are associated with depression later in life (e.g., Heneghan et al., 2013 ), but mixed evidence that neglect increases risk for depression independent of contextual factors. Many studies have found child sexual abuse to have large and independent effects on risk for depression later in life. For example, Fergusson and colleagues (2008) found that young adults who reported a history of childhood sexual abuse had mental health disorders, including depression, at a rate 2.4 times higher than that among those not exposed to such abuse. By contrast, Widom and colleagues (2007a) found that child sexual abuse was not associated with an elevated risk of major depressive disorder relative to matched controls, although physical abuse or multiple kinds of abuse did increase the risk for lifetime major depressive disorder. Additional studies have found that physical abuse increased the risk for adult depression (e.g., Brown et al., 1999 ). Some studies have found that neglect did not increase the risk for depression when statistical models included contextual factors ( Nikulina et al., 2011 ), although Widom and colleagues (2007a) found that neglect increased risk for current major depressive disorder relative to matched controls in adulthood.

As discussed in the section on individual differences later in this chapter, researchers also have examined how the timing ( Dunn et al., 2013 ; Thornberry et al., 2001 ) and severity ( Fergusson et al., 2008 ) of abuse and neglect affect the risk of developing depression. Other factors throughout the life course, such as the presence or absence of social support ( Sperry and Widom, 2013 ) and exposure to multiple traumas ( Banyard et al., 2001 ) or stressful life events in adulthood ( Power et al., 2013 ), have been found to interact with childhood experiences of abuse and neglect to influence the risk of developing depression later in life.

Dissociation

Dissociation is defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including—but not limited to—memory, identity, consciousness, perception, and motor control” ( Spiegel et al., 2011 , p. 19). Dissociation can be measured reliably and validly in children, adolescents, and adults ( Briere et al., 2001 ; Keck Seeley et al., 2004 ; Lanktree et al., 2008 ; van Ijzendoorn and Schuengel, 1996 ; Wherry et al., 2009 ).

Child abuse and neglect have been associated with dissociation among both preschool-aged and elementary-aged children ( Hulette et al., 2008 , 2011 ; Macfie et al., 2001 ), as well as among adults ( van Ikzendoorn and Schuengel, 1996 ). The existence of a subgroup of PTSD patients with high levels of dissociation has been demonstrated in clinical ( Lanius et al., 2013 ; Putnam, 1997 ), psychophysiological ( Griffin et al., 1997 ), neuroimaging ( Lanius et al., 2013 ), and epidemiological ( Stein et al., 2013 ) research. As a result, DSM-V is adding a dissociative subtype to the PTSD diagnosis ( Spiegel et al., 2011 a) (see the discussion of PTSD on p. 139).

High scores on dissociation measures have proven to be a predictor of externalizing behavior in children ( Kisiel and Lyons, 2001 ; Shapiro et al., 2012 ; Yates et al., 2008 ). In adults, high levels of dissociation are associated with refractoriness to standard treatments for a number of psychiatric conditions, as well as increased comorbidity ( Jans et al., 2008 ; Kleindienst et al., 2011 ; Wolf et al., 2012 ; Zanarini et al., 2011 ).

A meta-analysis of 55 studies ( Cyr et al., 2010 ) links abuse with disorganized attachment. Grienenberger and colleagues (2005) found that mothers who engaged in disrupted affective communication with their infants at 4 months (as measured using the AMBIANCE scale) were more likely to have toddlers who were classified as disorganized at 14 months. In turn, disorganized attachment at 14 months predicted high dissociation scores at age 20 years ( Lyons-Ruth, 2008 ). Disorganized attachment assessed during the child's second year predicted elevated levels of self-reported dissociation in mid-adolescence (age 16 years) ( Carlson, 1998 ) and early adulthood (age 19) ( Ogawa et al., 1997 ).

Based on findings from the Minnesota Mother-Child Project, Egeland and Susman-Stillman (1996) propose that dissociation may act as a mediator of child abuse across generations. In a longitudinal study of sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, a tentative generational loop can be hypothesized in which harsh and abusive parenting increases the risk for higher levels of dissociation in childhood and adolescence, which in turn increases the risk for impulsive behavior and harsh parenting of offspring. Further research, especially with a longitudinal design, is warranted to determine whether this hypothesized generational pattern of transmission represents an early opportunity for prevention of abuse in the next generation.

Posttraumatic Stress Disorder

In DSM-V, PTSD is classified as a trauma- and stressor-related disorder, a change from its previous classification as an anxiety disorder. PTSD develops following “exposure to actual or threatened death, serious injury, or sexual violation,” including directly experiencing the traumatic event, witnessing the event firsthand, learning that an actual or threatened violent or accidental death occurred to a family member or close friend, and experiencing repeated or extreme firsthand exposure to the details of the traumatic event ( APA, 2013c ). Behavioral symptoms of PTSD are divided into four categories: intrusion or reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity ( National Center for PTSD, 2013 ). Experiences of child abuse and neglect involve traumatic events that are often violent, invasive, and coercive ( Kearney et al., 2010 ). Furthermore, secondary trauma may result from experiences of child abuse and neglect, including separation from family or homelessness, which may also trigger a PTSD response ( Wechsler-Zimring et al., 2012 ).

A number of prospective and retrospective studies have found elevated rates of PTSD among individuals with a history of abuse and neglect ( Chen et al., 2010 ; Kearney et al., 2010 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Numerous studies have found that PTSD was preceded by abuse and neglect; links with sexual abuse were especially strong ( Chen et al., 2010 ; Gregg and Parks, 1995 ; Kendall-Tackett et al., 1993 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Kearney and colleagues (2010) report PTSD rates of 20-50 percent among youth who had been sexually abused, 50 percent among youth who had been physically abused, and 33-50 percent among youth who had experienced neglect combined with exposure to domestic violence. Kolko (2010) found that nearly 20 percent of youth in out-of-home care showed posttraumatic symptoms. Widom (1999) found increased risk for PTSD among adults who had experienced abuse and neglect as children, with 23 percent of those who had been sexually abused, 19 percent of those who had been physically abused, and 17 percent of those who had been neglected meeting criteria for PTSD at age 29, compared with 10 percent of the comparison group.

