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MonicaL.McCoyStefanieM.Keen-ChildAbuseandNeglect_SecondEdition-PsychologyPress2013.pdf
Child Abuse and Neglect
Child abuse and neglect are examined in this new edition—the latest research, what it entails, and how to recognize and report it. Federal law mandates the reporting of suspected child maltreatment by many professionals. This book will appeal to those who may one day fi nd themselves in the role of a mandated reporter.
Engaging learning tools are integrated throughout: Focus on Research boxes provide an in-depth look at research or methodologies. Case Examples and Debates encourage discussion about the gray areas in the fi eld. Legal Examples and Focus on Law sections explain judicial rulings including guides
for locating relevant state statutes. Discussion questions promote dialogue and deepen understanding of the material. Bold-faced key terms defi ned when fi rst introduced also appear in the book’s
glossary. Conclusions and Defi nitions help students focus on the key concepts introduced
in each chapter.
The new edition also includes the following features: A thorough updating of the citations and state and federal laws, along with the
latest statistics on incidence and prevalence based on the new National Inci- dence Study NIS-4.
A new chapter on resiliency (Chapter 10) and more discussion of resilience in the face of maltreatment in the chapters on types of abuse ( Chapters 4 –9 ) pro- vide a better understanding of why some children thrive despite experiencing maltreatment.
New “Profi les” boxes that feature information about graduate training in child maltreatment, descriptions of jobs in the fi eld, or biographies of people who work in the fi eld to increase students’ awareness of possible career opportuni- ties.
Web-based instructor and student resources including PowerPoints, weblinks, and a test bank with multiple-choice, short-answer, and essay questions.
More tables, fi gures, and photos to better illustrate and summarize key points. New sections on child maltreatment in military families ( Chapter 2 ), child obe-
sity as a result of maltreatment ( Chapter 5 ), teen “sexting” and its possible prosecution as child sexual abuse, and Susan Clancy’s controversial thesis published in The Trauma Myth ( Chapter 7 ).
Updated and more case examples including recent events that captured the pub- lic’s attention such as the case of Jessica Beagley convicted of child abuse for forcing her son to ingest hot sauce and of Latrece Jones convicted of negligent homicide for failing to have her son in a car seat.
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The book opens with the background on child maltreatment including its history, an overview of the research, and the risk factors. Details about mandated report- ing are also explored. Different forms of maltreatment—physical abuse, neglect, psychological maltreatment, sexual abuse, fetal abuse, and Munchausen by Proxy Syndrome—are then examined, along with resiliency, in a new chapter to this edition. Incidence estimates and consequences for each type of maltreatment are provided. Legal issues including forensic interviewing are then reviewed. The book concludes with an example of what happens to a child after a report is fi led along with suggestions for preventing child maltreatment.
Intended as a text for courses in child abuse, child maltreatment, family vio- lence, or sexual and intimate violence taught in psychology, human development, education, criminal justice, social work, sociology, women’s studies, and nursing, this book is also an invaluable resource to workers who are mandated reporters of child maltreatment and/or anyone interested in the problem.
Monica L. McCoy is a professor of psychology at Converse College in Spartanburg, South Carolina.
Stefanie M. Keen is an associate professor of psychology at the University of South Carolina Upstate in Spartanburg, South Carolina.
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Child Abuse and Neglect Second Edition
Monica L. McCoy
Stefanie M. Keen
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First edition published 2009 by Psychology Press
This edition published 2014 by Psychology Press 711 Third Avenue, New York, NY 10017
and by Psychology Press 27 Church Road, Hove, East Sussex BN3 2FA
Psychology Press is an imprint of the Taylor & Francis Group, an informa business
© 2014 Psychology Press
All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifi cation and explanation without intent to infringe.
Library of Congress Cataloging-in-Publication Data McCoy, Monica L. (Monica Louise) Child abuse and neglect / Monica L. McCoy, Stefanie M. Keen. — [Second edition]. pages cm 1. Child abuse—United States. 2. Child abuse—Law and legislation—United States. I. Keen, Stefanie M. II. Title. HV6626.52.M336 2014 362.76—dc23 2013028231
ISBN: 978-1-84872-605-5 (hbk) ISBN: 978-1-84872-529-4 (pbk) ISBN: 978-0-203-12069-9 (ebk)
Typeset in Stone Serif by Apex CoVantage, LLC
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v
CONTENTS
Dedication xi
Preface xiii
Acknowledgments xvii
Author Biographies xix
PART I Introduction/Purpose 1
CHAPTER 1 Introduction 3
A Brief History of Child Maltreatment 4
Responding to Children in Crises 7
Research on Maltreatment 16
Conclusion 21
Discussion Questions 21
CHAPTER 2 Risk Factors for Child Maltreatment 23
Family Factors 23
Child Factors 32
Extrafamilial Factors 33
Cultural Factors 37
Conclusion 39
Discussion Questions 40
CHAPTER 3 Mandated Reporting 42
The History of Mandated Reporting 42
Persons Required to Report 43
When to Report 45
How to Report 47
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vi CONTENTS
Failure to Report 49
Education Regarding Mandated Reporting 52
Confi dentiality and Mandated Reporting 55
Is Mandated Reporting a Good Thing? 56
Conclusion 57
Discussion Questions 58
PART II Types of Abuse and Their Effects 61
CHAPTER 4 Physical Abuse 63
Defi nition 63
Prevalence and Incidence 68
Corporal Punishment 69
Consequences of Physical Abuse 71
Caution: Not All Marks Are Signs of Abuse 82
Marks From Folk Medicine Practices 82
Nonphysical Consequences of Physical Abuse 84
Conclusion 88
Discussion Questions 88
CHAPTER 5 Child Neglect 90
Defi nition 90
Subtypes of Neglect 92
Incidence 113
Consequences of Neglect 114
Intergenerational Transmission of Neglect 121
Conclusion 122
Discussion Questions 122
CHAPTER 6 Psychological Maltreatment 123
Defi nition 123
Defi ning a Line on a Continuum of Behavior 133
Incidence 135
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viiCONTENTS
Consequences of Psychological Maltreatment 138
Conclusion 145
Discussion Questions 145
CHAPTER 7 Sexual Abuse 146
Defi nition 148
Incidence and Prevalence 153
Perpetrators 156
Victims 161
Extrafamilial Child Sexual Abuse 163
Child Sexual Exploitation 168
Consequences of Sexual Abuse 170
Conclusion 187
Discussion Questions 188
CHAPTER 8 Fetal Abuse 189
Defi nition 189
Incidence 190
Causes of Fetal Abuse 190
Effects of Drugs on Prenatal Development 191
Responding to Fetal Abuse 197
Conclusion 209
Discussion Questions 209
CHAPTER 9 Munchausen by Proxy Syndrome 210
Defi nition 210
Victims 214
Perpetrators 215
Incidence 216
Risk Factors 216
Consequences of MPS 218
Investigation of MPS 220
Controversies Related to MPS 224
Conclusion 228
Discussion Questions 229
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viii CONTENTS
CHAPTER 10 Resilience 230
Defi nition 230
Conclusion 243
Discussion Questions 243
PART III Legal Issues 245
CHAPTER 11 Forensic Interviewing of Child Victims 247
Children Providing Testimony 247
The Accuracy of Children’s Testimony 247
Recommendations for Conducing Good Forensic Interviews 269
Conclusion 271
Discussion Questions 276
CHAPTER 12 The Legal System and Child Maltreatment 277
Children and the Courtroom 277
Types of Courts 281
Testifying in Court 299
Conclusion 300
Discussion Questions 300
PART IV What Happens Next 301
CHAPTER 13 The Maltreated Child and Child Protective Services’ Response: What Happens After a Report Is Made? 303
Intake and Screening 310
Investigation and Initial Assessment 312
Family Assessment 319
Case Planning 320
Service Provision 322
Family Progress 323
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ixCONTENTS
Case Closure 324
Decision Making 324
Conclusion 326
Discussion Questions 326
CHAPTER 14 Preventing Child Maltreatment 328
Overview of Prevention Programs 329
A Public Health Issue 330
Primary Prevention 331
Secondary Prevention 339
Conclusion 343
Discussion Questions 344
Appendix of Abbreviations 345
Glossary 347
References 359
Subject Index 391
Author Index 401
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I dedicate this book to my mother, Julie McCoy, and to the memory of my father, Gary McCoy, who gave me the priceless gift of a happy childhood.
Monica L. McCoy
To Hannah and Leah, you are my sunshine.
Stefanie M. Keen
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xiii
Our purpose in writing this book was to create a textbook that was appropriate for an undergraduate course in Child Abuse and Neglect. There is a demand for this type of information because students preparing to enter many disciplines (psychology, edu- cation, social work, pre-med) are aware that they will be mandated reporters for child maltreatment while also realizing that they are not prepared to meet this obligation. In order to fulfi ll this role, students need education about what maltreatment entails, how to recognize and report it and how the issue is handled by Child Protective Services and the courts. The current research indicates that many professionals who are mandated reporters think that their training in this area has not been adequate. It is our hope that having a textbook that is grounded in research and the law will provide a more adequate preparation for those who are now, or who will become, mandated reporters of child maltreatment.
CONTENT
The text is divided into four main sections. In Part I , we provide background infor- mation on the problem of child maltreatment. This includes a brief history of child maltreatment as well as an introduction to some of the research limitations in the fi eld. The second chapter in Part I covers many of the possible risk factors for child maltreatment. It is diffi cult for some students to understand how a parent could harm their own child. It is our hope, that by considering many of the factors a family may be dealing with, students will recognize how maltreatment can occur, even among families who love their children. The fi nal chapter in Part I covers man- dated reporting in depth. It is good to fully understand what the role of a mandated reporter is before learning about the different forms of maltreatment, which make up Part II of the text. Chapters 4 to 9 cover each type of maltreatment (physical abuse, neglect, psychological maltreatment, sexual abuse, fetal abuse, and Munchausen by Proxy Syndrome) in detail. For each form of maltreatment, we provide defi nitions, estimates of incidence, and possible consequences. As appropriate, we cover issues and controversies that are relevant to that form of maltreatment. The last chapter in Part II covers the topic of resilience. Despite the many negative consequences asso- ciated with maltreatment that are addressed in chapters 4 to 9 , some victims go on to lead normal and even remarkable lives. Part III of the text deals with legal issues related to child maltreatment. Chapter 11 focuses on forensic interviewing, and Chapter 12 covers the legal system as it pertains to child maltreatment. Although mandated reporters have less to do with this part of the process, it is still valuable information for them to have. For instance, knowing how suggestible children are to certain forms of questioning, should make mandated reporters realize that they
PREFACE
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xiv PREFACE
should not attempt to interview children about allegations of maltreatment unless they have been trained to do so. Finally, Part IV of the book examines what occurs after a report of child maltreatment is made and prevention efforts. Chapter 13 details what happens to a child after a report of child maltreatment has been made to Child Protective Services. Although mandated reporters are not involved in this process, it is natural to be concerned about what happens after a reporter sets the investigative process in motion. Finally, the last chapter addresses the more optimis- tic issue of the prevention of child maltreatment. Although mandated reporters are required to notice and report child maltreatment, it would be better for everyone if the problem could be prevented.
LEARNING TOOLS
The book has several features that have been included to deepen understanding about child maltreatment. The fi rst time an important term or unfamiliar word appears, it is in bold type, and the defi nition appears in the margin. At the end of the book, you will fi nd a glossary of all the terms defi ned throughout the book. Many chap- ters have “Focus on Research Boxes.” This feature allowed us to go into depth about representative research studies, and to explain research methodologies that students may not be familiar with. We have also used “Case Examples” throughout the text, some fi ctional and some real. We have added these for two reasons. First, students tend to fi nd case studies interesting and easier to grasp than more theoretical mate- rial. Second, the cases provide you with a starting point to engage in discussion with your classmates about the many gray areas in this fi eld. Many chapters also contain “Profi les” of professionals working in the fi eld. These give students informa- tion about possible careers in the fi eld while highlighting how much good can be accomplished by dedicated people. Another learning tool involves instructions to “Search the Web.” The purpose of these sections is to encourage further reading on certain topics and to guide students to the laws relevant to their state. Finally, the “Legal Examples” and “Focus on Law” sections explain, in detail, legal cases, and judicial rulings that have had a signifi cant impact on how child maltreatment cases are handled by the courts. By studying these cases, we hope students gain a deeper appreciation for the legal complexities surrounding child maltreatment. At the end of each case example and at the end of every chapter, you will fi nd discussion ques- tions related to the material you have just read. Thinking about these questions and discussing your answers with your peers will help to test and expand your knowledge of the material.
NEW TO THIS EDITION
We have made a signifi cant number of changes to this edition in an effort to provide up-to-date information and to attempt to cover the wide range of issues related to maltreat. This edition includes:
More 250 new, updated references Updated statistics including National Incidence Study-4 data
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xvPREFACE
Updated state laws to refl ect new legislation More Case Examples, Legal Examples, and Focus on Research boxes Profi les of professionals working in the fi eld An expanded section on child fatalities A section on child maltreatment in the military Expanded information on the consequences of neglect Added coverage of child obesity as related to possible neglect Signifi cant expansion of sexual abuse chapter to cover extrafamilial abuse (in
churches, day-care centers, schools, and sports organizations) as well as sexual exploitation (child pornography, prostitution, and sex traffi cking)
An entirely new chapter on resilience Increased coverage of cultural issues Addition of new prevention programs that have been recently developed and/
or evaluated A teacher’s companion website (www.psypress.com/cw/mccoy) that includes
test questions (multiple choice, true/false, and essay), video suggestions, addi- tional discussion questions, and more case examples
We realize that no textbook can answer all of the questions students will ever have about child maltreatment. However, the goal of this book is to help future mandated reporters be better prepared to meet the challenges of fulfi lling that role.
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xvii
ACKNOWLEDGMENTS
A large number of people helped to make this book possible. We would like to take this opportunity to acknowledge the professional and personal support that we received while working on this book.
Our Professional Colleagues and Institutions The psychology department at Converse College: Dr. Rich Keen, Dr. Tracy
Ksiazak, Dr. Marie LePage, and Dr. Jan LeFrancois. Many thanks for being sup- portive throughout this entire process.
Converse College and Dean Jeff Barker, for granting me a sabbatical leave to work on this second edition.
Dr. Narina Nunez and Dr. Jennifer Gray for their feedback and suggestions for additions and revisions.
Dell Morgan, tireless interlibrary loan offi cer. This edition owes much to his amazing work at tracking down any and every source I needed.
The Department of Psychology and Center for Child Advocacy Studies at the University of South Carolina Upstate, I could not have asked for more won- derful colleagues.
Angela Talley Robinson, Program Coordinator for Adult and Child Protective Services with the Spartanburg County Department of Social Services, for tak- ing the time to talk with us about child protective services and for helping us to understand the child protection process.
Our Families A special thanks to Julie McCoy for proofreading and constant encouragement. With gratitude to Jud Stubbs for his help with pictures, photographs, and all
things technical. Thanks too for the support and love while I worked on this edition.
Thank you to Lynn and Al Dodd, for instilling in me the importance of educa- tion and the pursuit of knowledge. I attribute my love of learning wholly to their infl uence, and am grateful to them for their guidance in my own educa- tional achievements.
A special thanks also to Rich Keen. His patience and support during this project has been seemingly endless. Thank you for always being a stable presence and for taking up the slack when I was too immersed to know which end was up.
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xviii ACKNOWLEDGMENTS
Our Reviewers Further thanks are directed toward the reviewers who made many helpful sugges- tions during the writing process, including the following:
Mary Breaux, Sam Houston State University Mick Coleman, University of Georgia Alberta Ellett, University of Georgia Warren Galbreath, Ohio University Lisa Litz, Child Advocacy Center, Inc. Charisa Kiyô Smith, Juvenile Justice Project Derrik Tollefson, Utah State University Stephannie Walker, University of Wyoming Christine Wekerle, McMaster University Hillary Wing-Richards, James Madison University C. Thresa Yancey, Georgia Southern University along with other reviewers who prefer to remain anonymous.
Our Publisher Finally, we would like to thank the professionals at Psychology Press/Taylor & Francis for their assistance during this project; especially Fred Coppersmith and Debra Riegert.
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xix
AUTHOR BIOGRAPHIES
Monica L. McCoy, PhD Dr. McCoy is a professor of psychology at Converse College in Spartanburg, South Carolina. She earned her bachelor’s degree in psychology from Grove City College and her master’s degree in experimental psychology from Villanova University. She then obtained her PhD in experimental/developmental psychology, with a minor in statistics, from the University of Wyoming. Dr. McCoy currently teaches a broad range of undergraduate courses including Child Abuse and Neglect, Human Growth and Development, Statistics and Experimental Design, Social Psychology, and Sen- ior Seminar. Dr. McCoy’s research has focused on determining what factors have an impact on jurors’ decisions in cases of alleged child maltreatment. She is also inter- ested in exploring what the public knows about child abuse and neglect, and how mandated reporters become educated about maltreatment. In addition to her work at the college, Dr. McCoy has served as a guardian ad litem, and she has offered training for others who serve as court advocates for abused children and for volunteers at the local children’s shelter. She also serves on the board of directors for the Children’s Advocacy Center of Spartanburg, Cherokee, and Union Counties.
Stefanie M. Keen, PhD Dr. Keen is an associate professor of psychology at the University of South Carolina Upstate in Spartanburg, South Carolina. She earned her Bachelor of Arts degree in psychology from the State University of New York at Binghamton and her doctoral degree in clinical psychology from Indiana University. Dr. Keen currently teaches a variety of undergraduate courses including a senior seminar in Trauma and Posttrau- matic Stress, Introduction to Child Maltreatment, Developmental Psychology, and Abnormal Psychology. She is also involved in the education and training of future child welfare advocates through the University of South Carolina Upstate’s academic minor in Child Advocacy Studies. She is engaged in an active research program related to the psychological effects of traumatic stress including child maltreatment, intimate partner violence, and military-related trauma. Dr. Keen previously worked at the National Center for Posttraumatic Stress Disorder, within the VA Boston Health- care System, where she was engaged in both clinical work and research with military veterans. She serves on the board of directors for the Children’s Advocacy Center of Spartanburg, Cherokee, and Union Counties and is a trained facilitator for Darkness to Light’s Stewards of Children.
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PART I
Introduction/Purpose
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3
The purpose of this textbook is to provide you with an over-view of child maltreatment. This umbrella term includes both the abuse and the neglect of children. Child abuse is the term used for acts of commission—things a parent or caretaker does to a child that are inappropriate. Child abuse can include such diverse acts as beating, sexually assaulting, or verbally abusing a child. In each case, the adult is doing something to the child that is defi ned as maltreatment.
Conversely, child neglect is the term used for acts of omission— things a parent or a caretaker fails to do for a child when appropriate care would require that such things be done. Child neglect can include failure to provide for a child’s physical, emotional, medi- cal, or educational needs. In cases of child neglect, the parent fails to provide for the child even the minimum necessary for adequate care. Together, child abuse and child neglect make up child maltreat- ment. Although most researchers in the fi eld would agree to this terminology, it is important for readers of this literature to note that child abuse is also sometimes used synonymously with child mal- treatment. In other words, when some authors write of child abuse, they often mean both abuse and neglect. I also follow this usage largely because abuse is often a less awkward term than is maltreat- ment. On the other hand, child neglect does not include child abuse, so when you see that term, you can be fairly certain that the focus is on acts of omission. The problem of confusing terminology is something we will need to keep in mind as we explore the literature on child maltreatment. This particular fi eld is plagued with defi nitional issues. For example, what one author means by “sexual abuse” may be quite different from what another means by the same term. To be as clear as possible, I begin each chapter that focuses on a type of maltreatment by establishing a working defi nition for that form of maltreatment. When you read other authors’ chapters, you must be attentive to the defi nitions with which they are working.
Many students become frustrated by the lack of defi nitional consistency in the fi eld of child maltreatment. Although it does not make the situation any easier to deal with, it is helpful to note that the fi eld is a new one. Certainly, the mistreatment of children is not new; all recorded history includes references to acts we would today defi ne as maltreatment. However, the professional examination of child mal- treatment has a fairly short history. Many date the beginning of the professional research in this fi eld to the early 1960s.
CHAPTER 1
Introduction
child maltreatment
the abuse and/or neglect
of children. Specifi c
defi nitions vary by state
and purpose (legal,
research, etc.).
child abuse
an act, generally
deliberate, by a parent or
a caregiver that results in
harm or death to a child.
child neglect
the failure of a parent or
a caregiver to meet the
minimal physical and
psychological needs of a
child.
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4 INTRODUCTION/PURPOSE
A BRIEF HISTORY OF CHILD MALTREATMENT
Although we defi nitely hear more about child abuse today than we did in the past, this does not mean it is a new phenomenon. The psychohistorian Lloyd deMause edited The History of Childhood in 1974, which he began with the now familiar quotation:
The history of childhood is a nightmare from which we have only recently begun to awake. The further back in history one goes, the lower the level of child care and the more likely children are to be killed, abandoned, beaten, terrorized and abused.
deMause, 1974, p. 1
Ancient History
Historical research seems to support this rather grim statement. A study of ancient history reveals that infanticide (the act of killing an infant) was practiced in many
societies. While we still use this term today, there are two impor- tant differences to note between ancient and modern usage. First, modern developmental psychologists defi ne infancy as the period covering only the fi rst year or two of life (Farlex, 2013). In ancient times, the term infancy covered a much longer range, being identi-
fi ed as the period between birth and 7 years. Second, whereas infanticide is clearly illegal today, in ancient times it was often condoned by society. The historians Ten- Bensel, Rheinberger, and Radbill (1997) noted that in ancient times children did not have the right to live until that right was bestowed on them by their father. If the father withheld this right, then the infants were abandoned. In some cases, even fathers could not grant their child the right to live. For instance, the Roman Law of Twelve Tables actually required that any “dreadfully deformed” child be put to death, no matter what the parents’ desires were for that child. Reasons for infanticide included population control, appeasement of god(s), limitation of family size, and a way for an unwed mother to deal with shame. Allowing the murder of infants for any of these reasons suggests that children did not have even the most basic right—the right to life. Children who were permitted to live were considered the property of their fathers. As such, the rule of the father over the child was nearly complete. There is ample evidence that it was even socially acceptable in certain circles in ancient Greece for fathers to allow other men to use their sons sexually (Kahr, 1991). The respected philosopher Aristotle wrote, “The justice of a master or a father is a differ- ent thing from that of a citizen, for a son or a slave is property and there can be no injustice to one’s own property” (as cited in Helfer, Kempe, & Krugman, 1997, p. 5).
Middle Ages
During the Middle Ages, laws forbidding infanticide were passed. It is not clear whether the laws were carefully enforced, but the idea was taking hold that the child at least had the right to live. This does not mean that the Middle Ages were a glori- ous time for children. The widespread poverty of this time made children a liability. There are horrifi c stories of children who were severely mistreated by their parents in order to bring more money into their household. Some children were actually sold
infanticide
the killing of an infant,
particularly a newborn.
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5INTRODUCTION
for profi t by their own parents. Other children were mutilated so that they would be more effective beggars. Although wealthy strangers may have turned their back on a healthy child who was begging in the streets, it was harder to ignore a child who was blind or missing a limb; therefore, a child who was injured or deformed was likely to have more success on the streets.
Reformation
A dramatic change in the view of children occurred as a result of the Reformation of the 16th century. This religious movement, marked by a rise in Protestantism, had a signifi cant impact on how children were regarded. On a positive note, children were seen as fragile creatures of God who needed to be safeguarded. As persons created in God’s image, they had a soul and the right to life. On the other hand, all humans were born marked with the stain of original sin. These beliefs led to a resurgence of interest in educating children in a way that would overcome the stain of original sin. Parents and teachers were urged to use strict discipline in the hopes of molding chil- dren into moral human beings (Stone, 1977). John Robinson, a pastor of the Pilgrim Fathers in the Netherlands, wrote, “Surely there is in all children a stubbornness, and stoutness of mind arising from natural pride, which must in the fi rst place be broken and beaten down” (Stone, 1977, p. 116). The general acceptance of this approach was clear when the birch rod became a symbol of education. The normative view seemed to be an acceptance of the saying “Spare the rod and spoil the child.” Flog- ging became the normal punishment for any academic lapse, and records of the beatings reveal that they were often quite harsh. Children were whipped, generally with a bundle of birches, on their bare buttocks until they bled. Other teachers used a ferula (a fl at piece of wood that had a rounded end with a hole in the middle) to hit students on the hand or mouth which resulted in a painful blister (Stone, 1977). The beatings extended even into the college years. Students working toward their bachelor’s degree in the early 1600s could be fl ogged, not only by the college head but also by their deans and even their tutors.
While this paints a very bleak picture of childhood during the Reformation, there is some good news being reported in recent scholarship. Moran and Vinovskis (1986) found that this harsh child-rearing strategy may have been true of the prevailing public opinion, but many parents were resistant to using harsh discipline and instead raised their children with love and affection. This is also an important reminder that at any point in time, there will be great diversity in how children are treated, no mat- ter what the current prevailing public opinion is.
Enlightenment
It was not until the Enlightenment that things begin to improve for children in terms of the generally accepted views of child rearing. The next shift in how childhood was viewed has been largely attributed to the writings of John Locke and Jean-Jacques Rousseau. Locke saw children as tabula rasa, which means blank slate. Locke viewed children not as innately fl awed, but simply as blank or neutral. If children are tabulae rasae, then parents and teachers need only to shape children, to mold them into whatever is good; there is no need to eliminate innate
tabula rasa
a blank slate; a mind
that has not yet been
affected by experiences
or impressions.
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6 INTRODUCTION/PURPOSE
badness. Certainly, this would suggest that a kinder, gentler parent and educator were required. Rousseau’s philosophy went even further by saying that children were noble savages, neither evil nor blank, but endowed with an innate sense of right and wrong. Rousseau believed that a parent’s training would only interfere with a child’s innate, orderly, moral development. Instead of forcing or molding a child, an adult needs to be sensitive to a child’s needs (Berk, 1997). Children should be permitted to grow with very little constraint by parents or teachers.
Industrial Revolution
This shift in the view of human nature, from evil to neutral to good, does not mean that children have been treated gently since the Enlightenment! In fact, some of the saddest stories about the mistreatment of children come from the 19th cen- tury and the Industrial Revolution. Although the Industrial Revolution brought relief from hard labor for many, it was merely a new age of abuse for poor children who were brought into the labor force. Even very young children were forced to work long hours in horrifi c conditions in which they were exposed to occupational hazards.
Some of the most compelling child labor stories in the United States were about the “breaker boys,” who worked in the anthracite coal industry. The job for these boys was to pick impurities, such as slate, out of the coal before it was sold. In order to do this, the boys sat on benches that were suspended over the conveyor belts that carried the coal. They spent their days bent over, picking through the coal in order to remove any impurities. The air was thick with coal dust that settled in their lungs and led to harsh coughs. Their hands were covered with cuts and calluses from deal- ing with the rough and sharp material. The long days of their work were fi lled with noise and danger. Boys who fell from their suspended benches suffered burns, cuts, and occasionally death by suffocation. Some adults indicated that the work done by the breaker boys was even more dangerous than working in the mines (Hindman, 2002).
These abuses continued in the United States until child labor laws were passed and enforced. By the late 1800s, advocates for children began pushing for legislation that would protect children. By 1900, all industrialized states had some law that dealt with child labor, but the laws at this time varied substantially in terms of the rules they proposed and the seriousness of their enforcement. This discrepancy led advo- cates to fi ght for a federal law to protect children in the workforce. Initial attempts at passing and sustaining a federal child labor law were not successful for a variety of reasons, including charges that they were unconstitutional or that they gave the federal government too much power. The issue was not resolved until 1941, when the U.S. Supreme Court upheld the Fair Labor Standards Act, which limited child labor. In many ways, the passing of this federal law was anticlimatic, because most child labor in the United States had been eliminated by that time (Hindman, 2002). Children living in the United States today are well protected by the child labor laws. With only a few exceptions (acting, newspaper delivery, some types of family busi- nesses), children younger than the age of 14 are not permitted to work. Between the ages of 14 and 15, work for pay is limited by law. When school is in session, young adolescents may work a maximum of 3 hours per day and no more than 18 hours per week. When school is not in session, they can work no more than 40 hours per week. Some dangerous jobs such as coal mining, roofi ng, and logging may only be done by
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7INTRODUCTION
adults. Although the enforcement of the child labor laws in the United States is not perfect, it is generally considered to be fairly good. Although these laws were directed at eliminating child maltreatment at work, they were not relevant to what went on in the home.
Looking at maltreatment from a historical perspective can give us hope when we consider how far we have come in protecting children. Although children today still suffer from abuse and neglect, many would argue that the lot of children is far better now than it has ever been. The progress we have made is, to a large degree, the result of the work of child advocates. Although some may judge the response to child mal- treatment as too slow and too little, there have always been people who were willing to fi ght for children, and progress has been made.
RESPONDING TO CHILDREN IN CRISIS
History is peppered with notes that in some cases children were protected or treated gently. More than 6,000 years ago in Mesopotamia, there was a patron goddess for orphans who was believed to protect any child who did not have parents (Ten- Bensel et al., 1997). Continuing concern for orphans is seen in the presence of orphanages throughout recorded history. For example, both Athens and Rome had homes for orphans. In the 12th century, Pope Innocent III established some of the fi rst foundling houses to care for children who had been left behind in the wake of the Crusades. A more personal illustration can be found in the writings of Sir Thomas Moore, who lived from 1478 to 1535 and who clearly did not refl ect the punitive approach to child rearing that was prevalent during his lifetime. He wrote to his children:
I never could endure to hear you cry. You know, for example, how often I kissed you, how seldom I whipped you. My whip was invariably a peacock’s tail. Even this I wielded hesitantly and gently, so that sorry welts might not disfi gure your tender seats. Brutal and unworthy to be called father is he who does not himself weep at the tears of his child.
(Stone, 1977, pp. 119–120)
Colonial America
Despite these fl ashes of benevolence, the widespread recognition of and response to child abuse is a modern phenomenon. In colonial America, the father had nearly complete control over his wife and his children. Strict discipline was considered to be appropriate and was justifi ed by looking to the harsh justice meted out in the Bible. It was also permissible to turn a child over to another household as an indentured servant or an apprentice (who would receive training). The earliest recorded cases of child abuse involved masters and their apprentices. In severe cases of abuse, a child might be released from indentures, and in fatal cases a master could be punished. However, prosecutions for child abuse were rare and differed from modern cases in that they did not generally involve parents (J. Jones, 1978).
The fi rst recorded cases of child abuse charges against parents occurred in the 1670s and involved removing children from unsuitable homes. Study of these cases
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8 INTRODUCTION/PURPOSE
reveals that the homes were labeled “unsuitable” because the parents were not instilling the proper values (religious training and a strong work ethic) in their children (Myers, 2008–2009). Not until the 1820s did child neglect cases appeared in court. These cases, like the early abuse cases, rarely involved parents. Instead, child neglect charges were generally related to children living in institutions such as almshouses. For the most part, parents were allowed to treat their own children as they saw fi t (J. Jones, 1978). Some exceptions paved the way for the modern response to child maltreatment. For example, a father in Illinois was brought to trial for locking his blind son in a cold basement. The defense attorney argued that a parent could raise his or her child any way he or she saw fi t. The court did not agree. In 1869, the Illinois Supreme Court ruled that a parent must treat their child humanely and that needless cruelty would be punished by the law (Myers, 2008–2009).
The Case of Mary Ellen
Even though the earliest records of criminal cases of child abuse in the United States date back to the mid-1600s, the public recognition of child maltreatment in the United States is often tied to the case of Mary Ellen Wilson in the 1870s. The story of Mary Ellen’s early life is a sad one. According to public records, Mary Ellen was the biological daughter of Francis “Fanny” Connor and Thomas Wilson. Although Thomas may have known about the birth of his daughter, he never had the chance to meet her. Mr. Wilson, a soldier in the Civil War, was killed in May of 1864. As a young widow, Fanny Connor was not able to survive on the benefi ts she received from the government, so she went to work as a laundress and paid a woman named Mary Score to care for her daughter. After placing Mary Ellen with Ms. Score, Fanny would visit her daughter and act in a loving way toward her. However, after a short time, Fanny stopped showing up to visit her daughter, and she failed to send money for her care. After Mary Score had not received payment for 3 weeks, she left Mary Ellen at the Department of Charities and Corrections on July 7, 1865. This was the fi rst time the young Mary Ellen turned out to be a survi- vor. Despite the 85% death rate for infants in orphanages in New York at that time, Mary Ellen survived.
In 1866, when Mary Ellen was approximately 18 months of age (her exact birth date was never known), she was indentured to Mary and Thomas McCormack. Although Mary McCormack had given birth to three children prior to this time, none had survived. At the almshouse, Mr. Thomas McCormack alleged that Mary Ellen was his daughter and that her birth was the result of an affair he had with her mother. He was never asked to prove this claim, and the adoption was permit- ted without any proof of his paternity. Seven months after the adoption, Thomas McCormack died of cholera, and Mary McCormack subsequently married a man named Francis Connolly (Shelman & Lazoritz, 2005). Mary Ellen (shown in Figure 1.1 ) was living with Francis and Mary Connolly in 1873 when her plight came to the attention of Etta Wheeler (pictured in Figure 1.2 ), a Methodist missionary who vis- ited with the poor in New York. During Etta’s visits with a dying woman, she heard about a young girl, Mary Ellen, living in the same tenement house who was beaten and whipped by her mother. The dying woman told Ms. Wheeler about the small
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9INTRODUCTION
FIGURE 1.1 Mary Ellen. Photo Credit: The George Sim Johnston Archives of the New York Society for the Prevention of Cruelty to Children.
child, who was frequently heard crying and screaming amid the sounds of beat- ings. The pitiful sounds moved the ill woman to beg Etta Wheeler to fi nd help for the girl. Ms. Wheeler was moved by the plight of Mary Ellen and attempted to have her removed from this abusive home. She was not successful in obtaining assistance from the police or from any benevolent societies that existed at that time (TenBensel et al., 1997; Watkins, 1990).
It is at this point that the story gets a bit confused. What we do know is that Ms. Wheeler approached Henry Bergh, who was the president of the American
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10 INTRODUCTION/PURPOSE
FIGURE 1.2 Etta Wheeler. Photo Credit: The George Sim Johnston Archives of the New York Society for the Prevention of Cruelty to Children.
Society for the Prevention of Cruelty to Animals (ASPCA). After hearing about the case, Mr. Bergh sent a man to investigate Ms. Wheeler’s claims. While pretending to be a census taker, this gentleman gained access to every room in Mary Ellen’s home and was able to see the child in person. His report corroborated the story told by Etta Wheeler. Based on this information, Mr. Bergh was able to use his infl uence to have the child removed from her home by police offi cers the next day. Mary Ellen’s story has grown to include the myth that she was protected under the exist- ing animal protection laws. It has been said that Bergh argued for Mary Ellen to be considered an animal and given the rights any other animal would have, because she could not get aid as a child. This makes a good story, and it points out the fact that the American Society for the Prevention of Cruelty to Animals predates the
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11INTRODUCTION
Society for the Prevention of Cruelty to Children (SPCC) , but it is not exactly what happened. Instead, it seems that Mr. Bergh advocated for Mary Ellen as a prominent citizen, not as head of the American Society for the Prevention of Cruelty to Animals. Mr. Bergh also used his infl uence to get the case covered by the New York Times (Watkins, 1990) .
When Mary Ellen was brought before Judge Lawrence, he lis- tened to her story as well as testimony from Ms. Wheeler, neighbors, and the investigator for the New York Society for the Prevention of Cruelty to Animals. Judge Lawrence agreed that Mary Ellen needed to be rescued, and he appointed himself her temporary guard- ian. Not only did Judge Lawrence work to protect Mary Ellen, but he also punished Mrs. Connolly. After being found guilty of felonious assault, she was sentenced to 1 year of hard labor in the penitentiary (Watkins, 1990).
When no relatives could be found to take Mary Ellen, she was placed into a home for children until Ms. Wheeler again intervened and had Mary Ellen placed with Ms. Wheeler’s mother. Because of the deprivation of her early life, there was much Mary Ellen had to learn. For example, Etta Wheeler’s mother remarked that because the child had so rarely been outside, she did not know how to walk on uneven ground. She also had no experience with peers or appropriate discipline. However, Mary Ellen seemed to thrive in her new surroundings. Unfortunately, less than 5 months later, her new guardian died of tuberculosis. Mary Ellen was then taken in by Etta’s sister and brother-in-law, Elizabeth and Darius Spencer. There are not many details avail- able about Mary Ellen’s subsequent life, but we do know that when she was 24 years old, she married a widower, Lewis Schutt, who had two sons, and Mary Ellen and Lewis subsequently had two daughters. We also know that Mary Ellen named her fi rstborn “Etta,” in honor of the woman who had rescued her, and her second daugh- ter was named Florence. Both of her daughters went to college and became teachers. When asked about their mother, Etta and Florence said that she did not talk much about her childhood, but that she still carried the physical scars from the years of abuse. They also added that she was never a very strict disciplinarian with them! Mary Ellen lived to be 92 years old, a success story for child protection (Shelman & Lazoritz, 2005).
Largely as a result of the attention garnered by the Mary Ellen case, the Society for the Prevention of Cruelty to Children was founded in New York. Very quickly, this type of society spread across the nation. By 1900, there were 161 societies that had as their primary mission the protection of children (National Association of Counsel for Children, n.d.), and by 1922, there were more than 300 nongovernmental societies devoted to the protection of children. Although the number of groups advocating for children was growing rapidly, there were still many areas of the country, particularly rural areas where no such societies existed (Myers, 2008–2009).
Juvenile Court
Not long after the case of Mary Ellen, there was a major change in how children were treated by the legal system in the United States. In 1899, the fi rst juvenile court was founded in Illinois, and by 1920, all but three states had juvenile court systems. These court
Society for the
Prevention of Cruelty
to Children (SPCC)
a nonprofi t organization
that was founded in
1875 to protect children
and strengthen families.
The SPCC offers mental
health, legal, and
educational services.
Juvenile Court
a court established in
1899 to hear cases of
dependency and juvenile
delinquency.
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12 INTRODUCTION/PURPOSE
systems were established to deal with cases of juvenile delinquency as well as with children who were neglected or dependent on the state. With regard to delinquency, this court’s goal was to rehabilitate youthful offenders by keeping them separate from adult criminals and by focusing more on treatment than on punishment. Even though these were humanitarian goals, things did not work as smoothly as hoped. Because the focus was to be on helping children, it was deemed unnecessary to grant the juveniles the protective rights that adult defendants have in criminal court. Unfortunately this resulted in children, who had neither lawyers nor other constitutional rights granted to adults, receiving harsher sentences than their adult counterparts in criminal court. Instead of treatment or guidance, delinquents were simply being locked away.
In re Gault The practice of denying due process rights to juveniles was modifi ed after the pivotal case In re Gault (1967). Gerald Francis Gault, a 15-year-old boy, was found guilty of making lewd remarks over the telephone. If an adult had been found guilty of such a crime, the maximum sentence would have been a fi ne of $50 or 2 months in jail. Gerald Gault was sentenced to 5 years in a state industrial school in Arizona. So the “gentler” system of the juvenile court was planning to incarcerate a child for years for making what amounted to a dirty phone call. Clearly, the court was not working as intended—a move that was supposed to help children was in fact hurting them. After this case, juveniles were granted due process rights such as the right to an attorney, the notice of charges, the right to cross-examine witnesses, and the right to remain silent (Sagatun & Edwards, 1995). Although the early cases heard in juvenile court dealt more with delinquency than dependency, the use of this court to protect children has grown steadily, and today most child maltreatment cases are heard in this court (see Chapter 10 ).
Prince v. the Commonwealth of Massachusetts Another major legal step for the protection of children was the 1944 Supreme Court ruling in Prince v. the Commonwealth of Massachusetts. This ruling confi rmed that states do have the right to interfere in family relationships to protect children. The highest court in the land said that the government had the right to intervene in a family in order to protect the children, even when challenged with claims of religious freedom. The facts of this case revolved around Sarah Prince, a Jehovah’s Witness, who was convicted for violating the child labor laws. Ms. Prince had custody of her 9-year-old niece, Betty M. Simmons, and she had the child distributing religious lit- erature. She claimed that her rights to exercise her religious freedom as guaranteed by the Fourteenth Amendment were being violated by the child labor laws. In his majority opinion, Justice Rutledge wrote,
And neither rights of religion nor rights of parenthood are beyond limitation. Acting to guard the general interest in youth’s well being, the state as parens patriae may restrict the parent’s control by requiring school attendance, regulating or prohibit- ing the child’s labor, and in many other ways. Its authority is not nullifi ed merely because the parent grounds his claim to control the child’s course of conduct on
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13INTRODUCTION
religion or conscience. . . . the state has a wide range of power for limiting parental freedom and authority in things affecting the child’s welfare; and that this includes, to some extent, matters of conscience and religious conviction.
