Child abuse is a major public health concern that transcends racial, ethnic, religious, and socioeconomic boundaries. It has been correlated with problems of violence, substance abuse, anxiety disorders, depression, suicide, and other psychopathology. Studies suggest that the incidence of certain comorbidities are correlated with duration and severity of abuse, thus suggesting that reports of abuse to appropriate child protection agencies may have long term, as well as immediate, health benefits for the victim. Thus, it is essential that pediatricians and other healthcare providers understand the scope of the problem and how to identify cases of abuse and neglect, as well as families at risk. Here we outline the scope of the problem.
The Federal Child Abuse Prevention and Treatment Act (Pub. L. No. 93-247 (1974)) defines child abuse and neglect to be, at a minimum:
- Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.The definition of sexual abuse includes the following:
- The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or to assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct; or
- The rape, and in cases of caretaker or inter-familial relationships, statutory rape, molestation, prostitution, or other form of sexual exploitation of children, or incest with children.A child is defined to be a person who has not attained the lesser of:
- The age of 18; or
- Except in cases of sexual abuse, the age specified by the child protection law of the State in which the child resides.(1)
Each State may further define child abuse and neglect, provided the definitions fall within the minimum standard set by CAPTA. Massachusetts reporting laws define child abuse and neglect as follows (reporting laws for other States can be found here):
Injured, Abused, or Neglected Child means a child under the age of eighteen years who is suffering physical or emotional injury resulting from abuse inflicted upon him which causes harm or substantial risk of harm to the childs health or welfare including sexual abuse, or from neglect, including malnutrition, or who is determined to be physically dependent upon an addictive drug at birth.Abuse can be defined as the occurrence of one or more of the following acts between a parent [or primary caretaker] and the other parent or between a parent and child:
- Attempting to cause or causing bodily injury; or
- Placing another in reasonable fear of imminent bodily injury.Serious incident of abuse means the occurrence of one or more of the following acts between a parent [or primary caretaker] and the other parent or between a parent and child:
Most of the following descriptions are adapted from the U.S. Department of Health and Human Services guide, A Coordinated Response to Child Abuse and Neglect: A Basic Manual.(2)
Physical Abuse: characterized by physical injury (i.e. bruises and fractures) resulting from punching, beating, kicking, biting, burning, or otherwise harming a child. Although the injury is not an accident, the parent or caretaker may not have intended to hurt the child. The injury may have resulted from overdiscipline or physical punishment that is inappropriate for the childs age or condition. The injury may be a result of a single episode or of repeated episodes and can range in severity from minor bruising to death. Any punishment that involves hitting with a closed fist or an instrument, kicking, inflicting burns, or throwing the child is considered physical abuse regardless of the severity of the injury sustained.
Sexual Abuse: includes a wide range of behavior - fondling a childs genitals, oral-genital contact, intercourse, rape, sodomy, forcing a child to perform a sexual act on an adult, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials. Sexual abuse is usually defined as acts committed by a person responsible for the care of the child (i.e. a parent, babysitter, day care provider, etc.), whereas sexual assault is usually defined as acts committed by a person not responsible for the childs care.
Emotional/Psychological Abuse: includes acts or omissions by the parents or other persons responsible for the childs care that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders. In some cases, the acts alone (without any harm evident in the childs behavior or condition) warrant Department of Social Services (DSS) intervention; for example, the use of extreme or bizarre forms of punishment, such as torture or confinement in a dark closet. For less severe acts, such as habitual scapegoating, belittling, or rejecting treatment, demonstrable harm to the child is often required for DSS to intervene.
Physical Neglect: includes refusal of or delay in seeking health care, abandonment, inadequate supervision, and expulsion from home or refusing to allow a runaway to return home.
Emotional Neglect: includes such actions as chronic or extreme spouse abuse in the childs presence, permission of drug or alcohol use by the child, and refusal or failure to provide needed psychological care.
Educational Neglect: includes permission of chronic truancy, failure to enroll a child of mandatory school age, and inattention to a special education need.
Munchausen Syndrome by Proxy: a form of child abuse in which a parent (usually the mother) purposefully fabricates illness in her child or reports concerning symptoms (such as seizure activity, apnea, etc.) not seen by objective witnesses, and repeatedly seeks medical care for the child, denying knowledge as to the cause of the illness or injury. Acute signs and symptoms often subside when child and parent are separated.(3)
For more detailed descriptions, please see Injuries and Behaviors Indicative of Abuse.
The National Child Abuse and Neglect Data System (NCANDS)(4) reported the following statistics for the calendar year 2001:
An estimated 903,000 (12.4 per 1,000) children in the United States were victims of child maltreatment in the year 2001. These numbers increased slightly from the year 2000, when an estimated 879,000 (12.2 per 1,000) children were abused and/or neglected.
Types of Maltreatment:
Of those children maltreated,
- 57.2% suffered neglect (including medical neglect)
- 18.6% were physically abused
- 9.6% were victims of sexual abuse
- 6.8% suffered emotional or psychological abuse
- 19.5% of cases were classified as "other"
(Percentages do not add up to 100% as many children suffered multiple forms for maltreatment.)
Characteristics of Maltreated Children:
- Gender: 51.5% female; 48% male; 0.5% unknown
- Age: 27.7% of victims were 3 years old or younger; approximately 75% were younger than 12 years old.
- Race: 50.2% Caucasian; 25.0% African American; 14.5% Latino; 2.0% American Indian or Alaska Native; 1.3% Asian-Pacific Islanders.
There were an estimated 1,300 child fatalities (1.8 per 1,000 children) secondary to maltreatment in 2001; neglect accounted for the largest percentage of these deaths (35.6%). 40.9% of fatalities were in children less than 1 year old and 84.5% were in children under 6 years old. Approximately 1.5% of these fatalities occurred in foster care.
Reports and Services:
There were approximately 3 million referrals to child protection and social services agencies, regarding approximately 5 million children. 67.3% of these referrals were screened in (investigated). Preventative services were provided to approximately 2 million children. 58.4% of these children were victims of alleged abuse or neglect. whereas 28.8% were thought to not have suffered maltreatment after investigation. 19.0% of victims and 4.7% of non-victims were removed from their homes as the result of the investigation. Court actions were initiated for 17.5% of victims.
Characteristics of Perpetrators:
- Gender: 59.3% female; 40.7% male.
- Median Age: 31 years for females and 34 years for males. 42.3% of female perpetrators were under 30 years old, vs. 31.9% of male perpetrators.
- Relationship to Child: 80.9% of abuse/neglect was perpetrated by a childs parent; mothers were more than twice as likely as fathers to be the sole perpetrators (40.5% vs. 17.7%).
(1) National Clearinghouse on Child Abuse and Neglect Information.(December 31, 2000). Child Abuse and Neglect State Statutes Elements: Reporting Laws Number 1. Washington, DC: US Department of Health and Human Services.
(2) National Clearinghouse on Child Abuse and Neglect Information. (1992). A Coordinated Response to Child Abuse and Neglect: A Basic Manual. Washington, DC: US Department of Health and Human Services.
(3) Child Neglect and Munchausen Syndrome by Proxy. Portable Guides to Investigating Child Abuse. US Department of Justice. 1996.
(4) National Child Abuse and Neglect Data System (2003). Child Maltreatment 2001. Administration on Children, Youth, and Families. .