Some evidence indicates that PTSD may mediate the association between childhood abuse and neglect and later adverse outcomes. Wolfe and colleagues (2004) found that boys who had been abused or neglected in childhood and displayed a greater number of PTSD symptoms were at higher risk of perpetrating emotional abuse in a dating relationship compared with abused or neglected boys who displayed fewer trauma symptoms. Weierich and Nock (2008) found that the specific PTSD symptoms of reexperiencing, avoidance, and numbing mediated the relationship between childhood experiences of abuse and neglect and nonsuicidal self-injury. In a study of adult women survivors of childhood sexual abuse, Ginzburg and colleagues (2006) found that severe childhood maltreatment, including sexual abuse as well as other types of abuse or neglect, was significantly associated with experiencing high levels of dissociation in conjunction with PTSD, while less severe childhood maltreatment was not significantly associated with the dissociative subtype. Avery and colleagues (2000) examined PTSD and key areas of functioning based on interviews with sexually abused children and their nonoffending parents. Compared with sexually abused girls with low scores on the Child Posttraumatic Stress Reaction Index, sexually abused girls with higher scores expressed more worries; reported increased problems with sleep, appetite, headaches, and stomachaches; reported increased depression and suicidal ideation; displayed more problems in school functioning; and had higher levels of family disruption.

Personality Disorders

Evidence links child abuse and neglect with personality disorders. Johnson and colleagues (1999) found that adults with a history of abuse and neglect (as indicated by records and/or self-report) had a fourfold increase in personality disorders relative to those without a history of abuse or neglect. Physical abuse was associated with elevated antisocial and depressive personality disorder symptoms; sexual abuse was associated with elevated borderline personality disorder symptoms; and neglect was associated with elevated symptoms of antisocial, avoidant, borderline, narcissistic, and passive-aggressive personality disorders, as well as with attachment difficulties and other interpersonal and psychological problems. Widom (1998) reports an increase in risk for antisocial personality disorder for both males and females with a history of abuse and neglect. In a subsequent study, Widom and colleagues (2009) report an increase in risk for borderline personality disorder in males only, suggesting that there may be sex differences in the consequences of abuse and neglect. Natsuaki and colleagues (2009) found that personality problems, although not diagnosed personality disorders, worsened as adolescence progressed.

Finding: Abuse and neglect have profound effects on selected aspects of children's cognitive development. Although many attempts have been made to disentangle the effects of abuse and neglect, the balance of findings suggests that severe neglect may interfere with the development of executive functioning, and both neglect and abuse increase the risk for attention regulation problems and ADHD, lower IQ, and poorer school performance. Finding: As a result of abusive or neglectful responses from caregivers, children have a difficult time developing organized and secure attachments. As a result, abused and neglected children are at higher risk for the development of attachment disorders, particularly disinhibited social engagement disorder. Finding: Abused and neglected children often fail to develop effective strategies for emotion regulation, partly as a result of differences in processing of emotional cues. Difficulties with emotion regulation can lead to further problems, including externalizing and internalizing problems and challenges in peer relations. Finding: Children who experience abuse or neglect have been found to be at higher risk for the development of externalizing behavior problems, including oppositional defiant disorder, conduct disorder, and aggressive behaviors. Abused and neglected children also have been found to be at increased risk for internalizing problems, particularly depression, in childhood, adolescence, and adulthood. Finding: Among preschool- and elementary school–aged children, as well as adults, a history of childhood abuse and neglect has been associated with dissociation, which increases the risk for externalizing behavior in childhood and resistance to treatment for psychiatric conditions later in life. It has been suggested that dissociation may act as a mediator of harsh or abusive parenting across generations, although this hypothesis requires further research. Finding: A number of studies have found elevated rates of PTSD among individuals with a history of abuse and neglect. PTSD has been associated with physical, cognitive, psychological, social, and behavioral problems among youth who were abused or neglected in childhood.

• HEALTH OUTCOMES

Child abuse and neglect have effects on a number of health outcomes, from growth to illness to obesity. Connections have been found between problematic neurobiological outcomes of child abuse and neglect and health. One plausible mechanism for these effects relates to the purported frequent or chronic activation of the HPA axis. As discussed previously, the HPA axis is designed for responding in crises.

Growth and Motor Development

In their most extreme forms, abuse and neglect are associated with stunted growth. Children living in institutional environments ( Johnson et al., 2010 ) or adopted from highly neglecting institutional environments ( Johnson and Gunnar, 2011 ) sometimes show very delayed growth in height and head circumference. Olivan (2003) found that children placed in foster care between ages 24 and 48 months were significantly below normal for height, weight, and head circumference. Similarly, Chernoff and colleagues (1994) found that most children entering foster care had an abnormal physical screen involving at least one body system, and on average weighed less and were shorter than comparison children.

Gross motor development often is delayed among children with a history of institutional care who have then been adopted internationally ( Dobrova-Krol et al., 2008 ; Roeber et al., 2012 ). Roeber and colleagues (2012) found that children adopted from institutional settings showed motor system delays, with greater balance delays being predicted by length of time institutionalized and bilateral coordination delays being predicted by severity of deprivation. Rapid gains are seen after placement in adoptive homes, however ( Pomerleau et al., 2005 ). Although somewhat canalized (less responsive to genetic or environmental variations), the development of these gross motor abilities is dependent upon opportunities to engage in motor activities. Note that these findings regarding motor delays may be limited in their application to extreme cases of neglect in which young children are left alone in their cribs or otherwise neglected for extended periods of time.

Child abuse and neglect have been linked to various forms of physical illness as well as various indicators of physical health problems. Adolescents with a history of childhood abuse or neglect report a lower rating of their own health compared with low-risk peers ( Bonomi et al., 2008 ; Hussey et al., 2006 ). Likewise, more gastrointestinal symptoms were reported by adults who reported having been abused or neglected as children ( Walker et al., 1999 ). To examine whether this association resulted from shared method variance, van Tilburg and colleagues (2010) used data collected from multiple informants among a sample of 845 children enrolled in the longitudinal, prospective Longitudinal Studies of Child Abuse and Neglect. Across informants, youth who had experienced abuse or neglect had an increased likelihood of gastrointestinal symptoms, which often followed or coincided with sexual abuse.