(p. 5)
One important term that may be unfamiliar is the Latin phrase, parens patriae (pa-renz pa-tree). The translation is “father of his country,” and it asserts that the state is the ultimate guardian for children and the mentally incompetent. Although the care of chil- dren is entrusted to their parents, the state is the fi nal guardian. Whereas historically fathers had nearly total control of their chil- dren, the state was now clearly saying that it had the ultimate say in child rearing.
Professional Publications Related to Child Maltreatment
As the public and the legal system began to move forward in child protection, it also became an area of interest for professionals to study and write about. The article that truly seemed to spur the research in this fi eld was “The Battered-Child Syndrome.” This article was written in 1962 by fi ve medical doctors: Kempe, Sil- verman, Steele, Droegemueller, and Silver, and it was published in the very well respected Journal of the American Medical Association. In this article, Kempe et al. defi ned battered-child syndrome and described its incidence, its clinical manifes- tations, and its psychiatric aspects. A good portion of the article was devoted to techniques used to evaluate children, and this section was focused on the use of radiologic examination. It was the invention and application of pediatric X-rays that most aided doctors in moving from having a hunch about physical abuse to having concrete proof of maltreatment. Kempe et al. concluded their report by stating, “Above all, the physician’s duty and responsibility to the child requires a full evaluation of the problem and a guarantee that the expected reposition of trauma will not be permitted to occur” (p. 24). Many believe that this article created the study of child maltreatment as a distinct academic fi eld. This statement is supported by an examination of the number of papers related to child maltreatment that were published in the years before and after Kempe et al.’s article. In the decade prior to Kempe et al.’s article, only nine articles had been published that dealt primarily with child maltreatment. In contrast, in the decade following, 260 such articles were pub- lished (Dorne, 2002). This information explosion continues at an amazing rate. If you type the term “child maltreatment” into the PsycINFO search engine and limit it to 2007, you get 172 hits for just that 1 year. If you search the decade 1997 to 2007, you will get 1,618 entries! What professionals and students today need to do is to attempt to digest this information while keeping in mind that it is still a new fi eld of study.
Kempe et al.’s (1962) article not only spurred a dramatic increase in research, it was also the reason that the Children ’ s Bureau hosted a symposium focused on child abuse in 1962. It was at this
parens patriae
a Latin term meaning
that the State acts on
behalf of a child or
mentally ill person. The
State is the guardian of
those who cannot protect
themselves.
PsycINFO
an electronic database
produced by the
American Psychological
Association that indexes
the psychology literature.
Children ’ s Bureau
a division of the
Administration for
Children and Families
that is primarily
concerned with child
protection, child abuse
prevention, foster care,
and adoption within the
United States.
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14 INTRODUCTION/PURPOSE
conference that professionals began to set up the standards for the mandatory report- ing of child abuse by professionals (see Chapter 3 ).
Although most researchers agree that Kempe et al.’s (1962) article was a ground- breaking publication, it was not the fi rst professional publication on child abuse. A century before it appeared, a French physician, Ambroise Tardieu, wrote fairly extensively about child maltreatment. In the 1860s, Tardieu described the negative effects of child labor, the severity of physical abuse committed by some parents, the problem of infanticide, and even the sexual abuse of both female and male children (Labbe, 2005). Clearly, Tardieu was a man ahead of his time. Many things that are believed to be true concerning child abuse today were noted in Tardieu’s 37-page article. For instance, Tardieu noted that the victims who suffered the most serious injuries were the very young; that bruises on abused children’s bodies var- ied in coloration, indicating that they occurred at different times; that many of the marks on the children were in the shape of fi ngers; that there were a “frightening multiplicity” of wounds; and that doctors should inform the police if they see such injuries (Knight, 1986).
Although Tardieu’s paper was very thorough, it did not radically change the way physicians interpreted suspicious injuries in children. In 1888, 28 years after the publication of Tardieu’s paper, Dr. Samuel West published an article in the British Medical Journal examining severe swelling in the membranes surrounding the bones of several infants in the same family. This article on differential diagno- sis (selecting the correct diagnosis when several options are possible) considered scurvy, syphilis, and rickets as possible causal factors. That the injuries could be the result of trauma infl icted by parents was not even mentioned, despite the fact that none of the natural diseases discussed adequately explained the symptoms (Knight, 1986).
Considering that it took 100 years for the explosion of professional writing on child maltreatment to begin after it was fi rst addressed in the professional litera- ture, it becomes clear that more than interest and attention must be present for a topic to become popular: Society has to be ready to hear about the issue and act on it.
Federal Regulation and Law in the United States
In the beginning of the 1900s, there was a push to move the protection of children from private societies to government agencies. This was in line with a more gen- eral trend for both state and federal government to play a larger role in providing social services (Myers, 2008–2009). The Children’s Bureau was founded in 1912 to explore all issues related to child welfare including such diverse topic as infant mor- tality, orphanages, and dangerous occupations. The early work of the Bureau was to study and examine issues related to child welfare, not to develop regulations. Later the Children’s Bureau was instrumental in drafting the legislation behind mandated reporting (see Chapter 3 ). From the 1960s, the Children’s Bureau has had the author- ity to award grants to educate professionals who work in the child welfare fi eld. Over the last 100 years, the Bureau has guided the development of an educated, skilled workforce of social workers and provided signifi cant policy guidance in order to pro- mote child welfare (Thomas, 2012).
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15INTRODUCTION
National Clearinghouse
on Child Abuse and
Neglect (NCCAN)
a national resource
for professionals that
provides information
regarding child
maltreatment including
prevalence, incidence,
treatment, statistics, and
statutes.
dispositional hearing
a hearing during which
the judge enters their
decision as to what is in
the best interest of the
child.
The Social Security Act of 1935 included a section (521) on Child Welfare Services within the Title IV—Grants to States for Aid to Dependent Children. This section outlines the willingness of the federal government to help fund agencies “establish- ing, extending, and strengthening, especially in predominantly rural areas, public welfare services (hereinafter in this section referred to as child-welfare services) for the protection and care of homeless, dependent and neglected children and children in danger of becoming delinquents” (The Social Security Act, Part 3, Section 521, a). Although this law marks the beginning of the practice of child protection being partially funded by the federal government, it is striking that there is no mention of physical abuse.
This also illustrates the fact that the federal government does not have direct control over how states respond to children in need. However, Congress does have the right to decide how money should be spent to further national welfare. Therefore, the federal government can infl uence policy and practice by insisting that the states follow certain rules if they wish to be eligible for funding (Myers, 2002).
It was not until 1974 that the fi rst federal law on child abuse was passed in the United States, the Child Abuse Prevention and Treatment Act (CAPTA). This legislation provided states with funding for the investigation and prevention of child abuse as long as the states had mandated reporting laws. The act also established the National Clearinghouse on Child Abuse and Neglect (NCCAN) to serve as a clearinghouse for information about child maltreatment (see Search the Web 1.1). Since this time, the federal government has maintained an active role in the prevention and treatment of child abuse by funding states for complying with federal guidelines. The federal laws are regularly reviewed and updated to better meet the needs of children. For instance, when it was noted that many children were being “lost” in foster care and simply moving from one home to another with no permanent plan, the Adoption Assis- tance and Child Welfare Reform Act (PL 96–272) was passed in 1980. This law required that cases be reviewed every 6 months and dispositional hearings be held every 18 months (changed to 12 months in 1997). The law also required that each case have a case plan. All these steps were designed to ensure that no child would be lost in the system (Association for Natural Psychology, 2011). Today, in order to receive federal funding, states must comply with the CAPTA Reauthorization Act of 2010 (Child Welfare Information Gateway, 2011). This bill was passed by the U.S. Congress on December 8, 2010 and it extended CAPTA funding through 2015 ($1.039 billion over 5 years). One of the three main goals of the reauthoriza- tion was to improve the training of people who prevent, report, and respond to child maltreatment (Wengrovius, 2011). As you will see in Chapter 3, “Mandated Reporting,” a lack of training has been a signifi cant problem for professionals who work with children. The funding and regulations are constantly adjusted and updated, but it seems clear that the federal government will continue to play an active role in protecting children.
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16 INTRODUCTION/PURPOSE
RESEARCH ON MALTREATMENT
This textbook is based on the existing research on child maltreatment. Great strides have been made in understanding abuse and its consequences, but there is still much to learn. Progress has been impeded by how diffi cult it is to conduct research in this area. There are several concerns about research methodology that must be kept in mind as you consider the information presented in this book.
Only Identifi ed Children Are Studied
First, the research on maltreated children is conducted on identifi ed children. If you read an article that is comparing neglected children to nonneglected children, you need to remember a few things about the children in the groups that are being compared. If we know children in the neglected group have been neglected, then someone has labeled them this way. So, research on neglected children does not include children who are being neglected but have not yet been identifi ed as victims.
It is certainly possible that children who are suffering undetected neglect may differ from those who have been identifi ed. This may have led you to the next possible problem: Are there unidentifi ed neglected children in our nonneglected group? One or two such children in a large study should not cause any major problems, but researchers should not lose sight of the fact that these are diffi cult groups to clearly identify.
Because not all victims of maltreatment are known as children, some researchers have worked with a retrospective design. These studies collect data in the present that are based on recollections
SEARCH THE WEB 1.1
To see how information about child welfare that is gathered by the U.S. government, go to the following website: www.childwelfare.gov. This site is produced by the U.S. Department of Health and Human Services: Administration for Children and Families and is called the Child Welfare Information Gateway. Under the link for Child Abuse and Neglect, you will fi nd the following subheadings:
Overview Defi nition Identifi cation Statistics Risk and Protective Factors Perpetrators Impact Fatalities
retrospective design
a research design that
uses data based on
recollections of past
events. This type of
design is limited because
of concerns about
memory degradation
over time.
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17INTRODUCTION
of the past. In these cases, adults are asked to recall their past and any maltreat- ment they suffered, and then answer questions about their present situations. The most obvious limitation of this research is that we all have faulty memories. Our memory of our past is not like a video recording. Instead of being perfect records, our memories are biased by our life experiences, our current mood, and even the situation we are recalling. Furthermore, even if a person does accurately recall abuse, it is not a given that he or she will report the maltreatment. Just as children may be ashamed or unwilling to report abuse while it is happening, adults may also keep secrets for myriad reasons. Adults may deny being abused as children because they do not want to recall the painful events, because they are ashamed, or because they do not want to make their families look bad. On the other hand, and probably less common, it is also possible that a person would report a history of abuse when no maltreatment was actually suffered. For instance, a man who is currently charged with abusing his children may report that he too was a victim of abuse in an attempt to excuse or explain his current behavior. Finally, it is evident that there is not likely to be any corroborating evidence of abuse years after it allegedly occurred. For all of these reasons, one must be careful when interpreting data that have been collected retrospectively.
Problems With Separating Different Forms of Maltreatment
A further research concern arises when we want to compare the effects of differ- ent types of maltreatment. Take, for instance, a researcher who wants to study the impact of sexual abuse, physical abuse, emotional abuse, and neglect on attachment (the emotional bond between child and caregiver). This design assumes that we can identify children who suffer from just one type of maltreatment and compare them to others who suffer from one other type of abuse. If a parent is beating a child, can we truly say there is no emotional abuse involved? Unfortunately, as you will learn throughout this text, many children suffer simultaneously from multiple types of abuse. However, grouping maltreated children together also has its disadvantages, as a child who is raped is likely to be affected quite differently from a child who is not fed consistently (see Focus on Research 1.1 ).
FOCUS ON RESEARCH 1.1
Consider the following excerpt from a study by Alink, Cicchetti, Jungmeen, and Rogosch (2012). They do an excellent job of describing their maltreated sample that consisted of 125 children.
More than half of the maltreated children (60%) experienced multiple subtypes of abuse.
Among the maltreated children, 6% had experienced sexual abuse, 26% had experienced
physical abuse, 70% had experienced neglect, and 62% had experienced emotional mal-
treatment. Given the low frequency of sexual abuse and physical abuse, relative to neglect
and emotional maltreatment, children experiencing these forms of abuse were catego-
rized into an abuse group (PASA, n = 40). The remaining maltreated children had not been
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18 INTRODUCTION/PURPOSE
Effects of Maltreatment May Not Be Immediately Obvious
Also, when determining the effects of abuse, one needs to con- sider timing. Imagine that a researcher is interested in aggressive behavior among preschool boys who were the victims of physical abuse. This researcher may measure aggression among boys who come to the attention of Child Protective Services (CPS) when their abuse has been discovered. Imagine further that he fi nds no differences in aggressiveness between the physically abused boys and a comparison group of nonabused boys. Does this mean the boys have not learned aggressive behavior from their parents? Is it possible that children who are not initially aggressive as a result of abuse may become aggressive later in life when they are physically stronger? Could it be that boys only recently removed
abused, but had experienced neglect or emotional maltreatment; they were categorized in
a physical neglect/emotional maltreatment group (PNEM, n = 78). Most of the children
in the PASA group had also experienced neglect or emotional maltreatment. Finally, the
individual subtype of seven children (6%) could not be determined as a result of incom-
plete records (p. 227).
These conscientious researchers provide a thorough description of the types of mal- treatment suffered by the children in their sample. This gives you an idea of how diffi cult it can be tease apart the impact of one form of maltreatment. Due to small sample size, the researchers combined sexual and physical abuse into one group and physical and emo- tional neglect into a second group. What impact might this have on the interpretation of their results?
Alink et al. (2012) also matched the control group to the maltreated group in terms of socioeconomic status (SES):
The maltreated children were predominantly from low SES families, which is consistent
with national demographic characteristics of maltreating families (Sedlak et al., 2010).
Consequently, the nonmaltreated group was comprised of children from families who
were eligible for Temporary Assistance for Needy Families so we could ensure a low SES
group that was demographically comparable with the maltreated group (p. 226).
Because 94% of the maltreated children’s families were receiving public assistance, the researchers choose children from low-income families to be part of the control group (Alink et al., 2012). This meant the researchers were able to control for the effects of pov- erty and therefore avoid the problem trying to separate the impact of maltreatment and the impact of poverty on the children.
Any time you read research about child maltreatment, pay careful attention to how the groups involved are described. Be sure you have a clear picture of who the participants were before you think about the fi ndings of the study.
Child Protective Services
(CPS)
a government agency
charged with protecting
children and preserving
families. This is the agency
that responds to charges
of child maltreatment.
Not all states use the
title CPS; variations
include Department of
Family Services (DFS)
and Department of Social
Services (DSS).
6241-171-P1-001.indd 18 10/19/2013 10:13:49 AM
19INTRODUCTION
from abusive homes may be in shock and somewhat withdrawn at the time of the study and that this behavior will change later? Questions like these point to the importance of longitudinal research. This is research that follows participants for a long time: years, decades, a lifetime. Although this type of research provides excellent data, it takes years to complete, and it is costly. Of course, even with the nec- essary time and money, one would still need to fi nd participants who are willing to be a part of a continuing study and who will stay with the project. Attrition among participants can be a major impediment to longitudinal research. It is not unusual for partici- pants to drop out, move away, or even die.
Diffi culty Separating the Effects of Poverty and Maltreatment
Yet another concern about the research on child maltreatment is the fact that abuse is very often confounded with poverty. This means that many children who are identifi ed as victims of mal- treatment are also living in poverty. Therefore, if researchers fi nd that maltreated children exhibit language delays, we need to know if these delays are due to the maltreatment or to the poverty. Researchers work to control this problem by carefully selecting their control (nonabused) groups. If most of the children in the maltreated group live below the poverty line, then the same per- centage of children in the control group should be from families with similarly low incomes.
Socioeconomic status (SES) is only one variable that research- ers need to consider when they are selecting a comparison group. Other issues that should be considered include the make-up of the family, family dysfunction, age and sex of child, and environmental stresses. If we want to say that something about a group of children is the result of the maltreatment they suffered, then we must be confi dent that the groups we are comparing differ only in terms of maltreatment status. As you can imagine, this makes devising appropriate control groups an extremely challenging prospect.
Inability to Make Causal Statements
Another aspect of research on child maltreatment makes it diffi cult to make causal statements—to say this act caused this effect. We cannot make causal statements based on correlational research, and much of the research in this fi eld is, of necessity, correlational. In a correlational research study, an exper- imenter measures two variables to determine if they are related. The researcher does not manipulate anything. I can ask, for example, if there is a relationship between the number of hours a child is left alone and his or her vocabulary at age 3. I may fi nd that the two vari- ables are related: As hours left alone increase, vocabulary decreases. This would be a negative correlation, which means as one variable goes up, the other goes down. Now, it may be tempting and even
longitudinal research
a research design that
involves repeated
observations of a group
of participants at regular
intervals over a relatively
long time.
poverty
a situation in which
income and resources are
inadequate to obtain and
maintain an acceptable
standard of living.
Offi cial poverty levels are
set by the Social Security
Administration.
socioeconomic status
(SES)
a measure of a person’s
standing within a social
group based on factors
such as income and
education.
correlational research
a study in which two
or more variables are
measured so that the
degree of relationship
between them can be
measured.
6241-171-P1-001.indd 19 10/19/2013 10:13:49 AM
20 INTRODUCTION/PURPOSE
correct to say that being left alone for many hours causes a decrease in vocabulary, but we do not know this to be true from correlational work. Is it not possible that children with low vocabularies are left alone more often? That is, could it be that having a low vocabulary causes people to leave you alone more often? It could also be that some other, unexamined factor causes both of these things. Perhaps parents with low educa- tion are forced to work long hours to make ends meet. These parents may also have a lower vocabulary than do more educated parents and may feel that it is less important to speak to their children, so the children are alone more and speak less as a result of their parents’ educational level. Children who are left alone for a large number of hours but have parents who make speaking to them while they are at home a priority may have perfectly adequate vocabularies.
It is only when we conduct an experiment that we can be confi dent about cause-and-effect relationships. In an experiment, participants are randomly assigned to groups, and the groups are treated identically except for the one variable of interest. This would mean taking a sample of 100 children, assigning half of them to the condition of spending 1 hour alone per day and assigning the others to a second condition of spending 3 hours alone per day, and then measuring their vocabulary at some later date. Obviously, this is not an ethical solution to our research dilemma. If this sort of experimental manipulation is unethical,
it should be clear that we cannot ethically conduct true experiments that explore the consequences of child maltreatment.
This may be a bit confusing to those who do not have a background in research methods, so I want to provide a crazy example to help you remember the limitations of correlational data. I can tell you (quite truthfully) that there is a positive correla- tion between Coca-Cola sales and murder. As the number of Cokes sold increases, so does the murder rate. If I try to make a causal statement based on these data, you will fi nd that I sound a bit ridiculous. I could say that buying Coca-Cola makes you murder people. After all, there is a lot of sugar and caffeine in Coke, so maybe it leads to murder! Or, maybe committing murder causes an increase in Coca-Cola sales. Committing murder is hot, thirsty work, and you need a cool drink to refresh yourself! Either way, I look crazy. Can you fi gure out what causes this correlation? If you guessed heat or summertime, you are correct. This third variable explains the relationship between the other two; they are not causally linked.
Lack of Clear Defi nitions
Another issue in child maltreatment that has an impact on research is the lack of clear, consistent defi nitions for terms. As I mentioned earlier, this fi eld is plagued with defi nitional ambiguity. One place to look for defi nitions is in the law. However, because each state has its own laws, you will fi nd 50 defi nitions for child maltreat- ment instead of 1! Also, the defi nitions all include terms that are not operational. For
a term to be operationally defi ned, it must have a precise meaning that can be measured by way of observable operations. It is ideal in research situations for all variables to have operational defi ni- tions; this is the only way the exact meaning of a term can be clear. For example, “fails to meet child’s emotional needs” is a vague phrase. It is likely that multiple observers would disagree if they
experiment
a form of scientifi c
research in which a
researcher manipulates
one or more variables in
order to see the effects
on another variable or
variables.
operational defi nition
a precise defi nition of
a variable in terms of
observable procedures or
measurements.
6241-171-P1-001.indd 20 10/19/2013 10:13:49 AM
21INTRODUCTION
were rating the interaction of a mother and her infant over time using this criterion. A possible operational defi nition would be “the parent fails to respond to the child’s cry within 5 minutes.” Although we would have better interrater reliability with this second measure, we also lose something. After all, meeting a child’s emotional needs surely entails more than responding to cries. We could add to this by measur- ing the amount of time a parent makes eye contact with the child, the number of times a child is praised, and so forth. By all these ratings, we are trying to precisely measure a complex phenomenon. We are using these behavioral observations to measure, in a consistent way, how well a parent is meeting a child’s emotional needs. Even though there is no perfect solution to this problem, researchers can work on using the same or similar measures, and we can all be attentive to how researchers operationally defi ne their variables. (This information is generally included in the Methods section of a research report.)
The Secrecy Surrounding Child Maltreatment
Finally, abuse is by defi nition a private event. We are talking about behavior that occurs within the privacy of the home. This is an arena that is typically not open to intense examination. Also, parents and often children are motivated to keep abuse secret. Although it may seem obvious for parents to not want anyone to know because they fear punishment and loss of their children, why would children remain silent? Some children are threatened into silence. They are told explicitly not to let anyone know what is happening or something terrible will happen. Parents may even coach children to tell stories to account for injuries they have suffered. Other children have more complex reasons for not telling about abuse, reasons that range from a deep sense of shame to a lack of knowledge that what is happening is wrong or different from what goes on in other families. Because so many children will never self-identify, we need to be as observant as possible in order to fi gure out which chil- dren are being maltreated.
CONCLUSION
Although the mistreatment of children is not new, the formal, public study of it has a relatively short history, as does the consistent, legal response. Furthermore, even though a number of issues make research on child maltreatment challenging, none of them stops researchers from trying. Although progress may seem frustratingly slow at times, a historical context can help us maintain perspective. We know more today about child maltreatment than we ever have, and the research literature con- tinues to grow at an amazing rate.
DISCUSSION QUESTIONS
1. You may have heard newscasters making statements such as “Our children are at a greater risk today than ever. There is an epidemic of child abuse. Something must be done.” Based on the information presented in this chapter, would you agree or disagree with the points made by the newscaster? Why or why not?
6241-171-P1-001.indd 21 10/19/2013 10:13:49 AM
22 INTRODUCTION/PURPOSE
2. Which is worse: child abuse or child neglect? (Return to this question at the end of the course to see if your opinion has changed.)
3. Over time, there has been a trend toward more governmental intervention to protect children. Is this a good thing or a bad thing?
4. Some of the research limitations seen in this fi eld can be overcome, but oth- ers cannot (for ethical reasons). Does this mean we should stop attempting to study child maltreatment empirically? Why or why not?
5. Find a recent article that deals with either physical abuse or neglect. Does the researcher clearly defi ne the maltreatment term? Compare the operational defi - nition you fi nd with those found by your classmates. Did all of the researchers use the same defi nitions? Discuss how using different defi nitions has an impact on progress in the fi eld.
6241-171-P1-001.indd 22 10/19/2013 10:13:49 AM
23
There are many factors to consider when attempting to fi gure out why child maltreatment occurs. We are not able to simply say, “If x is true, then abuse will occur.” If it were determined that x caused child maltreatment, Child Protective Ser- vices (CPS) would have a much easier job. First, professionals could work to prevent or fi x x. Second, if x were present, CPS would know a child was at risk, and if x were absent, they would know the child was safe from maltreatment. Sadly, the picture that has emerged from research is not nearly so clear-cut. There does not seem to be any one factor that will cause maltreatment or prevent it from occurring. Instead, a multitude of factors increases the likelihood that a particular child will be the vic- tim of maltreatment. In trying to understand the complex phenomenon of child abuse, many researchers have found it helpful to keep the work of Bronfenbrenner in mind. This well-known psychologist says that in any attempt to understand human behavior, we must consider many levels of infl uence. We cannot look only at the child or even only at the family if we want to truly understand the problem. We must consider the broader social contexts in which these families exist. Researchers must examine the roles played by communities, local and federal government, the media, and even the time in which we live (Bronfenbrenner, 2000). Factors that increase the risk for child maltreatment have been identifi ed in all of these contexts. Although none of the factors discussed in this chapter means that a child will defi nitely be maltreated, each increases the likelihood that maltreatment will occur.
FAMILY FACTORS
Parental Factors
Because parents are the ones who abuse and neglect their children, we start with examining what issues increase the likelihood that a parent would become abusive. Although most parents will not maltreat their children, no matter what challenges those children or the environment they live in pose, other parents are more likely to succumb to abusive behavior. For instance, parents who struggle with issues such as depression, low self-esteem, substance abuse, emotional instability, or poor impulse control are more likely to maltreat, as are parents who were themselves the victims of child abuse.
Parental Sex Men and women are not equally likely to be perpetrators of child maltreatment. When it comes to child neglect, female caregivers are more likely to be guilty. Of all
CHAPTER 2
Risk Factors for Child Maltreatment
6241-171-P1-002.indd 23 10/19/2013 10:14:01 AM
24 INTRODUCTION/PURPOSE
neglect charges, 86% are made against women. This is largely accounted for by the fact that, in our culture, women are far more likely to be the primary caregivers for children than are men. On the other hand, 62% of all abuse charges are made against men, and men account for 87% of the charges of sexual abuse (Sedlak et al., 2010).
Parental Substance Abuse Parental substance abuse is frequently associated with all types of maltreatment; almost 80% of the families who come to the attention of CPS have some sort of sub- stance abuse problem (Winton & Mara, 2001). However, the relationship between parental substance abuse and child neglect is stronger than is the relationship between parental substance abuse and other types of maltreatment (M. G. Smith & Fong, 2004). When states were asked to report which problems were most likely to lead to child maltreatment, 85% listed substance abuse as one of the top two (poverty was the other leading cause). Substance abuse has also been noted in approximately two thirds of all cases involving child maltreatment fatalities. The relationship between substance abuse and maltreatment has been found among samples taken from CPS and in community samples. Another depressing fi nding has been that a history of substance abuse on the part of the parent increases the chance that he or she will maltreat a child. Ammerman, Kolko, Kirisci, Blackson, and Dawes (1999) conducted a research study aimed at exploring the link between substance use disorders and child abuse. They found that parents who currently had substance use disorders and those who had previously had a substance use disorder were at an increased risk for abusing their children. There was no difference in risk between parents who cur- rently had a substance use disorder and those who had had a substance use problem. The authors concluded that for mothers and fathers, both past and present substance use disorders are strongly linked to an increased risk for child maltreatment (see Focus on Research 2.1 ). Therefore, even if the parent is currently not using drugs, a history of drug use still increases the likelihood that he or she will maltreat children (Kelley, 2002). Not only does the abuse of drugs or alcohol inhibit the parents’ ability to be fully present for the child; the child may also have access to the substances or be endangered by riding in a car with an impaired parent.
FOCUS ON RESEARCH 2.1
Scannapieco and Connell-Carrick (2007) studied maltreating families in Texas who had at least one child between the ages of 0 and 48 months. The authors reviewed 9 months of records from a high-risk unit of CPS. They found that in families in which parents used alcohol or drugs, the rate of substantiation for child maltreatment was 52%. The rate of substantiation in families who did use alcohol or drugs was only 23%. They also found that children being maltreated by parents who used alcohol or drugs were more likely to face a host of negative circumstances including more dangerous living conditions, more impover- ished homes, a greater number of family stressors, a higher number of people living in the home, fewer available resources, a lower knowledge of children, and weaker parenting skills than were children being raised by nonmaltreating parents who used drugs and alcohol.
6241-171-P1-002.indd 24 10/19/2013 10:14:02 AM
25RISK FACTORS FOR CHILD MALTREATMENT
There are a number of mechanisms whereby substance abuse may lead to child mal- treatment. First, the direct effects of the drugs, or withdrawal from those drugs, may cause the parents to act out in anger or frustration. Many drugs are noted for their disinhibition of aggressive impulses. In an unim- paired state, an adult may well be able to resist the temptation to strike a child who is pestering him or her. However, while a person is under the infl uence of drugs, his or her inhibition mechanism is compromised. Even if adults do not become aggressive when under the infl uence, they are likely to show impaired judgment in other ways. You have probably noted, in yourself or others, the tendency to make particularly poor decisions when a substance like alcohol is involved. Parents who are addicts may also focus on the drug to the point that they cannot meet their chil- dren’s need (Kelley, 2002). Finally, if a pregnant woman uses drugs, she may have a direct impact on the fetus (see Chapter 8 , “Fetal Abuse”).
Although women who use drugs may value motherhood, they are likely to strug- gle with fulfi lling that role. Kearney, Murphy, and Rosenbaum (1994) interviewed 68 cocaine-using mothers who were not in treatment. Most of these women were heavy drug users; 85% had used cocaine more than 1,000 times. The women reported that they placed a high value on motherhood, they had high standards for raising chil- dren, and they tried to protect their children from their drug habit (e.g., they would not use in front of their children, but they would hire sitters or wait until the children were in bed). However, even though they did not want their drug use to interfere with their parenting, they did note that the cocaine use interfered with their paying attention to their children. Furthermore, their use of cocaine took money that could have gone to the children, and it decreased their ability to be a good role model for their children. Of the women in this study, 69% had, at some point, either lost custody of their children or voluntarily placed their children with family members. Although substance abuse is a substantial risk factor for child maltreatment, it is not the case that all parents who abuse substances also maltreat their children. When working with families, it is important to assess a range of factors that may lead to maltreatment (see Focus on Research 2.2 ).
disinhibition
a loss of the ability
to restrain from or to
suppress behaviors or
impulses.
FOCUS ON RESEARCH 2.2
Although parental substance abuse puts children at increased risk for child maltreatment, not all substance-abusing parents mistreat their children. Scannapieco and Connell- Carrick (2007) examined the factors that differentiated substance-abusing parents who were maltreating their children from those who were not. They reviewed the cases of 95 families that were all identifi ed as users of drugs or alcohol. Of these families, 52% had their cases substantiated for maltreatment whereas 48% did not. Scannapieco and Connell-Carrick found a large number of factors that differed signifi cantly between the two groups. With regard to home characteristics, parents who were abusive were also liv- ing in environments that were impoverished and/or dangerous, with more stressors and more people in their homes than were nonabusive parents. Caregiver factors also differed between the groups. Maltreating substance abusers had fewer resources, knew less about
6241-171-P1-002.indd 25 10/19/2013 10:14:02 AM
26 INTRODUCTION/PURPOSE
children and development, and had fewer parenting skills and less parental capacity than did the nonabusive substance users. With regard to social characteristics, the abusive par- ents seemed to suffer from social isolation and/or negative interpersonal relationships. Finally, it was noted that the abusive families were more likely to have had a history that included out-of-home care for the children and/or a history of previous maltreatment. The authors recommend that social workers assess not only substance abuse but also other risk and protective factors within the child’s environment.
Parental Mental Illness and Problematic Personality Traits As a group, people who abuse children are more likely to suffer from mental illness than are nonabusers. Maternal sociopathy and serious mental illness are both asso- ciated with an increased risk for child maltreatment (J. Brown, Cohen, Johnston, & Salzinger, 1998). For example, Sidebotham, Heron, and the ALSPAC Study team at the University of Bristol (2006) based their research on 114,256 children. Of these chil- dren, 293 were investigated for suspected maltreatment by the time they were 6 years old. Mothers who had a history of psychiatric problems were twice as likely to maltreat their children. However, the vast majority of people who maltreat their children do not meet the criteria for a major mental illness. The strongest relationship between mental illness and child maltreatment is depression, particularly maternal depression.
Depression Depression is the most common mental disorder. Between 10% and 25% of women and between 5% and 12% of men will struggle with depression at some point during their lives. People who suffer from a major depressive episode experience a host of symptoms including a depressed mood, lack of interest in most activities, weight loss without dieting, sleeping problems, fatigue, problems concentrating, and thoughts of death. By defi nition, these symptoms impair the person’s social functioning (American Psychiatric Association, 1994). Given these symptoms, it is not diffi cult to imagine that people who suffer from depression are at an increased risk for maltreat- ing their children. Zuravin, Bliss, and Cohen-Callow (2005) reviewed the literature on the link between maternal depression and child maltreatment and concluded that there is a positive correlation between the two. The relationship was particularly strong for mothers of young children. Across studies, it was noted that depressed mothers were less emotionally involved with their children and showed less affec- tion than did nondepressed mothers. Not only were depressed mothers lacking in positive interactions with their children; they were also more likely to be overtly hostile and to use harsh punishment than were other mothers.
Postpartum Depression If the onset of symptoms for depression occurs within four weeks of delivery, the descriptor postpartum is added to the diagnosis. Postpartum depression can be either nonpsychotic or psychotic. Although psychotic postpartum depression is rare (only one in 500 to 1,000 births), it is more likely if the mother has suffered from a
psychotic
mental disorders marked
by the loss of contact
with reality; generally
marked by delusions,
hallucinations, or serious
thought disturbance.
6241-171-P1-002.indd 26 10/19/2013 10:14:02 AM
27RISK FACTORS FOR CHILD MALTREATMENT
previous mood disorder, including postpartum depression following an earlier birth (American Psychiatric Association, 1994). In either case, it interferes with the rela- tionship between the mother and her infant. Researchers have found that even mild maternal depression during the fi rst months of a child’s life has a signifi cant, nega- tive impact on bonding between the mother and infant (Moehler, Brunner, Wiebel, Reck, & Resch, 2006). With regard to psychotic depression, one study of 108 women who suffered from severe mental illness during the postpartum period found that 53% of the mothers reported delusions about their infants. The nature of the delu- sions had a great impact on the mother’s interaction with her child. If the mother’s delusions were of persecution, she tended to provide competent, affectionate care. These mothers did differ, however, from normal mothers in that they were overly anxious if separated from their children. On the other hand, a mother who had delusions that her child was evil (e.g., a devil) or that the baby was not hers was signifi cantly more likely to be abusive (Chandra, Bhargavaraman, Raghunandan, & Shaligram, 2006). We should take special precautions with mothers experiencing psychotic depression because it is associated with abuse and infanticide; however, the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ( DMS-IV ; Ameri- can Psychiatric Association, 1994) notes that any maternal mood disorder increases the risk for infanticide.
Although most abusers do not have a mental illness, they are more likely than nonabusers to have the following personality traits: feelings of inadequacy, impul- sivity, violent tendencies, low self-esteem, immaturity, low frustration tolerance, and anxiety (Dorne, 2002). Raising children is a challenge for even the most even- tempered, well-balanced parents. People hampered by these types of personality traits are often unable to adequately meet the needs of their children.
Lack of Preparation It seems that many maltreating parents are simply not prepared to adequately fulfi ll the parental role. It has been reported, for example, that neglecting parents tend to lack basic caregiving skills such as food preparation and housecleaning, which are important in meeting a child’s physical needs. Neglectful parents also know less about children and child development than do nonneglecting parents. This lack of knowledge can lead to unrealistic expectations about what children should be able to do for themselves (Burke, Chandy, Dannerbeck & Watt, 1998; Dubowitz, Black, Starr, & Zuravin, 1993). A mother may fail to provide adequate food or supervision simply because she is unaware that her child needs such care. It is also possible that some neglectful mothers are not likely to learn the necessary parenting skills because they lack maternal motivation and they have less empa- thy for their children than do nonmaltreating mothers (Slack, Holl, McDaniel, Yoo, & Bolger, 2004).
Lack of knowledge can also lead to an overreliance on physical punishment. If a parent does not know any alternatives to corporal punishment to control a child’s behavior, he or she may resort to harsh, physical punishment for all infractions (Dorne, 2002). Because adults in the United States generally do not receive any for- mal instruction on parenting techniques, it is not uncommon to see adults who are bad parents simply due to ignorance. One has only to watch a few episodes of The Super Nanny to recognize that some parents have no idea how to control their chil- dren in appropriate ways.
6241-171-P1-002.indd 27 10/19/2013 10:14:02 AM
28 INTRODUCTION/PURPOSE
Closely related to a lack of preparation is the fi nding that both maternal age and education level are risk factors for child maltreatment. Younger mothers and women with lower educational levels are more likely to maltreat their children than are older, better educated women (J. Brown et al., 1998; Dubowitz et al., 2011; Paavilainen, Astedt-Kurki, Paunonen-Ilmonen, & Laippala, 2001). One study of 4,851 cases of child maltreatment found that more than 30% of the children involved were born to teenage mothers (Bolton, Laner, & Kane, 1980). Furthermore, Lee and Goerge (1999) found that even when they controlled for other sociodemographic variables (e.g., race, birth year, sex of child, birth order), there was still a signifi cant relationship between maternal age and all types of child maltreatment. By the time children were 5 years old, those born to mothers who were 17 or younger at the time they gave birth were 3.5 times more likely to be maltreated than were children born to mothers who were at least 22 at the time they gave birth. In 2012, Mersky, Berger, Reynolds, and Gromoske analyzed 1,411 cases of maltreatment. The most reliable predictor of maltreatment was the mother’s age at the time the child was born, with young mothers associated with greater risk. Sidebotham, Heron, and the ALSPAC Study Team (2006) reported that young parents were 3 times more likely to maltreat their children by the time children were 6 years old and that parents with low academic achievement had a 5 times greater risk of maltreating their children than did parents with more education. Certainly these data lend credence to the idea of attempting to prevent maltreatment by encouraging teenagers to complete their education and gain some degree of maturity before having children.
Intergenerational Transmission The idea that being maltreated as a child would increase the likelihood that you would maltreat your child is not new. Beginning in the 1970s, this connection was highlighted in the literature. However, many of these early reports were based on the recollections of adults who had already been identifi ed as abusers, and many of
these reports relied on clinical samples with poor control groups. As studies with stronger designs began to appear, a rate of inter- generational transmission of approximately 30% was reported. If this number is accurate, it would suggest that being maltreated does increase the risk that you would abuse your children, but that the majority of maltreated children do not go on to become abus- ers. Fenfang, Godinet, and Arnsberger (2011) followed a cohort of 405 children from 4 to 8 years of age. They reported that mothers
with a history of child abuse or neglect were 2.26 times more likely to be reported for maltreatment during the study than were mothers without such a history. There are still, however, some signifi cant limitations that should be noted about much of this work. For instance, the majority of studies do not account for the developmental status of the children studied. If the children (born to the previously abused mother) are young at the time of the study, it is not clear that they will not be abused later, or that a later-born child would not be abused (Belsky, 1993). In addition, if previ- ous victims are maltreating their children, and this is not known, they would be counted as nonabusive. Furthermore, it may be that certain types of maltreatment are more likely to be handed down than are others. Ney (1989) reported that the highest intergenerational transmission rate was for verbal abuse, whereas the lowest rate was for physical neglect. Finally, others have reported that parents who suffered
intergenerational
transmission
the passing down of a
trait or behavior from
one generation to the
next.
6241-171-P1-002.indd 28 10/19/2013 10:14:02 AM
29RISK FACTORS FOR CHILD MALTREATMENT
from one form of maltreatment may be at an increased risk for perpetrating a dif- ferent form of maltreatment. For instance, DiLillo, Tremblay, and Peterson (2000) found that women who were sexually abused as children were more likely to physi- cally abuse their own children than were women who were not sexually abused. This relationship was particularly strong for women who were still angry about their own victimization.
There are a number of reasons to explain why a maltreated child may grow up to be an abusive parent. First, the parent is simply doing what he or she knows. Most of what we learn about how to parent is from watching how our parents reared us. Researchers have noted that children as young as 3 years of age will inter- act with infant siblings in a manner that is similar to that used by their mothers. In other words, as early as the preschool years, children learn to parent by observing their own mothers (Ney, 1989). Even if we say we will not do what our parents have done, following through with this can be diffi cult, especially during times of frus- tration or stress. Second, being the victim of maltreatment can lead to problems such as poor attachment skills, lack of empathy, and social isolation. All of these can, in turn, make a person fail at parenting. Another possible effect of being victimized as a child is becoming a substance abuser as an adult. Victims report turn- ing to drugs to escape from problems or to help them deal with painful emotions. As reported earlier, substance abuse increases the chance that a person will abuse his or her child (Kelley, 2002). In this cycle, the effects of child maltreatment become risk fac- tors for the next generation. Dixon, Hamilton-Giachritsis, and Browne (2005) conducted a study that illustrates what factors might mediate the intergenerational transmission of abuse. They studied 135 families in which one or both parents had a history of physical or sexual abuse and 4,351 families in which neither parent had an abuse history. They followed the families for 13 months after the birth of their child. During this time, 6.7% of the families who had an abuse history were referred for maltreatment as compared to only 0.4% of the fami- lies who did not have an abuse history. In examining the families referred, it was noted that poor parenting style combined with other risk factors (parents who were younger than 21 years old, a history of mental illness, and living with an adult who was violent) led to maltreatment.