In a longitudinal prospective study, childhood abuse and neglect predicted health indices among middle-aged adults ( Widom et al., 2012 ). Both physical abuse and neglect predicted hemoglobin A1C (a biomarker for diabetes) and albumin (a biomarker for liver and kidney function); physical abuse uniquely predicted malnutrition and blood urea nitrogen (a marker for kidney function); neglect uniquely predicted poor peak airflow; and sexual abuse uniquely predicted hepatitis C ( Widom et al., 2012 ).

Findings from the Adverse Childhood Experiences study indicate a heightened risk for liver disease, lung cancer, and ischemic heart disease among adults who report multiple adverse experiences in childhood ( Brown et al., 2010 ; Dong et al., 2003 , 2004 ). The adverse experiences measured in the study include emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, as well as indicators of household dysfunction, such as domestic violence, parental divorce or separation, household member mental illness, household member substance abuse, and household member incarceration. Dong and colleagues (2003) found that the adjusted odds ratio for ever having liver disease ranged from 1.4 to 1.6 for different types of abuse and neglect; among individuals with more than 6 adverse childhood experiences, the adjusted odds ratio was 2.6. Notably, the risk of liver disease was substantially mediated by risk behaviors for liver disease, such as alcohol and drug use and various sexual behaviors. Brown and colleagues (2010) found an association between adverse childhood experiences and an increased risk of lung cancer, which was partially mediated by smoking behavior. In particular, exposure to a large number of adverse childhood experiences was strongly associated with premature death from lung cancer; among individuals who died from lung cancer, those with 6 or more adverse childhood experiences died an average of 13 years earlier than those with no adverse childhood experiences. Likewise, Dong and colleagues (2004) found that adverse childhood experiences increased the likelihood of ischemic heart disease. The association was substantially mediated by both traditional (diabetes, hypertension, physical inactivity, smoking, and obesity) and psychological (anger and depressed affect) risk factors, but the psychological risk factors of anger (adjusted odds ratio of 2.1) and depression (adjusted odds ratio of 2.5) had stronger associations with heart disease than the traditional risk factors.

In various studies, different forms of child abuse and neglect have been linked with increased body mass index and higher rates of obesity in childhood, adolescence, and adulthood. Some studies link neglect but not abuse to obesity (e.g., Johnson et al., 2002 ; Lissau and Sorensen, 1994 ), and some link physical abuse but not neglect ( Bentley and Widom, 2009 ). These differences may be the result of differences in the time points at which obesity is assessed, in sample characteristics, or in the adequacy of controls, or other factors. Knutson and colleagues (2010) found that specific types of neglect (supervisory versus care) predicted obesity at different ages. Care neglect, defined as inattention to such things as provision of adequate food and clothing, predicted body mass index at younger ages, whereas supervisory neglect, defined as parental lack of availability, predicted body mass index at older ages.

Finding: Experiences of child abuse and neglect have effects on many health outcomes, including risks for long-term chronic and debilitating diseases and, in extreme cases, stunted growth.

• ADOLESCENT AND ADULT OUTCOMES

While a number of the consequences of child abuse and neglect discussed previously in this chapter can be present across childhood, adolescence, and adulthood, this section focuses on behavioral outcomes that manifest specifically in either adolescence or adulthood.

Delinquency and Violence

Maxfield and Widom (1996) found that abuse and neglect experienced in childhood predicted violence and arrests in early adulthood. Adults with a history of abuse and neglect were more likely than adults without such a history to have committed nontraffic offenses (49 percent versus 38 percent) and violent crimes (18 percent versus 14 percent). Victims of childhood physical abuse and neglect were more likely to be arrested for violence (odds ratios 1.9 and 1.6, respectively) after controlling for age, race, and sex. These authors also found that abused and neglected girls were at increased risk for being arrested for violence relative to girls who had not been abused and neglected, with an odds ratio of 1.9. Smith and colleagues (2005) also found that abuse and neglect increase the risk of violent offending in late adolescence and early adulthood. Jonson-Reid and colleagues (2012) found a powerful effect for the number of child abuse reports predicting violent delinquency, with the association being linear for up to three reports. Two of these prospective longitudinal studies also found that sexual abuse increased the risk for general offending, but not violent offending ( Smith et al., 2005 ). Physical abuse appears to be strongly related to violence in girls, as demonstrated in a meta-analysis ( Hubbard and Pratt, 2002 ).

There is evidence that childhood abuse increases the risk for crime and delinquency. A number of large prospective investigations in different parts of the United States have documented a relationship between childhood abuse and neglect and juvenile and/or young adult crime ( English et al., 2002 ; Lansford et al., 2007 ; Maxfield and Widom, 1996 ; Smith and Thornberry, 1995 ; Stouthamer-Loeber et al., 2001 ; Widom, 1989 ; Widom and Maxfield, 2001 ; Zingraff et al., 1993 ). Despite differences in geographic region, time period, youths' age and sex, definition of child maltreatment, and assessment technique, these prospective investigations provide evidence that childhood maltreatment increases later risk for delinquency and violence. Replication of this relationship across a number of well-designed studies supports the generalizability of and increases confidence in the results.

Alcohol and Substance Use

As adolescents and adults, those with a history of abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect ( Gilbert et al., 2009b ; Jonson-Reid et al., 2012 ). The effects tend to be stronger for women, being seen even when other factors are covaried ( Simpson and Miller, 2002 ; Widom et al., 1995 ). For example, Widom and colleagues (1995) found no association between a history of abuse and neglect and alcohol use by young men, but found an association for women even after controlling for parental substance use and other correlated variables. A similar pattern of results emerged in a follow-up with these participants about 10 years later, when they were approximately 40 years old. Women with a documented history of child abuse and/or neglect were more likely to drink excessively in middle adulthood than those without such a history ( Widom et al., 2007b ); again, this difference was not seen in men. Girls with a history of physical abuse tend to start using substances (including alcohol, marijuana, tobacco, etc.) at younger ages than youth without such a history ( Lansford et al., 2010 ). Work by Lansford and colleagues (2010) suggests that this early initiation serves as the mechanism for later substance use in adulthood.