Just as not all diffi cult children or all children with disabilities will be abused, not all depressed parents or all parents with a history of being maltreated will abuse their children. Will the depressed parent who was abused as a child, and who is now the parent of a disabled child, defi nitely maltreat that child? No. These are three risk factors, but the parent and the child are just two pieces of the maltreatment puzzle. We also need to look at the entire family.
Family Structure and Functioning Factors
Families in which maltreatment occurs tend to score lower on a host of measures related to family functioning. In other words, child maltreatment is not the only problem seen within the family. Members of maltreating families report less togeth- erness and less communication within the family than do nonabusive families. Persons living in families that maltreat the children also report fewer positive inter- actions and a lower level of verbal exchange within the family (Paavilainen et al.,
attachment
a strong, affectionate
bond between two
people. Infants typically
form an attachment
to their primary
caregiver between 6 and
12 months.
6241-171-P1-002.indd 29 10/19/2013 10:14:02 AM
30 INTRODUCTION/PURPOSE
2001). There are also specifi c familial factors including single parenting, domestic violence, and large family size that increase the risk for child maltreatment.
Single Parents A familial risk factor for child maltreatment is being raised by a single parent. The National Incidence Study-4 (see Focus on Research 2.3 ) revealed that children living with their married, biological parents were at the lowest risk for serious maltreatment (2.6 per 1,000). The risk rose signifi cantly for children living with a single parent (11.9 per 1,000) and increased even more dramatically for children living with a sin- gle parent and his or her partner (20.8 per 1,000). This same pattern was seen for the risk of moderately serious maltreatment and for endangerment (Sedlak et al., 2010). This same pattern has been seen in longitudinal research. Radharkrishna, Bou-Saada, Hunter, Catellier, and Kotch (2001) followed at risk children from birth to 8 years of age and concluded that single mothers introduce a second risk into their chil- dren’s lives—the presence of father surrogates (boyfriends or stepfathers). The rate of maltreatment was the lowest when both biological parents were in the home. Mal- treatment increased slightly when children were with only their mothers, but the rate doubled when a father surrogate entered the family. The association between single parenting and maltreatment was also evident in the data from the National Center for Child Abuse and Neglect (NCCAN). Paxson and Waldfogel (1999) examined these data from 1990 to 1996 and concluded that states with a greater percentage of absent fathers had higher rates of child maltreatment. This connection was particularly strong for families with absent fathers and working mothers. J. Brown et al. (1998) noted that both low involvement on the part of the father and low paternal warmth were associated with an increased risk for child physical abuse.
FOCUS ON RESEARCH 2.3: THE NATIONAL INCIDENCE STUDIES
Congress mandates a periodic study of the incidence of child abuse and neglect in the U.S. So far, four National Incidence Study (NIS) reports have been written. The fi rst, NIS-1, was conducted in 1979–1980 and was published in 1981; NIS-2 was conducted in 1986–1987 and was published in 1988; NIS-3 was conducted in 1993–1995 and was published in 1996; and the most recent report, NIS-4, was conducted in 2005–2006 and was published in 2010 (Sedlak et al., 2010). The NIS reports are considered the best source of national information on the incidence of child abuse and neglect. The data that the report is based on come from a sample of 10,791 professionals who represent 1,094 agencies, 122 counties, and 126 CPS agencies. The participants surveyed were selected to accurately represent the popula- tion of the United States.
The 2010 study defi ned child abuse and neglect in two ways. First, the authors used the harm standard to label children as maltreated if they had already been harmed by some type of abuse or neglect. Second, they used the endangerment standard to include already harmed children and children who were at risk of being harmed by maltreatment.
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31RISK FACTORS FOR CHILD MALTREATMENT
Domestic Violence Sadly, having two parents does not guarantee safety from child maltreatment. Too often, intimate relationships are marked by violence. It is estimated that as many as 10 million children between the ages of 3 and 17 witness domestic violence each year in the United States. Children who grow up in homes where one parent is beating the other can be harmed directly or indirectly by this type of behavior. In some cases, children are physically harmed by being in the wrong place at the wrong time. In other cases, children are hurt when they attempt to protect the parent who is being beaten. Even if a child is not physically harmed by domestic violence, he or she may be psychologically harmed by seeing this sort of violence. Children who are exposed to domestic vio- lence exhibit a range of symptoms including aggression, anxiety, low self-esteem, academic diffi culties, and stress (Graham-Bermann, 2002).
Large Family Size Large family size also increases the risk of child maltreatment (Dubowitz et al., 2011; Paavilainen et al., 2001). In the National Incidence Study-4, children from the largest families (defi ned as families with four or more children) were at an increased risk for maltreatment when compared with children in families with fewer children. Inter- estingly, the lowest risk was associated with two to three children, and only children were at medium risk. Under the harm standard, the rate of maltreatment in families with four or more children was 21.2 per 1,000. The lowest rate of maltreatment was for families with two children (11.9 per 1,000). Families with only one child had a maltreatment rate of 17.9 per 1,000, and families with two children had a maltreat- ment rate of 15.7 per 1,000. Although it may be easy to speculate why families with four or more children were more likely to maltreat, it is less easy to explain why only children are at a greater risk than are those with one or two siblings. In families with many children, there are simply more responsibilities and stressors. Because the par- ent or parents have more to do, it is more likely that the demands of child rearing will overwhelm their available resources. On the other hand, only children may be at
NIS-4 had three main objectives:
1. The authors’ fi rst goal was to assess the incidence of child abuse and neglect in the United States as accurately as possible. To this end, they wanted to include all cases of maltreatment, even if they had not come to the attention of CPS. Therefore, data were collected not only from CPS, but also from a host of other professionals who are likely to be aware of maltreatment cases in their communities (law enforcement, public health workers, school personnel, day-care providers, etc.).
2. The NIS studies also measured changes in the incidence of child maltreatment across time by comparing rates found in previous reports to the current fi ndings.
3. Third, the researchers looked for relationships between demographic factors and child maltreatment.
domestic violence
violence, abuse, or
intimidation that takes
place in the context of an
intimate relationship.
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32 INTRODUCTION/PURPOSE
risk because they are the fi rstborn children and may have young, inexperienced par- ents. This same pattern of fi ndings was evident in the likelihood that children would suffer serious harm from maltreatment. This too was most likely in large families and least likely in families with two children (Sedlak et al., 2010).
Poor Family Functioning Paavilainen et al. (2001) compared maltreating and non-maltreating families. They found that the maltreating families had more problems with every type of family functioning assessed. The maltreating families had greater problems with commu- nication and shared fewer positive interactions with each other. It was also noted that family roles were less clear and less stable in maltreating families. Furthermore, members of maltreating families were less fl exible and had more diffi culty coping with change than did non-maltreating family members. The two factors that were most predictive of maltreatment were individuation (the development of a clear sense of self with a stable personality that is separate from others) and the perceived stability and security of the family. Of the families that had good functioning in both areas, 91% did not include maltreatment. Conversely, in 45% of the maltreat- ing families, the members were rated poorly on both individuation and perceived stability/ security.
CHILD FACTORS
Certainly, we can examine the most narrow level and look at the individual child. We should never blame child victims for the maltreatment they suffer; however, there are things about children that may increase the chances that they will be the victims of maltreatment. For instance, female children are at a greater risk for sexual abuse than are male children; younger children are more likely to be victims of maltreatment than are older children. Neither of these factors can be changed, but each points to a population that may need more protection. Young children are vulnerable for a number of reasons, including the fact that they are more depend- ent on caregivers than are older children; it is generally accepted that parents may use physical force against them; they are in greater danger of sustaining an injury due to their smaller size and strength; and they may have greater problems with regulating their emotions (Belsky, 1993). Children with diffi cult temperaments, dis- abilities, psychiatric illness, or retardation are also at a greater risk for physical abuse (J. Brown et al., 1998; Hibbard & Desch, 2007). Murphy (2011) reported that not only were children with disabilities 3 to 4 times more like to be victims of child maltreatment, they were also more likely to be seriously harmed by maltreatment than were children without disabilities. Even children with mild delays may be at an increased risk for maltreatment. Dubowitz et al. (2011) followed a group of at risk children for 10 years. They found that children with low scores on tests of mental development during the fi rst 3.5 years of life were at increased risk for maltreatment. These children did not meet the criteria for being diagnosed as developmentally delayed, but their mental scores were below normal. This could indicate that even minor delays pose greater challenges for parents and, therefore, increase the risk of maltreatment. An alternative explanation is that growing up in a family that is not psychologically healthy may impede normal mental development. Again, this does
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33RISK FACTORS FOR CHILD MALTREATMENT
not mean that abuse is the child’s fault, only that some child characteristics are risk factors for maltreatment. However, knowing what the child is like is not enough to predict maltreatment status. After all, most female children are not sexually abused, and most diffi cult children are not physically abused. We need to consider much more than the individual child if we want to fully determine the risk level for mal- treatment.
EXTRAFAMILIAL FACTORS
In addition to examining the child, the parents, and the family, we also need to con- sider what type of support the family is or is not receiving. What sort of communities are these families living in? Are support services available? Are families linked with the available services and with families who could provide support? Anyone who has spent considerable time with children knows that they can be challenging. Can par- ents get a break? Programs such as Mother’s Morning Out or informal programs that trade child care can provide a much-needed break for stressed parents.
Lack of Support
Maltreating parents often have very little social support from either family or friends. Many times, maltreating families are best described as socially isolated. Abusive parents report less involvement with their communities and churches than do nonabusive parents (J. Brown et al., 1998). Maltreating mothers report that they have fewer friends who are available to offer them support, and they report less frequent con- tact with the friends they do have than do nonmaltreating mothers. Maltreating mothers also rate the support they do receive from friends as low qual- ity (Bishop & Leadbeater, 1999). A number of explanations have been proposed to account for why maltreating parents are socially isolated. Some of this isolation may be due to the tendency of maltreating families to be more transient than are other families. In one study, families who were neglecting their children were signifi cantly more likely to have lived at their current address for less than 1 year than were con- trol families (Zuravin, 1989). Others have argued that maltreating parents may avoid contact with other people in an attempt to hide their inadequate parenting. On the other hand, it may be that the peers of maltreating mothers see them as abusive and actively avoid them. Finally, it may be that maltreating mothers reach out to other parents who are attempting to deal with similarly stressful life situations themselves. If an impoverished, substance-using mother attempts to rely on other drug-using women who are living in poverty to provide parenting assistance, it is not surprising that these attempts will fail (Bishop & Leadbeater, 1999).
It has also been reported that the relationships that abusive parents do have tend to be of poorer quality than those enjoyed by nonabusive parents (Belsky, 1993). Wil- liamson and Borduin (1991) reported that neglectful mothers seem unable to deal with the demands in their life, and they feel overwhelmed by the responsibility of raising children. Although all people experience moments when there seems to be too much to handle, one reason these mothers struggle more, and are more likely to fail, is that they have no one to turn to in times of need.
socially isolated
lacking suffi cient social
ties or support.
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34 INTRODUCTION/PURPOSE
In addition to a lack of child-care services or support, to understand the impact of a community requires our looking at what is offered physically. Are there safe places to play? Does the community have parks where families can gather to play, socialize, and support each other? It has likely already occurred to you that many of these community factors will be dramatically affected by the socioeconomic status (SES) of the area.
Poverty
Poverty is strongly correlated maltreatment. The authors of the National Incidence Study reported that family socioeconomic status (SES) was related to all categories of child maltreatment. Families were considered to have a low SES if any of the fol- lowing were true: the family income was less than $15,000 per year, the parents had less than a high school education, or a member of the family participated in a pov- erty program. In all cases, lower SES was correlated with a higher incidence of abuse. The risk of suffering any form of maltreatment according to the harm standard was 5 times greater for children from a low-SES family than for children from other fami- lies. The rate of maltreatment for low-SES families was 22.5 per 1,000 whereas the rate for other families was 4.4 per 1,000. This difference was more striking for neglect (16.1 versus 2.2 per 1,000) than for abuse (7.7 versus 2.5 per 1,000). The rates for sexual abuse were more similar (1.7 versus 0.6 per 1,000) (Sedlak et al., 2010). Other research- ers agree that poverty is associated with increased risk for physical abuse and neglect but not for sexual abuse (J. Brown et al., 1998). One of the most consistent fi ndings is that neglect, especially physical neglect, is clearly associated with poverty. Similar fi ndings have been published by Lee and Goerge (1999), who reported that children from impoverished neighborhoods were 6 times more likely to be neglected than were children from neighborhoods with a higher SES.
Not only is poverty associated with an initial fi nding of maltreatment; it is also a risk factor for multiple fi ndings of maltreatment. Palusci (2011) analyzed 177,568 confi rmed cases of maltreatment involving infants and young children (those younger than 5 years old). They found that infants and young children from families with inad- equate housing and from families receiving public assistance were signifi cantly more like to have a second maltreatment charge confi rmed in the next 5 years. The authors of this type of research assert that these differences are not due simply to the fact that poor children are more likely to come to the attention of professionals. Although it is pos- sible that the higher rates of reported child maltreatment among those with lower SES can be accounted for by the fact that poor children are more likely to be in contact with service providers (who would detect and report maltreatment), it is not the whole pic- ture. Even when contact with agencies is controlled for, low SES is still a signifi cant risk factor for child maltreatment. Sedlak and Broadhurst (1996) noted that the National Incidence Study is based on information from CPS and other professionals who are likely to see a broader range of clients. In addition, the report uses information from public schools, and 89% of the children in the United States do attend public schools. (See Focus on Research 2.3 for a review of the National Incidence Study procedures.) In other words, the relationship between poverty and child neglect is well established.
Not only were poor children found to be at a greater risk for maltreatment, according to the NIS-4, but they were also more likely to be seriously injured by that abuse than were children from families with higher incomes (Sedlak et al., 2010). Lack of money contributes directly to neglect by interfering with a family’s ability to provide for the children, and it contributes indirectly to other types of maltreatment
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35RISK FACTORS FOR CHILD MALTREATMENT
by increasing stress and frustration while decreasing opportunities for relaxation and breaks from the demands of parenting.
There are several reasons why an association might exist between poverty and child neglect. Dubowitz (1999) points out that families that are poor are more likely to be faced with a host of factors that are less common among the more affl uent, such as extreme stress, unemployment, unstable housing, poor community support, dangerous environments, and minimal access to health care. In many cases, the par- ents’ inability to cope with all of these things makes them unable to adequately provide for their children. Pelton (1994) further pointed out that because poor fami- lies tend to live in dangerous surroundings, there is less room for parental error. If a middle-class mother is distracted by a problem with her job and does not notice that her child has left the home, it is likely that the child will not be seriously harmed by wandering about a suburban area (lower in crime and traffi c) without supervision. A poor mother, living in the inner city, would need to be more vigilant to keep her child safe. Because the link between poverty and child maltreatment is so strong, federally funded programs have been established to provide child rearing assistance to low income families (see Case Example 2.1 ).
CASE EXAMPLE 2.1
A federally funded program to assist low-income pregnant women and families with children up to 3 years of age is Early Head Start (EHS). All 50 states have EHS programs. Although the programs vary by state, they are all focused on promoting healthy child development and posi- tive family functioning. EHS programs are designed to promote child development in all areas: physical, social, emotional, cognitive, and language development. A major focus for promot- ing child development is to educate parents and to encourage the development of a positive bond between parent and child. EHS also works to develop families. The program empowers families to be the best they can be by helping them to meet their social and fi nancial needs. The EHS programs are also community oriented. The EHS staff assesses community resources and helps to increase accessibility and service delivery. Finally, EHS programs are commit- ted to staff development. The professionals who work with EHS are well trained, and they receive ongoing supervision and further training as needed (Early Head Start National Resource Center, 2013). It is hoped that these services can get children and families off to a good start.
Closely related to poverty is the problem of unemployment. In addition to decreas- ing income, unemployment increases stress and decreases self-esteem while often putting the unemployed parents in constant contact with their children. The NIS-4 revealed that the rate of maltreatment according to the harm standard was higher for children of unemployed parents (15.9 per 1,000) than for the children of employed parents (7.6 per 1,000). Children of parents who were not in the workforce were at the highest risk (22.6 per 1,000). This last category included parents who were unem- ployed and not looking for employment, those who were retired, homemakers, and parents who were hospitalized or in jail (Sedlak et al., 2010). Other factors that are associated with poverty may also lead to child maltreatment. Many researchers have
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36 INTRODUCTION/PURPOSE
noted that there is a relationship between SES and authoritarian parenting (demand- ing with low warmth), lack of parental involvement, and less emphasis on creating independence in children (Trickett, Aber, Carlson, & Cicchetti, 1991).
Risk of Child Maltreatment in Military Families
In recent decades, there has been a good deal of media interest surrounding the issue of child maltreatment within military families. Part of this attention is the result of the changing demographic status of active duty soldiers. Historically, the majority of troops were single males who did not have children. However, it is now a fact that 43% of active duty soldiers have children (Gibbs, Martin, Clinton-Sherrod, Wal- ters, & Johnson, 2011). De Pedro et al. (2011) noted that between 2001 and 2011, approximately 2 million children had experienced the deployment of a parent and that there were 1.2 million children with current, active-duty soldiers as parents. The question at hand is how these children fare in comparison to the children of civil- ians. Both protective factors and risk factors can be seen in military families.
A number of factors could well be protective of children raised in military fami- lies. First, before someone can become an active-duty soldier, he or she is screened for a history of mental illness or criminal behavior. This eliminates some people who would be at heightened risk of being abusive. Soldiers also have a lower rate of illicit drug use (3%) than is seen among civilians (12%). In addition, at least one parent is employed full-time (by virtue of being in the military), and 90% of children in the military are being raised by two, married parents (Gibbs et al., 2011). Other research- ers have noted that the minimum educational requirement (high school diploma or equivalent) for soldiers provides another protective factor. In addition, military fami- lies have access to health care and to family support systems that may not be available to civilian families (McCarroll, Ursano, Fan, & Newby, 2004). In fact, the military provides free programs designed to build strong families (see Case Example 2.2 ).
CASE EXAMPLE 2.2
The military offers support to help build strong families in light of the demands of a military career. One available program offered by the Family Advocacy Program (FAP) is the New Parents Support Program (NPSP). This program is available on most military installations and is free to active-duty service personal and their families. In order to be eligible the family must be expecting their fi rst child or have a child who is younger than 3 years old. The NPSP program provides in-home support from professionals trained to provide information about parenting and support. For newborns, a nurse or a social worker can also visit the new fam- ily in the hospital to answer questions about basic care. In addition, the program provides both prenatal classes and instruction on parenting. If the NPSP workers notice that a family is struggling, they are also prepared to offer referrals to other resources. Finally, the NPSP sets up playgroups that are designed to help children develop physically and socially. As the children play, the parents are able to make connections with other young families. Although some families are referred to the NPSP, most families participate voluntarily, so there is no stigma attached to receiving this assistance (Military One Source, 2013).
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37RISK FACTORS FOR CHILD MALTREATMENT
On the other hand, some signifi cant risk factors are seen among military fami- lies. First, demographically, you have more young parents of young children than you see among civilian populations. It is also the case that more soldiers report a history of child maltreatment than do civilians. Researchers have further noted increased rates of alcohol abuse and criminal domestic violence among soldiers. Military families also deal with isolation due to frequent moving. This can be especially challenging for families living outside of the United States. These families may face a cultural isolation along with reduced access to child protective services (Cham- berlain, Stander, & Merrill, 2003). Finally, episodes of “single” parenting due to deployment may increase the risk of maltreatment for children in military families. In fact, deployment seems to bring a great deal of stress to military families, and it is associated with an increase in divorce and spousal violence as well as increased behavior problems and fear in children (Gibbs et al., 2008, 2011). Children with deployed parents have been shown to have an increase in number of temper tan- trums, acts of defi ance, fi ghting, crying, and sleep problems, among other issues (Barker & Berry, 2009). All of these behaviors are likely to increase the stress level of the remaining parent.
In military families, child maltreatment is handled by Family Advocacy Pro- grams (FAPs) and local CPS offi ces (if the family is stationed in the United States). Some researchers have noted a lower rate of maltreatment among military families attributable to lower rates of neglect in particular. McCarroll et al. (2004) tracked rates of maltreatment among military and civilian families from 1995 until 1999. They found that there was signifi cantly less neglect in military families (3.1 per 1,000 compared to 6.9 per 1,000). However, other types of maltreatment did not differ in rates per 1,000 (Sexual Abuse: 0.08 for military and 1.3 for civilian; Physi- cal Abuse: 2.0 for military and 2.5 for civilian; Emotional Abuse: 1.0 for military and 0.9 for civilian). However, some researchers have cautioned that there may be a signifi cant increase in child maltreatment following deployment(s). Rentz et al. (2007) did a time-series study of maltreatment in Texas from 2000 to 2003. Approximately 12 months after the September 11, 2001 attacks, the number of deployments increased dramatically. This was accompanied by a 22% increase in substantiated cases of child maltreatment. During this time, no increase was seen in civilian maltreatment rates.
CULTURAL FACTORS
Looking beyond the community, one also needs to consider the broader society. For instance, how accepting is a given culture of violence? When we listen to the music of the times, watch the movies being released, and tune in to the daily television shows, what messages are we receiving about violent behavior? Are chil- dren portrayed as innocent or as sexual beings? What messages are being sent about the importance of patient, nurturing parent- ing? What is the level of acceptance for corporal punishment by parents; how far can parents go before their behavior is consid- ered inappropriate? What is the political climate with regard to parenting? The U.S. government has historically been reluctant to interfere with the sanctity of the family, and this cautious approach
culture
the socially transmitted
behaviors, arts, beliefs,
and institutions that
characterize a group of
people.
corporal punishment
physical punishment
such as spanking or
slapping.
6241-171-P1-002.indd 37 10/19/2013 10:14:02 AM
38 INTRODUCTION/PURPOSE
is seen in the traditionally low legal costs associated with violence within the family (Gelles & Straus, 1988). Consider how much more likely you are to be prosecuted for hitting my child than for hitting your own! We do not often consider these “big- picture” questions, but it seems clear that they can have an impact on the likelihood of maltreatment.
The United States is a country that tolerates a high level of violence. The rates of violent crime are shocking. During 2010, there were 1,246,248 violent crimes reported. Among these were 14,748 murders, 778,901 aggravated assaults, and 84,767 forcible rapes (The Disaster Center, 2012). It has been argued that this violent setting provides a background for the acceptance of violence within families.
Americans are also generally accepting of corporal punishment. Interestingly, the only people you can legally hit in the United States are children. This attitude probably grows out of the prevalent societal thought that children are the prop- erty of their parents. Even though corporal punishment is not considered abusive in the United States, it has been noted that abusive parents are more likely to make frequent use of physical punishment and power assertion than are nonmaltreating parents (J. Brown et al., 1998). Although some laws and court decisions have called this into question, many still assert that parents should be allowed to raise their chil- dren as they see fi t (Belsky, 1993).
Acceptance of physical punishment is only one example of something that can vary between cultures. People from different cultures share a set of attitudes, beliefs, and behaviors that are passed down from one generation to the next. Many of these things are related to child-rearing practices. Furthermore, there is no universal, cross- cultural agreement about what constitutes child maltreatment (Raman & Hodes, 2012). It seems that each culture comes with its own ideas about what is normal or expected.
Many have noted that the rates of child abuse reports, the number of children in foster care, and the type of services provided to families all vary by ethnic group (Elliott & Urquiza, 2006). It is important to explore whether these rates refl ect true differences in child maltreatment across groups, or whether they indicate an unfair, or culturally insensitive approach to families from different cultural, racial, or ethnic groups.
In working with children from diverse families, the professional’s goal is to acknowledge cultural differences while still protecting children (Raman & Hodes, 2012). In order to do this, professionals need ongoing training. While it is true that culturally sensitive work is diffi cult because cultures are subjective and always changing, it must be attempted. Even while acknowledging that great variation can occur within as well as between cultures, and that cultural boundaries are not always clear, there are things workers can do to promote better service for families from diverse backgrounds (Hughes, 2006). For example, agencies that serve chil- dren can make sure that all signs and forms are available in the primary languages spoken by the families they serve. They should also employ people who speak the languages their clients speak or, at the very least, engage the services of trained interpreters. Although language differences are obvious, professionals also need to be educated about more subtle cultural differences. For instance, if people from a particular culture are reluctant to seek assistance from people outside their family, this is something professionals should be aware of before making decisions about a family’s level of cooperation (Fontes, 2008). People who work with children from
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39RISK FACTORS FOR CHILD MALTREATMENT
diverse cultures need to be especially aware of cultural differences in child rearing practices. For example, Fontes (2008) described a case study where a practicing Sikh family was found guilty of child maltreatment for swaddling their toddler at nap time. The caseworker thought this practice was a form of abusive restraint. Further investigation revealed that this practice was normal and comforting to the child. Furthermore, all of the children in the home were happy and healthy. Although there are instances were restraints are overused, or they are too tight, this was not occurring in this family. Finally, workers should receive ongoing training designed to identify and reduce biases against other groups and stereotypes about people from other cultures. Although I highlight cultural issues throughout this text, I do not provide full coverage of this complex topic. If you are interested in further exploring issues of cultural diversity, I recommend L. A. Fontes’s (2008) book Child Abuse and Culture: Working with Diverse Families. In this easy to read text, Fontes provides information about culturally sensitive assessment, interviewing, and pre- vention.
CONCLUSION
Even if we consider all of these levels of infl uence, we still do not have a simple additive model for maltreatment. For instance, imagine you hear about a young, disabled boy being raised by his single, unemployed mother in a poor, dangerous community where messages of violence are prevalent in the entertainment that surrounds them and severe physical punishment is an accepted community norm. Do you know that he will defi nitely be abused? Although this is certainly not an ideal child-rearing scenario, it is not the case that there will defi nitely be maltreat- ment. All of these things are risk factors; none of them, alone or in combination, causes abuse. Surely, it would be appropriate to be concerned about a family fac- ing so many hardships, but we cannot assume the boy is being maltreated. In one longitudinal study of risk factors for child maltreatment (Brown et al., 1998), the authors found that children who faced no recognized risk factors for child maltreat- ment had only a 3% chance of experiencing any form of maltreatment during their life (0% for physical abuse, 2% for neglect, and 1% for sexual abuse). At the other end of the risk spectrum, children who had four or more risk factors had a preva- lence rate of 24% for child maltreatment (16% for physical abuse, 15% for neglect, and 33% for sexual abuse). Based on this information, the authors recommended that a large number of risk factors should be assessed in order to determine the level of risk the child is facing.
Just as there are risk factors for abuse, there are also protective factors that can pre- vent abuse, even when multiple risk factors are present. Diverse factors ranging from good health to a supportive extended family to good schools can all serve as com- pensatory factors (see Chapter 10 , “Resilience,” for more information on protective factors). All of these factors make abuse more or less likely; none of them guarantees either abuse or safety. In assessing a particular situation, we should attempt to meas- ure both the risk factors and the protective factors in the child’s environment. When the risk factors outweigh the supportive factors, maltreatment is more likely to occur (see Case Example 2.3 ).
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40 INTRODUCTION/PURPOSE
DISCUSSION QUESTIONS
1. Think about your own upbringing. What risk factors, if any, were present in your family? What protective factors existed in your family?
2. Which risk factors do you think are more predictive of maltreatment and which are less predictive of maltreatment? For instance, would you be more concerned about a child whose only risk factor was that they came from a large family or a child whose only risk factor was a mother with a substance abuse problem?
CASE EXAMPLE 2.3
Mary Beth was 17 years old, and she had been dating her 18-year-old boyfriend, Joe, for almost a year when he seemed to be drifting away from her. In order to keep him with her, she got pregnant. When Mary Beth’s mother found out she was pregnant, she threw her out of the house. Mary Beth quit high school and moved in with Joe and his friends. Joe seemed excited about the baby, but Mary Beth found it diffi cult to live with his three room- mates. The roommates smoked and drank and left the apartment messy. After the baby, Isaac, was born, Mary Beth begged Joe to move out and get their own place. The young family moved into a one-bedroom apartment that Joe could barely afford even though he worked full-time as a mechanic.
Mary Beth’s aunt Barbara tried to help the young family fi nancially, and she offered to babysit while Mary Beth studied for her GED. Mary Beth tried to study, but she found caring for her newborn son exhausting. She was tired all of the time and feeling sad. The more she thought about everything she had to do, the less she felt like doing anything. Joe worked long hours and was angry to come home to fi nd a crying baby and a dirty apart- ment.
Aunt Barbara found a free parenting class geared to new parents, and she convinced the couple to sign up. She also offered to take care of the baby while they attended the classes. Even though Joe was worn out from working, he reluctantly agreed to go to the classes with Mary Beth.
Although Mary Beth and Joe became more skilled at parenting, they continued to have problems with their relationship. Mary Beth was really down most of the time, and money was always tight. Mary Beth began to worry that Joe was going to leave her and the baby. Even though having the baby had seemed like a good idea, Mary Beth started to think it was a mistake. She decided to give less attention to the baby and concentrate on making Joe happy.
DISCUSSION QUESTIONS
1. What risk factors are present in Isaac’s life? 2. What protective factors are present?
6241-171-P1-002.indd 40 10/19/2013 10:14:02 AM
41RISK FACTORS FOR CHILD MALTREATMENT
3. Based on the information presented in this chapter, if you were given $1 mil- lion to prevent child abuse in your community, how would you spend your funds?
4. Does research on child factors related to child maltreatment amount to blam- ing the victim? Why or why not?
5. Are there risk factors that would be unethical to attempt to eliminate? For instance, should family size be limited, or should adults who suffer from depression be prevented from having children?
6. While watching the news, you hear a local politician say, “Only married people should have children because single parenting causes child maltreatment.” How would you respond?
6241-171-P1-002.indd 41 10/19/2013 10:14:02 AM
42
It has been my experience that many students who elect to take a child abuse and neglect course do so because they are, or know they will become, mandated reporters. This is a role that can be intimidating, and the best way to address these insecurities and to better serve maltreated children is to learn more about abuse and neglect, as well as what exactly one is obligated to do as a mandated reporter. As you will see, it is a complex role that will place you in situations with no easy answers.
THE HISTORY OF MANDATED REPORTING
States adopted mandated reporting laws in the 1960s as part of the child abuse prevention movement. In 1962, this movement was spurred by the publication of “The Battered-Child Syndrome” (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962) and by a conference addressing child abuse that was sponsored by the fed- eral government in that same year. Once child abuse was recognized as a problem that the government should take a role in addressing, it was clear that there would need to be some way to bring these abused children to the attention of authorities. Given that there is a general reluctance to interfere with families and parenting practices, there needed to be some way to push people to make referrals. Profession- als at this conference recommended laws requiring physicians to report possible physical abuse. This recommendation was quickly endorsed by the American Medi- cal Association, the American Humane Association, and the Children’s Bureau of the U.S. Department of Health (Myers, 1998). Although all states and the District of Columbia had mandated reporting laws by 1967, it was not until the Child Abuse
Prevention and Treatment Act of 1974 that states were required to list mandated reporters as well as to provide immunity for them in this role, and to ensure confi dentiality of records in order to be eligible for federal aid (Kalichman, 1999). States are required to have such laws; however, it is up to each state to decide exactly who is a mandated reporter, what type of penalty will be imposed
for failure to report suspected maltreatment, and what safeguards will be in place to protect reporters from criminal or civil action (e.g., being sued). Although all states grant immunity from civil and criminal liability to mandated reporters, this does not hold if one self-reports. In other words, if you report that you are abusing a child, you cannot claim immunity under the reporting laws, and yes, people have tried (Small, Lyons, & Guy, 2002).
CHAPTER 3
Mandated Reporting
mandated reporters
people required by
law because of their
occupation to report
suspected cases of child
maltreatment to the
proper authorities.
immunity (legal)
exception from civil
or criminal liability or
prosecution.
6241-171-P1-003.indd 42 10/19/2013 10:14:10 AM
43MANDATED REPORTING
The Impact of Reporting Laws
There is no doubt that the mandated reporting laws have been successful in increasing the number of reports made to Child Protective Services (CPS). There were approxi- mately 10,000 reports of child maltreatment made in 1962, and there were almost 3 million made in 1992 (Lindsey, 1994). So, if the goal of the mandated reporting laws was simply to increase the number of cases brought to the attention of CPS, it is clear that they fulfi lled that role. The question of whether they have improved the situation for maltreated children is addressed later.
PERSONS REQUIRED TO REPORT
Originally, states only included physicians as mandated reporters. Because the focus in the 1960s was on physical child abuse, it made sense to target those profession- als who were most likely to see a physical injury. Over time, the understanding of child maltreatment grew to include nonphysical injury and physical injury that may not require a physician’s care (e.g., bruising). In order to detect these cases, the lists of mandated reporters have grown to include many classes of people who come into contact with children as part of their professional duties. Today, states typically include all medical personnel, teachers, day care providers, religious personnel, counselors (privileged communication is abrogated to allow for disclosure of child maltreatment), social service per- sonnel, police, and others. Some states have more expansive lists that include such occupations as undertakers, Christian Science practitioners, bus drivers, animal control offi cers, and even fi lm developers (who may become aware of abuse, particularly sexual abuse, when they develop pictures). You may fi nd it interesting to note that lawyers are rarely listed as mandated reporters due to attorney–client privilege (see Legal Example 3.1 ).
abrogated
cancelled or annulled
by offi cial means or
authority.
LEGAL EXAMPLE 3.1
Information exchanged between an attorney and their client is generally considered part of a privileged communication in that any information gathered cannot be used against the client. In keeping with this tradition, attorneys were not originally listed as mandated reporters. However, in recent years, some states have changed their statutes to include attorneys. Some states, such as Texas, have very explicit statutes regarding attorneys and mandated reporting. The Family Code of Texas §§ 261.101; 261.202 reads, “the requirement to report applies without exception to an individual whose personal communications may otherwise be privileged, including an attorney . . .” Mississippi lists attorneys as mandated reporters, but does not address privileged communication at all. Other states list attorneys as mandated reporters, but then acknowledge privileged communication. For example, Oregon includes attorneys as mandated reporters but notes, “an attorney is not required to make a report of information communicated to the attorney in the course of represent- ing a client, if disclosure of the information would be detrimental to the client” (Rev. Stats §419B.010). Similar statues are in place in Ohio and Nevada. Other states list only attorneys
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44 INTRODUCTION/PURPOSE
Some states (e.g., Kentucky, Mississippi, North Carolina) simply require that any- one with knowledge of maltreatment is mandated to report that information. For some professionals, the question of mandated reporting is especially complex. As noted ear- lier, many states specifi cally list clergy as mandated reporters. In fact, 26 states list clergy and 18 include anyone, so in the majority of states, members of the clergy are mandated reporters of child maltreatment. This is complicated by the idea of privileged communication; especially in a confessional setting. Although six states (New Hamp- shire, West Virginia, North Carolina, Oklahoma, Rhode Island, and Texas) explicitly deny privilege to clergy, the law is less clear in other states (Child Welfare Informa- tion Gateway, 2010). It is important that you be aware of the state law where you live so that you know if you are required to report suspicions of child maltreatment (see Search the Web 3.1 ).
in certain roles as mandated reporters. For instance, New York lists district attorneys and assistant district attorneys as mandated reporters (Soc. Serv. Laws §413), California lists dis- trict attorney investigators (Penal Code §11165.7), and Arkansas lists prosecuting attorneys and attorneys ad litem (Ann. Code §12-18-402).
SEARCH THE WEB 3.1
With the Internet, it has become easy to search for relevant state statutes. To fi nd the stat- ute that lists mandated reporters for your state, you can log on to the site titled the Child Welfare Information Gateway, which now includes the information previously included on the page for the National Clearinghouse on Child Abuse and Neglect Information at www.childwelfare.gov/systemwide/laws_policies/state. At this site, you need to complete three steps:
1. Select the state you are interested in knowing about. 2. Choose an issue or issues. The relevant issues would be Immunity for Reporters of
Child Abuse and Neglect, Making and Screening Reports of Child Abuse and Neglect, Mandatory Reporters of Child Abuse and Neglect, and Penalties for Failure to Report and False Reporting of Child Abuse and Neglect.
3. Submit your request by selecting “Go.” You will then see a copy of the mandated reporting statute for the state you selected.
Permissive Reporters
What if you suspect child abuse and you are not a mandated reporter? You are still allowed, and even encouraged, to report. Nonmandated reporters are referred to as permissive reporters. There is no legal consequence if a permissive reporter fails to report suspicions, yet many people feel a moral obligation to protect chil- dren they believe are at risk.
permissive reporter
a person who is allowed,
but not required, to
report suspected child
maltreatment.
6241-171-P1-003.indd 44 10/19/2013 10:14:10 AM
45MANDATED REPORTING
Conducting Research and Reporting Obligations
One recent controversy has developed around the role of research and mandated reporting. Are people who research child maltreatment obligated to report suspicions of maltreatment? Researchers are not generally listed as mandated reporters, so for the most part, they fall under the category of permissive reporters. The one exception to this is medical doctors who are mandated to report maltreatment in both research and clinical settings (B. Allen, 2009). Researchers who are not phy- sicians fi nd their role complicated by informed consent. Before people agree to participate in a research study, they are asked to give their informed consent. In addition to telling participants what will be expected of them during the experiment, researchers guar- antee them confi dentiality. Although it is clear that the mandate to report trumps confi dentiality for a mandated reporter, it is not clear how these two issues are balanced for a permissive reporter. In order to avoid such situations, some researchers limit questions that might lead to allegations of abuse. Others may include a notice of this limitation to confi dentiality on their informed consent sheet. These approaches may keep the question from arising, but they also mean that data are incomplete and that some children may continue to be at risk when they could have been identifi ed and referred to CPS (Farberman & Finch, 1997). Again, there are no easy answers, but this is a question that should be discussed with an institutional review board (IRB) before data collection begins. Every institution where research occurs must have a board composed of individuals charged with the task of ensuring the ethical treatment of research participants. Before any research pro- ject is conducted, the researchers submit a proposal to the IRB for approval. In this proposal, all risks and benefi ts are explored, and plans to ensure participants’ safety are laid out. If the IRB does not approve the proposal, the research may not be conducted.
WHEN TO REPORT
Determining whether you are required to report is actually the easy part. A much more diffi cult decision is deciding when to report. The typical standard is that you should report when you have “reasonable cause” to believe that a child has been, or may be, maltreated. This, of course, requires you to know the legal defi nitions of mal- treatment (subsequent chapters in this book are devoted to providing you with that information) and what “reasonable cause” means. How sure do you have to be before you report? As you may guess, there is no black-and-white answer to this question. One possibility is to err on the side of caution and report even the smallest suspicion. Although this certainly covers you as mandated reporter, it overwhelms CPS and takes time that could be devoted to more serious cases. On the other hand, waiting until you have solid proof may leave a child in a dangerous situation when he or she should have received help. Most professionals recommend that you discuss your sus- picions with senior colleagues whose opinions you trust. Let them guide you in your early decisions about which cases should be referred as you develop a feel for what is “reasonable cause.” Also, by seeking the input of other reasonable people, you are
informed consent
the ethical requirement
that participants
voluntarily agree to take
part in an experiment
only after they have
been told what their
participation will entail.
institutional review
board (IRB)
a group of professionals
charged with
determining whether the
benefi ts of a proposed
research project outweigh
the potential costs to
participants.
6241-171-P1-003.indd 45 10/19/2013 10:14:10 AM
46 INTRODUCTION/PURPOSE
fulfi lling the requirement of the law; you are checking to see if the present situation would cause a reasonable person to make a report. When you seek advice, limit your discussion of the case to those who need to be involved. Part of protecting children is protecting their privacy. Another way to begin to develop a feel for reasonable cause is to examine case studies that include a discussion of reporting issues. Seth Kalich- man’s (1999) book titled Mandated Reporting of Suspected Child Abuse: Ethics, Law, and Policy is an excellent resource. He provides 12 case studies in which suspected abuse was not reported and 7 cases in which a report was made. Each of the case studies is followed by commentary and a list of “lessons learned.” Exercises such as these will help you to bridge the gap between the law and practical experience (see Search the Web 3.2 ).
SEARCH THE WEB 3.2
Deciding whether to report child maltreatment is challenge for most people. Many agen- cies dedicated to the safety of children provide information that is designed to help those faced with this situation. The American Humane Association has a section on their web- page titled “Stop Child Abuse.” The link for this information is www.americanhumane .org/children/stop-child-abuse/report-child-abuse/step-1-evaluate-situations.html.
You will fi nd four steps outlined on this page:
Step 1: Evaluate Situation for Child Abuse Step 2: Report Child Abuse Step 3: Understanding Child Abuse Laws Step 4: Help Prevent Child Abuse
It may be helpful to keep in mind that you are not necessarily making an accu- sation when you call CPS; you are expressing concern for a child’s well-being. It is not your job to investigate the claim or to provide proof. Finally, if you wait until you are sure abuse has occurred, you have violated the law. The law requires that you report suspicion, and leaves the determination of abuse to CPS. Research reveals that several factors increase the likelihood that professionals will report. These fac- tors include more serious maltreatment, suspicion of sexual abuse (as compared to physical abuse or neglect), and alleged victims who are younger. Furthermore, most mandated reporters will call CPS anytime a child discloses abuse (Myers, 1998).
There is some concern that the threshold for considering a situation abusive enough to report may be relatively high. Ashton (1999) had 86 graduate students in social work evaluate vignettes in terms of their “seriousness” and then indicate whether they would report in that situation. Participants were asked to rate the seri- ousness of the incident on a scale from 1 to 7, where 7 represented very serious. She found that a rating of 6.5 on this 7-point scale was needed before two thirds of the sample would report. Several scenarios described in this study did not meet this threshold. For example, readers assigned an average rating of less than 6.5 to the
6241-171-P1-003.indd 46 10/19/2013 10:14:10 AM
47MANDATED REPORTING
following situations: (a) a 9-year-old is left alone most of the day and night, parent is working; (b) parents make child kneel in closet; and (c) father punches drunk teen. This means that less than one third of the sample would have reported these situa- tions to CPS.
The best predictor that a mandated reporter will call CPS is how confi dent they are that maltreatment has occurred (VanBergeijk, 2007). It certainly makes sense that this would be the guiding principal. The job of the mandated reporter is then to hone their skills to notice the signs and symptoms of maltreatment.
HOW TO REPORT
If you decide to report a case of suspected child maltreatment, you may call your local CPS, your state child abuse hotline, or the police. If you are not sure of how to contact your local or state services, you can call the National Child Abuse Hotline for assistance (1-800-4-A-CHILD). Because laws vary from state to state, be sure to know the laws of the state where you live.
When you call, be prepared to offer as much complete and detailed information as possible (making notes of suspicious behav- ior, markings, and so on is recommended). It is a good idea to note the date, time, and location of any suspicious marks or comments. The fi rst thing you will be asked to do when you call is to provide the name of the child and where that child can be located. If CPS cannot locate a child, social workers are not going to be able to intervene. Although this may seem obvious, CPS workers can tell stories of receiving calls with virtually no information, for exam- ple, about what some woman was doing to her child in a rest area, but with no other details provided! You will also be asked to supply the name and location of the alleged perpetrator, as well as his or her relationship to the victim, if you have this knowledge. After CPS has this basic information, staff will want to know specifi cally what you have seen or heard that has led to your suspicion of mal- treatment. Be as accurate as possible, and resist the temptation to exaggerate the situation to get faster service, or to downplay the situation so that nobody will get into trouble. You may then be asked for the names of any other people who may have knowledge of the abuse. Finally, you will be asked to provide your own name and a contact number where you can be reached (Chil- dren’s Bureau, 2005).
Many reporters, mandated and permissive, are reluctant to leave their name with CPS. Anonymous reporting is permissible, but it is not recommended for several reasons. First, reports are generally considered to be more credible if the reporter is willing to leave his or her name. CPS workers who are pressed for time may allot more resources to investigating those calls they think are most likely to be true. Second, if CPS needs to ask you a follow-up question, it is necessary for them to know who you are and how to reach you. Third, if you are a mandated reporter, this provides a clear record that you have performed your duty. If you are required to report and opt for an anonymous call, be sure to keep a record for yourself of when you called and whom you spoke to so that you can prove you reported. Finally,
National Child Abuse
Hotline
1-800-4-A-CHILD; a
phone line that is staffed
24 hours a day, 7 days
a week, by professional
counselors who can
answer questions about
child maltreatment. The
counselors have access
to a very large database
of resources including
emergency, social
services, and support
services.
perpetrator
a person who commits
an offense or crime.
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48 INTRODUCTION/PURPOSE
reporters are protected in that the family is never told who made the report to CPS. This, of course, does not mean that families would not fi gure out that you were the reporter. For instance, imagine that you are a daycare provider who asks a mother about suspicious bruising on her infant, and gets vague or defensive answers. Being unconvinced by the mother’s account, you make a report, and then CPS contacts the mother. It is likely that she will assume you made the call, and she may decide to confront you about it. What you know, because of CPS policies, is that she is only guessing; she does not know for a fact that you made the report. Although a situation such as this can be intimidating and even frightening, the law requires reports even if you are concerned for your own safety (see Case Example 3.1 ). There is no discre- tion for mandatory reporters: “Professionals who have attained a level of reasonable suspicion of child abuse are not afforded professional judgment and legal fl exibility in reporting” (Kalichman, 1999, p. 153).
CASE EXAMPLE 3.1
One reason that mandated reporters may be reluctant to report suspected child maltreat- ment is that they are afraid that the parents may become very angry with them for making the report. All reports to CPS or the police are anonymous. A family is never told who made the report. However, parents may guess that you are the one who made the call and may confront you about it. There are steps mandated reporters can take to handle this potential problem. First, before any specifi c situation arises, it is good to have a protocol in place at the school, day care, club, or wherever children are gathered. Is there a person who you can refer angry parents to who is trained to handle such situations? Does your organi- zation have a safety plan and/or security offi cers? Are there panic buttons available? Who should you contact if you are concerned a parent may become violent? Another thing that should be done before a situation arises is that parents should be informed of the agency policy regarding suspicions of child maltreatment. Parents should be notifi ed verbally and in writing that any concerns about abuse will be reported to the authorities. Parents should know that reporting is a fulfi llment of state law, it is not at the discretion of the employees (Karageorge & Kendall, 2008).
During any confrontation, the best advice is to remain calm and professional. Do not act shocked about the allegations or imply guilt. Gently explain the role of the mandated reporter. Let the parents know that the report means you were worried about their child and that you want the child to be safe. You can also assure the parents that you and your organization will do whatever you can to support the child during this diffi cult time (Kara- george & Kendall, 2008).
After the confrontation, be sure to document the incident and make a report to your supervisor. Write down in as much detail as possible what occurred. If there were witnesses, have them report their observations as well. While it is normal to be afraid, it does not mean you are exempt from reporting (Karageorge & Kendall, 2008).
6241-171-P1-003.indd 48 10/19/2013 10:14:10 AM
49MANDATED REPORTING
FAILURE TO REPORT
What happens if a mandated reporter fails to report suspected maltreatment? Failure to report is considered a misdemeanor and may result in fi nes (typically around $1,000, with a range of $25 in Pennsylvania to $5,000 in Michigan and Washington) and/or jail terms of 10 days to 1 year (Small et al., 2002). Professionals who fail to report can also be sued for malpractice in all states. In addition, several states (Arkansas, Colorado, Iowa, Michigan, New York, and Rhode Island) have laws that specifi cally target the willful failure to report abuse (Myers, 1998).
The landmark case for failure to report in the United States is Landeros v. Flood . In this 1976 case, the Supreme Court of Cali- fornia held that a child could sue a physician who had examined him or her, seen injuries consistent with abuse, failed to report that abuse, and allowed the child to be returned home where he or she suffered further injury. The facts of this case indicated that when the plaintiff was 11 months old, she was treated by Dr. Flood at the San Jose Hospital. At that time, she suffered from a spiral fracture of the right tibia and fi bula, her entire back was bruised, and she had assorted abrasions on her body. In addition, the doctor noted that she had a nondepressed linear fracture of the skull that was partially healed. The plaintiff’s mother was not able to provide a suffi cient explanation for these injuries. Because Dr. Flood failed to properly diagnose battered-child syndrome and report to authorities, the child was returned home. She subsequently suffered additional injuries including puncture wounds, burns, bites, and traumatic blows to her eye and back. When the plaintiff was brought to a different hospital just two months later, she was immediately diagnosed with battered-child syndrome, her case was reported to authorities, and she was taken into protective custody. Although the trial court originally ruled that Dr. Flood owed no duty to the child, the California Supreme Court said that the malpractice laws required a certain level of knowledge in both diagnosis and treatment. The court further held that it was reasonable to expect a medical doctor to be able to diagnose and treat battered-child syndrome (Sagatun & Edwards, 1995).
Despite these penalties, it is clear that many professionals do not report as man- dated by law. For example, many researchers have found that approximately one third of therapists were not willing to break confi dentiality by reporting suspected abuse (Kalichman, Craig, & Follingstad, 1989; see section titled Confi dentiality and Mandated Reporting for further discussion of this issue).
There are several reasons why a professional may opt not to make a report when he or she suspects maltreatment. Some professionals say that they are not confi dent that making a report will help the child. These professionals frequently cite previous contact with CPS that they did not fi nd helpful. Other professionals, particularly therapists, say that their decision not to report was motivated by a desire to protect the therapeutic relationship they had established with their client. They believe that they are better able to treat their client than CPS, and that disrupting the therapeutic relationship would be counterproductive. If a report would lead to distrust of the therapist, then that therapist would be less likely to be helpful
misdemeanor
a crime that is less serious
than a felony and is
usually punished with
a lesser penalty (a fi ne,
forfeiture, or less than
1 year in prison).
malpractice
professional negligence;
failure to exercise the
minimum degree of care
expected by professional
standards.
therapeutic
relationship
the working alliance
between a counselor and
a patient.
6241-171-P1-003.indd 49 10/19/2013 10:14:11 AM
50 INTRODUCTION/PURPOSE
to the client. Given that a likely result to an investigation by CPS would be that the parent would be ordered to seek counseling, therapists note that they are back where they started, but with a less cooperative client. These therapists want to focus on what is best for a specifi c family instead of following blanket reporting laws that may not be best in every situation (Crenshaw & Bartell, 1994; Gushwa & Chance, 2008).
There is some evidence that therapists’ concerns are well founded. R. Brown and Strozier (2004) examined three studies looking at the impact of reporting and found that in 25% of the cases a report had a negative impact on the therapeutic relation- ship (termination, missed appointments, late arrival for sessions, and/or anger with therapist). Of course, the fl ip side of this investigation was that 75% of the time, the impact of reporting was either neutral or positive.
Regardless of therapists’ concerns, they are still mandated reporters. If they fail to report suspected abuse, they can be fi ned, jailed, or sued per the mandated reporting laws of their state no matter what justifi cation they offer.
You can also be charged with failure to report if you do not make your report to the agencies listed in the state law. For instance, a teacher may report suspicions of abuse to his or her principal and assume this fulfi lls his or her obligation as a man- dated reported. However, if the allegations are never reported to the police or CPS, the teacher has not done what the law required. Ignorance of the reporting laws is not a suffi cient defense for failure to report to the proper agency (see Case Example 3.2 )
CASE EXAMPLE 3.2
Ms. Mitchell has a 6-year-old girl, Erica, in her class who has been acting withdrawn and sad. One day, Erica tells Ms. Mitchell that her mom’s boyfriend touched her in her private places. Ms. Mitchell comforts Erica and promptly fi les a written report with the school principal per her school’s policy. Ms. Mitchell is told that the principal, Ms. Kendall, will handle the problem, and she assumes she has fulfi lled her duty. She does not make a call to CPS or the police to report her suspicions.
Three months later, Erica is diagnosed with genital herpes, a sexually transmitted infec- tion, after her mother takes her to the pediatrician because she has sores on her labia. The doctor immediately informs CPS about the situation. During the investigation, Erica is asked why she did not tell anyone what was happening to her. She says that she did tell—she told her teacher a long time ago. On investigation, it is revealed that Ms. Kendall never reported the allegations. The principal said she had previous interactions with Erica during which it was proved that Erica had lied about another student stealing from her. Because the principal knew Erica had a history of lying, she did not believe her. The principal argued that it was not fair to make such serious allegations when the child could not be trusted to tell the truth.
In this case, both the teacher and the principal are guilty of failure to report suspected child maltreatment.
DISCUSSION QUESTIONS
1. What should Ms. Mitchell have done in this situation? 2. Why was Ms. Kendall’s decision not to report problematic?
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51MANDATED REPORTING
Although some may report because they are afraid of the possible penalties associated with failure to report, the strongest motivation to make reports for most people is to stop current child abuse and prevent future abuse. When people fail to report, more children are put at risk (see Case Example 3.3 ).
CASE EXAMPLE 3.3
Recently, the nation was shocked by allegations that Jerry Sandusky (JS), a former defense coordinator at Penn State University had sexually abused more than 10 boys over a 15-year period. Furthermore, it came to light that the beloved coach, Joe Paterno, had known of some of the alleged incidents and had not involved the police. Although JS has pled “not guilty” to the allegations, he was arrested on December 7, 2011 and charged with 52 counts.
As the grand jury prepared the case, it became clear that numerous persons, including many educated professionals and mandated reporters, had known of the alleged inap- propriate behavior and had failed to make a report to the proper authorities. Although in many cases people will say they did not report because they were not sure what they saw was abusive, that is not a plausible excuse for all witnesses in this case. In 2000, Jim Calhoun, a janitor, says he saw JS perform oral sex on a boy who was pinned against a wall in the locker room. Although this witness told other janitors and his supervisor, it was not reported to authorities. Others had suspicions and did not feel sure enough to report. Both the assistant principal and a teacher at a high school where JS volunteered were uncom- fortable with the relationships JS had with the boys, but neither reported. When a graduate student, Mike McQueary, allegedly saw JS anally assault a young boy in 2002, he did report to Joe Paterno who, in turn, reported to the athletic director. At this point, JS was asked to give up his key to the locker room and the people in charge of The Second Mile (a program started by JS to help at-risk children) were informed. However, the police were not notifi ed.
Moreover, when allegations were reported, they were not acted on appropriately. In 1998, a mother called the police at Penn State to report that her 11-year-old son told her that JS showered with him and hugged him repeatedly. Although JS admitted that he showered with this boy and others and even said, “I wish I were dead,” no criminal charges were fi led. In 2009, a mother called a high school and alleged that her son was sexually abused by JS. The school banned JS from their campus, and the school offi cials notifi ed the police. This, after more than a decade of failed reporting and poor investigation, led to a full investigation. The criminal trial began on June 11, 2012.
Although people are arguing in the legal arena about who knew, or who suspected, what at what time, it seems clear that the community let children down. Not only were early vic- tims not helped promptly, the appropriate steps were not taken to prevent future victims. Before his death from lung cancer at the age of 85, Joe Paterno said, “This is a tragedy. It is one of the great sorrows of my life. With the benefi t of hindsight, I wish I had done more” (Chappell, 2012; Vieth et al., 2012). On June 22, 2012, a jury returned a verdict of guilty on 45 of 48 counts (4 charges were dismissed by the judge during the trial: 2 were unproved, 1 was brought under a statute that did not apply, and 1 was duplicative). The most seri- ous charges for Victims 2, 5, and 6 resulted in the not-guilty verdicts, but Sandusky was found guilty of the most serious charges, including involuntary deviate sexual intercourse,
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52 INTRODUCTION/PURPOSE
EDUCATION REGARDING MANDATED REPORTING
Although it is likely that the previously mentioned dilemmas will never be fully resolved, there are other impediments to reporting that can be reduced or eliminated through education. A study by Kenny (2001) revealed that many of the doctors and teachers surveyed lacked knowledge about the reporting process. In this study, 75% of physicians and 62% of teachers indicated that their preservice training in child abuse was either minimal or inadequate. Signifi cantly, these mandated reporters did not know that they were immune from prosecution if they made a report that turned out to be unfounded. Knowing that one cannot be sued for reporting in good faith may increase the likelihood of reporting. Kenny also found that mandated reporters preferred to report to their colleagues and/or supervisors than to CPS and that, in some cases, this was the policy at their hospital or school. All mandated reporters need to know that state policy is clear on this issue: The person who suspects the abuse is the one who is mandated to report to protective services; a report to your supervisor does not fulfi ll this obligation. Finally, many of the professionals surveyed said they were not aware of the signs of maltreatment. All these concerns can be addressed with preservice and in-service training on abuse and the reporting laws. However, it seems that training for careers that will require mandated reporting does not include suffi cient and appropriate education about child maltreatment.
Recently, researchers have stressed the fact that training should have a strong legal emphasis. M. C. Smith (2006, 2010) reported that mandated reporters would be better served if their education about child maltreatment focused on both the legal defi nitions of maltreatment (as opposed to personal beliefs) and the criteria required to mandate a report. Across a variety of careers, Smith found that the decision to report is often infl uenced by personal beliefs instead of legal defi nitions. We all have strongly held beliefs about how children should be raised. I have worked with stu- dents who have said things such as “My mom used a belt on me, and I turned out fi ne” as a reason for not reporting a child who was bruised by a belt. On the other end of the spectrum, I know of mandated reporters who want to report all parents who are not perfect in their eyes. Frequently, students tell me they would report parents for neglect if their child was dirty. Although we may believe that parents should be
for other victims (Scolforo & Armas, 2012). On October 9, 2012, Sandusky was sentenced to prison for 30 to 60 years. This means he will not be eligible for parole until he is 98 years old. Sandusky continues to say he is innocent.
DISCUSSION QUESTIONS
1. Is it more diffi cult to make allegations if the alleged perpetrator is seen as a “pillar of the community”? If so, what can be done to help children who may be victims of perpetrators who present as upstanding citizens?
2. Do we take the sexual abuse of boys more lightly than the sexual abuse of girls? Is this true even if the alleged perpetrator is male in both cases?
3. Is there ever a situation where a grown man showering naked with young boys would be appropriate, or should such behavior always be considered abusive?
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53MANDATED REPORTING
loving, kind, attentive, encouraging, and patient at all times, the law does not man- date ideal care, only minimally adequate care. As you learn the legal defi nitions of each form of child maltreatment, you will see that some of them contradict your per- sonal beliefs. However, as a mandated reporter, you must follow the legal defi nitions.
Many students who are preparing for careers that will require mandated report- ing seem to know that they are not receiving enough training in this area. A good number of researchers have found that students preparing for careers as mandated reporters do not feel that they are adequately prepared to fulfi ll this role. In a study of 236 future health care providers, DeMattei, Sherry, Rogers, and Freeman (2009) reported that 27.2% felt they were not adequately prepared to recognize signs of maltreatment, and only 54.3% of them knew they could be charged with a crime for failure to report suspected child maltreatment.
It is also import to train mandated reporters to recognize all forms of maltreat- ment. For example, J. Fraser, Mathews, Walsh, Chen, and Dunne (2010) reported that although nurses felt confi dent about reporting physical or sexual abuse, they were less knowledgeable about neglect and emotional abuse. Eisbach and Driessnack (2010) found that nurses were quick and confi dent in reporting clear, objective signs of child maltreatment such as severe bruising or injuries inconsistent with parental report. However, in cases in which the evidence was more subjective, as in neglect cases, nurses tended not to report. Eisbach and Driessnack further noted that only 8.4% of referrals to CPS come from health care providers, which they interpret as evidence of underreporting. Morelen and Shafer (2012) call for special attention to be paid in training mandated reporters to notice and report emotional maltreatment. Forty-eight of the states specifi cally mention emotional maltreatment or abuse in their mandated reporting statutes. However, if reporters wait for objective or physical signs before reporting, this type of maltreatment will be missed. It is important for professionals who work with children to be aware of the research on emotional abuse and its potential effects on children (see Chapter 6, “Psychological Maltreatment”).
The good news is that there is a concentrated effort to increase and improve training in child maltreatment at both the graduate and the undergraduate level (see Profi le 3.1 ).
PROFILE 3.1
Victor I. Vieth, JD
Victor earned his bachelor’s degree from Winona State University and his Juris Doctorate from Hamline University School of Law. He currently serves as the executive director of the National Child Protection Training Center (NCPTC). The training center, located on the campus of Winona State University, is committed to training future and current pro- fessionals in the recognition and investigation of child maltreatment. In order to make training as realistic as possible, the campus includes fi ve mock courtrooms, four forensic interview rooms, and a mock house. The NCPTC trains around 15,000 professionals every year. Victor Vieth is a passionate speaker on an array of topics from the “Investigation and/ or Prosecution of Child Abuse and Neglect” to “Preparing for and Testifying as an Expert Witness.” When you hear Victor speak, it is clear that he is committed to eradicating child maltreatment through his own work and through training others. A big part of the work done by NCPTC is encouraging schools across the country to improve the training
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54 INTRODUCTION/PURPOSE
There have also been changed in CPS response to calls about possible maltreatment in the last decade. Instead of investigating all calls in the traditional manner, states now have differential response tracks (also called dual-tracks or alternative responses). Although serious cases are still investigated in the traditional manner, cases that are of low to moderate risk are being referred for assessment rather than investiga- tion. These assessments are voluntary and the focus on identifying family strengths and offering services to families (Child Welfare Information Gateway, 2008) (see Search the Web 3.3 ). This topic is covered in more depth in Chapter 13, “The Mal- treated Child and CPS Response: What Happens After a Report Is Made?” Knowing that there are options that are less punitive may make reporters less reluctant to call.
they offer in child maltreatment. As of June 2012, 23 schools had Child Advocacy Stud- ies (CAST) programs. A full list can be seen on the NCPTC website at www.ncptc.org. The programs include certifi cate programs, minors, majors, and graduate programs. Finally, Victor Vieth publishes extensively in the area of child maltreatment. He recently published “Unto the Third Generation” (2006), which outlines the steps we would need to take to eliminate all child abuse in the United States in the next three generations. On the second page of this book, Vieth begins to outline the steps of his battle plan to end child abuse. The fi rst step is that “abused children must be reported into the system and those reports must be of high quality.” To achieve this, “every university must teach students entering professions where they will be mandated reporters the skills necessary to perform this task and mandated reporters in the fi eld must receive annual training on the detection of abuse and their obligations to report” (Vieth, 2006, p. 6).
Vieth, V. (2006). Unto the third generation: A call to end child abuse in the United States within 120 years. Journal
of Aggression, Maltreatment & Trauma, 12 (3/4), 5–54.
FIGURE 3.1 Victor I. Vieth, JD. Photo Credit: Winona State University/National Child Protection Training Center.
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55MANDATED REPORTING
CONFIDENTIALITY AND MANDATED REPORTING
All mental health professionals are exposed to the rules of confi dentiality during their training. Both legal and ethical guidelines make it abundantly clear that com- munication between a client and helping professional is to be kept confi dential. However, as should be clear by now, there are limits to this confi dentiality that have been established by law. Professionals are obligated to break confi dentiality if their client threatens violence toward themselves or others and if the professional suspects child abuse. How can a mental health professional make peace with these two com- peting, and mutually exclusive, demands?
Mental health professionals are directed by their ethical guides to inform their clients as soon as possible or feasible about the limitations of confi dentiality. Whereas some counselors interpret this to mean they should carefully spell out the limits of confi dentiality near the beginning of the fi rst session, others interpret this to mean telling the client immediately after they disclose child maltreatment (Gushwa & Chance, 2008).
One possible solution is the forewarning of clients. Before mental health profes- sionals begin to work with a client, they should inform the client of the limits of confi dentiality. Clients should be told that anything they say will be held in con- fi dence unless they threaten violence or admit to child abuse. This then allows the client to decide what to confi de in the therapist (Crenshaw & Lichtenberg, 1993). Even though this is one way to avoid the ethical/legal dilemma, it is obvious that it is not a perfect solution. Imagine, for instance, a woman who seeks out a therapist because she knows she is maltreating her child and wants help to be a better parent. When she shows up for her fi rst appointment, she is told that if she tells her thera- pist that she has abused her child, the therapist will call CPS. What is this mother to do? Will this sort of forewarning prevent her from discussing this issue with her therapist? Will forewarning prevent her from getting the help she needs to be a bet- ter parent?
Another possible approach to this dilemma is informing. In this case, the thera- pist does not forewarn the client, but if the mental health professional begins to suspect abuse, he or she tells the client he or she is going to make the report before
SEARCH THE WEB 3.3
For a look ahead at the difference between a traditional, investigative response to alle- gations of child maltreatment, and the newer differential response, see this information provided by the Child Welfare Information Gateway:
www.childwelfare.gov/pubs/issue_briefs/differential_response/differential_responsea .cfm
You will fi nd a defi nition of “differential response.” There is a section comparing and contrasting the traditional response with the newer,
differential response. There is a table comparing and contrasting assessment and investigation.
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56 INTRODUCTION/PURPOSE
making the call. The hope is that this will maintain the therapeutic relationship (Crenshaw & Lichtenberg, 1993). Clearly, this option is also not a perfect solution. As long as the current laws regarding mandated reporting exist, therapists will need to struggle with this issue.
A third alternative would be for the therapist to encourage the client to self- report. If the client is willing to make the call to CPS, it could fulfi ll the reporting requirement and preserve the therapeutic relationship (the therapist would need to witness the call). While the parent would be admitting maltreatment, he or she would also be showing willingness both to take responsibility and to take initiative in seeking help to keep the child safe.
One possible change that has been suggested is to modify the existing laws so that mental health professionals (MHPs) are not required to report less serious instances of child maltreatment if the family is in therapy (Emery & Laumann-Billings, 1998). Of course, defi ning “less serious” will have its challenges, but advocates argue that this could reduce the caseload for CPS and offer better, uninterrupted service to clients.
IS MANDATED REPORTING A GOOD THING?
Now that reporting laws have been in existence for around 40 years, it may be time to ask whether they are a good thing. Interestingly, few people seem to raise this question. The reasoning seems to be that if the laws increase reporting, they are working and effective. As previously mentioned, the laws do increase reporting, but do they help children? In 1994, Lindsay examined U.S. statistics to determine if man- datory reporting led to a decrease in the most serious form of maltreatment, child fatalities. Unfortunately, they found that there had been little change in fatality rates over more than 30 years of mandated reporting.
One concern about mandated reporting has been the possibility of racially biased reporting. Are professionals more likely to assess for child maltreatment and report possible abuse if a child is a member of a minority group? Moreover, is this due to racial bias or does it refl ect an actual higher rate of maltreatment among certain minority groups? It is the case that Black children are reported to CPS at a rate that is approximately twice that seen for White children, and cases involving Black chil- dren are substantiated twice as often as cases involving White children. In addition, the NIS-4 (Sedlak et al., 2010) report found that the rate of maltreatment for Black children was 49.6 per 1,000 whereas the rate for White children was 28.6 per 1,000. After reviewing national data, B. Drake, Jolley, Lanier, Fluke, Barth, and Jonson-Reid (2011) concluded that the difference is not due to a reporting bias, but is attributable to the fact that Black children are at greater risk for child maltreatment because they are more likely to face serious risk factors for maltreatment such as poverty. Despite Drake et al.’s conclusion, more than 11 states currently have task forces that have been directed to study this racial disparity. We need to be careful to be as objective as possible in assessing for child maltreatment. While it would be wrong to overreport based on racial status, it is also problematic to be reluctant to report due to minority status.
Some have questioned whether the costs of mandated reporting outweigh the potential benefi ts. Although not much attention has been devoted to the costs of mandatory reporting, some researchers are trying to address this complex question.
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57MANDATED REPORTING
The United States and Australia have led the way in legislating mandated report- ing. Because all states in the United States require reporting, it makes comparison within the country impossible. However, in Australia, New South Wales has man- dated reporting laws, but Western Australia does not, so a comparison can be made there. Like any study done outside of the laboratory, it will not be perfect, because New South Wales and Western Australia will obviously differ in more ways than just reporting laws. With that limitation in mind, consider the following informa- tion that was published in 2002 after New South Wales had mandated reporting laws for 25 years. Of the reports made to protective services in New South Wales, 59.6% were investigated, and those had a substantiation rate (maltreatment was found) of 21.3%. Conversely, 97.4% of the calls to protective services in Western Australia were investigated, and 44.2% of them were substantiated. (According to Emery and Laumann-Billings, 1998, the substantiation rate in the United States is less than 33%, and 40% of those cases receive no services.) The concern is that mandatory reporting is increasing the number of reports and investigations, but not the number of children helped. In fact, investigating unfounded claims may be wasting resources that could be better used to aid children in families in other ways. In addition, an unnecessary investigation can be disruptive and painful to the family involved.
On the other hand, Mathews and Bross (2008) point out that some sort of man- dated reporting is essential for cases of maltreatment to come to the attention of authorities. They note that only 0.5% of substantiated reports originate from the child, 0.1% come from the alleged perpetrator, and 4.0% come from the nonabusing parent. In contrast, mandated reporters are responsible for more than 67% of the substantiated cases of child maltreatment in the United States.
The decision of whether to mandate reporting does not have to be simply yes or no. There is precedent for modifi cation of the mandatory reporting laws in the United States to address these concerns. For example, in 1995, Missouri incorporated a system in which reporters could select “assessment” for less severe situations or “investigation” for more serious incidents. After two years, Missouri saw a decrease in reports and an increase in substantiation rates (Delaronde, King, Bendel, & Reece, 2000). This may be a way to get the best of both worlds.
As the debate over how to most effectively help children rages on, professionals will continue to do their best under the current guidelines. The advice that is easiest to agree on at this time is to be aware of the relevant laws and to learn as much as possible about maltreatment and its effects on children.
CONCLUSION
If you enter a profession where you become a mandated reporter of child maltreat- ment, you will have to make diffi cult decisions about when to make reports. You are already on your way to preparing yourself for this role by reading the information in this text and familiarizing yourself with your state laws. Even though there are many controversial issues related to mandated reporting, the current laws require mandated reporters to provide reasonable suspicions to the proper authorities. To build your skills, you can discuss hypothetical cases with your colleagues and work out what you should do if you were in such a situation. Similarly, when confronted with a real case, turn to your more experienced colleagues for advice.
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58 INTRODUCTION/PURPOSE
DISCUSSION QUESTIONS
1. Read the following scenarios and decide whether you would make a call to CPS based on the information you have. In cases where you are unsure, what fur- ther information would you seek to help you make your decision? Write down your answers now and return to these scenarios at the end of the course to see if your responses have changed.
a. Imagine you are a second-grade teacher and you have a student, Nathan, about whom you are concerned. When 7-year-old Nathan arrives at school, he is very dirty and frequently says that he is hungry. You have taken to giving him cereal bars in the morning, and he seems grateful for them. Although Nathan does not appear to be malnourished, he is small for his age. Academically, Nathan is not a strong student, and he almost never com- pletes his homework assignments. He says there is nobody at home to help him with his schoolwork work. Although you have asked Nathan’s mother to come in for a conference, she says that because she works full-time and is a single mother, she cannot make it to school. When you ask her about breakfast, she says that Nathan is hard to get up in the morning and, there- fore, does not have time for breakfast.
b. Ten-year-old Jocelyn has really changed this year. She used to be very outgo- ing, but over the past few months, she has become withdrawn. She almost never makes eye contact, and she pulls away if you touch her. When you talk to her about her feelings, she tells you that she is sad, but she will not say why. Jocelyn’s mother says that Jocelyn is having a diffi cult time adjusting to her new stepfather because she is used to having her mother all to herself. When you ask Jocelyn about her stepfather, she says she used to like him, but now she does not. When you press for more information, she says she does not want to talk about him. Later she admits that she does not like her stepfather because he makes her keep secrets. She will not tell you what the secrets are, and she begins to cry.
c. In your role as a kindergarten aide, you frequently have to reprimand 5-year- old Zachary because he bullies his peers. He seems especially vicious toward the youngest and smallest children. One day you are leading Zachary away from the playground by placing your hand on his back. When he winces, you lift his shirt and notice a bruise on his back. Zachary says that he fell down the stairs at home and hurt his back. When Zachary’s mother picks him up, you mention the bruise and she says that Zachary is a bit wild and hurt himself when he fell from a tree in their yard over the weekend. Two weeks later, you notice some bruising on Zachary’s ear. He says he hurt him- self playing and his mother supports his story. Neither provides any details about how this new injury occurred. It is now April, and when you look over Zachary’s school record, you notice that he has missed about fi ve days of school each month this year.
d. As a worker at a day-care facility, you are in charge of the room for the 4-year-olds. One day you see Sally kissing one of the boys in the pretend kitchen. When you ask what they are doing, Sally informs you that they are “TV kissing with open mouths.” You gently explain that this is not
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59MANDATED REPORTING
appropriate behavior and direct the children to another activity. However, two weeks later, you fi nd Sally and a different boy showing each other their private parts. Sally also tells you that it feels good when she touches her “front privates.” When you talk to Sally’s mom, she says that recently Sally has become very interested in the difference between boys and girls. She apologizes for Sally’s behavior in class and says she will talk to her. Although Sally’s mother seems a bit embarrassed, she does not seem very concerned.
2. How do you think you would feel if you had to make a report of suspected child maltreatment? How might a colleague or other professional help you cope with any negative feelings?
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PART II
Types of Abuse and Their Effects
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63
When someone hears the term child abuse , what most often comes to mind is a picture of a child who has been physically abused. This makes sense because child physical abuse (CPA) was the fi rst type of child maltreatment to be identifi ed by professionals, and it leaves the most visible marks on its victims. Although growing media atten- tion to other types of maltreatment (such as sexual and emotional abuse) may eventually change this, for many people, the image of a bruised and battered child is the one that is most closely tied to the concept of child maltreatment.
DEFINITION
The defi nitions of physical abuse vary, but a general way of thinking about this type of maltreatment is to label any act by a caregiver that results in a nonacci- dental physical injury to a child as physical abuse. This provides a starting point, but it does not fully defi ne the concept. For example, driving under the infl uence of alcohol with a child in the car can be labeled physical abuse, even though any injury to the child would be accidental. Most people are comfortable seeing driving under the infl uence as child abuse, but a nonaccidental injury that occurs when a parent is engaging in corporal punishment to correct their child’s behavior is more controversial. In this scenario, any injury to the child is nonaccidental, but the parent’s behavior was intended to teach the child, not to harm him. Another complicating factor is that physical abuse at one age may not be physical abuse at another age. For example, a slap to the face of a newborn (see Figure 4.1) is consid- ered to be child physical abuse, whereas slapping the face of an adolescent is not necessarily labeled as maltreatment. Finally, in some descriptions of physical abuse, the risk of injury can also be part of the defi nition. For instance, Alabama defi nes physical abuse as including “harm or threatened harm to the health or welfare of a child” (§26-14-1(1)-(3)). Other states only include harm that has already occurred. For example, Connecticut’s law reads, “Abused means that a child or youth has been infl icted with physical injury or injuries by other than accidental means” (§46b-120). ( See Case Example 4.1. )
CHAPTER 4
Physical Abuse Monica L. McCoy
child physical abuse
an act by a caregiver that
results in a nonaccidental
injury to a child.
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64 TYPES OF ABUSE AND THEIR EFFECTS
CASE EXAMPLE 4.1
Consider the father’s behavior in the following case that took place in Baltimore, Maryland, in 2004. A 12-year-old girl was having trouble with her computer while her father napped on the couch. When she fi rst approached him, he asked her to wait until after his nap. The second time the girl interrupted his sleep, he yelled at her. The third time she woke him, he kicked a step stool in anger. The stool ended up fl ying over the couch and hitting his daugh- ter in the face. He immediately took her to the hospital, where she received three stitches in her nose and was treated for other abrasions to her face (Parks, 2004).
In this case, the Department of Social Services felt that the father’s acts constituted physical child abuse. The Hartford County Circuit Court agreed with the Department of Social Services, saying, “It was certainly foreseeable that when he kicked the stool in her direction, the stool could have struck her” (Parks, 2004, p. 1). The court of appeals, how- ever, was not convinced. They noted that under Maryland law, the court could not fi nd someone guilty of child abuse if the injury was “accidental or unintentional and not reck- less or deliberate” (Parks, 2004, p. 1).
DISCUSSION QUESTIONS
1. Is kicking a step stool when a child is in the room reckless? 2. Was the injury to the child the result of a deliberate act on the part of the father? 3. Which court’s decision do you agree with?
FIGURE 4.1 An infant with a slap mark on the face. Photo credit: Lawrence Ricci, MD.
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65PHYSICAL ABUSE
The authors of the Fourth National Incidence Study, or NIS-4 (see Focus on Research 2.3 for a description of this study), wrote that “physical abuse includes shaking, throwing, purposefully dropping a child; hitting; pushing, grabbing, drag- ging or pulling; punching or kicking; and other physical abuse” (Sedlak et al., 2010, p. 3–6). The National Clearinghouse on Child Abuse and Neglect Information (2005) provided a similar defi nition: “All states and territories provide defi nitions for physical abuse. The term is generally defi ned as any nonaccidental physical injury to the child, and can include striking, kicking, burning, or biting the child, or any action that results in physical impairment of the child.” This provides a general defi nition while also reminding the reader that small differences will occur between states.
Defi nitions in State Laws
To fi nd the statute that defi nes physical abuse for your state, you can log on to the site titled “The Child Welfare Information Gateway,” which now includes the infor- mation previously found on the page for the National Clearinghouse on Child Abuse and Neglect Information (see Search the Web 4.1 ).
SEARCH THE WEB 4.1
Go to the following website: www.childwelfare.gov/systemwide/laws_policies/state/. At this site, you need to complete three steps in order to fi nd the statute for a specifi c state.
1. Select the state you are interested in knowing about. 2. Choose an issue or issues. The relevant issue for fi nding a state’s defi nition of physi-
cal abuse would be Defi nitions of Child Abuse and Neglect. 3. Submit your request by clicking Go. You will then see a copy of the statute for the
state you selected.
There are some specifi c issues you should consider when read- ing state law. For instance, does the statute deal specifi cally with bruising, and if so, does it include severity of bruising? Some states, like Colorado and Idaho (§19-1-103 and §16-1602, respectively), list “skin bruising” from nonaccidental injury as evidence of abuse, yet in other places, such as Hawaii, the description of abusive bruising reads “substantial or multiple skin bruising” (§350-1). A second issue of interest is the overlap between abuse and neglect statutes seen in some states. For instance, Arizona statute 8-201 includes the following in its defi nition of physical abuse: “permitting a child to enter or remain in any structure or vehicle in which volatile, toxic, or fl ammable chemicals are found or equipment is possessed by any person for the purpose of manufacturing a dangerous drug.” Even though this behavior would certainly increase the child’s
statute
a law passed by a
legislative body.
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66 TYPES OF ABUSE AND THEIR EFFECTS
risk of injury, it also describes neglect (lack of supervision). Another issue is that of harmed, which all states include, versus threaten to harm or put at risk for harm, which only some states include. In terms of protecting children, it seems like a good idea to remove them from risky situations before they are actually harmed by their parents. On the other hand, it is extremely diffi cult to prove that a parent has placed a child in a situation with an unacceptable level of risk.
Some states have unique behaviors included in their statutes describing physi- cal abuse. For example, Illinois specifi cally notes that female genital mutilation is considered abusive (Ch. 325, §5/3), and Florida Ann Stat. §39.01 states that a physi- cally abusive parent is one who “purposely gives a child poison, alcohol drugs or other substances that substantially affect the child’s behavior, motor coordination, or judgment of that results in sickness or internal injury.” Minnesota law specifi es that shaking a child under 3 years of age constitutes physical abuse as does the “unreasonable interference with a child’s breathing” (§626.556). Although these behaviors would likely be considered abusive in all states, it is interesting to see what behaviors each state’s legislature decides to list in its statute. The specifi c behaviors listed may indicate that professionals in that state are especially sensi- tive to that particular form of maltreatment. Often a high-profi le case involving a specifi c form of abuse leads to changes in the wording of the state law (see Case Example 4.2 ).
CASE EXAMPLE 4.2
The sad situation that has become known as the “Baby Haley” case illustrates many of the concepts dealt with in this text: physical abuse, mandated reporting, investigation by Child Protective Services (CPS), criminal court, and civil court. In June of 2004, offi cers arrested Tommy Joe Owens, 31, and his girlfriend, Charlotte Kay Claiborne, also 31, at their mobile home in eastern Tennessee (Balloch, 2005a). Although the couple was originally arrested on charges of forgery (Claiborne) and failure to appear in court (Owens), more serious charges were fi led once the condition of the children living in the home was discovered (Balloch, 2005b). The couple was subsequently charged with aggravated child abuse, reckless endan- germent, and felony child neglect regarding Mr. Owens’s 3-year-old daughter, Haley. They were also charged with the neglect of two other children in the home. In addition, both Owens and Claiborne tested positive for methamphetamines (Balloch, 2005a). At the time that Haley was removed from their care, she had numerous serious injuries. She had multiple burns and bruises on her arms, legs, eyes, and buttocks. The burn to her eyes was believed to be chemical in nature, and it was so severe that it required surgery. Furthermore, her ears and nose were damaged, and she was suffering from a fever (Balloch, 2005b).