Evidence linking abuse and neglect to substance abuse in adulthood is mixed ( Gilbert et al., 2009b ; Widom et al., 1999 ), with retrospective and prospective findings differing. For example, Widom and colleagues (1999) describe findings based on defining child abuse and neglect prospectively and retrospectively using self-reports (i.e., following their sample forward and asking adults whether they had been abused or neglected as children). The findings based on these two types of data differed dramatically. The prospective data showed no increase in risk of substance abuse at age 29, whereas the retrospective data showed significant differences. Interestingly, a later follow-up with this sample ( Widom et al., 2006 ) found that in middle adulthood, abused and neglected individuals compared with controls were about 1.5 times more likely to report using any illicit drug (in particular, marijuana) during the past year, and reported use of a greater number of illicit drugs and more substance use–related problems. Findings such as these provide support for the importance of longitudinal studies because without the subsequent follow-up, there would have appeared to be no increase in risk for adults who had experienced childhood abuse or neglect; these findings also illustrate the importance of contextual factors in understanding consequences.

Suicide Attempts

Experiences of abuse and neglect in childhood have a large effect on suicide attempts in adolescence and adulthood ( Brown et al., 1999 ; Fergusson et al., 2008 ; Gilbert et al., 2009b ; Widom, 1998 ). Among adults in their late 20s, Widom (1998) found that 19 percent of those with a history of abuse or neglect had made at least one suicide attempt, as compared with 8 percent of a matched community sample. Fergusson and colleagues (2008) found high rates of suicide among a New Zealand sample as well. These effects are seen for physical and sexual abuse even after accounting for other associated risk factors ( Fergusson et al., 2008 ). Trickett and colleagues (2011) found, through a prospective design, more incidents of self-harm and suicidal behaviors among women who had been sexually abused than among a control group of women who had not been sexually abused.

Sexual Behavior

Studies have investigated the association between child abuse and neglect and several aspects of sexual behavior, including early sexual initiation and sexual risk behavior, teen pregnancy, and prostitution and the risk for commercial sexual exploitation of children and adults.

Early Sexual Initiation and Sexual Risk Behavior

Children who experience abuse and neglect may initiate sexual activity at earlier ages than other children ( Lodico and DiClemente, 1994 ; Noll et al., 2003 ; Springs and Friedrich, 1992 ; Wilson and Widom, 2008 ). In addition, there is limited evidence of an association between child abuse and neglect and increased risky sexual behaviors ( Jones et al., 2010 ; Senn et al., 2008 ). This association has been studied most frequently for sexual abuse; however, Jones and colleagues (2010) found that physical and emotional abuse, but not neglect, contributed to risky behaviors over and above the effects of sexual abuse. Trickett and colleagues (2011) undertook one of the most extensive longitudinal studies of developmental outcomes for female victims of sexual abuse. The majority had experienced severe sexual abuse, defined by the type of abuse (with vaginal and anal penetrative abuse seen as most severe), the length of time over which the abuse occurred, and the relationship of the abuser to the victim. In addition to earlier initiation of sexual activity among women who had been sexually abused in childhood, the authors found less use of birth control ( Noll et al., 2003 ). For both abused and nonabused women, having a large number of male peers in childhood networks was associated with a lack of birth control use in adolescence ( Trickett et al., 2011 ). For abused females, however, having high-quality relationships with male peers and nonpeers in childhood was associated with greater birth control use in adolescence; in the comparison group, this association was not found.

Teen Pregnancy

Evidence linking childhood sexual abuse and increased risk for teen pregnancy has been mixed. Trickett and colleagues (2011) found that severely sexually abused females reported significantly higher rates of teen pregnancy and teen motherhood than nonabused females (abused = 39 percent, nonabused = 15 percent). In a meta-analysis of previously published studies of sequelae of child sexual abuse, Noll and colleagues (2009) found an increased risk for early pregnancy among girls who had been sexually abused. In contrast, using a prospective cohort design that followed children with documented cases of abuse and neglect into young adulthood, Widom and Kuhns (1996) found no evidence that childhood sexual abuse was a significant risk factor for multiple early sexual partners or teenage pregnancy.

Prostitution and Risk for Commercial Sexual Exploitation of Children and Adults

In a prospective study, Widom and Kuhns (1996) found that sexual abuse and neglect, but not physical abuse, were associated with later prostitution. In a subsequent study, Wilson and Widom (2010) examined the role of problem behaviors as a pathway to adult prostitution and found that adult victims who had experienced child abuse and neglect were more likely than nonvictims to report having been involved in prostitution as adults or prostituted as juveniles ( Wilson and Widom, 2008 ). Stoltz and colleagues (2007) found a significant relationship between child abuse and neglect (sexual, physical, and emotional) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada.

While an important topic, evidence that child abuse and neglect increase the risk for commercial sexual exploitation of children is very limited and comes primarily from retrospective studies of sexually exploited youth. Some older studies have reported that experiences of childhood sexual abuse influenced the decision of young women to become involved in commercial sex work ( Bagley and Young, 1987 ; Silbert and Pines, 1983 ). A comprehensive look at those issues will be presented in a forthcoming Institute of Medicine report from the Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States.

Finding: Experiences of abuse and neglect in childhood have a large effect on delinquency, violence, and suicide attempts in adolescence and adulthood. Finding: Adolescents and adults with a history of child abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect, although this relationship has been found most frequently in women. Finding: Children who experience abuse and neglect may initiate sexual activity at earlier ages than comparison groups. Childhood sexual abuse also has been found to be associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors. Finding: Studies seeking an association between child abuse and neglect and teen pregnancy or adult prostitution have reported mixed results.

• INDIVIDUAL DIFFERENCES IN OUTCOMES

This chapter has presented extensive evidence that children who are abused or neglected, as a group, are at increased risk for a variety of problematic outcomes. However, not all children who experience abuse or neglect experience these negative consequences. Not surprisingly (given what is known about typical development), children vary in the outcomes they experience even when exposed to the same type of abuse or neglect, with outcomes ranging from the most problematic to functioning well across domains. As discussed earlier in this chapter, an ecological-transactional model is helpful for understanding outcomes related to abuse and neglect as influenced by the interplay of risk and protective factors that occur at multiple levels of a child's ecology. Through examination of compensatory resources in children and their environment, an ecological-transactional framework can aid in understanding children who exhibit resilient outcomes despite having been abused or neglected ( Cicchetti and Toth, 2009 ; Luthar et al., 2000 ). Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. However, neither a child's individual strengths nor the surrounding environment alone can predict resilient outcomes. As noted by Jaffee and colleagues (2007 , p. 233), “the fit between the child and the environment is the best predictor of children's psychological well-being.” The following sections describe research examining explanatory factors for differences in outcomes related to child abuse and neglect.