In addition to the charges fi led against Owens and Claiborne, Haley’s babysitter, Teresa Draughn, was charged with failure to report suspected child abuse (Balloch, 2005a). Although nonprofessional babysitters are not mandated reporters in most states, Tennessee law states that “any person who has knowledge that a child has been harmed by abuse or neglect must
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67PHYSICAL ABUSE
report” (§§37-1-403; 37-1-605). Witnesses suggested that not only did Draughn fail to report the abuse; she may have also actively tried to conceal some injuries (Balloch, 2005b).
Only Mr. Owens’s case went to trial; both of the women pled no contest to the charges against them. The babysitter, Draughn, was sentenced to 11 months of probation for fail- ure to report child abuse. The judge’s order required that she receive counseling and that she enroll in either a GED program or a vocational training program. In addition, she was not allowed to have any contact with Haley, and she had to pay $400 in court costs (Alapo, 2005). The girlfriend, Claiborne, was sentenced to 20 years, of which she must serve at least 15 years, for three counts of aggravated child abuse (Balloch, 2005b).
At the trial of Mr. Owens, Haley’s 10-year-old stepsister testifi ed that she and the other children had caused most of Haley’s injuries. However, on cross-examination, the child appeared confused and was not able to provide believable responses to questions about the abuse (Balloch, 2005c). A medical doctor, Mary Campbell, testifi ed that Haley had suffered signifi cant nonaccidental injuries. She noted that Haley had been burned, possibly with hot water, but more likely by chemicals. Other burns were determined to be consistent with ciga- rette burns. She stated that an ear injury was likely the result of a direct blow to the organ. Finally, one bruise was described as possibly being infl icted by a coat hanger (Balloch, 2005b). Mr. Owens testifi ed on his own behalf at his trial. Although he admitted using methampheta- mines and shoplifting, he maintained that he was not guilty of abusing Haley. Owens’s lawyer argued that even though the evidence showed that Haley had been injured, it did not prove that Owens had infl icted those injuries (Balloch, 2005c). At the conclusion of the trial, the jury deliberated for less than 1 hour before fi nding Mr. Owens guilty of three counts of aggra- vated child abuse and one count of aggravated neglect (“East Tennessee Man Convicted,” 2005). Mr. Owens was subsequently sentenced to 95 years in prison (Balloch, 2005d).
After Haley was released from the hospital, she was placed with her mother, Rosemary Spicer. According to Ms. Spicer, Haley has more surgeries ahead of her, and she still suf- fers from nightmares. Although Ms. Spicer had been in a custody dispute with Mr. Owens prior to the arrest, she said she never thought he would harm Haley. Ms. Spicer has fi led an $11.5 million civil suit against Owens and Claiborne. In addition, a $600,000 claim has been fi led against the Department of Children’s Services (DCS) on her behalf (Satterfi eld, 2005). The claim against the DCS asserts that initial reports to investigate Haley’s situation were ignored. After the arrests, three employees at the DCS were disciplined internally for the oversight (Balloch, 2005a).
DISCUSSION QUESTIONS
1. Do you think appropriate verdicts and sentences were rendered in this case? Were the punishments too mild, too severe, or adequate a. for Draughn? b. for Claiborne? c. for Owens?
2. In this case, was it appropriate for Ms. Spicer to sue Owens and Claiborne for dam- ages?
3. Was it appropriate for Ms. Spicer to sue the DCS?
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68 TYPES OF ABUSE AND THEIR EFFECTS
PREVALENCE AND INCIDENCE
Throughout this text, the rate of maltreatment is discussed in terms of incidence and prevalence. Incidence is the term used to refer to the number of new cases that occur
or are diagnosed each year. In terms of physical abuse, the incidence may be described as the number of cases substantiated by Child Pro- tective Services (CPS) in a given year. Prevalence is defi ned as the total number of cases in a specifi ed population at a given point in time. In other words, prevalence tells you how many people in a population have ever suffered from that problem. For physical abuse, prevalence data tell you how many people in the population of interest have ever been victims of substantiated cases of physical abuse.
Although it is not as common as child neglect, which is covered in the next chapter, across the years, child physical abuse accounts for approximately 22.7% of all calls to the Department of Social Services and is associated with nearly two thirds of child fatalities (Kolko, 2002). In 2010, 17.6% of all substantiated cases of child maltreatment dealt with physical abuse. This represented 12,380 children (U.S. Children’s Bureau, 2011). According to National Inci- dence Study-4 (see Focus on Research 2.3 ) the incidence of physical abuse according to the harm standard in 2005–2006 was 4.4 per 1,000 children. This is slightly lower than the numbers from 1993
and slightly higher than the numbers reported in 1986, but the differences are not statistically signifi cant. According to the endangerment standard, physical abuse had an impact on 6.5 per 1,000 in 2005–2006. This is signifi cantly lower than the number reported in 1993 but is signifi cantly higher than the number reported in 1986 (see Table 4.1 ; Sedlack et al., 2010).
Sedlack et al. (2010) broke the 2005–2006 incidence of maltreatment down into subcategories of severity. Unfortunately, this information was not reported separately for physical abuse, but instead, the authors summarized injury from all maltreat- ment. Fatal maltreatment occurred at a rate of 2,400 children in 2005–2006, or 0.03 per 1,000. Serious maltreatment included such things as life-threatening injuries (e.g., something that stopped the child’s breathing), injuries leading to long-term impair- ment (e.g., third-degree burns), and injuries that required professional intervention in order to prevent long-term impairment (e.g., broken bones). During 2005–2006, there were 487,900 cases, or 6.6 per 1,000, that were classifi ed as serious. The third category, moderate, included cases in which some observable sign of injury persisted for at least 2 days, even if it did not require medical care. Sedlack et al. reported 694,700 cases of moderate maltreatment, or 9.4 per 1,000. None of these fi ndings was signifi cantly dif- ferent from the rates reported in the NIS-3 for incidence rates in 1993.
incidence
the number of new
cases occurring or being
diagnosed in a year.
prevalence
the number of cases
that exist in a specifi ed
population at a given
point in time.
substantiated
a report of child
maltreatment that has
been confi rmed by child
protective services.
TABLE 4.1 Incidence Numbers for Physical Abuse as Reported by the NIS-4 NIS-2 (1986) NIS-3 (1993) NIS-4 (2005–2006)
Harm Standard 269,700 4.3 per 1,000
381,700 5.7 per 1,000
323,000 4.4 per 1,000
Endangerment Standard
311,500 4.9 per 1,000
614,100 9.1 per 1,000
476,600 6.5 per 1,000
Source: Sedlak et al. (2010), pp. 3–4, 3–15.
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69PHYSICAL ABUSE
A recent prevalence study was conducted by Felitti and Anda (2009). They exam- ined more than 17,000 participants. Their sample was interesting in that it would be considered a low-risk group. The people who took part in the survey were middle class, and all of them had good health insurance. The authors found a prevalence rate of 28% for childhood physical abuse. In other words, more than one in four of these adults had a history of physical abuse. One would expect this number to be even higher if the sample included more people from high-risk groups (e.g., poor, lacking insurance).
CORPORAL PUNISHMENT
One important question that arises when you discuss physical abuse concerns dif- ferentiating between child physical abuse and physical punishment that is legal. In some countries (e.g., Austria, Denmark, Finland, Germany, Iceland, Israel, Italy, Nor- way, and Sweden), such a distinction is not needed because their laws forbid any corporal punishment and label all such behavior as abusive.
Most parents in the United States admit to using corporal punishment. Gershoff (2002) reported that by the time a U.S. child is 14 years old, there is a 94% chance that they have been spanked. Because corporal punishment is legal and common in the United States, one must try to establish guidelines for what is and what is not abusive. This can be a tricky business. Let us take, for example, the state law of South Carolina. According to §20-7-490, the state’s defi nition of child physical abuse includes injury in cases of excessive corporal punishment, but allows appropriate cor- poral punishment: “child abuse and neglect does not include corporal punishment or physical discipline that is reasonable in manner and moderate in degree.”
This defi nition has terms that are open to interpretation. For instance, consider “reasonable in manner and moderate in degree.” Can you imagine that rational, educated persons may disagree about what types of physical punishment meet these criteria? As mentioned earlier, some countries have passed laws saying that any physical punishment is unreasonable. Therefore, U.S. legislators clearly disagree with them by allowing corporal punishment at all. Even within the United States, attitudes vary greatly about what is reasonable. For instance, Southerners tend to be more accepting of harsh physical punishment than are Northerners. Many times, when college classes attempt to defi ne physically abusive punishment, much debate erupts over spanking a child with an object (from a wooden spoon to a belt). In these informal discussions, although many Northerners are shocked by the very idea that a parent would use a belt in disciplining, many Southerners accept it as normative. Not only do interpretations vary by region; they also vary by time. What was once accepted as appropriate parenting (say, by our grandparents), is now considered abu- sive. So, even though many young adults report that their parents were punished with a belt, they have no intention of using a belt to spank their own children. As we hear more and more stories of permissive parents and out-of-control children, it is possible that the pendulum will swing back toward a greater acceptance of harsher physical punishment. Or, more optimistically, a greater concern for the rights and dignity of children may push parents to learn about, and adopt, effective, nonphysi- cal means of behavior modifi cation. As professionals working with children, you will not only need to familiarize yourself with state and federal laws, but you will also need to understand how the terms used in those laws are interpreted by your com- munity. (See Case Example 4.3. )
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70 TYPES OF ABUSE AND THEIR EFFECTS
CASE EXAMPLE 4.3
Jessica Beagley has become infamous for punishing her 7-year-old son by forcing hot sauce into his mouth and making him swish it around and hold it in his mouth without swal- lowing it. Jessica Beagley and her husband, a police offi cer, have four biological children and the adopted twin 5-year-old boys from Russia in 2008. Prior to being adopted by the Beagleys, the boys had been living in poverty (ABC News, 2011). While one of the twins adjusted well following the adoption, the other did not. Jessica Beagley says that traditional forms of discipline did not work with one son. In order to punish him for mis- behaving in school and lying about it, she forced hot sauce into his mouth and then made him stand under a cold shower while he screamed (McLaughlin, 2011).
Ms. Beagley’s behaviors became public knowledge when she submitted a video of the punishments to the Dr. Phil show. Jessica Beagley maintains that she needed help with her son and was reaching out to the show for assistance. She made the video at the request of the show producers who said that her description of the punishment was not suffi cient. Jessica Beagley had her 10-year-old daughter record the punishment on October 21, 2010 (McLaughlin, 2011). When the episode of Dr. Phil titled “Mommy Confessions” aired on November 17, 2010, audiences across the United States and Russia were outraged. Some in Russia wanted to demand that the boys be returned (ABC News, 2011).
Following the airing of the show, the case was investigated, and Jessica Beagley was charged with child abuse. A jury found the 36-year-old Beagley guilty of a single, misde- meanor charge of child abuse that could be punished by up to 1 year in prison and/or a fi ne of up to $10,000. The district court judge, David Wallace, said that “Beagley was not the worst kind of offender and this is not the worst kind of offense” (p. 1) and that with exception of this incident, Beagley was a good mother, as he handed down a suspended sentence. As long as Ms. Beagley does not violate probation for 3 years, she will not face any jail time, nor will she have to pay any fi ne. She was ordered to continue receiving counseling services along with her sons (Hopkins, 2011).
DISCUSSION QUESTIONS
1. Do you think that Jessica Beagley’s actions constituted child abuse? Why or why not? 2. If you think that Ms. Beagley’s actions were abusive, was her sentence appropriate? 3. Ms. Beagley claims that she reached out to Dr. Phil because she was desperate to get
help with her son. Do you believe this was her motivation? 4. Was the Dr. Phil show right to air the video, or should its producers have simply
reported the case to CPS? 5. If, in fact, the producers of the Dr. Phil show asked Ms. Beagley to make the video, are
they also guilty of hurting the boy?
Even if corporal punishment is not labeled as child abuse, it might still be bad for children. Gershoff (2002) did a meta-analysis of 88 studies on corporal punishment and found that the use of physical discipline was only associated with one positive outcome. Corporal punish- ment is consistently found to increase immediate compliance. On the other hand, corporal
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71PHYSICAL ABUSE
punishment was associated with a host of negative effects during childhood (lower levels of moral internalization, more aggression, an increase in both delinquent and antisocial behavior, poorer quality of the relationship between parent and child, and lower levels of mental health) and in adulthood (greater aggression, more crimi- nal and antisocial behavior, poorer mental health, and an increased likelihood of abusing their spouse or child). Finally, Gershoff reported a signifi cant relationship between corporal punishment and child physical abuse. Of course, it must be noted that this research is correlational in nature. It would not be ethical to assign some children to spanking and others to no-spanking conditions. And, it might be that children who are spanked often are different from nonspanked children even before the punishment.
Do Laws Against Corporal Punishment Protect Children?
Would children be safer if corporal punishment was not permitted in the United States? Certainly, this would address the problem of trying to defi ne appropriate corporal pun- ishment. Because some countries have enacted bans on spanking, there are data that speak to this question. Larzelere and Johnson (1999) attempted to assess the impact of the ban on spanking that was enacted in Sweden in 1979. Their fi rst discovery was that shockingly little research had been done to assess the impact of the spanking ban on child abuse rates. They found only seven articles with pertinent information, and many of them were weak in terms of empirical evidence. Still, they were able to draw several conclusions. First, the spanking ban did not eliminate spanking. A year after the ban, 28% of parents admitted to either spanking or slapping their children during the previous year. In addition, the rate of spanking, as assessed by retrospective design, was barely changed by the ban. Second, the rate of physical child abuse was at best unchanged in the 20 years following the ban. Some evidence points to a small increase in physical abuse after the ban. It may be that banning spanking without educating parents about alternative types of discipline could actually increase physical abuse. In these cases, parents may become so frustrated by their inability to enforce their rules that they lose control with their children. It is possible that any increase due to this type of problem would resolve itself after parents became more adept with alternative means of discipline. As for now, the relationship between spanking and child physical abuse is not clear. The one thing that is known at this time is that a law prohibiting corporal punishment does not eliminate either spanking or child physical abuse.
CONSEQUENCES OF PHYSICAL ABUSE
Bruises
The most obvious effects of physical abuse are the immedi- ate medical or health problems caused by abuse. The most common physical injury associated with child physical abuse is bruising. Bruises are mostly commonly caused by blunt force, but they can also result from suction, biting, or tight restraint (Skellern & Donald, 2011). All children will occasionally be bruised as the result of normal play or accidental injury, but there are characteristics of abusive bruising that arouse suspicion.
bruising
injury in which
capillaries are damaged,
allowing blood to seep
into the surrounding
tissue; generally caused
by striking or pressing
that does not break the
skin.
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72 TYPES OF ABUSE AND THEIR EFFECTS
When assessing a bruise, one must fi rst consider the age of the child. Prior to being able to move around without help, it is rare that a child will suffer an accidental bruise. Given that children do not begin to crawl until approximately 6 months of age, any bruising prior to this age should raise questions. This does not, of course, mean that all young infants with bruises have been abused. Certainly, young children can be accidentally dropped or allowed to roll off a bed or a changing table. As children begin to crawl and walk, it is common to see bruises on certain parts of their body. Accidental bruises tend to be on areas of the body where the bone is close to the surface and on the parts of the body with which the child leads. For instance, areas on the front of a child such as the forehead, chin, knees, and shins are low-suspicion areas for abuse, as are the back of the head and the back of the arm from the elbow down. As you think about a child playing and exploring his or her environment, it is easy to imagine an accidental bruise occurring in these places. New crawlers can bang their forehead against objects, and new walkers frequently run into things with their shins. On the other hand, bruising on the ears, trunk, genitals, or the back of the hands is suspicious (Johnson, 2002). Not only are these places where an accidental bruise is unlikely; they are also common locations for abusive injuries. As a general rule, bruises on the peripheral parts of the body are more likely to be accidental, and bruises are the central parts of the body are more likely to be the result of abuse, as shown in Figure 4.2 .
FIGURE 4.2 Bruise location: areas that lead to high suspicion for abuse and areas that are related to low suspicion for abuse
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73PHYSICAL ABUSE
In addition to considering the location of the bruise on the body, the pattern of the bruise provides information about its cause. An examination of bruising may reveal that the bruise is the mark left by a palm or an object such as a hanger, a belt, a spoon, or a cord (see Figure 4.3). In these cases, you can see the shape of the object on the child’s skin. If the story the parent or child provides to explain the mark is not consistent with the pattern you see, there is cause for suspicion.
Certainly, seeing a child with many bruises may cause concern. One way to assess whether the injuries occurred at one time, as could be the case in a serious accidental injury such as falling from a tree, or over time is to pay attention to the coloring of the bruises. The color cannot tell you exactly how long ago an injury occurred, but it does give some indication. New bruises tend to be red, but within 6 to 12 hours, they begin to turn blue. Approximately 12 to 24 hours after an injury, bruises are black- ish purple in color. About 4 to 6 days after an injury, a dark-greenish tint appears, and within 5 to 10 days, the bruise fades to a pale green or yellow. All of these color changes are much more obvious on lighter skinned children, so special attention is necessary to notice the same degree of bruising on a child with darker skin. A child who has many suspicious bruises at various stages of healing may be the victim of child physical abuse.
A special case of bruising in abused children is the human bite. Bites leave a distinct pattern that makes them fairly easy to identify. Furthermore, it is diffi cult to argue that a bite was accidental. In some cases, forensic dentists have even been
FIGURE 4.3 A child with bruises that resulted from being hit with a belt. Photo credit: Lawrence Ricci, MD.
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74 TYPES OF ABUSE AND THEIR EFFECTS
FIGURE 4.4 Although this may look bad, it is the result of an accidental injury. This 8-year-old boy was hit in the eye while playing baseball. When you see an injured child, you should not assume the worst.
able to identify perpetrators by analyzing bite marks (Brodeur & Monteleone, 1994). If you notice a bite mark on a child, it is a good idea to ask the child what caused the mark.
As you think more about child physical abuse, it is important that you keep in mind that children do suffer accidental injuries. Even a bruise that looks bad can be the result of normal childhood play, such as that shown in Figure 4.4 . It is appropri- ate to ask a child or their parent how an injury happened. Generally, children who have suffered an accidental injury do not mind telling you about it; they may even enjoy the attention.
Fractures
Most mandated reporters other than medical doctors would not be expected to assess fractures, because this type of evaluation requires expert training in radiology. Also, if you thought a child had an untreated fracture, you would immediately refer the
child to a medical doctor. Still, there are some basic facts about fractures that a nonmedical professional can know that might help in assessing a child’s history. (See Profi le 4.1 to read about a doctor who has dedicated her life to assessing children for possible mal- treatment.)
fractures
the partial or complete
breaking of bone or
cartilage.
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75PHYSICAL ABUSE
The greatest incidence of abusive fractures is seen in young children. Most children who suffer fractures from physical abuse are younger than 2 years of age, and between 55% and 70% of them are younger than 1 year old. Compare this to the fact that less than 2% of all accidental (nonabusive) fractures are seen in children who are younger than 18 months old. Given these numbers, fractures in infants are always worth not- ing carefully. The biggest red fl ag is when the history provided by the caregiver does not adequately correlate with the injury seen on an X-ray. In other words, what the
PROFILE 4.1
Carole Jenny, MD
Dr. Carole Jenny is a strong and dynamic advocate for children. She earned a BA in zoology from the University of Missouri, a BMS from Dartmouth Medical School, an MD from the University of Washington, and an MBA in health care from the Wharton School of Finance and Commerce. Dr. Jenny is currently a pediatrician, a professor of pediatrics at the Warren Alpert Medical School of Brown University, and director of the Child Protection Program at Hasbro Children’s Hospital in Providence, Rhode Island. Dr. Jenny has put her expertise to work by evaluating thousands of children for suspected abuse and testifying as an expert witness in court as needed. Her alumni magazine, Dartmouth Medicine, describes her as “Tough and Tender” (Lunardini, 2009, p. 1). Dr. Jenny believes in using all of the resources available to thoroughly assess children for signs of abuse. She encourages doctors to do thorough interviews, to use the best technology for physical assessment, and to meet with interdisciplinary teams to best protect children. Dr. Jenny also travels the country to share her expertise with others who work to protect children from maltreatment.
FIGURE 4.5 Dr. Carole Jenny. Photo credit: Karenphilippi.com.
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76 TYPES OF ABUSE AND THEIR EFFECTS
parent says occurred would not have caused an injury of this severity. (For examples, see the section Injuries From Falls in this chapter.) Other suspicious fractures are those found during an exam for an unrelated problem. For instance, if a child is pre- sented as suffering from pneumonia and the doctor discovers a rib fracture, there is cause to be concerned about a possible abusive injury. Nonabusive parents are almost always aware when their child has suffered a trauma that could break a bone, and they readily describe it to physicians. Another potential indicator of abusive fractures is when multiple fractures are noted on different parts of the body and the reported history did not include a major trauma (such as a car accident). Finally, a fracture becomes more suspicious when the child has other injuries such as burns or bruises. If a doctor is suspicious, a complete skeletal survey should be done. A “baby gram,” which x-rays the entire body with just one or two pictures, is not considered a suf- fi cient investigation (J. Moore & Smith, 2006).
There are also certain bones that are more likely to be broken in abusive situ- ations. Breaks of the long bones of the arms and legs are seen frequently in abuse cases, yet abusive fractures to the hands and feet are not common. Long-bone breaks are often spiral breaks, which means they were caused by twisting the limb. This can happen accidentally, especially in an older child, but this type of break is suspicious in young children. Rib fractures are also often the result of abuse. Because a child’s ribs are somewhat pliant, a signifi cant amount of force is required before they will break. Ribs can be broken by direct blows or by extreme squeezing. Finally, skull fractures in infants (that were not caused by the birth process) are suspicious. These can result from a direct blow to the head or from a child being hit against something (J. Moore & Smith, 2006).
Head Injuries
In addition to assessing for fractures and bruising, doctors need to assess potentially abused children for head injuries. This type of injury is common in abuse situations, and it can have dire consequences. Hekmatpanah, Pannaraj, and Callans (2002) reviewed the records of 190 abused children who had been treated at the University of Chicago Medical Center between 1965 and 1995, and whose primary trauma was a head injury that required hospitalization. All of the children were younger than 48 months of age (4 years), 89% were younger than 3 years, and 63% were younger than 1 year. The most common symptom at admittance was depressed level of con- sciousness (64%), which was followed by respiratory distress (32%), seizures (32%), and vomiting (23%). Frequent signs included retinal hemorrhage (41%), bulging fontanel (44%) and capillary change (22.5%). The outcomes for this type of injury were quite serious. Of the children, 22 (12%) died as a result of their injuries. Others suffered delayed physical development (15%), delayed mental development (8%), or both (2%).
It has recently been noted that young children at high risk for child abuse, should be assessed for occult head injuries (fractures that are not detected by standard X-rays until 3 to 4 weeks after the injury is sustained). In one sample of 51 high-risk chil- dren, 19 (37.3%) were found to have occult fractures that did not show up on X-rays, but that were evident using computed tomography or magnetic resonance imaging (Rubin, Christian, Bilaniuk, Zazyczyn, & Durbin, 2003). Given that head injuries are often associated with serious, negative outcomes, it is necessary to spend the extra time and money to do full assessments using the best technology.
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77PHYSICAL ABUSE
Shaken Baby Syndrome
Abusive head injury may be the result of shaken baby syndrome (SBS) or shaken impact syndrome (SIS). These terms were fi rst used in the 1970s when doctors began to notice a set of injuries that results when a young child has been violently shaken. In these cases, an adult grasps a child by the arms or the trunk and shakes the child forcefully. This sharp shaking causes the brain to collide with the skull. In addition to the violent shaking, the child’s head may also make contact with a hard surface such as a wall or the fl oor. Like many of the injuries we have been discussing, shaken baby syn- drome is seen almost entirely in children younger than 2 years of age, and frequently the child is younger than 6 months. In most cases, there are no externally observable signs of shaken baby syndrome; however, some children may have bruises where they were held. This lack of obvious, visible symptoms does not mean they are not injured. Shaking can cause serious injury, including subdural hema- tomas (blood pools between the dura and the brain) and retinal hemorrhage (bleeding on the surface of the retina). Although you cannot see these injuries with the naked eye, there are symptoms you can note. Victims of SBS are often extremely irritable, they have problems feeding (including a decreased appetite or vomiting for no appar- ent reason), and they are lethargic, which may include poor muscle tone (K. Wells, 2006). Because shaking a baby can cause serious injury, some hospitals now send newborns home in onesies that say “Don’t Shake Me” and include a toll-free phone number for parents who feel out of control. The thinking behind this campaign is that even though parents know not to hit a child, they may not realize that shaking a child can be just as harmful. Although educating caregivers about the dangers of shaking is an important fi rst step, it is also necessary to provide assistance to parents who may be overwhelmed by the caregiving role. It seems that parents who shake their children are frequently frustrated by their inability to soothe a crying child.
Injuries From Falls
When presenting a child for treatment, many parents report that the child was injured by falling. What researchers have found, however, is that falls from short distances generally do not cause signifi cant harm to children. A common situation is for a child to fall from a bed or a sofa. Helfer, Slovis, and Black (1977) studied the hos- pital incident reports for 85 children younger than the age of 5 years who had fallen a distance of approximately 3 feet (generally from a bed or a sofa). Of these children, 57 were not injured, 17 had very minor injuries (small cuts or scrapes and/or bloody noses), 20 ended up with a bump or a bruise, and only 1 had a skull fracture (which did not include any soft-tissue damage). In 40 of these cases, X-rays were taken, and the only fracture revealed was the one already noted. Because parents only seek medical help when they think a fall may have resulted in an injury, Helfer et al. also surveyed parents at a pediatric clinic. They asked parents to complete a survey indi- cating any instances in which their children fell from a bed or couch and what the consequences of the fall were. Although it is probable that parents were more likely to recall falls that resulted in injury, the results still indicated that short falls do not result in traumatic injury. In 176 of these incidents (80%), there were no observable injuries at all. In 37 cases (17%), the child sustained a minor injury such as a bruise or
shaken baby syndrome
(SBS)
a condition of severe
internal bleeding,
particularly around
the brain or eyes, that
is caused by violently
shaking an infant or a
young child.
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78 TYPES OF ABUSE AND THEIR EFFECTS
a scratch. In only six falls (3%) did the child suffer a serious injury (a fracture). Three children fractured their clavicles, two had skull fractures with no serious head injury (both of whom were younger than 6 months), and one had a fractured humerus. None of the children suffered life-threatening injuries. The authors concluded that serious injury from a short fall is extremely unlikely. Therefore, if a parent reports that a child has fallen a short distance and has suffered an extreme injury, the profes- sional should consider that the parent is not providing an accurate history.
Others have since replicated the fi nding that serious injuries are not likely to result from short falls. When researchers examined data from hospital and daycare settings and from public injury databases, they concluded that the chance that a child would die from a short fall (less than 1.5 meters/4.7 feet) is less than 1 per million per year (Chadwick et al., 2008). Even falls from greater distances are generally not fatal. One study by Chadwick, Chin, Salerno, Landsverk, and Kitchen (1991) found that of 65 children who had fallen from 5 to 9 feet, none died. Further, only 1 of 118 children who fell from 10 to 45 feet was fatally injured (see Focus on Research 4.1 ). Along these same lines, Barlow, Niemirska, Gandhi, and Leblanc (1983) reported that only 14 of 61 infants and children who fell four or more stories were killed, and 47 survived with few permanent injuries.
FOCUS ON RESEARCH 4.1
In 1991, Chadwick, Chin, Salerno, Landsverk, and Kitchen published an article titled “Deaths From Falls in Children: How Far is Fatal?” in The Journal of Trauma. The setting for their study was the trauma center at the Children’s Hospital in San Diego, California. The authors examined records for cases that had occurred between August of 1984 and March of 1988. They identifi ed 317 cases in which children had allegedly been injured by a fall. Of these, 283 indicated the estimated distance of the fall, so these became the focus of the study.
The children who had fallen were generally young. At the time of the injuries, 30 were younger 1 year, 145 were between 1 and 3 years old, 61 were between 4 and 6 years, 65 were from 7 to 12 years, and 16 were older than 13 years at the time of the injury. More male children (199) had fallen than had female children (118).
The authors then looked at how far the parent or caregiver reported that the child had fallen. The most common report was of a short fall. Of the falls, 100 were estimated to be between 1 and 4 feet. Sixty-fi ve reported falls were from a distance of 5 to 9 feet. Seventy- fi ve of the children were said to have fallen between 10 and 14 feet. Twenty-four falls were from a distance of 15 to 19 feet. Seventeen falls were from heights of 20 to 29 feet, and two falls were from distances between 30 and 45 feet.
The next information gathered from the fi le was whether the falls resulted in a fatality. Only eight children died of their injuries. What was striking, however, was the relation- ship between the reported distance of the fall and fatality. Seven of the fatalities were from children who had reportedly fallen a distance of 4 feet or less. None of the children who had fallen between 5 and 9 feet died, and only one of the children who had fallen between 10 and 45 feet had died. Based on these results, the authors said one would end up with the absurd conclusion that the risk of death from short falls is 8 times greater than the
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79PHYSICAL ABUSE
risk of falls from 10 to 45 feet. Because this seemed unlikely to them, they focused more extensively on the cases in which children had died, hoping to determine whether the caregivers had provided an accurate report of how the injury had occurred.
Of the seven children who died following an allegedly short fall, one 11-month-old was reported to have fallen down the stairs, because the child was found at the bottom of the stairs by a babysitter; nobody observed the fall. (A fall down stairs is considered a series of short falls, not a long fall). In addition to massive head injuries, this baby had small, round bruises on both arms, the inner thighs, and the labia major. Two infants were reported to have died after suffering a fall while in an adult’s arms. In one case, a babysitter said she fell while carrying a 13-month-old child upstairs. In addition to the current injuries, this child had an older, healing fracture of the tibia. In the other case, a father reported that he had fallen against the crib with his then 6-week-old child in his arms. He did not take the child for treatment until 6 days later, at which time the child was unconscious. The fi nal four children who died as the result of a short fall were said to have either suffered a standing fall (two) or fallen from a bed or table (two). The authors found these accounts to be prob- lematic because of the work done by Helfer, Slovis, and Black (1977), who reported that of 180 falls by small children that took place in a hospital, there were no fatalities. Children suffered minor injuries, if any. The authors then concluded that all of the deaths that alleg- edly occurred following short falls may have been false reports. The authors hypothesized that abusive parents may not realize that short falls are unlikely to cause serious injury in children, so they use the short fall as an excuse for what may, in fact, be abusive injuries.
Burns
The most likely victims of abusive burns are infants and young children. Although many children suffer accidental burns, it is often possible to determine from the characteristics of the burn whether it was the result of abuse or an accident. Because abuse has been found to be the cause of between 10% and 25% of burn injuries in children, it is good to assess for possible abuse when presented with a burned child (K. Feldman, 1997).
A common burning agent is tap water. Once water exceeds 130 °F, it will cause second-degree burns on a child in approximately 10 seconds. This is why some parents who have young children have the temperature on their water heater lowered to between 120 °F and 125 °F. Although this is a good safety measure, especially once children can turn on faucets (at about 24 months), it is not necessary to prevent burns when a child is supervised. A parent would not accidentally leave a child in 130 °F water long enough for the child to burn because the threshold for a pain response is 114 °F to 118 °F (K. Feldman, 1997). A parent may accidentally place a child in water that is hot enough to burn him or her, but the par- ent will remove the child immediately once he or she hears the child’s cry of pain.
If you see a child with a tap-water burn, there are some features you can look for to determine the origin of the burn. First, consider burns to the hands and feet. If children accidentally place one of their extremities in hot water, they will imme- diately remove it. This results in a burn with an irregular contour and splash marks
burns
injuries caused by fi re,
heat, or acid; fi rst-degree
burns cause red skin,
second-degree burns
result in blisters, and
third-degree burns cause
deep skin destruction.
6241-171-P2-004.indd 79 10/19/2013 10:14:27 AM
80 TYPES OF ABUSE AND THEIR EFFECTS
above the burn. By contrast, a child whose hand or foot has been forcibly immersed in hot water will have a burn with a relatively even edge and few splash marks. These burns have been described as “glove” or “sock” burns because the area of burned skin looks like one of those objects. Because the child was not free to kick his or her feet or to fl ail his or her arms, there will not be as many splash marks. Another telling pattern from a tap-water burn results when a child is held in a hot tub. These vic- tims show burns over much of the torso, but a patch of skin on the buttocks will be spared. This happens because the part of the bottom that was pressed against the tub did not burn because the tub surface was cooler than the water (K. Feldman, 1997; Johnson, 2002).
Another suspicious type of burn is the pattern burn. In other words, the burn clearly resembles a common hot object. These burns may indicate that a hot object was placed on the child or that the child was held against the hot object (see Fig- ure 4.6). A frequent source of pattern burns is cigarettes. The result of a cigarette burn is a clear, circular imprint that, after healing, resembles a small pox vaccination. Acci- dental cigarette burns are likely to occur on the fi ngers or the mouth (when the child mimics smoking with the wrong end); abusive burns are usually seen on body parts that are generally covered by clothing (abdomen, genitals, etc.) Also, in abuse cases, you frequently see multiple burns; accidents most often result in only one cigarette burn (K. Feldman, 1997).
Other abusive pattern burns result from objects that are easily available in a home—heating grates, heated silverware, clothing irons, curling irons, and the like.
FIGURE 4.6 A child with a burn from a cigarette lighter. Photo credit: Lawrence Ricci, MD.
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81PHYSICAL ABUSE
At this point, many female readers are probably recalling an instance when their mother accidentally brushed their forehead with a curling iron while trying to make them look good for picture day. This is clearly not the type or placement of a pattern burn that would concern a mandated reporter. More suspicious curling-iron burns would be found on the trunk of the body, and they would refl ect a deeper burn than one would get from grazing the forehead. For instance, in an abusive situation, the imprint of the entire length of the curing iron might be visible on the child’s back. Likewise, a child may step on a heating grate that is located on the fl oor and acci- dentally burn the bottom of one foot. However, it is not likely that they would then put their other foot on the grate as well. So, a single, blurred, surface burn is more likely to be accidental, whereas multiple, deep, and clearly defi ned burns are more suspicious (K. Feldman, 1997). And, of course, you still need to consider the child’s developmental level. If a child is not yet walking, he or she should not be able to burn the bottom of even one foot.
Although many mandated reporters are frustrated by the language of “likely” or “suspicious” instead of more concrete rules for determining the origin of injuries, it is not possible to give black-and-white answers. The best we can do is consider the injury, and then, if suspicious, compare what we see to the parent’s and/or child’s report of what happened. If one remains skeptical, call CPS. Ultimately, it is the job of CPS to determine whether a child has been abused.
Finally, the abused child may try to hide these injuries. These children may wear inappropriate clothing such as long sleeves and pants during the summer months or be wary of physical contact. Contrast this to the showing-off behavior that is often seen in children with accidental injuries. The reluctance to let others see an injury can provide one more reason to be concerned about a mark on a child.
Death
Unfortunately, some cases of child physical abuse are fatal. Whether more maltreat- ment deaths are due to neglect or physical abuse is not clear. Some studies attribute more fatalities to neglect, whereas other studies fi nd that physical abuse is linked to more fatalities. The Child Welfare Information Gateway reports data on fatalities due to child maltreatment. It reports that an estimated 1,560 children died from abuse and neglect in 2010. Almost half of these (40.8%) suffered from more than one type of maltreatment. Neglect alone was responsible for 32.6% of fatalities; physical abuse for 22.9%; and medical neglect for 1.5% of fatalities. The children who were most vulnerable were the very young. Children younger than the age of 1 accounted for 47.7% of child fatalities whereas 79.4% of those who died were younger than 4 years old. In most cases (79.2%), the caregiver responsible was one of the parents acting alone or with someone else. Mothers alone accounted for 29.2% of fatalities. Mothers were more likely to be guilty in neglect cases whereas fathers and boyfriends of the mother were more likely to be guilty in physical abuse cases. The perpetrators tended to be young (mid-20s), poorly educated, impoverished, and depressed (Child Welfare Information Gateway, 2012). Other researchers have reported higher rates of fatalities from child physical abuse than from neglect. Klevens and Leeb (2010) exam- ined 1,374 cases of death in children younger than 5 years of age that were reported to the National Violence Death Reporting System. They noted that 600 of the deaths were due to child maltreatment. Two thirds of the deaths were attributable to abusive
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82 TYPES OF ABUSE AND THEIR EFFECTS
head trauma, and 27.5% were due to other forms of physical abuse. Only 10% of the maltreatment deaths were attributed to child neglect. Klevens and Leeb did fi nd the same perpetrator pattern that was reported by the Child Welfare Information Gate- way in 2012. Mothers were more likely to be guilty in cases of child neglect, whereas fathers (or father substitutes) tended to be the perpetrator in cases of physical abuse. They also found that they very young were at the highest risk; more than half of the victims were younger than 1 year old.
CAUTION: NOT ALL MARKS ARE SIGNS OF ABUSE
As we learn to recognize signs of child abuse, we must be careful not to assume that all suspicious-looking marks are evidence of child abuse. Some conditions may
be easily mistaken for abuse. For instance, both chicken pox and impetigo (a bacterial skin infection that causes blisters that will eventually burst and form a crust; Medline Plus, 2006) can look like cigarette burns, and Mongolian spots can look like bruises. Mongo- lian spots are congenital and are present at birth or within the fi rst few weeks of life. The spots are bluish gray in appearance, so they look similar to bruises. However, unlike bruises, they do not change color over time. Most children do experience a disappearance of the marks by the age of 4 years. Mandated reporters want to be especially careful when assessing marks on children of certain ethnic groups such as Asians, Hispanics, and children from East Africa, who experience high rates of Mongolian spots (Tannous & Abdul-Ghani, 2005). In addition, a child may suffer from a condition such as osteogenesis imperfecta (OI) or a platelet aggregation disorder that can mimic child physi- cal abuse. Children who suffer from osteogenesis imperfecta have a genetic disorder that causes their bones to break easily. This gives rise to the more commonly used name of the disorder, “brittle bone dis- ease.” A child with osteogenesis imperfecta can break a bone doing something as innocent as rolling over during sleep (Osteogenesis Imperfecta Foundation, 2006). Children who have a platelet aggrega- tion disorder have platelets that do not form plugs at injury sites. This means that the child will bruise easily and will suffer from nosebleeds as well as bleeding of the gums (Canadian Hemophilia Society, 2006). If you have a child in your care at a day care or school, you should be made aware of any condition the child has that may be confused with
signs of child abuse or that might have an impact on your dealings with them. If you are not sure about a particular child, ask a nurse or supervisor to review the child’s record and inform you of anything you need to know to assess marks on the child.
MARKS FROM FOLK MEDICINE PRACTICES
A problem that requires sensitivity to cultural diversity is dealing with children who have been treated with folk medicine practices. The term folk medicine encompasses all health practices that have
impetigo
a contagious skin
infection that is marked
by blisters that erupt and
form crusts.
Mongolian spot
a birthmark that is a
smooth, fl at, bluish-gray
spot that looks like a
bruise.
osteogenesis imperfecta
a genetic disorder in
which bones fracture
easily.
platelet aggregation
disorder
a medical condition that
occurs when platelets do
not form plugs at injury
sites.
folk medicine
health practices that
come from cultural
traditions; native
remedies.
6241-171-P2-004.indd 82 10/19/2013 10:14:27 AM
83PHYSICAL ABUSE
grown from cultural traditions. The roots of these practices can be anything from the empirical use of natural food remedies to superstition. When these practices confl ict with accepted Western treatment, that problems arise. If parents does something they believe will help their child, and Western medical knowledge suggests the prac- tice hurts the child, is the parent abusive?