Characteristics of Abuse or Neglect Experiences

Characteristics of a child's exposure to abuse or neglect have been shown to influence the risk for problematic outcomes. Such characteristics include the point within the course of a child's development at which an experience of abuse or neglect occurs; the chronicity of abuse or neglect experiences, taking into account their duration and frequency; the severity of the experiences; and the type of abuse or neglect ( Bulik et al., 2001 ; Collishaw et al., 2007 ; Keiley et al., 2001 ; Manly et al., 2001 ).

Among a sample of adult female twins, Bulik and colleagues (2001) found an association between characteristics of the abuse experience (e.g., a high level of severity of child sexual abuse, such as attempted or completed intercourse and the use of force or threats) and certain psychiatric disorders. In examining the effect of timing on outcomes related to child physical abuse, Keiley and colleagues (2001) found that children who experienced such abuse while under the age of 5 were at higher risk for negative outcomes than those who experienced the same type of abuse at age 5 or older. Jonson-Reid and colleagues (2012) found that nearly all children who experienced chronic, persisting abusing or neglect showed adverse outcomes in adulthood: 91.9 percent of children showed at least one negative outcome if they had 12 or more reports of abuse or neglect ( Jonson-Reid et al., 2012 ).

The concept of resilience serves as a useful lens for evaluating the differing outcomes of children exposed to abuse and neglect. By examining factors that contribute to whether children experience maladaptive outcomes in response to abuse or neglect, researchers can gain a better understanding of how better to prevent and treat these consequences. While resilience has been defined in various ways, it can be understood as “a good outcome in spite of high risk, sustained competence under stress, and recovery from trauma” ( McGloin and Widom, 2001 , p. 1022).

The study of resilience in the context of child abuse and neglect must take into account several factors. First, as shown throughout this chapter, consequences of child abuse and neglect can manifest in multiple domains of functioning. Therefore, a child's subsequent adaptation or maladaptation following abuse or neglect must be assessed in terms of multiple outcomes rather than a single indicator, such as depression ( Afifi and Macmillan, 2011 ; McGloin and Widom, 2001 ). Second, resilience is not a static construct, meaning that a child can exhibit resilient outcomes at a certain point in the course of development but may still experience problematic outcomes at a later time. It follows that analysis of resilience in abused and neglected children should include a temporal component ( McGloin and Widom, 2001 ). Third, many factors believed to promote resilience in response to child abuse and neglect can also serve to promote positive adaptation more generally in response to other childhood stressors, making it imperative for studies to include a comparison group that has not been abused or neglected ( Collishaw et al., 2007 ). Finally, resilience might usefully be considered from the perspective of allostatic load ( Danese and McEwen, 2012 ). That is, some children who experience abuse or neglect do not show problematic outcomes, but as abuse, neglect, and other adverse childhood experiences accumulate, they challenge children's ability to cope with the negotiation of life tasks.

Results from a study of adults who were the subjects of substantiated cases of child abuse or neglect as children indicate that 22 percent of abused and neglected individuals met the criteria for resilience, which required successful functioning in 6 of 8 domains ( McGloin and Widom, 2001 ). A study by Collishaw and colleagues (2007) examined resilience to adult psychopathology within a representative community sample, finding that 44 percent of adults who reported abuse during childhood reported no psychiatric problems in adulthood and demonstrated positive adaptation in other domains.

Protective factors supporting resilience have been examined at the levels of the individual, family, and social environment, with resilience being measured in childhood, adolescence, and early adulthood. In a review of protective factors for resilience following child abuse and neglect, Afifi and Macmillan (2011) identify three protective factors that are best supported by findings from longitudinal and cross-sectional studies: a stable family environment, supportive familial relationships, and personality traits that support social skills.

Individual-level protective factors identified among those displaying resilience following child abuse and neglect include personality traits (e.g., high ego control, high self-esteem, internal locus of control, external attributions of blame, and attribution of success to own efforts); gender (females more resilient than males); and relationship capabilities ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee and Gallop, 2007 ; Jaffee et al., 2007 ). There is some evidence that intelligence or cognitive ability functions as a protective factor ( Masten and Tellegen, 2012 ), but it has not always been found to be significant in supporting resilience ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ). Jaffee and colleagues (2007) found that children with protective individual-level characteristics were likely to be resilient in low-stress environments (59 percent), but children with the same protective individual-level characteristics were less likely to be resilient in highly challenging environments.

Family-level protective factors include a caring and safe home environment; positive changes in family structure (e.g., intervention, cessation of visiting rights, or removal to foster care); and supportive familial relationships at the time of abuse ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee et al., 2007 ). In a sample of sexually abused girls in foster care, family support was not found to be a protective factor, but peer influences, school plan certainty, and positive future orientation were ( Edmond et al., 2006 ). Other social-level protective factors include supportive relationships with non-family members, such as teachers or camp counselors, and supportive relationships with peers in adolescence ( Flores et al., 2005 ; Jaffee et al., 2007 ).

Gene x Environment Interactions

Historically, those working in the field of child abuse and neglect were unable to examine whether such adverse experiences interacted with biological risk or protective factors (e.g., so-called risk or protective genes)—specifically, whether experience interacted with underlying genetics. This situation has changed over the past 20 years as advances in molecular genetics have enabled a search for gene x environment (GxE) interactions. A number of such interactions have been studied in the last several decades in relation to early adversity generally and child abuse and neglect in particular. Critics of these approaches charge, among other things, that examining single gene and single environment combinations in interactions capitalizes on chance. In addition, some experts in genetics argue that the action of any single gene is likely to be very small, and to detect its effects will likely require very large sample sizes. Nonetheless, some GxE findings have emerged as robust and apparently replicable.

The 5-HTT gene is perhaps at the top of this list. This gene regulates reuptake of serotonin (a neurotransmitter that has various functions, including regulation of mood and sleep and some cognitive functions, such as memory and learning) at the synaptic cleft. The gene has long and short allelic variants that confer differential reuptake efficiency. Rodent, nonhuman primate, and human studies (e.g., Caspi et al., 2003 ) have shown that two alleles confer advantage among animals raised in stressful environments. Caspi and colleagues (2003) found that adults who had experienced stressful life events as children were more likely to have a major depressive disorder if they had one or two short alleles. Those who had two long alleles were no more likely to develop depression than individuals who had not experienced stressful life events.

A second genetic polymorphism that has received much attention is a functional polymorphism in the promoter region of the monoamine oxidase A (MAOA) gene. MAOA encodes the MAOA enzyme and selectively degrades serotonin, norepinephrine, and dopamine. Abused and neglected boys with the genotype conferring low levels of MAOA expression were found to be more likely to develop a range of externalizing behaviors, including conduct disorder, antisocial personality disorder, and violent criminality ( Caspi et al., 2002 ). However, subsequent studies have failed to replicate these findings or have demonstrated only partial replications ( Huizinga et al., 2006 ; Widom and Brzustowicz, 2006 ). For a recent review of the GxE literature concerned with child depression and abuse, see Dunn and colleagues (2011) .

Finding: Not all children who experience abuse or neglect show problematic outcomes. Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. These factors, along with risks and stressors at each level, interact with one another to predict resilient outcomes. Finding: There is a positive association between the number of risk factors for abuse and neglect to which a child is exposed and the likelihood of experiencing adverse outcomes. Finding: The timing, chronicity, and severity of child abuse and neglect, as well as the context in which they occur, have been shown to impact the associated outcomes.

• ECONOMIC BURDEN

Although the total costs of child abuse and neglect are difficult to gauge because much abuse is unreported ( Waters et al., 2004 ), a number of studies over the last few decades have attempted to document the economic burden of child abuse and neglect on society ( Corso and Fertig, 2010 ; Fang et al., 2012 ; Wang and Holton, 2007 ; Waters et al., 2004 ). Economic burden or economic impact analyses typically quantify burden by aggregating the direct medical expenditures resulting from a condition, the direct nonmedical expenditures associated with a condition, and the subsequent indirect losses in productivity potential for society. These analyses often are called cost of illness/injury analyses .

Examples of direct medical expenditures include inpatient and outpatient hospital care, mental health care, medical transport required in the event of an emergency, medications and medical devices, and the medical treatment of chronic conditions resulting from the abuse. Multiple studies since the 1993 NRC report was issued have assessed the direct medical costs associated with child abuse and neglect ( Brown et al., 2011 ), particularly the inpatient costs associated with severe abuse ( Courtney, 1999 ; Evasovich et al., 1998 ; Irazuzta et al., 1997 ; Libby et al., 2003 ; New and Berliner, 2000 ; Rovi et al., 2004 ).

Direct nonmedical expenditures include use of the child welfare system, law enforcement, and the criminal justice system. Studies have included nonmedical costs in their assessment of the economic burden of child abuse and neglect ( Staudt, 2003 ; Zagar et al., 2009 ).

Productivity losses include the child's missing school or performing at subpar levels in school because of the abuse, parents missing work or performing at subpar levels at work because of the abuse situation or having to deal with child welfare and criminal justice services, and permanent losses in lifetime productivity potential because of premature death. Productivity losses and economic well-being have been incorporated into a number of analyses of the economic burden of child abuse and neglect ( Brown et al., 2011 ; Corso and Fertig, 2010 ; Corso et al., 2011 ; Currie and Widom, 2010 ; Fang et al., 2012 ).

Gelles and Perlman (2012) estimate that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion each year—$33.3 billion in direct costs and $46.9 billion in indirect costs. An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to lost productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012 ). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity.

Currie and Widom (2010) found that adults who had experienced abuse and neglect in childhood had lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect. A higher percentage of adults who had been abused or neglected as children worked in menial, semiskilled positions at age 29 compared with adults who had not been abused or neglected—62 versus 45 percent, respectively. More of the abused and neglected group has been unemployed at some point during the previous 5 years (41 versus 58 percent, respectively). And fewer of those from the abused or neglected group were currently employed or had a bank account, owned a car, or owned their home. Larger effects were seen for women than for men.

Analyses of the economic burden of child abuse and neglect could be strengthened by greater transparency in the study methods, including a full accounting of all cost categories that may be impacted by abuse and neglect and transparency in the unit cost estimates for each cost category, as well as a methodologically sound choice of study design for estimating economic burden ( Corso and Fertig, 2010 ; Corso and Lutzker, 2006 ; Fang et al., 2012 ). Several approaches could be taken to estimate economic burden, each of which has advantages and disadvantages that could potentially result in overestimating or underestimating the true economic cost of child abuse and neglect. Options include using cross-sectional data to compare the medical costs for an abused/neglected population compared with a nonabused/nonneglected population, including only those health care costs that can be explicitly linked to diagnosis-specific health care utilization (and costs) through the use of diagnosis and external cause codes used in inpatient settings, and supplementing either of these two approaches by including the costs of the fraction of other health conditions attributed to child abuse and neglect.

Finding: Although the total costs of child abuse and neglect are difficult to gauge, a number of studies have attempted to document the economic burden of child abuse and neglect on society, including such measures as direct medical and nonmedical expenditures and productivity losses. One study estimates that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion annually ( Gelles and Perlman, 2012 ). Finding: Some studies have shown that adults who experienced abuse and neglect in childhood have lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect.

• CONCLUSIONS

Child abuse and neglect appear to influence the course of development by altering many elements of biological, cognitive, psychosocial, and behavioral development; in other words, child abuse and neglect “get under the skin” ( Hertzman and Boyce, 2010 ) to have a profound and often lasting impact on development. Brain development is affected, as is the ability to make decisions as carefully as one's peers, or executive functioning; the ability to regulate physiology, behavior, and emotions is impaired; and the trajectory toward more problematic outcomes is impacted. Effects are seen across domains, with the interplay across brain and behavioral systems being particularly striking.