Cao Gio
Some Southeast Asians practice Cao Gio . In this form of treatment, the practitioner massages a heated ointment or oil on an ill child’s neck, spine, and ribs. Next, a coin or a spoon is run along the child’s skin with fi rm, downward strokes. This results in red, linear marks (burns or abrasions) on the child’s skin (Brodeur & Monteleone, 1994). The parents are not doing this because they are angry with the child, and they are generally willing to readily discuss what was done to the child (Johnson, 2002). Therefore, we see some similari- ties to physical abuse (child suffers a nonaccidental injury at the hands of a caregiver), but other differences (parents are not angry or secretive and believe they are helping). To make this situation even more confusing, there is disagreement among Western pro- fessionals as to whether Cao Gio is a harmful practice. Some (e.g., R. Davis, 2000, p. 94) argue that “there is no need to discourage the use of Cao Gio in conjunction with the use of Western health treatments.” R. Davis (2008) states that this prac- tice, which has been handed down for generations, is not harmful and is believed by the people using it to be helpful. Yeatman and Van Dang (1980) interviewed 46 Vietnamese living in the United States about Cao Gioand found support for this position . Of the participants they interviewed said, 94% said they had practiced Cao Gio, and they all said they felt better after the treatments. In addition, none of the participants knew of anyone who had been hurt by Cao Gio. Based on these results, the authors recommend that U.S. doctors should not discourage Cao Giobecause that may make Vietnamese patients distrust them. Unfortunately, not all doctors agree that Cao Giois harmless. A research letter published in the Journal of the American Medical Association in 2002 stated that possible complications of Cao Gio include burns, cerebral hemorrhage, and camphor intoxication from a balm used in coining (Rampini, Schneemann, Rentsch, & Bachli, 2002).
If some doctors believe a procedure to cause unnecessary pain and/or suffering, should it be considered abusive? Galanti (1997) make s the following thought-pro- voking statement in the second edition her book Caring for Patients From Different Cultures: Case Studies From American Hospitals : “It is not that Asians never abuse their children, but rubbing them with coins is not the way they do it, any more than Americans abuse their children by having thin pieces of metal wrapped around their teeth and tightened until their teeth move out of place. Braces are often applied for primarily aesthetic reasons. Coin rubbing, at least, is an attempt to heal. Appar- ently, it often works. Only the failures show up in the medical system” (p. 123). If this example does not engage you, consider the common practice of male circumci- sion in the United States. Although this painful and unnecessary medical procedure is accepted by most Americans, is it possible that people from other cultural back- grounds would consider it to be abusive?
Cao Gio
a Southeast Asian
practice in which a
practitioner massages a
heated ointment or oil
on an ill child’s neck,
spine, and ribs and then
runs a coin or spoon
along the child’s skin
with fi rm, downward
strokes.
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84 TYPES OF ABUSE AND THEIR EFFECTS
Caida de Mollera
Another example of folk medicine that some consider child abuse is found in the remedies used to treat Caida de Mollera (fallen fontanello). Children with Caida de
Mollera have a sunken anterior fontanel (space between the bones in an infant’s skull). This can be the result of severe illness, signifi - cant weight loss, or dehydration. Folk treatments include holding children upside down and perhaps shaking them (in an up-and- down motion) or slapping their feet. The impact of this treatment is debated. Some researchers clearly feel that it is dangerous and note that the procedure does not cure dehydration and it may cause retinal hemorrhages or other symptoms that mimic shaken baby syndrome (Brodeur & Monteleone, 1994; Johnson, 2002). Conversely, Hansen (1997) argues that signifi cant force is required
to cause shaken baby syndrome, but the folk treatment of Caida de Mollerais neither violent nor forceful. So, if a baby presents with symptoms of shaken baby syndrome and the parents admit to Caida de Mollera, this folk treatment is not necessarily the cause of the observed injury.
What should be done in cases such as these? Perhaps the best advice for profes- sionals is to be knowledgeable about local folk medicine practices and then attempt to provide education about other, more accepted medical treatments (Brodeur & Monteleone, 1994). The purpose behind the reporting laws is to help children. You must ask yourself whether this child would be better served by a referral to CPS or by parental education.
NONPHYSICAL CONSEQUENCES OF PHYSICAL ABUSE
Intellectual and Academic Problems
Not only does physical abuse hurt a child’s body, but we also see problems that are not necessarily physical in nature. For instance, most, although not all, studies show that victims of childhood physical abuse suffer from intellectual and academic prob- lems. These problems can be seen in academic performance and in school behavior. Victims of childhood physical abuse have lower test scores on measures of overall intellectual ability and on specifi c tests in math and reading. In addition, they are more likely to receive special education services, and they are diagnosed with learn- ing disabilities more often than are their nonabused peers. Most of these documented differences remain even when socioeconomic status is controlled for by researchers (Miller- Perrin & Perrin, 1999; Mills et al., 2011). Physically abused children are also more likely to be disciplined in school, and they are more likely to be suspended than are nonabused children. Researchers have also noted that victims of child physical abuse are 2.5 times more likely to repeat a grade than are nonabused children. Failure to pass a grade can be related to academic and/or behavioral problems. Although some children may suffer from intellectual problems due to brain injury that resulted from abuse, others do not perform well in school because they are too distracted by their home situation to concentrate. Still others struggle because they miss a lot of school. Students may be kept home when their parents are attempting to hide an abusive injury, or the child may be too hurt to attend. In either case, their sporadic attendance
Caida de Mollera
a sunken anterior
fontanel (space between
the bones in an infant’s
skull) that can be the
result of severe illness,
signifi cant weight loss, or
dehydration.
6241-171-P2-004.indd 84 10/19/2013 10:14:27 AM
85PHYSICAL ABUSE
is, at least partly, to blame for their school failure. Finally, abusive families frequently move around a great deal, which leads to discontinuity in the educational process. All of these factors can have a negative impact on school performance (Kolko, 2002).
Changes in Cognitive Processing
It has also been noted that, as a group, victims of child physical abuse may think differently than do nonabused children. For instance, physically abused children are more likely to assume that others have hostile intentions. If a classmate accidentally bumps into a child who has been the victim of physical abuse, the abused child will generally assume that the child who bumped him or her did it on purpose. This, of course, is likely to provoke a hostile response in return. The tendency to attribute hostile intent to others may be related to abused children’s more general problem with perspective; they are not good at examining a situation from another person’s perspective (Kolko, 2002). In nonabusive households, children learn to consider oth- er’s perspectives through interactions with their parents. When parents gently and rationally encourage children to think about what others were thinking or feeling, they develop the child’s ability to take on another’s perspective. When lacking this type of interaction, children do not spontaneously develop this ability.
Issues With Interpersonal Relationships
Not surprisingly, these victims have diffi culties in forming strong interpersonal relationships. They are often insecurely attached to their parents and are frequently categorized as having a resistant or avoidant attachment to their caregivers. This poor attachment relationship lays a weak foundation for future relationships. As a result, physically abused children have a great deal of troublemak- ing friends because they have not developed the appropriate social skills. Researchers have found that victims of physical abuse are defi cient in certain prosocial behaviors such as smiling when they are with their peers, and their interac- tive play skills are below age level (Miller-Perrin & Perrin, 1999). These social defi cits can lead children to being rejected by their peers.
Aggression
One of the most extensively documented effects of physical abuse is aggression. In a physically abusive household, aggression is modeled as a way to solve problems and as an appropriate behav- ior. Aggressive behavior in physically abused children is a robust fi nding that is seen across a variety of settings (Miller-Perrin & Per- rin, 1999). Victims of physical abuse indicate a greater willingness to use physical punishment than do their nonabused peers. No matter how much some people want to deny that they are shaped by their parents, parents are children’s fi rst, and most profound, models. A number of studies have demonstrated a link between early child abuse and later delinquent behavior. For instance, Widom (1989) reported that children who were physically abused prior to the age of 11 were signifi cantly more likely than their peers to have a juvenile
interpersonal
relationship
social association,
connection, and
involvement between
two people.
aggression
behavior that is intended
to cause harm or pain; a
disposition to behave in
a violent way even when
not provoked.
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86 TYPES OF ABUSE AND THEIR EFFECTS
delinquency record (26% vs. 16.8%), to have an adult criminal record (28.6% vs. 21.1%), and to have a violent criminal record (11.2% vs. 7.9%). A literature review by Malinosky-Rummell and Hansen (1993) found evidence supporting a strong link between physical abuse during childhood and subsequent violent behavior in adult- hood. People who suffered physical abuse as children were more likely to engage in aggressive behavior including fi ghting and violent criminal activity. They were also more likely to report violence toward dating partners, spouses, and their own chil- dren. Although the estimated range for the rate of intergenerational transmission of abuse stretches from 7% to 70%, most researchers suggest that approximately 30% of abused children will become abusive parents.
Substance Abuse
Physical abuse during childhood has also been linked with subsequent substance abuse. These children are at an increased risk for using legal drugs such as alcohol and tobacco and illegal drugs (Lown, Nayak, Korcha, & Greenfi eld, 2011; Pelcovitz, Kaplan, DeRosa, Mandel, & Salzinger, 2000). Not only are victims of child physical abuse more likely to use alcohol; they are more likely to develop alcohol depend- ence and to suffer negative consequences from their use of alcohol than are their nonabused peers. People with a history of child physical abuse reported more alcohol-related fi ghts, legal issues, health problems, work problems, and family prob- lems than did non abused people (Lown et al., 2011). Victims of child physical abuse are also more likely to engage in heavy episodic drinking during their teenage years and into early adulthood than are their nonabused peers (Shin, Miller, & Teicher, 2012). The use of alcohol and other drugs can be seen as a form of delinquent behav- ior, but it may be mediated by a child’s internal pain that results from abuse. In other words, the substance abuse is less about acting out and more about self-medicating to deal with issues of depression and low self-esteem.
Internalizing Symptoms
Abused children show externalizing symptoms such as aggression, and they show internalizing symptoms. Child victims of physical abuse generally have lower self- esteem than do their nonabused peers. They tend to show evidence of hopelessness and depression at a higher rate than do their nonabused peers (Kolko, 2002; Miller- Perrin, & Perrin, 1999). Physically abused children in psychiatric (Kazdin, Moser, Colbus, & Bell, 1985) and nonpsychiatric (Allen & Tarnowski, 1989) settings have signifi cantly higher scores on measures of depression and self-concept than do nona- bused comparison children. This is true even when samples are matched for age, sex, race, and socioeconomic status (SES). It is important to note, however, that just because physically abused children are receiving higher scores than are nonabused children, they are not necessarily scoring within the impaired range when compared
with standardized norms (D. Allen & Tarnowski, 1989). Fuller- Thomson, Baker, and Brennenstuhl (2012) studied 3,774 women and 2,868 men and found that a history of child physical abuse was strongly associated with suicidal ideation. Women who reported being physically abused as children were more than 7 times more likely to report suicidal ideation than were nonabused women. Men
suicidal ideation
thoughts about suicide;
plans to end one’s life;
may include suicide
attempts.
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87PHYSICAL ABUSE
with a history of child physical abuse were more than 6 times more likely to report suicidal ideation than were nonabused men. These differences were maintained even when the researchers controlled for other factors (e.g. SES factors, adverse childhood conditions, stressors) that may have led to suicidal ideation.
Sadly, and shockingly, even young children commit suicide. The Centers for Dis- ease Control (CDC) reports that suicide is the 14th leading cause of death among those younger than 12 years old. This translates to 0.8 children per 100,000. The suicide rate among those between 10 and 14 years old is 1.3 per 100,000, and among those between 15 and 19 years old, the rate jumps to 7.67 per 100,000 and is the third leading cause of death during those years. Among the youngest victims of suicide, you have a history of depression, but in many children, you see other symptoms instead. Young children who are impulsive, or those with attention defi cit hyperac- tivity disorder (ADHD) or conduct disorder are at an increased risk for suicide (Beam, 2008). In one examination of 266 suicide attempts or suicidal ideation at a psy- chiatric hospital, it was noted that children younger than 12 were more likely to have ADHD whereas children from 12 to 18 years of age were more likely to suffer from mood disorders (Ben-Yehuda et al., 2012). Related to their impulsivity, younger children are more likely to commit suicide via an impulsive act such as running into traffi c or jumping from a high spot (Beam, 2008). This means that in addition to being attentive to signs of depression in young children, you should also pay attention to their level of impulsivity.
Posttraumatic Stress Disorder
Being physically abused as a child also increases the likelihood that the individual develops posttraumatic stress disorder (PTSD) , a disorder that may arise after someone has experienced an intense, negative event. The Diagnostic and Statistical Manual of Mental Disorders ( DSM ) , Fourth Edition (American Psychiatric Associa- tion, 1994), indicates that this episode must be something that involved “actual or threatened death or serious injury, or a threat to the physical integrity of self or others,” and that the person responded to this event with “intense fear, helplessness or hor- ror” (1994, p. 467). A person suffering from PTSD will persistently reexperience the event (e.g., intrusive thoughts, dreams), avoid reminders of the event, and show increased forms of arousal. These symptoms must persist for over a month before a diagnosis would be made (American Psychiatric Association, 1994). Margolin and Vickerman (2007) reported that in a community sample, 15.2% of boys and 27.4% of girls who had experienced physical abuse met diagnostic criteria for PTSD. Among clinical samples, the numbers jump to 18% for boys and 50% for girls. Furthermore, women who are physically abused as children are at increased risk for being raped and/or assaulted as adults. This further injury can increase the PTSD symptoms shown by these revictimized females (Schumm, Hobfoll, & Keogh, 2004). So, not only does physical abuse lead to post-traumatic stress disorder in some children, but in others, it also makes them more vulnerable to future violence, which may make the existing PTSD more severe.
posttraumatic stress
disorder (PTSD)
an anxiety disorder that
occurs in response to
experiencing extreme
stress (generally
involving actual or
threatened death or
serious injury). The
person experiences
symptoms including
reexperiencing the
event, avoiding stimuli
reminiscent of the event,
and increased arousal for
at least 1 month .
Diagnostic and
Statistical Manual of
Mental Disorders ( DSM )
a manual published by
the American Psychiatric
Association that lists the
criteria for diagnosing
mental disorders as well
as provides information
on causes, age of onset,
gender differences, and
prognosis.
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88 TYPES OF ABUSE AND THEIR EFFECTS
Other Consequences
Finally, children who are the victims of childhood physical abuse are at an increased risk of suffering from a range of other psychiatric disorders including
major depression, dysthymia, attention defi cit hyperactivity disorder (ADHD) , conduct disorder, and oppositional defi - ant disorder (Borger, Cox, & Asmundson, 2005; Pelcovitz et al., 2000). In a study of 43,093 people, 3,097 reported a history of child physical abuse. The victims had a higher lifetime preva- lence for a large number of psychiatric disorders as compared to the nonabused participants. Of the participants with a history of physical abuse, 84% went on to develop some type of disorder. Furthermore, the chances of developing a mood disorder, an anxi- ety disorder, a substance use disorder, or making a suicide attempt were all related to the frequency of maltreatment. As the number of abusive incidences increased, so did the risk for developing a disorder. The disorders most strongly associated with a history of child abuse were ADHD, PTSD, and bipolar disorder (Sugaya et al., 2012). Likely related to an increase in mental illness and lower educational achievement, victims of physical abuse earn 32.5% less than do their nonabused peers (Tanaka et al., 2011) and they have fewer assets (Currie & Widom, 2010). Clearly, these victims suffer not only external, physical injuries, but internal damage as well. As a mandated reporter, you should be attentive to both forms of damage when you are assessing a child for poten- tial physical abuse.
CONCLUSION
Nearly 23% of all calls to CPS involve allegations of child physi- cal abuse. Although defi nitions vary by state, there is a general agreement about the types of acts that constitute this type of mal- treatment, especially at the more severe end of the spectrum. Over time, physicians and mental health professionals have become more adept at noticing the signs of child physical abuse. Due in large part to the mandated reporting laws, these professionals are now more likely than ever to report their suspicious fi ndings to the authorities. Although all forms of maltreatment are a challenge to
prove in court, the physical marks left by this type of maltreatment can aid investiga- tors in proving their case and securing safety for the child.
DISCUSSION QUESTIONS
1. Over time, the defi nition of child physical abuse has changed. The trend has been to classify more behaviors as abusive. Is this a good thing or a bad thing?
dysthymia
a chronic, mild
depression that persists
for more than 2 years.
attention defi cit
hyperactivity disorder
(ADHD)
a mental disorder
characterized by a
limited attention span,
overactivity, restlessness,
and impulsiveness.
conduct disorder
a personality disorder
of childhood marked
by persistent disruptive
behavior and repeated
violation of the rights
of others and of societal
norms.
oppositional defi ant
disorder
a disruptive pattern of
behavior in childhood
that is characterized
by defi ance and
disobedience as well as
hostile behavior. These
behaviors persist for
at least 6 months and
interfere with everyday
functioning.
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89PHYSICAL ABUSE
2. Should people who engage in folk medicine practices be prosecuted for child physical abuse? Why or why not?
3. If you read in the newspaper that a father told doctors that his 2-year-old son had fallen off the couch and broken his arm and fractured three ribs, what would you think about his account?
4. How important are parental intentions in the assessment of child physical abuse? Should acts that were not meant to harm the child, but did cause harm, be considered abusive?
5. Do you think that laws regarding child physical abuse should cover only harm, or both harm and threatened harm? Why?
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DEFINITION
Child neglect is an act of omission. Parents or caregivers are not doing some-thing that they should be doing for their children. Neglect can be thought of as the failure to meet the minimum requirements for care; it is not the failure to pro- vide ideal care. Although we focused on physical abuse in the previous chapter and devote this chapter to neglect, the federal government identifi es abuse and neglect together as follows:
Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious injury or emotional harm, sexual abuse, or exploitation, or an act or failure to act which presents an imminent risk of serious harm.
(42 U.S.C.A. §5106g(2))
As you can see, this defi nition does not provide much guidance about what, exactly, constitutes child neglect. One common complaint heard from people who work in child protection is that the language used to defi ne maltreatment is not precise. To further complicate matters, each state, and the District of Columbia, has its own defi nition of child neglect. What the defi nitions have in common is that neglect entails the failure of parents or caregivers to meet needs for food, clothing, shelter, protection, and medical care. There are, however, substantial differences among the states’ statutes.
Differences in State Defi nitions of Child Neglect
States differ in whether they take into consideration the parents’ ability to provide for their children. Consider the following statutes:
Arizona: “Neglect or neglected means the inability or unwillingness of a parent, guardian or custodian to provide for that child . . .”(§8-201)
Nevada: “because of the faults or habits of the person responsible for his welfare or his neglect or refusal to provide them when able to do so” (§432B.140)
Wisconsin: “Neglect means failure, refusal, or inability . . . for reasons other than poverty, to provide . . .” (§48.981)
In these three examples, you see three different ways of determining neglect. Arizona considers failure to provide for the child to be neglect, whether that failure is due to the parents being unwilling or unable to provide. Parents who are incapable of providing
CHAPTER 5
Child Neglect
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91CHILD NEGLECT
because of poverty or mental illness are considered neglecting, as are parents who fail their children due to their disinterest in them. Nevada has a softer approach by only labeling parents as neglectful if they do not provide for their children when they are able to do so. Finally, Wisconsin exempts parents who cannot provide due to poverty, but does not exclude those who are unable to provide for other reasons.
Fetal Neglect States also differ in their inclusion or exclusion of fetuses in their neglect statutes. Recent years have seen a dramatic increase in the legal penalties for women who use drugs while they are pregnant. By 2005, 5 states had neglect statutes that dealt explic- itly with exposing fetuses to drugs or alcohol, and by 2011, this number had increased to 12. For example, Illinois defi nes a neglected child in part as “a newborn whose blood, urine or meconium contains any amount of a controlled substance or a metabolite thereof” (Ch. 325 §5/3). Min- nesota includes the following statement in its defi nition of neglect: “Prenatal exposure to a controlled substance, used by the mother for a nonmedical purpose, as evidenced by withdrawal symptoms in the child at birth, results of a toxicology test performed on the mother at delivery or the child at birth, or medical effects or developmen- tal delays during the child’s fi rst year of life that medically indicate prenatal exposure to a controlled substance” (§626.556). Drug use during pregnancy may seem more like an act of abuse than an act of omission; however, legislators have chosen to see this behavior as the failure to provide an adequate prenatal environment. For an in- depth exploration of this topic, see Chapter 8 , “Fetal Abuse.”
Postnatal Exposure to Drugs As states are beginning to address prenatal exposure to drugs, others are adding postnatal exposure to drugs (or at least the man- ufacturing of drugs) to their defi nitions of neglect. At least 10 states have listed exposure to drug production as a specifi c way in which parents may fail to provide a safe environment for their children. Iowa’s legal defi nition of child neglect includes the following sentence:
The person responsible for the care of a child has, in the presence of the child, manu- factured a dangerous substance, possesses a product containing ephedrine, its salts, optical isomers, salts of optical isomers, or pseudoephedrine, its salts, with the intent to use the product as a precursor or an intermediary to a dangerous substance. (§232.68)
Similarly, South Dakota law defi nes a neglected child in part as one “whose parent, guardian or custodian knowingly exposes the child to an environment that is being used for the manufacturing of methamphetamine” (§26-8A-2).
Unique Aspects of State Laws There are many other states that have fairly unique entries in their neglect stat- utes. Nebraska’s law includes leaving a child under age 6 in a car unsupervised (§28-710), the law in Montana mentions failure to provide cleanliness (§41-3-102),
meconium
dark greenish-brown
material that builds up in
the digestive tract before
birth; excreted as fecal
matter shortly after birth.
metabolite
a product of metabolism.
toxicology
the study of poisons and
drugs and their effects.
postnatal
occurring after birth.
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92 TYPES OF ABUSE AND THEIR EFFECTS
both Connecticut and Mississippi mention threats to the child’s moral development (§46b-120; §43-21-105). and California differentiates between neglect and serious neglect (§11165.2). Some states (Idaho, New Mexico, North Carolina, North Dakota, and Ohio) include improper adoption as part of neglect, whereas most do not. For instance, North Carolina includes in its defi nition of a neglected child one “who has been placed for care or adoption in violation of law” (§7B-101).
Finding Your State’s Law Once again, it should be clear that you need to know what the law is in the state(s) where you live and work. This information can be found on the website for the National Clearinghouse on Child Abuse and Neglect Information (see Search the Web 5.1 ).
SEARCH THE WEB 5.1
The defi nitions of child abuse established by each state can be found at www. childwelfare .gov/systemwide/laws_policies/state/index.cfm.
1. Under Number 1, select the state or states you are interested in learning about. 2. For Number 2, check Defi nitions of Child Abuse and Neglect. 3. For Number 3, click Go.
SUBTYPES OF NEGLECT
Although many state laws provide only a minimal defi nition of child neglect, Child Protective Services (CPS) has developed a more complete and complex defi nition that is based on the state laws. The broad concept of child neglect is broken down into different subtypes and these are all defi ned separately.
Physical Neglect
First, there is physical neglect, which is the type of situation most commonly associated with the term “neglect.” This type of neglect is defi ned as the failure to meet the minimal physical needs of the child. These physical needs include food, shelter, and clothing as well as protection from harm or danger. Certainly, there is much debate about what constitutes the minimal level of acceptable care and what should be labeled as maltreatment.
On the extreme ends of the continuum, you can imagine a family in which the child is starved to the point of being malnour- ished (obvious physical neglect; see Case Example 5.1 : Extreme Neglect) and a family in which the child receives three nutritious,
physical neglect
the failure to meet the
minimal physical needs
of the child.
malnourished
having a medical
condition caused by an
improper or insuffi cient
diet.
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93CHILD NEGLECT
well-balanced meals per day along with two healthy snacks (food needs are met exceptionally well). We could all probably agree that the fi rst family is not meet- ing its child’s minimal needs and that the second family is providing adequately. But, where do you cross the line from inadequate to adequate? Consider a family in which the children are given donuts for breakfast every day because it is their favorite food and because it is easy. For lunch and dinner, they eat fast food, and a frequent treat is a trip to the ice cream store. Are the physical needs of these children being met? Assume the children are of normal weight and generally healthy; does this have an impact on your decision? If this sort of diet seems neglectful to you, how much of this sort of food can a child be served by parents who are not neglectful? If a 5-year- old child has never been served a vegetable, are his or her parents neglectful?
CASE EXAMPLE 5.1: EXTREME NEGLECT
In September 2002, a couple was arrested in Tampa, Florida, and charged with maltreating a 7-year-old child. The mother, Connie Warrington, and her boyfriend, David LaPointe, had locked the girl, Mandy, 1 in her room for months and given her only minimal food and water. The child, who should have weighed between 50 and 55 pounds, weighed only 29 pounds when the police found her. The room where she was kept had no furniture other than a bare mattress; the child was forced to use a small closet as a bathroom, and she did not attend school (Humphrey, 2002). Apparently, Warrington occasionally tried to sneak food to Mandy when LaPointe was not around, but she said she could not leave LaPointe because she had nowhere else to go (Morelli, 2002a).
The police learned of the case from Mandy’s biological father, who saw the conditions she was living in when he arrived from New York with a court order to take the child. Investigation revealed that this was not the fi rst time the authorities had been contacted about Mandy. In January 2001, Warrington, LaPointe, and Mandy had been living in New York when they came to the attention of Child Protective Services (CPS). The allegations at that time were that Mandy had been absent from school, that she was not adequately supervised, and that she was medically neglected. The determination at that time was that Mandy was not in imminent danger (Morelli, 2002b).
Then, in May 2002, the family was again reported to CPS. Warrington and LaPointe had admitted Mandy to a psychiatric hospital because she was having problems with incontinence. The staff at the hospital began to suspect that Mandy was being maltreated. When Warrington and LaPointe realized that the hospital staff was going to report them to the state authorities, they took Mandy from the hospital against the doctor’s orders, and they fl ed to Florida (Morelli, 2002a). New York social services did not contact Florida authorities to report the move because at the conclusion of their investigation in 2001, they did not think Mandy was at high risk, and they were not able to investigate in 2002 because the family had left the state.
When Mandy’s biological father learned of her location in Florida, he obtained the court order and went to get her. Warrington handed her daughter over without confl ict, and Mandy went back to New York with her father. Once in New York, Mandy was treated for malnutrition and dehydration. It was also noted that she was bruised and had a human
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94 TYPES OF ABUSE AND THEIR EFFECTS
bite mark on her back. In addition, the doctors had to surgically remove a bead that Mandy said LaPointe had shoved into her ear because she was bad. Mandy also reported that LaPointe said he locked her up and refused to feed her because he hated her (“Couple Accused,” 2002). Detective John Yaratch, who investigated the case, reported that LaPointe was jealous of the affection his girlfriend had for Mandy (Morelli, 2002a).
When the police arrested Warrington and LaPointe, the state took custody of the cou- ple’s young children, a 1-year-old boy and a 3-year-old girl. Both children were healthy, and it appeared that they had not been maltreated (Humphrey, 2002).
Because Mandy was too traumatized to testify in court, prosecutors settled for a plea bargain with LaPointe. He was sentenced to 6 years 4 months in prison for aggravated child abuse and child neglect. After his release, he will serve 10 years of probation. War- rington pled guilty to child neglect and to failure to report child abuse (Good, 2004).
In 2004, Mandy was healthy and living with her biological father (Good, 2004).
CASE POINTS
1. Many cases involve more than one type of maltreatment. Mandy suffered from several forms of neglect (physical, emotional, medical, and educational) and was physically and psychologically abused.
2. It is possible that only one child in a family may be maltreated. Despite the horrifi c treatment of Mandy, her siblings were not maltreated. In this case, Mandy was tar- geted because she was not the biological child of the father fi gure in the home. In other cases, it is not clear why one child is singled out for maltreatment.
3. Mandy’s sad story also points to a problem in the system. Although this family had been reported to CPS, it took years for her to be removed from the family. Certainly, technology has made it easier to track children, but we still see breakdowns in com- munication when families relocate—especially across state lines.
DISCUSSION QUESTIONS
1. Should CPS be held responsible for failing to protect Mandy? If so, what sort of pen- alty would be appropriate?
2. Should Warrington and LaPointe retain custody of their two young, nonmaltreated children?
3. Should Warrington be allowed contact with Mandy? If so, under what conditions?
ENDNOTE
1. The child’s name was changed to protect her privacy.
The Chronic Nature of Neglect One of the problems with defi ning neglect is that we are often talking about a pattern of behavior, not just one or two instances. Nearly all parents will occasionally feed their children food with questionable nutritional value, and we do not call this neglect. How- ever, a parent who breaks his or her child’s arm once will be labeled as physically abusive.
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Therefore, with neglect, we need to know not only that something is not being done, but also that it is not being done on such a consistent basis that the child’s minimal needs are not being met. We also need to keep in mind that we are not requiring that parents provide optimal care, only the minimal level of acceptable care. Many parents are not doing a great job of meeting their children’s needs but do not fall to the level of neglect. One yardstick that is used is whether the child is maintaining normal growth. If a child is at a normal height and weight and relatively healthy, it is generally presumed that his or her food needs are being met adequately.
Although it has long been recognized that not providing enough food for a child constituted neglect, in recent years, people have questioned whether overfeed- ing children should also be considered maltreatment. Specifi cally, should parents of obese children be considered neglectful? Researchers have noted that the rate of childhood obesity has increased signifi cantly over the last 30 years. Approximately 2 million children in the United States suffer from severe obesity (BMI > 99th per- centile). Being dramatically overweight increases the risk that the child will suffer from other conditions including type II diabetes, sleep apnea, hypertension, hyper- lipidemia, orthopedic problems, nonalcoholic fatty liver disease, and social distress (Arani, 2002; Darwin, 2008; Mitgang, 2009–2010; Murtagh & Ludwig, 2011). These obese children are also at risk for developing chronic obesity related illnesses as adults. Obesity can shorten the life span and in very rare cases, it can prove fatal. In 2004, BBC news reported the shocking case of a three-year-old girl who died of heart failure due to extreme obesity. This child should have weighed around 32 pounds and instead weighed nearly 84 pounds. While there are some rare cases where severe obesity is attributable primarily to a genetic or endocrine problem, the vast majority of cases include multiple causes including excess food consumption and too little exercise (Murtagh & Ludwig, 2011; Varness, Allen, Carrel, & Fost, 2009). The World Health Organization (WHO) has indicated that even if genetics play a substantial role in weight gain, it is a condition that can be controlled largely through environmen- tal changes (Arani, 2002).
The bar for state intervention is generally high. Before CPS is likely to take action, all the following conditions should be met. First, it must be believed that the child faces imminent harm if left with the family. Second, there needs to be a reasonable belief that state intervention would be helpful (i.e., is there an alter- native placement available that would more adequately meet the child’s medical needs?). Third, before removing a severely obese child from the home, it is impor- tant that all other strategies have been exhausted. An immediate issue arises with the fi rst condition. Because most of the conditions that are comorbid with obesity are chronic, it is not likely that the harm will be imminent. Rather, the concern is that if left untreated, the child will develop more serious conditions as they age. In addition, children with the same degree of obesity will have different health outcomes (Arani, 2002). The decisions are, of course, easier on the extreme ends of the spectrum. Researchers suggest that obese children who have no comorbid con- ditions should not be considered victims of medical neglect. On the other hand, obese children with comorbid conditions that constitute serious imminent harm in childhood (as opposed to later in life) would be labeled as medically neglected. The cases in the middle are more diffi cult to determine (obese children with comorbid conditions that increase risk for serious harm later in life but that are reversible
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96 TYPES OF ABUSE AND THEIR EFFECTS
and obese children with comorbid conditions that increase risk for serious harm later in life and are not reversible; Varness et al., 2009). Arani (2002) adds that even if medical problems are not causing immediate harm, it is possible that the child is being seriously harmed if their weight interferes with normal social interactions or the ability to live a normal life (e.g., walk, run, and play normally; ride a bike; jump rope; climb trees).
The courts across the United States are beginning to recognize that morbid obe- sity can be grounds for CPS intervention. In California, New Mexico, Pennsylvania, Texas, Michigan, Iowa, Indiana, and New York, courts have ruled that CPS was acting appropriately when they intervened due to morbid obesity (Mitgang, 2009– 2010). The children involved have ranged in age from 3 to 16 years of age. Although most cases have focused on current, physical harm, the degree of harm has ranged from “life-threatening” to “life-limiting.” Some judges have also referenced current psychological or social harm that has resulted from the obesity. Finally, although less common, some judges note future harm, particularly the shortening of the life span (Mitgang, 2009–2010). The interventions have ranged across cases, but most have involved removal of the child from the home for at least a short time. Most cases require some type of health or nutritional education. Because many cases involve parents who are also obese, there is a concern that nobody in the family knows how to eat properly to maintain good health. One court in New York required that both the mother and the obese daughter attend cooking classes. In extreme cases, courts may order a visiting nurse or trained homemaker to visit or even move in with the family to provide education and supervision. Other court requirements focus on increasing the amount of exercise the child gets. In one case, the court required that the family obtain a gym membership for their obese child and that the child be taken to the gym two to three times per week. Because many of these interventions require money, some treatment plans involve income sup- port (see Case Example 5.2 ).
CASE EXAMPLE 5.2
Anamarie Martinez-Regino weighed 6 pounds 13 ounces when she was born in New Mexico. At 9 months of age, Anamarie weighed 30 pounds and had to be hospitalized for respiratory problems (according to the World Health Organization, a 9-month-old girl should weigh about 18 pounds). By the time Anamarie was 3-years-old, she weighed 131 pounds (weights between 25.5 and 38.5 pounds would be considered normal). At this time, Anamarie was admitted to the hospital and put on a liquid diet. After losing 10 pounds in 3 weeks, she was returned to her family with instructions that the family continue the liquid diet the hospital had started. Anamarie’s parents did not follow this medical advice because they said their pharmacist was not able to provide the liquid diet because it was on back order. Two months later, Anamarie was back in the hospital because she was having trouble breathing and she had a fever. At that time, it was noted that she had gained weight since being released. Anamarie’s physician notifi ed CPS of her condition, and both deemed it “life-threatening.” Anamarie was then removed from
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97CHILD NEGLECT
Although there has been a push to consider obesity a form of medical neglect, some urge caution with this approach. Diekema (2011) argues that before protec- tive custody is considered in cases of morbid obesity, there needs to be evidence that it works. Do children lose weight in protective custody, or at least stop gaining weight? Are they healthier? Are the potential health gains for the child greater than the psychological costs of being removed from the family? Finally, Diekema urges professionals to recognize that parents do not have total control over what or how much children eat.
Another parental behavior that has recently been considered neglectful is the failure to make sure that children are adequately restrained when traveling in a car (e.g., car seats or seat belts). Part of the neglect statutes state that parents must make reasonable efforts to protect their children from harm, and not using a car seat does put a child at risk. Prosecution of these cases has been complicated by discus- sions of whether parents know the risk associated with lack of proper restraints (see Legal Example 5.1 ). Before racing to condemn parents, consider the fact that most school buses do not have seat belts.
family and placed in foster care. In their own defense, Miguel Regino and Adela Martinez said that they had not neglected Anamarie’s health. In fact, they had sought medical treatment for her since she had been 3 months old. They said that the advice they were given was contradictory and that medical personal were accusatory when dealing with them. They also noted that they do not have medical insurance. Anamarie spent slightly more than 2 months in protective custody before being returned to her family. The details of the agreement were not released to the public, and it is not known if Anamarie lost weight while in the state’s custody, although her mother says she did not (Arani, 2002).
Four years after her return home, Anamarie’s mother gave an update to a reporter. Although Anamarie is still obese (weighing 200 pounds), her weight gain has slowed. This has been due to a host of factors including medication for insulin resistance. Anamarie does suffer from problems secondary to diabetes including asthma and sleep apnea. She also has other, unrelated developmental delays. Adela Martinez says that after Anamarie was returned to them, a staff member from the state lived with them for months to oversee Anamarie’s care. However, she says her last contact with the state was in 2001. Adela says that Anamaria is on a strict diet, that she has physical and speech therapy, and that she takes part in an adaptive physical education class. In addition, she sees her pediatrician once a month (“Anamarie 4 Years Later,” 2005).
DISCUSSION QUESTIONS
1. Were Anamarie’s parents guilty of medical neglect? Why or why not? 2. Was CPS justifi ed in removing Anamarie from her parents care, or should they have
attempted to assist the family in caring for Anamarie? 3. Was it appropriate to return Anamarie to her parents’ care?
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98 TYPES OF ABUSE AND THEIR EFFECTS
LEGAL EXAMPLE 5.1
The case of Latrece Jones shows how diffi cult it can be to legally determine whether a parent has been negligent. When Latrece was 18 years old, she was riding in the front passenger seat of a car with her 2-year-old son, Carlon Bowens Jr., in her lap. The car was driven by Carlon’s aunt, Letitia Abernathy, and there were fi ve other children and one adult in the back seat. Another vehicle failed to yield and hit the car causing the passenger side airbag to deploy. This broke Carlon’s neck, and he was killed. Nobody else in the car was seriously injured. Latrece Jones was charged with criminally negligent homicide by the State of Tennessee and was found guilty by the trial court. Her conviction was upheld by the Court of Criminal Appeals. However, the conviction was overturned by the Supreme Court of Tennessee. The main question was whether the mother’s actions constituted gross negligence. The prosecution argued that the mother knew that she was putting her son at an unacceptable level of risk. They noted that there were stickers on the visor of the car not- ing that children younger than 12 years of age can be seriously injured or killed by air bags.
Second, the hospital where Latrece had given birth gave all parents a pamphlet about car safety information prior to discharge. Third, they pointed out a recent campaign of pub- lic service announcements in the area designed to education parents about car safety. While this convinced the fi rst two courts, the Supreme Court of Tennessee said that although this information was available, there was no evidence that Latrece had actually read any of it. The court also noted that the need for so many education campaigns indicates that people do not think parents already know this information. Last, the Supreme Court noted that a recent survey reported that only 60% of children were properly restrained. Based on these arguments, the Supreme Court did not think that Latrece’s behavior constituted gross neg- ligence. It should also be noted that Letitia Abernathy, the driver, was charged separately for criminally negligent homicide and violation of the child restraint law. The children in the back seat were all in her care; she ran a day care from her home. She testifi ed that she had restraints in her car, but was driving a rental because she had been in another accident earlier that day. Ms. Abernathy pled guilty to the lesser charge of reckless endangerment and violation of the child restraint law ( State of Tennessee v. Jones , 2004).
DISCUSSION QUESTIONS
1. Which verdict do you agree with for Latrece Jones—guilty or not guilty? Why? 2. Is it reasonable to assume that a parent should have known car safety rules in 1998
when Carlon died? If not, is it reasonable to assume that after more than a decade of educational campaigns, parents should have this knowledge now?
3. Who is more responsible for Carlon’s death—the driver or the mother? 4. Given that Ms. Jones lost her son, was additional punishment by the court neces-
sary? Why or why not?
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99CHILD NEGLECT
Appropriate Shelter Shelter needs are similarly complex. The law generally requires that parents provide a “suitable place of abode,” without specifying exactly what that would be. Is a car a suitable place of abode? Is a tent acceptable? Would raising a child in a tepee be appropriate? Must a home have electricity and running water to be considered suit- able? If you live in a state where you cannot be labeled as neglectful simply because you are poor, will this change who is and who is not a neglected child? Although no state law lists precisely what is required, unwritten norms that vary from one community to the next develop among social workers. On a case-by-case basis, CPS workers determine whether a home is suitable, and if they feel it is not, they present the case to a judge. One aspect that workers consider is the cleanliness of the home. Although nobody would argue that a house had to be immaculate in order to provide a good environment, truly fi lthy homes can be considered a sign of neglect
Another issue is related to the condition of the home provided for the children. Although there is a great deal of leeway as to how clean a house has to be, extreme fi lth can lead to charges of child neglect. In one case, police were responding to a criminal domestic violence (CDV) call when they came upon a house that was infested with roaches, had trash everywhere, and smelled extremely bad. There were four children in the home ranging from 1 to 7 years of age. When a deputy removed the blanket that was covering one of the children, more than 30 roaches ran from under it. Although the case for CDV was not made, the children were placed in the care of their grandparents while the adults in the home were arrested and charged with neglect (Vaughn, 2012b).
Related to appropriate cleanliness, there has been an increase in the attention paid to hoarding in recent years. Part of this attention has come from the media and television shows such as TLC’s Hoarding: Buried Alive , while more academic interest has centered around the inclusion of hoarding as a diagnosis in the new, fi fth edi- tion of the Diagnostic and Statistical Manual of Mental Disorders ( DSM - V ; previously, hording was listed only as a symptom of obsessive-compulsive disorder). Hoarding behavior includes acquiring and keeping possessions that have limited or no value. This amount of things collected is so great that it precludes using the areas of the home for their intended purposes. In addition, the accumulation causes distress or impairs functioning (Mataix-Cols et al., 2010). Hoarding can also be dangerous if piles of accumulated items collapse or if collections create a fi re hazard. Weiss (2010) notes that parents who hoard may be charged with child neglect based on the failure to provide an adequate living space.
In one tragic case, a mother who was an animal hoarder was charged with neglect. The mother, Lydia Price, had more than 200 animals (many of which were dead) in a small home with her, her mother, and her four children. Her 14-year-old son, who had special needs, was found dead in the backyard. The cause of death was broncho- pneumonia, and offi cials were not sure if his death resulted from the animals or the fi lthy living conditions. All of the children had animal bites and scratches. Ms. Price was charged with criminal neglect of a disabled child in addition to child endanger- ment, animal hoarding, and animal cruelty (Gutowski, Sadovi, & Jaworski, 2011).
Adequate Supervision CPS also requires that parents adequately supervise their children in order to protect them from harm. State laws vary, but all require that children attain a certain age
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100 TYPES OF ABUSE AND THEIR EFFECTS
(usually 12 years) before they can be left at home alone. This sort of neglect includes not only lack of supervision but also inadequate supervision. It is not enough for parents to be physically present; they must be somewhat attentive to the child or children present. As you may guess, this leads to another gray area. A parent who has passed out after drinking is clearly not providing adequate supervision, but what about the parent who is on the phone or in the bathtub? Once again, one needs to consider the age and immediate circumstances of the child. Being distracted by an important phone call while an infant is safe in the playpen is different from being distracted while the infant is in a pool (see Case Examples 5.3 and 5.4 ).
CASE EXAMPLE 5.3
This case came to the attention of the authorities when Alylcia Ramsey’s neighbors noticed that she was passed out in her front yard and they called the police. Before deputies arrived, her husband, Chirstopher Atkins, carried her into the home. When the police arrived, they knocked and shouted. Nobody answered the door, but they could hear children crying inside of the home. When police entered, they found Ms. Ramsey passed out on the couch with two children and a third child was in an infant seat on the fl oor. Mr. Atkins was asleep in the bed, and the deputies had diffi culty awakening him. Once awake, Mr. Atkins reported that he had worked all night and then taken Ms. Ramsey to the methadone clinic. The children were dirty and had soaked diapers, but they were otherwise unharmed. After being checked out by the local hospital, the children were placed in a shelter, and both adults were charged with neglect. A neighbor testifi ed that she had seen the family in the car earlier and noted that none of the children had been in car seats or seat belts.
DISCUSSION QUESTIONS
1. Do you agree that Ms. Ramsey and Mr. Atkins are guilty of child neglect? If so, what types of neglect are evident in this case?
2. What do you think the proper intervention would be in this case? 3. What risk factors do these children face? 4. What protective factors, if any, do you see in this case?
CASE EXAMPLE 5.4: PHYSICAL NEGLECT—LACK OF SUPERVISION
CASE 1
Amber Johnson was charged with child neglect after a neighbor spotted Johnson’s 2-year- old son playing in the parking lot and in his mother’s car unsupervised. When the neighbor went to Johnson’s apartment, she found her asleep and could not wake her. At that point, the neighbor called the police. Johnson told the police that she had taken both prescription and nonprescription drugs in the last 24 hours. The police also noted that the
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101CHILD NEGLECT
contents of Johnson’s purse had spilled and that 15 Soma pills and 3 diazepam pills were on the fl oor in easy reach of the child (“Mother Faces Neglect,” 2005).
CASE POINTS
1. A parent can be charged with neglect even if the child is not harmed. The fact that the child was exposed to unacceptable risk is suffi cient for a charge of neglect. In this case, the child could have been harmed by playing unsupervised in an unsafe area or by ingesting drugs.
2. This case also highlights the frequent connection between parental substance use and child maltreatment charges.
DISCUSSION QUESTIONS
1. Do you think Ms. Johnson was guilty of child neglect? If so, what action(s) should be taken (e.g., removal of the child from her care, mandatory counseling, jail)?
2. In this case, the child was not harmed. Does that affect your analysis of the situation?
CASE 2
Three children, ages 8 years, 2 years, and 17 months, were left in a car for more than 30 minutes while their babysitter shopped for groceries. The outside temperature that day was 93 degrees. Store employees noticed the children, and they brought them water. The employees also called the police. The babysitter was ticketed on suspicion of child neglect (Sanfranek, 2005).
CASE POINTS
1. Although neglect is often defi ned as a chronic pattern of behavior, one severe inci- dent can also be labeled as neglect.
2. It is not only parents who can be charged with child neglect. Anyone who is acting in loco parentis can be charged with child maltreatment.
DISCUSSION QUESTIONS
1. Was the babysitter guilty of child neglect? 2. Does the age of the children left in the car affect your decision? How old is “old
enough” to be left alone in a car?
CASE 3
A woman called the sheriff’s offi ce to report that two toddlers (both 3 years old) were walking barefoot and unsupervised along a highway. Their diapers were dirty, and their clothes were stained with the juice of poisonous berries. The adults who were responsible for the children were asleep at the time that the children wandered away (“2 Wandering Toddlers,” 2005).
CASE POINT
This case illustrates the importance of considering a child’s developmental age when assessing level of supervision. Older children may be safe when playing outside alone, but this is not true for toddlers.
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102 TYPES OF ABUSE AND THEIR EFFECTS
DISCUSSION QUESTIONS
1. Were these caregivers guilty of child neglect? If so, what penalty would be appropri- ate for them?
2. Would your answer to the fi rst question change if the children had been harmed?
CASE 4
A 26-year-old-woman, Sandra Davis, was charged with child neglect after leaving her four children alone at home on a Saturday night. All four children died in a fi re caused by a candle that was being used to light the apartment, which had no electricity or heat. Davis told fi refi ghters that she had been gone for only minutes, but other witnesses said she had been away for hours (“Mother Is Charged,” 1984).
CASE POINT
This tragic case illustrates the fact that child neglect can lead to fatalities. The consequences of neglect can be as severe as the consequences of abuse.
DISCUSSION QUESTIONS
1. Was Ms. Davis guilty of child neglect? If so, what would be an appropriate punish- ment?
2. If nothing had happened to the children that night, would Ms. Davis be guilty of child neglect?
3. The children’s ages were not provided in this case. How would your responses change based on the ages of the children involved?
Being present and attentive is the fi rst part of not being a neglectful parent, but this alone is not suffi cient to keep children safe. Parents are also expected to provide a
safe atmosphere for their children. Unnecessarily exposing a child to possible harm is considered child endangerment —a form of physical neglect. Even though it is impossible to protect children from all possible harm, caregivers are expected to use good judg- ment to keep the children in their care safe from unnecessary risks (see Case Example 5.5 ). For instance, exposing children to inappro-
priate sexual material can be considered a failure to provide a safe atmosphere. There is a great deal of discussion about what is too sexual for a child of a certain age to see, but there is general agreement that it not appropriate to expose young children to graphic sexual material. Failure to provide a safe environment can result in charges of child neglect.
child endangerment
placing a child in
a situation that is
potentially harmful.
CASE EXAMPLE 5.5: CHILD NEGLECT—ENDANGERMENT
In April 2005, Donald Poplick was charged with child neglect for furnishing a fi rearm to a minor. Poplick was arrested after a 3-year-old child in his care was seen playing with an
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103CHILD NEGLECT
Domestic Violence Recently, attention has been paid to children who are exposed to domestic violence. Chapter 2 noted that domestic violence is a risk factor for child maltreatment. The question at hand is whether it is also a form of child maltreatment. Although it is obvious that living in a home in which there is violence is not an ideal situation for children, it has been diffi cult to say what form of child maltreatment it should be considered. If the child is physically hurt, perhaps by attempting to intervene, it could be considered physical abuse. However, even if the child is not harmed physically, he or she may be harmed psychologically by witnessing the abuse or by knowing that is happening in the home. In such cases, domestic violence may best be labeled a form of psychological maltreatment. In all cases, it can be seen as a form of child endangerment, because it places the child in a dangerous environment. There has been a push recently to say that exposing a child to domestic violence is a crime or to increase the penalty for domestic violence if it happens in the presence of a child. For instance, Georgia’s law reads as follows:
Any person commits the offense of cruelty to children in the third degree when such a person, who is the primary aggressor, intentionally allows a child under the age of 18 to witness the commission of a forcible felony, battery, or family violence battery; or having knowledge that a child under the age of 18 is present and sees or hears the act, commits forcible felony, battery, or family battery.
Georgia Code Ann. §16-5-70
Idaho law states that penalties for domestic violence are doubled if they are commit- ted in the presence of a child under the age of 16 (Idaho Code §18-918). Because it
unloaded gun. Poplick denied giving the gun to the child, but said he had shown the child how to load, unload, and operate his shotgun (“Man Accused of Letting 3-Year-Old,” 2005).
CASE POINTS
1. It is important to consider a child’s developmental level when assessing caregiver behavior. Even though it may have been acceptable to teach a child of 12 to operate a shotgun, giving this information to a 3-year-old shows a striking lack of good judg- ment.
2. This case also shows that caregivers and police may have radically different ideas about what is safe or appropriate behavior. Poplick freely admitted to behavior that the police thought constituted child endangerment.
3. Finally, even if parents do not expose the child to harm deliberately, they are still neglectful if they allow the child to be in a potentially harmful environment. In this case, the 3-year-old should not have had access to a gun.
DISCUSSION QUESTIONS
1. Was Mr. Poplick guilty of child neglect? If so, what would an appropriate punish- ment be?
2. Would your response change if the child had accidentally injured or killed himself?
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104 TYPES OF ABUSE AND THEIR EFFECTS
is estimated that as many as 10 million children are exposed to domestic violence each year (Straus, 1992), this represents an area of study that desperately needs more attention from researchers and legislators.
Indicators of Possible Physical Neglect Because each family situation is unique, it is diffi cult to say what exactly constitutes neglect. Frequently professionals put together lists of things a CPS worker can look for in determining whether a child is being neglected. Consider the following list that was provided by Sagatun and Edwards (1995, p. 28) in the book Child Abuse and the Legal System:
Neglect may be suspected if the following physical indicators are present:
1. Lack of adequate medical or dental care
2. Chronic sleepiness or hunger
3. Poor personal hygiene; dirty clothing; inadequate dress for weather conditions
4. Evidence of poor supervision; child is left alone in the home or unsupervised under circumstances when he or she should have been supervised
5. Conditions in the home constitute a health hazard
6. Home lacks heating or plumbing
7. Fire hazards or other unsafe conditions in the home
8. Inadequate sleeping arrangements
9. Nutritional quality of food in the home is poor
10. Spoiled food in refrigerator or cupboards
As is often the case with neglect, some of the items (1, 4, 5, and 7) on the list seem clearly harmful, while others are occasionally true of almost every home. Who among us has not come upon some scary, moldy thing growing in our refrigerator or has not let a child get extremely dirty? These items require us to consider not just one instance, but a pattern of behavior that interferes with the child’s welfare. A child who comes in from a hard day at play and is fi lthy until his or her parent gets him or her bathed is not neglected. A child who shows up for school day after day in dirty, smelly clothing that elicits teasing and taunts from his or her classmates may be neglected.
Harder still are the items on the list that are open to interpretation. Take Item 8, for example, “Inadequate sleeping arrangements.” What does this mean? Is it pos- sible that what it means to me may be quite different from what it means to you? Often this item is interpreted to mean that after a certain age, children should have a room that is separate from rooms of the opposite sex (parents and siblings). This leads to two questions: (a) At what age does room sharing among family members of the opposite sex become inadequate? and (b) Regarding impoverished families, if a family can only afford a one-bedroom apartment and they have male and female children, what are they to do?
Questions such as these exemplify the point that decisions about child maltreat- ment are often more art than science. Caseworkers can be given things to look for
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105CHILD NEGLECT
and be aware of, but there are no easy answers. The caseworker assesses each situa- tion and brings the case before the court. Ultimately, family court judges decide on a case-by-case basis if the child’s physical needs are being met or if the parents are guilty of neglect.
Emotional Neglect
A second subtype of neglect is emotional neglect. This type of neglect is defi ned as the failure to meet the child’s emotional needs. As you might imagine, this is even more diffi cult to quantify than is physical neglect. The National Incidence Study-3 provides the following defi nition for emotional neglect: “the failure to provide adequate affection and emotional support and permitting a child to be exposed to domestic violence” (Stowman & Donohue, 2005, p. 496). Emotional neglect is rarely charged as the sole type of maltreatment because it is so diffi cult to operationally defi ne and to prove. Although extreme cases of emotional neglect may be clear, it is much more diffi cult to say how much emotional attention is enough or how many moments of neglect constitute likely harm. This aspect of maltreatment is explored in-depth in the Chap- ter 6 “Psychological Maltreatment.”
Medical Neglect
A third, and often controversial, type of neglect is medical neglect: the failure to provide prescribed medical treatment. Whereas some states simply list medical along with other subtypes of neglect, others have more extensive coverage. For instance, the law in North Carolina defi nes a neglected child, in part, as one “who is not provided necessary medical or remedial care” (Gen. Stat. §7B-101). Kansas has a more detailed description defi ning medical neglect as the “failure to use resources available to treat a diagnosed medical condition if such treatment will make a child substantially more comfortable, reduce pain and suf- fering, or correct or substantially diminish a crippling condition from worsening” (Ann. Stat. §38-2202). This type of neglect has proved to be a particularly sensitive area when parents’ religious beliefs confl ict with the advice of medical doctors, often in life-or-death situations. For instance, the beliefs of Jehovah’s Witnesses prohibit blood transfusions, and some Buddhists believe that a body cannot go into the next life if any of the organs have been removed (Cantwell, 1997). These beliefs can result in parents refusing to permit their child to receive lifesaving medical interventions. Some medical cases are serious enough that the child’s life is at risk, or it is likely that there will be a signifi cant negative impact on the child’s health if he or she does not receive treatment. In such situations, the courts have been called on to force the parents to allow treatment even if the treatment confl icted with their religious beliefs.
In other cases, parents refuse to follow doctor’s orders for reasons that are not related to religion. Sometimes parents simply disagree with medical experts about what treatment is in the best interest of their child (see Case Example 5.6 ). These situations must be assessed by a judge on a case-by-case basis.
emotional neglect
the failure to meet a
child’s emotional needs.
medical neglect
the failure to seek
medical treatment or to
provide treatment that
has been prescribed.
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106 TYPES OF ABUSE AND THEIR EFFECTS
CASE EXAMPLE 5.6: MEDICAL NEGLECT
In 2003, Parker Jensen was 12 years old when his parents, Daren and Barbara Jensen, took him to the doctor to have a growth on his tongue removed. A biopsy showed the tumor to be cancerous and Parker was diagnosed with Ewing’s Sarcoma. Doctors consider this a rare and aggressive form of cancer. The survival rate with aggressive treatment is estimated to be 70%. Following the surgical removal of the growth, Parker’s doctors recommended chemotherapy. Barbary and Daren were reluctant to follow the doctor’s recommendation. They worried about the effects of chemotherapy on their son’s growth. They were further worried that the treatments would leave him sterile. The Jensens also questioned the accu- racy of the diagnosis. When the Jensens refused chemotherapy, they were charged with medical neglect and the State of Utah was granted custody. However, before social services could pick Parker up, his parents moved him to Idaho. Daren Jensen was arrested in Idaho and charged with kidnapping and custodial interference. Daren spent 4 days in jail follow- ing his arrest. Over a 2-year period, the Jensens would agree to see more doctors and follow their recommendations. However, they refused to submit to chemotherapy even though it was recommended by four doctors. The Jensens kept pointing out that Parker did not have any cancer cells; in fact, Parker felt great and had no symptoms at all. The doctors argued that chemotherapy could prevent a reoccurrence of cancer. The department of social ser- vices eventually dismissed the case because the Jensens (including Parker) were not willing to submit to chemotherapy and they did not think that boy would benefi t from chemo- therapy if he were unwilling (Hunt 2011).
In 2005, the Jensens sued the University of Utah doctor and the state for their actions in this case. After a lengthy court battle, the Utah Supreme Court ruled in 2011 that the Jensens could not sue the doctors or the state because they had acted in Parker’s best inter- est. In 2012, Parker Jensen, 21 years old, remained completely healthy (Hyde, 2012).
CASE POINTS
1. Some involved, caring parents refuse medical treatment because they disagree with doctor’s recommendations.
2. The state has a right to protect children, and medical experts are considered more knowledgeable than are parents when it comes to medical issues.
DISCUSSION QUESTIONS
1. Do you think the Jensens were guilty of medical neglect? 2. It turned out that Parker remained healthy without treatment. If he had died, would
it make a difference with regard to your assessment of medical neglect? 3. Is it possible that parents may know better for their child than medical experts?
Legal Precedents The legal rulings have been complex in this area. In 1944 in Prince v. Massachu- setts (see Chapter 1 for a full description of this case), the U.S. Supreme Court ruled that “the right to practice religion freely does not include the liberty to expose the
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107CHILD NEGLECT
community or child to communicable disease, or the latter to ill health or death.” However, in 1974, the federal government said that states must provide religious exemptions to child abuse and neglect charges if they wanted to receive federal funds. Because states are largely dependent on federal funds, the vast majority of them quickly added this exemption and did not charge parents with medical neglect if they withheld treatment for religious reasons. Nine years later, in 1983, this fed- eral mandate was repealed, and states were allowed to remove religious exemptions from their statutes without risking the loss of federal funds. However, due to well- organized lobbying on the part of supporters of religious exemption, the process of repealing the exemptions has been slow (Asser & Swan, 1998). The federal govern- ment took another step back toward protecting children, regardless of their parent’s beliefs, in 1984. The Child Abuse Prevention and Treatment Act of 1984 (PL 98–457) stated explicitly that the failure to secure medical treatment for a seriously ill new- born is medical neglect unless such treatments would serve only to prolong dying. This battle is not likely to be resolved quickly because people on both sides of the issue have strong feelings about what is right. On one hand, advocates of religious exemptions cite their constitutional guarantee to practice religion, yet others believe that failure to provide medical treatment for seriously ill children is neglect no matter what the parental motivation. The Commit- tee on Bioethics of the American Academy of Pediatrics released a strong statement in 1988 recommending that all pediatricians work to increase the public’s awareness of the dangers to children inherent in religious exemptions and to work to legislate protec- tions for all children from medical neglect.
The Age of the Child Much of the focus on medical neglect is on infants and young children, but older children can also be medically neglected. However, as children age, they are more able to speak for themselves and say whether they want a specifi c treatment. Teenag- ers have generally been allowed to refuse medical treatment for serious conditions based on their religious beliefs because they are seen as mature enough to make such decisions even if they are not yet legal adults (Dubowitz, Black, Starr, & Zuravin, 1993). Even allowing only older children to make medical decisions that involve refusal of treatment does not sit well with everyone. An adolescent may have a better understanding of his or her medical condition and the possible consequences of not getting medical treatment; however, many argue that adolescents are not truly free to opt for treatment that their families are adamantly opposed to and/or that they are not mature enough to make such important decisions on their own (see Legal Example 5.2 ).
American Academy of
Pediatrics
an organization of
approximately 60,000
pediatricians dedicated to
the health of all children.
LEGAL EXAMPLE 5.2: RELIGION-MOTIVATED MEDICAL NEGLECT AND THE MATURE MINOR
In 1987, a young girl identifi ed in court records as “E.G.” was diagnosed with acute nonlym- phatic leukemia. When the girl and her mother, Rosie Denton, learned that the treatment would involve blood transfusions, they declined based on their convictions as Jehovah’s Witnesses that the “eating” of blood is prohibited. Mrs. Denton did agree to permit any
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108 TYPES OF ABUSE AND THEIR EFFECTS
other medical treatments, and she signed a release form saying that the medical facility was not liable for failure to conduct the blood transfusions.
Because Mrs. Denton refused to give parental consent for the blood transfusions, the State of Illinois fi led a child neglect petition in juvenile court. At the initial hearing on Feb- ruary 25, 1987, Dr. Stanley Yachnin testifi ed that if E.G. did not receive the transfusions, it was likely that she would die within 1 month. He further testifi ed that treatment with blood transfusions and chemotherapy, E.G. had an 80% chance of achieving remission. However, Dr. Yachnin did note that the long-term prognosis was still poor, with only 20% to 25% of patients having a long-term survival rate even with full treatment. Dr. Yachnin went on to testify that E.G. was a mature minor who appeared to understand the conse- quences of her decision to refuse treatment. He also testifi ed that she seemed sincere in her religious beliefs. The associate general counsel for the University of Chicago Hospital, Jane McAtee, corroborated Dr. Yachnin’s testimony.
After hearing the testimony, the juvenile court judge appointed Ms. McAtee as E.G.’s temporary guardian and gave her the authority to consent to blood transfusions on E.G.’s behalf. Following several blood transfusions, E.G. was well enough to testify in further hearings held on April 8, 1987. E.G. testifi ed that she did not wish to die, but that based on her deeply held religious convictions, she did not want to receive transfusions. She said she felt her wants and beliefs were being completely disregarded by the courts. Dr. Littner, a psychiatrist, testifi ed that E.G. had the maturity level of an 18- to 21-year-old and was competent to make her own medical decisions.
Again, the judge ruled that E.G. was medically neglected and that a state-appointed guardian should continue to assent to treatment on her behalf. The court ruled that the state’s interest in the case was greater than that of E.G. or her mother.
The case was appealed, and the appellate court ruled that as a mature minor who was nearly 18, E.G. was partially emancipated and could, therefore, refuse medical treatment. The appellate court did, however, uphold the medical neglect charge against Rosie Denton.
Finally, the case was brought before the Illinois State Supreme Court. Although the case was technically moot by this time because E.G. had reached the age of 18, the court agreed to hear the case because it presented an issue of substantial public interest. The court found that the age of 18 is not an “impenetrable barrier.” The justices noted that in many specifi c situations minors were treated as adults by the court (e.g., a 12-year-old may seek medical care if he or she may suspect a sexually transmitted disease, is addicted to drugs or alcohol, and is pregnant; at 16, a child may be declared emancipated; children younger than 18 may be charged criminally as adults; females younger than the age of 18 may undergo an abortion without parental consent).
Based on this reasoning, if a trial judge fi nds a minor to be mature, they should allow that minor to refuse medical treatment. This should be done on a case-by-case basis in order to balance the rights of the minor with the State’s duty to protect those who can- not protect themselves. The court also noted that the interests of third parties should be considered (i.e., if the parents disagree with the child and want the child to receive medical treatment, their opinions should be weighed heavily). The Illinois State Supreme Court ruled that in this case, E.G. should have been allowed to refuse medical treatment, and they ordered the lower court to expunge the fi nding of medical neglect against Rosie Denton ( In re E.G. , 1989).
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109CHILD NEGLECT
In trying to make decisions about complex issues, it is helpful to have as much information as possible. A question for researchers is to determine how many chil- dren are harmed by religious exemptions and to assess whether this harm could have been prevented (see Focus on Research 5.1 ).
DISCUSSION QUESTIONS
1. Should E.G. have been forced to have the blood transfusions? 2. If you think E.G. was old enough to make this type of medical decision, what should
the “cutoff” age be: 16 years, 14 years, 12 years, 10 years? 3. Given that the experts in the fi rst trial testifi ed that E.G. was very mature, were you
surprised that the judge ruled against her?
FOCUS ON RESEARCH 5.1: RELIGION-MOTIVATED MEDICAL NEGLECT AND CHILD FATALITIES
In 1998, Asser and Swan published a paper in Pediatrics that presented their review of 172 child deaths that occurred between 1975 and 1995 in which there was clear evidence that the parents had withheld medical treatment because of religious convictions. The cases they reviewed were collected from the nonprofi t organization Children’s Healthcare Is a Legal Duty (CHILD), which gathers information on cases of religiously motivated child medical neglect. Doctors reviewed the cases and determined the likely outcome if the child had received the standard medical care that had been available at the time of the child’s illness.
They found that in 81% of the cases, the child’s chance of survival if treated with conventional medical care would have been greater than 90%. In an additional 10% of the cases, the survival rate would have been more than 50% with medical treatment, and in all but 2% of the cases, it was determined that the child would have benefi ted in some way from medical treatment. Not only would medical care have dramatically reduced child fatalities; it also would have prevented a great deal of pain and suffering.
Five religious groups that accounted for 83% of the fatalities in this study:
Faith Assembly 64 deaths First Church of Christ, Scientist (Christian Science) 28 deaths Church of the First Born 23 deaths Faith Tabernacle 16 deaths Endtime Ministries 12 deaths
The researchers concluded that a great deal of child pain, suffering, and death is directly attributable to the failure to seek medical treatment motivated by religious beliefs. They also proposed that the actual numbers are likely much higher than those they reported because it is suspected that many cases of religiously motivated medical neglect go undoc- umented. Finally, the authors stressed that many of the deaths they explored were from conditions that are easily cured in a medical center, such as dehydration, appendicitis, and antibiotic-sensitive bacterial infections.
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110 TYPES OF ABUSE AND THEIR EFFECTS
Delay in Seeking Treatment Medical neglect also includes the failure to seek help for a medical condition in a timely manner when a reasonable person would have realized that the child needed professional medical attention (Winton & Mara, 2001). This does not mean that a parent who waits a day to seek treatment for an injury that is not clearly traumatic is guilty of medical neglect. Many attentive parents (mine included) have waited a day before a trip to the hospital only to fi nd out that a bone was broken! In order for a caregiver to be charged with delay of treatment, the injury must be serious and the delay obvious (see Case Example 5.7 ).
CASE EXAMPLE 5.7: MEDICAL NEGLECT
In August of 2005, a 13-year-old girl was found near death in her home. The girl was emaci- ated, having lost between 30 and 40 pounds as she battled an infection for weeks without medical attention. The infection, which had become life threatening, began when the girl attempted to pierce her own belly button. Despite the dramatic weight loss, extreme pain, lethargy, pus around the wound, and loss of control of the bowels, her mother did not seek medical help. Instead, the mother wrapped her 13-year-old in diapers (D. Slack, 2005). Although the family did ultimately call 911, the police notifi ed Child Protective Services (CPS) on suspicion of delay of treatment. Denise Montero, the spokeswoman for CPS, said it was the worst case of medical neglect she had ever seen. CPS also took custody of the girl’s 15-year-old brother (Smalley & Slack, 2005a).
An investigation revealed that the mother, Debora Robinson, had been investigated twice before for child neglect. Although CPS would not reveal details of the previous investigations, they did say they were not as serious as the current situation. The fi rst case was closed after CPS determined that the mother was providing adequate care, and the second case was closed by a judge. CPS is not required to monitor cases after they have been closed.
Ms. Robinson maintains that she did not realize the severity of her daughter’s illness. When she was confronted by the police, she threatened to harm herself, so she was sent to the hospital for psychiatric evaluation (Smalley & Slack, 2005b). After Ms. Robinson was released from the hospital, she was charged with “wanton and reckless behavior creating a risk of serious bodily injury to a child” (a felony charge). She was also charged with child endangerment, which is a misdemeanor (Levenon & Jadhav, 2005).
At the time of her arrest, Ms. Robinson was a single mother with no health insurance and was suspicious of doctors. She had a history of mental illness. She told a psychologist that she feared a doctor would sexually abuse her daughter if she took her for treatment. Despite these issues, she was indicted by the Suffolk County Grand Jury on September 28, 2005 (Associated Press, 2005).
CASE POINTS
1. In this case, you see how problematic a delay in seeking medical treatment can be for a child; a simple infection can turn into a life-threatening illness.
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111CHILD NEGLECT
Mental Health Neglect
A fourth subtype of neglect is mental health neglect, which is defi ned as the failure to comply with recommended psychological treatment. In these situations, parents have not sought or followed through with the mental health services recommended to them by professionals (e.g., school psychologists, medical doctors). Hart and Brassard (1987) suggested that in order to make a diagnosis of mental health neglect, the following criteria should be met: (a) a team of two or more appropriately accredited mental health professionals must conclude that the child has a serious emotional or behavioral problem, and (b) the child’s caregiver refuses to provide or maintain the suggested treatment. Hart and Brassard further argued that the caregiver should be notifi ed of treatment options in writing and that the mental health professionals should ensure that scheduling and paying for the treatments are within the caregiver’s ability.
Mental health neglect also includes unacceptable delay in seeking or providing treatment that the child needs when a reasonable layperson would have realized that mental health treatment was necessary (e.g., after a suicide attempt). Currently, the issue of mental health neglect is not widely addressed by CPS, and correspondingly, little research exists on this subtype of neglect.
Educational Neglect
The fi fth subtype of neglect, educational neglect, is often the easiest to document. This type of neglect is defi ned generally as the failure to meet legal requirements for school attendance. The National Incidence Study-4 (Sedlak et al., 2010) defi ned educa- tional neglect as any of the following three situations:
1. Permitted chronic truancy—the child is absent for an average of at least 5 days per month after the parent has been noti- fi ed, and the parent has not done anything to address the situation.
2. The complex causes of medical neglect are clear in this case. This family was con- fronted with poverty, single parenting, maternal mental illness, and a lack of health insurance. It is diffi cult to say what precisely caused the medical neglect.
3. Finally, this case shows how diffi cult it is to substantiate neglect before children are seriously harmed. Despite two previous investigations by CPS, this tragic story was not prevented.
DISCUSSION QUESTIONS
1. Was Ms. Robinson guilty of child neglect? If so, what punishment would be appro- priate?
2. Does the fact that Ms. Robinson had a history of mental illness have an impact on your decision in this case?
3. Should CPS be held responsible for not doing something to protect this child earlier?
mental health neglect
the failure to seek
help for a child’s
severe psychological
problems or to comply
with recommended
therapeutic procedures.
educational neglect
the failure to meet
legal requirements for
school enrollment or
attendance, or the lack
of attention to special
educational needs.
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112 TYPES OF ABUSE AND THEIR EFFECTS
2. Failure to enroll/other truancy—the parent has failed to enroll a school-aged child in school, allowing the child to miss at least one month of school, or the parent keeps the child at home for inappropriate reasons (e.g., to work or to watch younger siblings) at least 3 days per month. (Note that parents are exempt from enrolling their children in school if they document according to state law that the child is receiving adequate homeschooling and attaining academic achievement that is appropriate to the child’s developmental level.)
3. Inattention to special education needs—the parent fails to follow recom- mended interventions for remedial education without a reasonable cause.
Because schools keep excellent attendance records, this is often the simplest way to demonstrate neglect. According to the NIS-4, in 2005–2006, 360,500 (4.9 per 1,000) children were victims of educational neglect according to the harm standard. Also, edu- cational neglect often co-occurs with other types of maltreatment that may be harder to prove. For instance, physically abusive parents may keep their children at home so that others will not see bruises and ask the children what has occurred. Even if you cannot provide evidence of other maltreatment, educational neglect is enough to get CPS involved. Some teachers and CPS workers also consider educationally neglectful parents to include those who are not involved with their child’s education or who do not cooperate with suggested programs to aid in their child’s learning, but this sort of defi nition has not had legal success. Of course, a child in an approved homeschooling situation is not required to meet the state attendance requirement, but homeschooling parents can still be charged with educational neglect if they fail to keep up with age- appropriate work or to foster peer interaction. It is, however, important to note that this is truer in theory than in practice. Cases such as this are not likely to come to the attention of CPS, and even if they did, they would have low priority.
Abandonment
Perhaps the most extreme act of neglect is abandonment. Rates of abandonment in the United States are relatively low but range across the nation from a low of 0.4% in San Francisco to a high of nearly 2% in Washington, D.C. The term abandonment cov-
ers a range of behaviors, from leaving a newborn anywhere from a hospital to a trash bin, to kicking an older child out of the home. In the most severe cases, when infants are left in unsafe places with a low chance of being discovered alive, the labels of attempted infanticide or child abuse may be more appropriate than neglect (Giardino & Giardino, 2002).
In order to keep newborns safe, many states have passed “safe haven” laws that allow parents to leave infants at designated locations such as a hospital or a fi re station. The parent may remain anonymous, and they will not be prosecuted for abandonment. Most states limit the age of the child to a few days or a few months of age. While the spirit of the law has been applauded, others note that they are not used much and that desperate mothers are not likely to know about them. When 19-year-old Jamie Marie Smith gave birth in her trailer, she opted to leave her new- born at a well-lit apartment complex even though Indiana (where she lived) had a safe haven law that would have protected her if she left the baby in a designated safe area. The baby was found and adopted, but Ms. Smith was charged with criminal neglect
abandonment
desertion; severing
ties with and failing to
support one’s own child.
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113CHILD NEGLECT
(Bernstein, 2001). In 2008, Nebraska passed a safe haven law that covered children from birth to 19 years of age. In just 4 months, more than 30 children were aban- doned. However, they were not infants (four were 17 years old, two were 16 years old, six were 15 years old, two were 14 years old, three were 13 years old, and eight were 11 or 12 years old). Nebraska rewrote the law to only protect infants (Fox News, 2008). Although safe haven laws do still exist to protect infants, it seems to be the case that some parents are in dire need of assistance in caring for older children as well.
INCIDENCE
The U.S. Children’s Bureau (2011) reported that of the children who were maltreated in 2010, 78.3% of them were neglected. This is much greater than the percentages associated with other types of maltreatment (17.6% were physically abused, 9.2% were sexually abused, 8.1% were emotionally abused, and 2.4% were medically neglected). The NIS-4 report indicated that in 2005–2006, 771,700 were victims of neglect according to the harm standard. This is not signifi cantly different from the numbers reported in the NIS-2 or the NIS-3. In 2005–2006, approximately 2,251,600 children were endangered by neglect. This is not signifi cantly different from the 1993 report, but it is signifi cantly higher than the number reported for 1986 (see Table 5.1 ). Even though these are all very high numbers, they most likely underestimate the problem because they include only those cases that have been brought to the atten- tion of professionals and identifi ed as neglect. Because neglect is often diffi cult to see, it is likely that the incidence of neglect is actually much higher (Sedlak et al., 2010). The most frequently reported type of neglect is supervisory neglect (approximately 70% of substantiated neglect cases include supervisory neglect). These cases involve children being left alone or being left with an inappropriate caregiver. The second most common type of neglect is environmental neglect (about 66% of neglect cases include environmental neglect). In these cases, the child’s home presents a safety or health hazard. The numbers add to more than 100% because many children experi- ence both forms of neglect (Mennen, Kim, Sang, & Trickett, 2010).
In cases of neglect, the perpetrators are almost always the birth parents. In 92% of all neglect cases, the perpetrator is one or both of the child’s birth parents. It is more likely that children will be neglected by women (86%) than by men (38%). (Many children are neglected by both women and men, so the combined percent- ages are more than 100.) This difference is due to the fact that female caregivers are generally the primary caretakers and are therefore more likely to be held accountable for any shortcomings in child care (Sedlak et al., 2010).
TABLE 5.1 Incidence Numbers for Neglect as Reported by the NIS-4 NIS-2 (1986) NIS-3 (1993) NIS-4 (2005–2006)
Harm Standard 474,800 7.5 per 1,000
879,000 13.1 per 1,000
771,700 10.5 per 1,000
Endangerment Standard
917,200 14.6 per 1,000
1,961,300 29.2 per 1,000
2,251,600 30.6 per 1,000
Source: Sedlak et al. (2010, pp. 3–4, 3–15).
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114 TYPES OF ABUSE AND THEIR EFFECTS
CONSEQUENCES OF NEGLECT
Although child neglect has not received nearly the attention that has been garnered by physical abuse, recent researchers have begun to address the “neglect of neglect” in their work. The common consensus seems to be that this type of maltreatment is simply less obvious and less dramatic than physical or sexual abuse, so it is not given as much attention. There is also a consistent belief that neglect is not as bad as abuse. Despite this belief, the statistics indicate that it is not a true conclusion. Not only is neglect the most commonly reported and substantiated type of maltreatment (49% of cases are neglect), it is also a leading cause of fatalities from child maltreatment (42%) and can cause lifetime impairment (Cantwell, 1997). In 2010, 508 children died as the result of child neglect in the U.S. (U.S. Children’s Bureau, 2011). Further- more, researchers assert that emotional neglect leads to more severe outcomes than any other type of maltreatment (Bath & Haapala, 1992; Eckenrode, Laird, & Doris, 1993; Rohner, 1986). Rohner (1986) reported that as many as 74% of emotionally neglected children suffer grave consequences including such things as serious failure to thrive and suicide attempts.
Resilient Children
Not all children will be negatively affected by being neglected. The consequences to the child are dependent on numerous factors including the severity and duration of the neglect along with many child factors. The age and developmental level of the child at the time of the neglect will have a major infl uence on how the neglect has an impact on the child. A parent who is too drunk to feed an infant for a few days will see dire effects, but a parent who fails to feed a 12-year-old for the same period may see no effects. As children become more capable of caring for themselves, neglect is less likely to have a serious physical impact on them. This is not to say that they may not be harmed emotionally by their parents’ indifference toward them. Other child factors may protect the child such as intelligence, creativity, a good sense of humor,
or a strong tendency toward independence. Children who survive less-than-ideal child rearing with minimal negative effects are often referred to as resilient children. This resilience can come from within, as mentioned, or from outside of the child. For instance, children who fi nd support from a caregiver or mentor beyond the family may not suffer the ill effects of neglect seen in children with- out these resources (NCCAN, 2001). See Chapter 10 , “Resilience,” for a more thorough discussion of children who are resilient in the context of child maltreatment.
Consequences of Neglect in Infancy
The impact of neglect will vary with the age of the child. Young children are at risk for some of the most serious, physical effects of neglect. Some severely neglected infants will be diagnosed with nonorganic failure to thrive (NFTT). These infants, who were once in the normal range, now fall below the fi fth percentile for height and weight in the absence of any organic explanation (Wallace,
resilient
being able to recover
easily from diffi cult
circumstances; the ability
to bounce back and
persevere; being able to
adjust to misfortune;
adaptable.
nonorganic failure to
thrive
a child’s failing to reach
normal milestones
for physical growth
(falling below the third
percentile) when the
child has no known
organic disease.
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115CHILD NEGLECT
1996). They are also likely to display psychomotor delays during infancy, and they are at risk for continued growth problems, school failure, and mental retardation. In many cases, these infants are malnourished due to inadequate feeding. In some cases, this may be intentional on the part of the parent who is not interested in meeting the demands of an infant. In other situations, this neglect may be the result of parental inexperience. Some parents have no idea how much or how often a new- born should eat. I once worked with parents who were feeding their newborn when they ate: three times per day. They did not realize that this was insuffi cient feeding for a newborn. Still other parents underfeed their child to save money or to prevent the child from becoming overweight. Finally, even parents who meet their child’s physical needs may have an infant with nonorganic failure to thrive. It appears that some infants who are deprived of emotional attachment may lose weight and withdraw even if their physical needs are being met. Researchers have reported that frequent touch from caregivers is absolutely necessary for both physical and psycho- logical growth (Black, 1998).
Poor Attachment Another possible consequence of neglect is poor attachment. Normally developing children form a close attachment with a primary caregiver by the time they are 6 to 8 months old. This relationship is characterized by close physical contact, sep- aration anxiety, and pleasure upon reunion. In an experimental setting, attachment is assessed using the strange situation task when the child is approximately 1 year old. This test involves the parent, generally the mother, entering a playroom with their infant. A child who is securely attached to a parent should explore this new environment while using the parent as a base. In other words, the child will bring new toys to the parent’s attention or try to engage the parent in play in addition to exploring on their own. The next step in this task is the entry of a stranger. At this point, the securely attached child will move to the parent and examine the parent’s facial expression for cues about the stran- ger. This behavior, termed social referencing, allows a parent to guide a child by expression alone. For instance, a parent who looks fearful or tense will communicate to the child to stay close. Conversely, a relaxed, smiling parent lets the child know that this new person is safe and that the child should feel free to return to play. Next, the parent leaves the room and the child is alone with the stranger. The typical response in a securely attached child is crying or other signs of being upset. They suffer separation anxi- ety when the adult they are attached to leaves them. Finally, the parent returns and researchers observe the reunion between parent and child. The baby with a secure attachment will eagerly approach the parent, and have a joyful reunion. It is clear that the infant prefers a parent to a stranger. When researchers observe this pattern or behavior, they say that the infant has a secure attachment. This sort of relationship is believed to be the result of consistent, warm, and loving parent- ing. The child has learned to trust this adult and to look to this adult for guidance (Bowlby, 1982).
psychomotor
pertaining to the
function of voluntary
muscles.
strange situation task
a laboratory task
designed to measure an
infant’s attachment to a
caregiver.
social referencing
reading another person’s
facial expressions in
order to decide on an
appropriate response.
secure attachment
an infant’s using a
caregiver as a secure base
from which to explore
his or her surroundings.