Risk and protective factors across multiple levels of a child's ecology interact to influence outcomes related to child abuse and neglect. Factors that influence resilience across these domains are important to an understanding of how to protect children from the adverse outcomes discussed in this chapter. Evidence suggests that the timing, chronicity, and severity of the abuse or neglect matter in terms of outcomes. The more times children experience abuse or neglect, the worse are the outcomes ( Jonson-Reid et al., 2012 ). As Jonson-Reid and colleagues (2012) point out, it is not enough to know whether an event happened; one must also know how ongoing the problem is. The committee sees as hopeful the evidence that changing environments can change brain development, health, and behavioral outcomes. There is a window of opportunity, with developmental tasks becoming increasingly more challenging to negotiate with continued abuse and neglect over time.

Future research in this area needs to focus on disentangling the effects of child abuse and neglect from those of other conditions. There is a need to explore beneath the surface to understand the behavioral, neurobiological, social, and environmental mechanisms that mediate the association between exposure to abuse and neglect and their behavioral and neurobiological sequelae.

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Gateway Church elder says accepting resignation of pastor in sex abuse scandal was ‘difficult’ decision

Four days after they learned of decades-old child sex abuse allegations against their senior pastor, Robert Morris, hundreds of Gateway Church employees filed into an auditorium in Southlake, Texas, on Tuesday to learn his fate.

Some staff members appeared solemn as they found their seats. Others looked angry. One attendee pulled out her cellphone and secretly hit record. Later, she shared the audio with NBC News and described the meeting in an interview. A second person who attended confirmed her account and the recording’s authenticity.

Kenneth W. Fambro II, a real estate executive who serves on Gateway’s board of elders , struggled through tears as he delivered the news that employees had come to hear: Morris, one of the nation’s most prominent evangelical leaders, was resigning from the church he’d founded 24 years earlier.

“This,” Fambro said of accepting Morris’ resignation, “has been one of the most difficult decisions in my life.”

The recording of Fambro’s remarks reveals the deeply conflicted feelings of church leaders as they come to terms with the knowledge that their founding pastor — the man who’d built Gateway into one the largest megachurches in America and served on former President Donald Trump’s spiritual advisory board — had confessed to engaging in “inappropriate sexual behavior” with a child.Fambro opened Tuesday by acknowledging that he and other church officials had long known that Morris had admitted to sexual misconduct when he was young. It was a story Morris told so often over the years from the pulpit and in one-on-one meetings that “you can get kind of numb” to it, Fambro said, according to the recording.

“Pastor Robert did a phenomenal job of being open and transparent about his transgressions and his past, his moral failures,” Fambro said, speaking on behalf of the elders board, which is charged with governing the church. 

“What we did not know was that she was 12 years old.”

Cindy Clemishire, the woman who accused Morris of molesting her as a child, disputed the notion that Morris had been transparent. In a statement to NBC News, she said she was disturbed that Gateway elders struggled over whether to remove him from leadership.“What is so difficult about accepting the resignation from a man who repeatedly sexually abused a little girl for almost five years and then lied about it?” Clemishire said after having reviewed a transcript of the recording provided by NBC News. “Why wasn’t he terminated?”

Clemishire and her lawyer, Boz Tchividjian, contend that she contacted Morris and church officials with her allegations in 2005 and 2007 and that Gateway’s board of elders should have long ago investigated Morris’ version of events. (Fambro began attending the church in 2006 and became an elder in 2014, according to Gateway’s website.)

Morris hasn’t been charged with a crime and didn’t respond to messages requesting comment.

The allegations were made public Friday in a post published by The Wartburg Watch , a website focused on exposing abuse in churches. Clemishire, 54, described in the post and in a subsequent interview with NBC News how Morris had molested her for years beginning on Christmas night in 1982, when she was 12.Initially, Morris and Gateway’s elders responded Friday and Saturday by acknowledging in statements that Morris had several sexual encounters with a “young lady” when he was in his 20s and saying he had been transparent about his sin and had repented.

“Since the resolution of this 35-year-old matter, there have been no other moral failures,” the elders said in a message to employees Friday.

But some Gateway parishioners and staff members viewed the statement itself as a moral failure. Why had church leaders described the alleged sex abuse of a 12-year-old with euphemisms?

Fambro didn’t address that question in his remarks Tuesday, and he and other church elders didn’t respond to messages requesting comment. A spokesperson for Gateway also didn’t respond.

The person who made the recording of Tuesday’s staff meeting said she shared it with a reporter because she believes the board of elders is “gaslighting” employees about its initial defense of Morris and needs to be replaced. NBC News isn’t naming the woman because she fears retaliation.

At the meeting, Fambro defended the board of elders, which he said had been fielding criticism from members who felt leaders had taken too long to respond to the crisis.He said leaders had deliberated during multiple hourslong meetings Monday and Tuesday and were following the guidance they’d long gotten from their now-former senior pastor. 

“If you’ve been here long enough, you’ve heard Pastor Robert say, ‘Before we can move, we need to hear God,’” Fambro said. 

Fambro also told employees he and the other elders “have great compassion” for Clemishire and don’t condone what happened to her.

“You won’t hear us try to explain it away,” Fambro said. 

But, he added, that doesn’t mean “we don’t love Pastor Robert, that we’re not defending him.”

He then spoke extensively about the profound impact Morris had on his life and on the lives of tens of thousands of church members. Fambro encouraged the audience not to let the revelations of child sex abuse make them lose sight of the good that God had done — and would continue to do — through Gateway and Morris.

“So yes, there is an anointing on this house. Yes, there is an anointing on Pastor Robert,” Fambro said. “But both/and, yes? There was some stuff that was done. They both can exist.”

Fambro asked the staff to pray for Morris’ family, including his son James Morris, who is associate senior pastor and had been scheduled to succeed his father upon his planned retirement next year. Robert Morris is still pulling for Gateway, Fambro said, which was why he is stepping down.

“Pastor Robert wants to see Gateway Church succeed in the body of Christ,” Fambro said. “Pastor Robert wanted to resign to not be a distraction.”

Clemishire said the elders’ continued support for Morris “makes me sick.”“How can a church believe that a man can be anointed by God after sexually abusing a child and then lying about it for decades?” she said. “This is repulsive.”

Although elders had asked those in attendance not to record Tuesday’s meeting, Fambro seemed to sense that his words might eventually reach a broader audience. He said he worried someone would “take a sound bite, a clip, part of a sentence” and twist its meaning.

In closing, before another church leader stepped forward to describe the counseling services that would be available to employees, Fambro encouraged the audience members to focus on what they can do to help the church succeed. 

“I can dwell on the past,” he said. “You guys can, as well. Or I can choose to say: ‘That’s a data point. How can I affect the future?’” 

“‘How,” Fambro added, “do we move forward?’”

Mike Hixenbaugh is a senior investigative reporter for NBC News, based in Maryland, and author of "They Came for the Schools." 

Principals say parents need to be vigilant as explicit AI deepfakes become more easily accessible to students

Principals at two Victorian private schools caught up in online misogyny scandals, including AI deepfake nude images, say the behaviour is widespread.

Warning: This story contains offensive language and references to sexual violence.

Earlier this month, artificial intelligence-generated fake nudes of 50 girls in years 9 to 12 at Bacchus Marsh Grammar were created.

"This is something that affects the 50-odd girls. But the reality is, it has reverberated throughout the community as well," Bacchus Marsh Grammar principal Andrew Neal told 7.30.

"This is not a Bacchus Marsh Grammar issue. This is not a school X or Y issue. It's an issue for every school in the country, indeed every school anywhere."

School captains Jake Parton, Tansy Seymour, Pravallika Tripurana and Ishnoor Gill said they were shocked to learn their classmates had been exploited in this way.

"It was gross, it was disgusting to see something like that happen to people in and around our communities," Jake told 7.30.

The series of explicit fake photographs was created with AI, using real photos of the students taken from social media, then circulated on Instagram and Snapchat.

A teenage boy, who is a former student of the school, was arrested but so far has not been charged.

Tansy Seymour says the incident has left her and other female students nervous about using social media.

"This incident just makes me personally more aware of the things that are put out online and how dangerous artificial intelligence is," she said.

'Synthetic child abuse material'

Cyber safety expert Susan McLean, who previously had 27 years' experience in the Victorian Police Force, says the ability to create fake sexually explicit images has become frighteningly easy in the last couple of years.

"There are hundreds of apps that promote creating a nude image or taking someone's clothes off," Ms McLean told 7.30.

She said some of the apps or websites simply asked a user to say they were 18 and then created the image with the consent of the person.

In response to the surge in AI platforms targeting children, eSafety Commissioner Julie Inman Grant announced "world-leading" new standards that would require social media platforms and other cloud and messaging companies to detect and remove child abuse and terror content.

The new standards would capture examples of AI deepfake pornographic images like those created of Bacchus Marsh Grammar students.

"As little as three years ago, it took hundreds of images of a person's face, vast amounts of computing power, and a lot of technical expertise to create a credible deepfake," Ms Inman Grant said.

"But with the accessibility, capability and proliferation of open-source AI apps, often nudify apps or undressing apps, or apps that blatantly say you just choose the age of a child you want, and a body type … within seconds, will create an image for you.

"We've given these incredibly powerful tools to kids on their smartphones, where they're harvesting images of their classmates on social media.

"They're creating deepfaked, image-based abuse, which is incredibly distressing.

"And when it deals with underage teens, it's also synthetic child sexual abuse material."

'Holy grail for paedophiles'

Ms Inman Grant said if allowed by federal parliament, the standards would come into effect after six months and after a 15-day disallowance period had expired.

"The standards will put the onus back on the platform libraries and the apps themselves from creating this kind of content," she said.

"The companies are frankly turning a blind eye on file storage platforms and photo sharing platforms. So that's really the holy grail for paedophiles."

The commissioner said if the standards were implemented, they would be world-leading in requiring tech companies to scan, report and remove child abuse material.

Mr Neal has welcomed the proposal.

"We can educate children, we can provide them with information, and we can tell them about the dangers, their parents can do that," Mr Neal said.

"Ultimately, we need the support of the third arm, which is government, to put some boundaries in."

Ms McLean is supportive of the commissioner's new powers, which include fining tech companies up to $800,000 a day.

However, she is concerned it will not stop the offending.

"We know that fines alone don't always change business practices of platforms because they have a truckload of money and they can simply pay the fine," Ms McLean said.

A shared responsibility

Examples of online misogyny being dealt with by schools are not restricted to AI deepfakes.

Last month, two students were expelled from Yarra Valley Grammar for creating a list of female students and ranking them from "wifeys" to "cuties" to "unrapeable".

"Everyone was able to see just how objectifying and humiliating it was, and I think there was 100 per cent a lot of anger — it is a disgusting act," Yarra Valley school captain Noah Cameron told 7.30.

Yarra Valley school principal Mark Merry said he had no hesitation in expelling the perpetrators but said that action gave no guarantee when it came to his school and the potential for sexually explicit deepfake images.

"Could it happen here? Absolutely," Mr Merry told 7.30.

He says that while schools have a role to play in teaching respect, he believes most of the material is made inside homes.

"The primary responsibility has to be the family," he said.

"I'm not blaming families, because the technology has got ahead, and so quickly, that a lot of parents just aren't familiar with it."

Ms McLean said all schools should increase educational programs around cyber safety, but agreed parents needed to be vigilant too.

"We have to work more on education because a lot of young men are growing up with cultural pornography," Ms McLean said.

"They're using it to work out how to have a relationship and of course that translates to their willingness to create these nude images because they don't actually see anything wrong with that."

'Dangerous precedent?'

Ms Inman Grant says if the proposed standards are passed by parliament, Australia will lead the way in forcing tech companies to combat online child abuse material.

"We think so many of the US technology companies pushed so vociferously against them because it is actually requiring them to do things," she told 7.30.

"Currently, on platforms like Signal and Apple, if a user comes across child sexual abuse material, you can't even report it to them."

In a submission to the eSafety Commissioner earlier this year, Apple said it: "Fully shares concerns around the proliferation of abhorrent child sexual abuse material and pro-terror content."

However, it went on to say the company had: "Serious concerns that the draft standards pose grave risks to the privacy and security of our users and set a dangerous global precedent."

Watch 7.30 , Mondays to Thursdays 7:30pm on ABC iview and ABC TV

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