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116 TYPES OF ABUSE AND THEIR EFFECTS
As you might expect, we see disrupted attachment in infants who have been neglected. Researchers suspect that as many as two thirds of neglected children may be poorly attached to their mothers by 1 year of age. These infants are especially
likely to show avoidant or resistant styles of attachment. Children who have an avoidant attachment seem generally unresponsive to their parent in the strange situation task. In addition, they are not distressed when their parent leaves and may not show any observ- able reaction at all. When the parent returns, they do not rush for a joyous reunion, but instead are slow to react and may fail to cling if picked up by the parent. These infants do not show a clear preference for the parent or the stranger. Infants who are described as having a resistant attachment are often clingy prior to the time the parent leaves the room. They will stay very close to the parent and fail to explore the playroom. Like the securely attached baby, they are distressed at separation, but unlike the securely attached infant, they are not happy when the parent returns. At reunion, these infants appear angry, and they may resist the parent by push- ing or hitting. They are not easily calmed down by their parent.
Beyond odd behavior in the strange situation task, what does it mean to have an insecure attachment? Psychologists now believe that the fi rst relationship a child has forms the basis for all of their future relationships. As we grow, we use our fi rst relationship as a model for subsequent relationships. Therefore, a good early rela- tionship will make it more likely that we will be able to form satisfying relationships throughout our lives. Poor attachment in infancy has also been linked to aggression in elementary school and lower levels of cognitive development (Cantwell, 1997).
Other Signs of Possible Infant Neglect There are a number of other signs that may indicate an infant is being neglected. If an infant shows a number of the symptoms listed below in the absence of other psy- chopathology that would explain them, it may point toward a problem of neglect.
Poor muscle tone. A child who is not moved about and encouraged to move and reach will have less developed muscle tone than a child who is engaged in frequent movement by caregivers. These babies also have diffi culty supporting their own weight (Crosson-Tower, 2005).
Flat, bald spot on the back of the head. A child who is left lying in a crib most of the time will have a skull that is fl at in the back, and hair is unlikely to grow or will be rubbed off if the child is rarely upright (Crosson-Tower, 2005). As a note of cau- tion, with the “Back to Sleep” movement to decrease sudden infant death syndrome by always placing children on their backs to sleep, we may see more of this symptom in nonneglected children.
Lack of smiling, babbling. Normal children will begin to smile by six weeks in response to other people. At 1 to 2 months of age, children begin to make vowel sounds that we label as cooing, and consonant/vowel combinations that make up babbling appear between 3 and 6 months. In children who are neglected, we see few smiles and hear very little cooing or babbling. This happens because infants do not persist in smiling or vocalizing if they are not reinforced for doing so.
resistant attachment
an insecure attachment
style in which infants
cling to their caregivers
at times and resist
closeness at other times.
avoidant attachment
an insecure attachment
style in which the infants
tend to avoid or ignore
their caregivers.
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117CHILD NEGLECT
Rashes and/or infections. Infants who are not changed and bathed consistently will develop diaper rashes and infections.
Lower intelligence. Physically neglected children have lower overall IQ scores at 24 and 36 months than nonmaltreated children. Emotionally neglected children show the same IQ defi cits at 12, 18, 24, and 36 months (Gowan, 1993).
Consequences of Neglect in Childhood
Language Delays One of the most consistent fi ndings regarding neglected children is that they suffer from language delays (R. Allen & Oliver, 1982; Crosson-Tower, 2005; Fox, Long, & Langlois, 1988). Children whose parents do not engage them in conversation or pay atten- tion to them do not learn to listen to and comprehend complex sentences. If a teacher tells the class to go in, put their coats away, pick up their reading books, and sit down, a neglected child’s lin- guistic capabilities may be overwhelmed. Being more familiar with only hearing short commands such as “shut up” or “go away,” these children may focus on only one aspect of the teacher’s instructions (Crosson-Tower, 2005; see Focus on Research 5.2 ).
language delays
the failure to develop
language skills according
to the usual timetable
resulting in development
that is signifi cantly below
the norm for a child of a
given age.
FOCUS ON RESEARCH 5.2: CHILD NEGLECT AND DELAYS IN LANGUAGE DEVELOPMENT
Allen and Oliver (1982) studied language development in 79 children with an average age of 47 months (3 years 11 months). Their participants included 13 abused children, 7 neglected children, 31 abused and neglected children, and 28 nonmaltreated children. The maltreated children were selected from cases handled by the Family Resources Center in St. Louis, Missouri. This center provides services to maltreating families. The nonmal- treated children were selected from a local day care and did not differ signifi cantly from the maltreated children in terms of age, family income, maternal education, race, or the presence of a father fi gure in the home.
Allen and Oliver measured language development with the Preschool Language Scale (PLS, Zimmerman, Steiner, & Pond, 1979). This test assesses language competence in two ways: It measures both receptive (auditory comprehension) and expressive (verbal produc- tion) language ability. Items assessing receptive language require nonverbal responses to verbal questions. For instance, a child may be asked to point to a specifi c object. To assess expressive language ability, children are asked questions that require a spoken response. The PLS is considered a well-constructed test of verbal ability in preschool children.
The researchers found that neglect was the only variable that was signifi cantly related to either receptive or expressive language ability. In both cases, neglect was associated with lower scores of language ability. Children who were only physically abused (and not neglected) did not differ signifi cantly from their nonmaltreated peers in this study.
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118 TYPES OF ABUSE AND THEIR EFFECTS
Intellectual and Academic Problems Not surprising, given their signifi cant language delays, neglected children have documented cognitive defi cits and underachieve academically (Pianta, Egeland, & Erickson, 1989). Researchers examined the academic performance of 47 neglected children and compared them to a control group of matched socioeconomic status. The children who were neglected scored signifi cantly lower than their nonmaltreated peers on a composite index of school performance and on tests assessing mathemat- ics and language arts.
There are several possible explanations for these academic defi cits. First, it may be that neglected children are less successful because they are less persistent and less enthusiastic than are their peers when engaged in learning tasks (Egeland, Sroufe, & Erickson, 1983). Nonneglectful parents help their children to develop persistence by encouraging their early efforts, even if they are not perfect. Second, some of these academic defi cits may be attributable to poor attendance. In one study, the neglected children had missed signifi cantly more days of school during the past year than had their nonmaltreated peers. Although the children in the comparison group had missed an average of only 4.52 days, the neglected children had been absent an aver- age of 21.35 days (Wodarski, Kurtz, Gaudin, & Howing, 1990).
Another explanation for poor academic performance is that the lower IQ scores seen in neglected infants persist into childhood. Neglected children have lower IQ scores than their classmates. Rogeness, Amrung, Macedo, Harris, and Fisher (1986) studied a large group of children (539) who had been admitted to a private, psy- chiatric hospital for children. The ages of their participants ranged from 4 to 16 years. Their sample included 99 children who had experienced physical abuse, 128 who had been neglected but not abused, and 313 who were not maltreated. They compared Wechsler Intelligence Scale for Children (WISC) scores for all children. The WISC provides an overall IQ score as well as scores on verbal and nonverbal subtests. The subtests that make up the verbal scale involve questions that are posed verbally to a child and require a verbal response. The nonverbal tests make up the performance scale and do not require a verbal response (e.g., children are asked to put pictures in order, to construct puzzles, or to match a block design). The neglected boys in their sample had signifi cantly lower full-scale IQ scores than did either the physically abused boys or the nonmaltreated boys. This difference was attributable to low subtest scores on two verbal tests, information (responding to questions about information that a child of a certain age should know) and vocabulary (word defi ni- tion). That neglected boys struggled with these areas is consistent with the lack of environmental stimulation they receive. The neglected girls did not differ from the
The authors conclude that their data supports the theoretical explanation that the language development of neglected children is hindered by a lack of stimulation. However, they acknowledge that a correlation study cannot be used to establish cause and effect (see Chapter 1 ). What this study does show is that neglect is correlated with poor lan- guage development in the preschool years. The researchers suggest that the treatment of neglected children should include speech therapy and/or intensive language stimulation in addition to addressing emotional issues.
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119CHILD NEGLECT
physically abused girls in terms of IQ, but both maltreated groups had signifi cantly lower full-score IQ scores, verbal scores, and performance scores than did the non- maltreated girls.
Impaired Socialization Neglected children are also impaired socially; they do not have many friends (Erick- son & Egeland, 2002). Researchers have found that neglected children tend to be passive socially, and they are less likely than their nonmaltreated peers to display affection or initiate playful interactions (Crouch & Milner, 1993).
To assess socialization skills, researchers utilize a technique called “peer rating.” Children are asked to list three children in their class whom they would most like to play with and three children whom they would least like to play with. Researchers use these ratings to classify children in one of the following categories:
Popular: frequently listed as preferred playmates and rarely listed as someone a child does not want to play with
Peer Rejected: frequently listed as someone a child wishes to avoid, but rarely listed as a preferred playmate
Peer Neglected: a child who does not show up on either set of lists Controversial: a child who appears frequently on both the positive and the nega-
tive list Average: a child with an average number of appearances on the preferred lists
and a small number of appearances on the least preferred list
Neglected children are frequently neglected or rejected by their peers. Why would peers neglect a neglected child? One explanation may tie back to language delays. A child who is not profi cient in language may fi nd that it is diffi cult to communicate with the other children. Also, a child who has not learned from loving, attentive parents how to approach others and engage them in play will not have the skills to approach peers. Bousha and Twentyman (1984) observed maltreated and nonmal- treated children interacting with their mothers in their home environment. They found that the neglectful mothers interacted signifi cantly less with their children than did physically abusive or nonmaltreating mothers. They also noted a depressed rate of positive social behavior on the part of the neglected children (e.g., they were less likely to initiate social interaction, and they showed less inquisitive or explora- tory behavior). Many neglected children also suffer from low self-esteem, which may prevent them from seeking out attention from others and cause them to be simply more withdrawn than other children. Taken together, these factors may make the child who is neglected at home the same one who is overlooked at school.
Although it may seem intuitive to expect that neglected children would be peer neglected, what causes some of these children to be rejected by their peers? First, as a group, neglected children are more aggressive than are other children, and this is frequently linked to peer rejection. Rogeness et al. (1986) reported that neglected boys, but not girls, had higher levels of conduct disorder than did those in a nonmal- treated control group. Bousha and Twentyman (1984) suggested that the increased rate of aggressive behavior among neglected children may be the result of the child doing whatever is necessary to get his or her mother’s attention. Neglected children tend to engage in a high number of both positive and negative attention-seeking
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120 TYPES OF ABUSE AND THEIR EFFECTS
behaviors at school. As we all know, young children are very competitive when it comes to getting the teacher’s attention. A child who demands a disproportionate share of this attention is going to meet with hostility from peers. Children who are physically neglected also tend to be unappealing in more direct ways. These children are not dressed well; they often appear dirty and may have an unpleasant smell. If you have spent any time around young children, you will know that diplomacy is not their strong suit; they may very well tell the neglected child, “You stink!” Finally, children whose needs are not met at home may be more likely to steal or act impul- sively to get what they want (Winton & Mara, 2001). Any of these behaviors will increase the chance that the child will be rejected by peers.
Trauma-Related Symptoms Although neglect does not seem to meet the criteria for post-traumatic stress disorder (PTSD; e.g., experiencing or witnessing an event that threatens serious injury), some have argued that neglected children may experience the unavailability of a caregiver as traumatic. Milot, St.-Laurent, Ethier, and Provost (2010) noted that preschool teachers reported more PTSD symptoms in neglected children than in nonneglected children. This was true even when they tried to ensure that the children in the neglected group had not experienced any other type of maltreatment. The neglect alone was enough to lead to PTSD symptoms.
Consequences of Neglect in Adolescence
Certainly adolescents are more capable of caring for themselves than are younger children. However, this does not mean that neglect does not harm older children. Also, because neglect is generally a chronic condition, children who are neglected as adolescents often have a long history of being neglected.
Runaways One risk associated with neglect in adolescence is leaving home early. It makes sense that a child would be more willing to leave a home if his or her needs were not being met there. However, life on the street is dangerous, especially for adolescents. These young runaways may end up engaged in crime or as the victims of crime.
Social Isolation Not only are their needs not being met at home, neglected adolescents also have trouble developing a network of support outside of their family. Many neglected children are socially isolated during adolescence. Their poor social skills continue to inhibit them in making and maintaining friendships. Some neglected children may be drawn to gangs in order to meet their need to belong (Cantwell, 1997).
Intellectual/Academic Problems Neglected children have a higher rate of school expulsion and dropout than do their nonneglected peers, and those who remain in school are more likely to have low achievement scores. Perez and Widom (1994) followed 413 children who had been maltreated and found that neglect as a child still predicted lower IQ and lower
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121CHILD NEGLECT
reading ability at the age of 28. In other words, the children do not outgrow the intel- lectual defi cits fi rst noted in infancy.
Delinquency Researchers have noted a positive correlation between neglect and later criminal con- duct. When McCord (1983) reviewed the cases of 48 men who had been neglected between 1939 and 1945, she found that 73% of them had been convicted for crimi- nal behavior, as compared to only 23% of the control group. Whereas 31% had been convicted only as juveniles, 17% had both juvenile and adult records, and 27% had only adult records for criminal behavior. It may be that the relationship between neglect and delinquency is mediated by IQ. If, as noted earlier, neglected children have lower IQs, this may be what contributes to higher rates of delinquency. A num- ber of studies have demonstrated that adolescents with lower IQs are more likely to engage in delinquent behavior than are their more intelligent peers (Perez & Widom, 1994).
Psychiatric Disorders Finally, neglected children have a higher rate of psychiatric disorders, and they are more likely to attempt suicide than are their peers. Williamson and Borduin (1991) had mothers and adolescents complete the Global Severity Index of the Symptom Checklist-90-Revised (Derogatis, 1983). This test measures symp- toms of several psychological problems including somatization, obsessive-compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psy- choticism. They found that the neglected adolescents had signifi cantly higher scores than did those in the nonmaltreated control group. In addition, mothers completed the Revised Behav- ior Problems Checklist (RBPC, Quay, & Peterson, 1987), which is used to screen for behavior disorders in children and adolescents. Maternal ratings on the RBPC revealed that neglectful mothers rated their adolescents as having higher levels of conduct disor- der and socialized aggression than were seen in the nonneglectful mothers’ ratings of their teenagers.
INTERGENERATIONAL TRANSMISSION OF NEGLECT
As part of the Minnesota Parent-Child Project, Pianta, Egeland, and Erickson (1989) studied the relationship between child maltreat- ment and the care the mother had received as a child. They found that seven of the nine mothers who had been neglected as children went on to maltreat their own children, most often by neglecting them (three mothers were rated as seriously maltreating, and four were labeled as questionable caregivers). This not only highlights the fact that being neglected may start a cycle of maltreatment, but it also illus- trates that this is not inevitable; not all of the neglected mothers went on to be poor parents.
somatization
the expression of
psychological distress as
physical symptoms.
obsessive compulsions
the persistent intrusion
of unwanted thoughts
accompanied by
ritualistic actions.
phobic anxiety
worry about irrational
fears.
paranoid ideation
abnormal suspicion that
is not based on fact.
psychoticism
impaired contact with
reality.
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122 TYPES OF ABUSE AND THEIR EFFECTS
Other researchers have looked at what factors may help to break the cycle of abuse. Four things have been identifi ed that may help prevent abused children from becoming maltreating parents. First, the presence of a supportive adult during child- hood can help a child to be resilient. This person models appropriate behavior for the child and gives the child positive feedback and attention that partially compensates for the lack of attention from parents. Second, having a supportive, competent part- ner to help raise children can protect the next generation. This person can reduce the stress of parenting and serve as a positive model. Third, mothers who engage in therapy that helps them come to terms with their past are better able to parent appropriately. Fourth, mothers who incorporate their own maltreatment into their life story are less likely to maltreat their children. Women who dissociate themselves from the abuse they experienced are less likely to move beyond their past and be good mothers (Erickson & Egeland, 2002).
CONCLUSION
In cases of child neglect, caregivers fail to meet the minimum acceptable level of care necessary to ensure the child’s physical and psychological health. Instead of actively doing something to hurt the child, the parents are failing to do what is needed. Although certain subtypes of neglect have been well researched, others, such as men- tal health neglect, are only beginning to receive attention.
Not only is child neglect the most common type of child maltreatment; research- ers also have carefully documented its negative impact on child development.
Clearly, this form of maltreatment, which is too often seen as “not as bad as physical abuse,” has very real, very negative consequences for many children. Being the victim of child neglect increases the chances that a child will suffer social, emo- tional, and cognitive defi cits that persist throughout his or her lifetime.
DISCUSSION QUESTIONS
1. Were you surprised by the number and variety of behaviors that fall under the category of “child neglect”? Do you think it would be helpful to have a more narrow defi nition?
2. Which type of neglect do you think you would most be comfortable reporting to CPS? Which type would you be least comfortable reporting?
3. If a parent is not providing for his or her child or children because the family is impoverished, is the parent guilty of child neglect?
4. How would you compare the consequences of child neglect to the conse- quences of child physical abuse?
5. Discuss “adequate supervision” with your classmates. Can you come up with specifi c rules? For instance, at what age should a child be permitted to play in her own yard unsupervised? At what age should she be allowed to cross a street in a subdivision on her own? Is it permissible to take a nap while your toddler plays in the family room?
6. Should the government be allowed to order parents to let their children receive medical treatment that the parents do not believe in for religious reasons?
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123
DEFINITION
Psychological, or emotional, maltreatment includes both psychological neglect and psychological abuse. In cases of psychological neglect, the parents fail to meet the emotional needs of their children. Parents who ignore their children or who fail to make emotional contact with their children may be guilty of psychological neglect. In psychological abuse, the parents are engaging in behaviors that actively harm a child’s mental health. For instance, a parent who yells at a child, calling the child stupid, lazy, and no good, or a parent who threatens the life of a child may be considered psychologically abusive. What is diffi cult about this type of maltreatment is evident in my use of the phrase “ may be considered.” There is probably no such thing as a parent who never ignores the emo- tional needs of a child. There are times when even the best caregiver is distracted, tired, or too angry to provide the perfect emotional response to a child. We do not, however, say that all parents are psychologically neglectful. Likewise, nearly all par- ents occasionally speak more harshly to a child than is ideal, and we do not label them psychologically abusive. Contrast this with physical abuse. If a parent inten- tionally burns a child once, he or she is guilty of physical abuse, but how many times does a parent have to say something negative to a child before he or she is guilty of psychological abuse? Does it matter if the parent is saying something that happens to be true? In other words, if you call your lazy child “lazy,” is that abusive? To com- plicate things further, tone of voice and intent may be as important as what is said. Have your parents ever threatened your physical well-being, or even your life? Before you say, “Not mine!” see if any of the following statements sound at all familiar:
Stop crying or I will give you something to cry about. I brought you into this world, and I darn well can take you out of it. If you want to live to see your next birthday . . .
Hearing phrases like the ones above is a fairly normative part of growing up in the United States (As an interesting side note, this is not true in all cultures. While I was lecturing at the University of Iceland, I mentioned these phrases, and my students were appalled that any parent would ever say such a thing to a child!) Is a statement like this psychologically abusive if the child knows the parent does not mean it? Is it suffi cient to make the statement nonabusive if the person voicing the threat does not mean it, even if the child is unsure?
CHAPTER 6
Psychological Maltreatment
psychological neglect
a parent’s failing to meet
the emotional needs of
his or her child.
psychological abuse
parental behaviors that
actively harm their
child’s mental health.
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124 TYPES OF ABUSE AND THEIR EFFECTS
Despite these very real diffi culties in pinpointing exactly what psychological mal- treatment is, psychologists know that children’s mental health can be endangered by how they are treated emotionally. As you will see later in this chapter, psychological maltreatment has very real, negative consequences for its victims. Therefore, exten- sive attempts have been made to defi ne psychological maltreatment. First, I cover legal defi nitions, then psychological defi nitions.
Legal Defi nitions
Although there is not a uniform legal defi nition of psychological maltreatment (Baker, 2009), every state and territory in the United States, with the exceptions of Georgia and Washington, mentions emotional abuse in its child abuse statutes, and nearly half of these provide some type of defi nition that is generally based on child outcomes (National Clearinghouse on Child Abuse and Neglect, 2005). Psychologi- cal, or emotional, neglect is less well covered in the statutes.
Some state’s statutes provide only minimal coverage of psychological abuse. They mention that it is against the law but provide no further information. For instance, Alabama statute 26–14–1 (1)–(3) reads “Harm or threatened harm to a child’s health or welfare can occur through nonaccidental physical or mental injury, sexual abuse or attempted sexual abuse or sexual exploitation or attempted sexual exploitation.” The statute goes on to defi ne “sexual abuse” and “sexual exploitation,” but no fur- ther information is provided about mental injury. Similarly, in Connecticut, statute 46b-120 defi nes abused as “in a condition that is the result of maltreatment, includ- ing but not limited to malnutrition, sexual abuse or sexual exploitation, deprivation of necessities, emotional maltreatment or cruel punishment.”
Other states provide more information about how one would know if psycho- logical abuse had occurred. For instance, Arizona’s statute (§8-201) reads
Abuse means the infl iction of or allowing another person to cause serious emotional damage to the child, as evidenced by severe anxiety, depression, withdrawal, or unto- ward aggressive behavior, and such emotional damage is diagnosed by a medical doctor or psychologist, and the damage has been caused by the acts of an individual having care, custody, and control of a child.
In Nevada, the relevant statute (§432B.070) states that “mental injury means an injury to the intellectual or psychological capacity or the emotional condition of a child as evidenced by an observable and substantial impairment of his ability to function within his normal range of performance or behavior.” Even with this added detail, it is still not obvious what marks a child as a victim of psychological maltreat- ment. For this reason, several states, including Alabama and Indiana as mentioned earlier, say that such a fi nding must be supported by the diagnosis of a medical or mental health professional. This presumes, of course, that such professionals have a clear defi nition from which to work. You can also see from the preceding statutes that some states focus on mental harm caused by the parents, whereas others include instances in which parents allow others to harm their children psychologically.
Although most states explicitly mention psychological abuse, the same can- not be said for psychological neglect. In many states, psychological neglect must be inferred from the statutes that describe neglect more broadly. Consider Missouri’s
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125PSYCHOLOGICAL MALTREATMENT
statute (§210.110), which defi nes neglect as the “failure to provide, by those respon- sible for the care, custody, and control of the child, proper or necessary support; education as required by law; nutrition; or medical, surgical, or any other care neces- sary for the child’s well-being” (emphasis added). In cases such as this, emotional responsiveness would fall under other necessary care. A few states directly describe emotional neglect in their child abuse statutes. For example, Montana statute 41-3- 102 directly addresses psychological neglect by stating that “psychological abuse or neglect means severe maltreatment through acts or omissions that are injurious to the child’s emotional, intellectual, or psychological capacity to function, including acts of violence against another person residing in the child’s home” (emphasis added).
Even in the laws that include more detail, it is still not perfectly clear what behav- iors constitute psychological maltreatment. When professionals are asked to assess this sort of maltreatment, what are they looking for? Is psychological maltreatment defi ned as the acts of adults or the effects on children? For answers to these ques- tions, we turn to examining how psychologists defi ne psychological maltreatment.
Psychological Defi nitions
Most of the research on psychological maltreatment is very new. This form of child maltreatment was not addressed by professionals until the 1980s, and it was not included in policy and research on a consistent basis until the 1990s. The Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ( DSM-IV ; American Psychi- atric Association, 1994) lists diagnostic codes for physical abuse, sexual abuse, and neglect, but it does not do so for psychological maltreatment (Mar- shall, 2012). The closest diagnostic code is probably parent–child relational problem (V61.20), which is appropriate when clinical intervention is geared toward the relationship between the parent and the child and that interaction is characterized by a pattern of behavior that impairs the child or the family. Although this sounds as if it may cover psychological maltreatment, the examples of inappropriate interactions included in the DSM-IV are impaired communication, overprotection, and inadequate discipline, which do not seem necessarily refl ective of emotional maltreatment. In addition, it would not be appropriate if the focus of the treatment were on the child alone (American Psychiatric Association, 1994).
Although researchers have been slow to focus on psychological maltreatment, it is not because professionals have not recognized the need for such information. In 1958, Robert Mulford wrote, “It is signifi cant that at this stage of the development of child protective services atten- tion is being focused nationally on emotional neglect of children” (p. 19). Then what accounts for the slow progress in this area? It may well be that research on psy- chological maltreatment has been hampered by the extreme diffi culties involved in defi ning what exactly is meant by terms such as emotional abuse and emotional neglect .
The problem of defi ning psychological maltreatment was highlighted in 1991 when the editors of the journal Development and Psychopathology devoted an entire issue to assessing the progress on defi ning this type of maltreatment (Cicchetti, 1991). Because the study of psychological maltreatment has such a short history, it should not be surprising that there are many ongoing debates.
parent–child relational
problem
a mental disorder marked
by clinically signifi cant
impairment in the
interaction between
parent and child that
has an impact on family
functioning or leads
to the development of
negative psychological
symptoms in the parent
or the child.
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126 TYPES OF ABUSE AND THEIR EFFECTS
First, despite that it is done consistently, not all psychologists agree with using psychological and emotional as synonyms in this context. As O’Hagan (1993) points out, emotional means feeling, and emotional development entails learning to express and interpret emotions. Psychological , on the other hand, means pertaining to the mind, and psychological development is related to improving mental processing through more advanced cognitive skills. Although different, these terms are related and are frequently used to refer to the same types of behavior, even if the terms are not used perfectly. Although I am aware of these differences, I use the terms inter- changeably in this chapter, as do most authors in the fi eld.
Child Outcome Versus Parental Behavior Another primary source of contention is whether the focus of the defi nition should be based on child outcomes (as is the case with most legal statutes), or on parental behavior. S. Hamarman and Bernet (2000) argue that psychological maltreatment should be defi ned as ill treatment by adults. First, this type of defi nition would allow for the possibility of prevention or intervention before harm has occurred. If this type of maltreatment is only recognized after a child has been harmed, there is no hope for prevention. Second, it is very diffi cult to establish that any par- ticular emotional outcome was caused by one specifi c antecedent. For instance, just because a child is anxious, it does not follow that the anxiety was caused by verbally abusive parents. Even if it is known that the child’s parents were verbally abusive, it is still possible that something else led to, or contributed to, the child’s anxiety (dangerous neighborhood, overly critical teacher, bully at school, etc.). A third possibility is to defi ne psychological maltreatment as the interaction between an adult’s behavior and a child’s vulnerabilities. This allows one to consider the developmental level of the child at the time of the behavior, as well as his or her individual sensitivity. Furthermore, interactions are observable, whereas things such as parental motivation and the negative impact on the child’s psychological development are not. Because negative interactions can be observed, they can be quantifi ed in terms of frequency and content. This allows researchers to estab- lish norms against which psychological maltreatment can be specifi cally defi ned (McGee & Wolfe, 1991).
The Meaning of Psychological Another obstacle to understanding psychological maltreatment is knowing precisely what is meant by psychological. Does this mean that the parent’s behavior was non- physical, or does it mean that the child was harmed in a nonphysical or emotional way by the behavior? McGee and Wolfe (1991) point out that if one classifi es nega- tive parental acts as either physical or psychological and child outcomes as either physical or psychological, one has four possible pairings. If a parent hits a child and the child develops a bruise, you have a physical parental act and a physical child outcome. The classifi cation in this situation is straightforward: child physical abuse. On the other hand, if a parent continually showers a child with insults and the child becomes depressed, you have a nonphysical act and a nonphysical outcome. This would clearly fall under the rubric of psychological abuse. This leaves two pair- ings that are not as obvious. Consider a parent who is not emotionally responsive to a child, and the child develops asthma. In the case of a nonphysical parental act with a physical child outcome, the authors argue that the label of psychological
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127PSYCHOLOGICAL MALTREATMENT
maltreatment is still appropriate. However, in cases where a physical act (such as sex- ual abuse) leads to a psychological consequence (such as anxiety), McGee and Wolfe do not think psychological maltreatment is the appropriate label. In this scenario, the interaction is already labeled and defi ned as a different sort of maltreatment (sex- ual abuse in my example). In order to avoid overlap among defi nitions, this should not be considered psychological maltreatment (see Table 6.1 ).
Parental Intention Most psychologists do agree that parental intention is not an issue in defi ning psy- chological maltreatment (Glaser, 2002). Some research suggests that even parents with good intentions may become verbally aggressive (see Focus on Research 6.1 ). However, it does not matter whether the parent deliberately ignored the child, intended to harm the child with harsh words, or behaved out of ignorance. In any case, maltreatment has occurred.
TABLE 6.1 McGee and Wolfe’s (1991) Conceptualization of Psychological Maltreatment PHYSICAL PARENTAL ACT PSYCHOLOGICAL PARENTAL ACT
PHYSICAL CHILD OUTCOME Child Physical Abuse Psychological Maltreatment PSYCHOLOGICAL CHILD OUTCOME
Not Psychological Maltreatment Psychological Maltreatment
Source: McGee and Wolfe (1991).
FOCUS ON RESEARCH 6.1
Eugene M. DeRobertis (2012) explored verbal aggression toward children from the per- spective of the mother. She gathered detailed information from 10 mothers who were not abusive but who could recall instances of being verbally aggressive toward their own children. In analyzing the accounts provided by these mothers, DeRobertis found that the instances of verbal aggression were actually rooted in a sense of caring for the child and a desire to fulfi ll the moral obligation to raise a child who behaved properly. Things would begin to go wrong when the child refused to cooperate and the mothers experienced the child’s defi ance as a threat to their ability to be good mothers. Although the mothers tried to imagine reasons for the child’s disobedience, they tended to focus on willful resistance. Not only did this threaten the mother’s authority; it also caused the mothers to worry about the child’s future. For example, one mother recalled her child’s refusal to allow a dental cleaning. She was upset about the immediate disobedience and the potential long- term consequences. As the mothers felt they were losing control of the situation, they became emotional. The mothers indicated that the felt frustrated, manipulated, and pan- icked. This emotional response led to a time when the mothers “snapped.” The resulting
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128 TYPES OF ABUSE AND THEIR EFFECTS
The Defi nition According to the American Professional Society on the Abuse of Children One of the premier professional groups in the area of child mal- treatment is the American Professional Society on the Abuse of Children (APSAC) . In 1995, the society published a defi nition of psychological maltreatment that included six subtypes. The general defi nition is that “psychological maltreatment means a repeated pattern of caregiver behavior or extreme incident(s) that convey to children that they are worthless, fl awed, unloved, unwanted, endangered, or only of value in meeting another’s needs” (APSAC, 1995, p. 2). Furthermore, there are six major subtypes: (a) spurning, (b) terrorizing, (c) isolating, (d) exploiting/corrupting, (e) denying emotional responsiveness, and (f) mental health, medical, and edu- cational neglect.
Spurning captures what fi rst comes to mind when most of us think of psychological abuse. This category consists of verbal and nonverbal caregiver behaviors that are hostile toward and rejecting of the child. It includes belittling, degrading, sham- ing, ridiculing, publicly humiliating, and repeatedly singling out one child for punishment (scapegoating) or failing to reward one child. Other researchers simply use the term rejecting to refer to this type of behavior. If authors use rejecting instead of spurning, they often add degrading as a separate category (Hart, Germain, & Brassard, 1987). The second subtype, terrorizing, is the label given to caregivers who threaten a child or a child’s loved ones or possessions with violence or abandonment. Less obvious, it includes placing a child in unpredictable, chaotic, or recognizably
verbal aggression seemed to happen almost against their will. They aggressive comments generally attempted to instill guilt, encourage embarrassment or induce fear. After the outbursts, the mothers reported remorse for their behavior and many apologized. The mothers were surprised and saddened by the intensity of their own responses and the fact that they had infl icted emotional pain on their children.
DISCUSSION QUESTIONS
1. How does this research relate to the theoretical discussion of psychological mal- treatment occurring on a continuum between good parenting, bad parenting and maltreatment?
2. Review the risk factors for maltreatment covered in Chapter 2 . How might some of those factors push parents toward becoming verbally aggressive more often?
3. If psychological abuse arises from the child’s disobedience, is it the child’s fault? Why or why not?
4. Given that all parents are likely to be frustrated at times by disobedient children, what advice would you give them to help avoid becoming verbally aggressive?
American Professional
Society on the Abuse of
Children (APSAC)
a national nonprofi t
organization that is
committed to preventing
child maltreatment,
promoting research,
informing U.S. public
policy, and educating
the public about
maltreatment.
spurning
caregiver behaviors that
are hostile toward and
rejecting of a child.
terrorizing
a caregiver’s threatening
his or her child or the
child’s loved ones or
possessions with violence
or abandonment, or
placing the child in a
dangerous situation.
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129PSYCHOLOGICAL MALTREATMENT
dangerous situations. Isolating includes confi ning a child within a space and failing to allow the child appropriate opportunities to socialize with others. Exploiting/corrupting is the subtype used to describe instances in which parents encourage their children to develop inappropriate behaviors. This encouragement may take the form of modeling some negative behavior, permitting it, or actively encouraging the child to take part in it. The types of activities covered by this category range from criminal acts (e.g., teaching a child to steal) to acts that are developmentally inap- propriate (e.g., parentifi cation of the child, or refusing to allow the child to become autonomous). Acts that restrict or interfere with a child’s cognitive development also fall under this category. The next subtype, denying emotional responsiveness, refers to parents who ignore their child or who show no emotional reac- tions when interacting with the child. Parents whose behavior is classifi ed as denying emotional responsiveness interact with their child infrequently and do not express affection for the child. The fi nal type of psychological maltreatment is mental health, medi- cal, and educational neglect. Parents who ignore their child’s needs in any of these areas, or who fail to provide them with necessary services, are guilty of this type of psychological mal- treatment (APSAC, 1995).
Glaser’s Defi nition Although the criteria established by the APSAC is commonly taught and well rec- ognized, it is not without its critics. Glaser (2002) has argued that its framework does not have a theoretical basis and that there is overlap among the subtypes. In addition, some of the subtypes are not cohesive. For instance, Glaser argued that “restricting or interfering with cognitive development” is not clearly related to the category of exploiting/corrupting, even though it is listed there.
Glaser (2002) proposed an alternative understanding of psychological maltreat- ment based on a conceptual framework of a child’s needs. Glaser stated that in order for a child to be psychologically healthy, their needs must be recognized and respected by those who care for them. The defi nition proposed by Glaser has fi ve subtypes (Glaser, 2002, pp. 703–704):
1. “Emotional unavailability, unresponsiveness, and neglect.” This fi rst category is used to describe parents who are insensitive as well as those who are not available or responsive to their children. This includes caregivers who are preoccupied by things ranging from drug addiction to demanding jobs. These parents can be physically or psychologically unavailable, and they do not arrange for suffi cient alternative care.
2. “Negative attributions and misattributions to child.” Attributions are the explanations we make for another person’s behavior. They can be positive, neutral, or negative. Say, for instance, that a young child brought a fl ower to his mother. The mother could make a positive attribution by thinking, “My son is a sweet, caring boy who wants to show me his love,” or a neutral attribution
isolating
confi ning a child or
not allowing a child to
have the opportunity to
socialize with others.
exploiting/corrupting
encouraging children to
develop and engage in
inappropriate behaviors.
denying emotional
responsiveness
a caregiver’s ignoring his
or her child or showing no
emotional reactions while
interacting with the child.
mental health, medical,
and educational neglect
caregivers’ failing to
meet their children’s
psychological, medical, or
educational needs.
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130 TYPES OF ABUSE AND THEIR EFFECTS
such as, “He must have seen this fl ower on his way home and decided to pick it for me.” It is in psychologically abusive cases that we see mothers making a negative attribution such as “He must have done something really bad, and he is trying to distract me with this stupid fl ower. He has always been a sneaky child.” In each case, the child’s behavior is identical; what varies is how that behavior is interpreted. If a parent consistently makes negative attributions, then he or she is likely to become hostile toward the child and ultimately reject the child. Because such parents think the child is driven by bad things, they also think this rejection is what the child deserves. Sadly, over time, children may come to believe these things about themselves.
3. “Developmentally inappropriate or inconsistent interactions with child.” This type of behavior is seen among parents who do not seem to know what sort of behavior is appropriate for children of a given age. As a result, they may have inappropriate expectations of their child. For example, a mother may tell her toddler to come inside after 15 minutes and then punish him or her when the child fails to do so, without understanding that young children have a very poor perception of time. Parents may also expose children to situations they are not old enough to handle. A parent’s asking a young child for advice on dating would be considered age-inappropriate. Although the term is not used by Glaser, others talk about overpressuring. When overpressuring a child, a parent expects too much, too soon, from the child (academically, physically, or socially) and makes the child feel that he or she is not meeting expectations (S. Hamarman & Bernet, 2000). On the opposite end of the spectrum, instead of expecting too much, some parents will be extremely overprotective and not allow their children to explore in age-appropriate ways. These children are then deprived of the experiences that they should be having.
4. “Failure to recognize or acknowledge the child’s individuality and psychologi- cal boundaries.” This category captures parents who use their child to fulfi ll their own needs. An extreme example is seen in factitious disorder by proxy (see Chapter 9 ), when a parent makes a child ill to attract attention. More com- monly, this may be seen when children are used as weapons in diffi cult divorce situations.
5. “Failing to promote the child’s social adaptation.” A parent could maltreat a child through neglect by simply failing to provide age-appropriate experiences, or could deliberately missocialize the child by teaching the child to behave in ways that are inappropriate.
Although Glaser (2002) admits that rigorous work needs to be done to validate these subtypes, she does say that agreement among her multidisciplinary team has been high with a sample of 60 cases.
As you may have noted, the criteria of the APSAC and those proposed by Glaser are not radically different. The similarity between these defi nitions indicates that some consensus may be developing about how to defi ne psychological maltreat- ment. The areas of discrepancy should be the targets of future research.
As you think about the defi nition of psychological maltreatment, it may be help- ful to consider some scenario. Read the cases presented in Case Examples 6.1 and discuss them with colleagues to see if you reached similar conclusions.
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131PSYCHOLOGICAL MALTREATMENT
CASE EXAMPLE 6.1
DISCUSSION QUESTIONS
For each of the cases below, answer the following questions:
1. Are the parents guilty of psychological maltreatment? 2. If so, what type of psychological maltreatment is present? 3. What sort of intervention, if any, is necessary to help this family?
Beth, age 17, was concerned that her boyfriend, Bob, was going to leave her. In an attempt to keep him, she stopped taking her birth control pills without Bob’s knowledge and became pregnant. Although Bob stayed around during the pregnancy, he left shortly after their son, Sean, was born. Beth continually tells Sean that he is a failure because he was not good enough to keep his father around. When a friend tells Beth that she should not say things like that, Beth says it does not matter because Sean is only 22 months old and does not understand what she is saying. Although Beth does her best to take care of Sean, she does not seem to enjoy being with him, and she seldom plays with him.
Barbara desperately wanted to be a ballerina when she was a little girl, but her mother refused to pay for the necessary lessons. Now, as a mother, Barbara is determined that her little girl, Ashley, will be a professional dancer. She started taking Ashley to dance lessons when she was 18 months old, and now that Ashley is 6 years old, she has lessons 6 days per week and practices 2 hours per day. Lately, Ashley has begun to complain about dancing and asks to spend more time with her friends. Her mother explains that the practice is necessary to meet her goals, and that Ashley can play when her practice and homework are complete. When Ashley asked if she could try out for the soccer team with her friend, her mother explained that she could not risk an injury that would inter- fere with dance. Whenever Ashley says she wants to quit dancing, her mother sends her to her room.
Brandon was raised by extremely strict parents and turned out to be a very success- ful businessman. In return, he is very strict with his own three sons, who are currently 8, 10, and 13 years old. When the children do not perform to his expectations, he lets them know that they have let the family down and that they should be ashamed of themselves. After being sent to his room, the offending child has to report to the family at dinnertime about his failure and apologize. The child is not allowed to join the family for the meal until Brandon is assured that the child is contrite. The children have been punished in this manner for offenses such as coming in late for dinner, for making poor grades (less than an A), for accidentally breaking a vase, and for fi dgeting during church services.
Realizing that few people are suspicious of a young child, Tony and Linda encourage their 4-year-old daughter to take things from stores. Their daughter, Sara, thinks of this behavior as a fun game and is not at all distressed about it. Tony and Linda justify their behavior by saying that money is really tight and that it is appropriate for Sara to help out. They also point out that if Sara was caught, nothing bad would happen to her because of her young age.
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132 TYPES OF ABUSE AND THEIR EFFECTS
Overlap With Other Forms of Maltreatment The problem of defi ning psychological maltreatment is further complicated by its tendency to co-occur with forms of maltreatment. It is well established that dif- ferent types of maltreatment are likely to coexist and this is particularly true of psychological maltreatment. Claussen and Crittenden (1991) compared families who had been reported for child abuse or neglect (excluding cases of sexual abuse) with a community sample of families who were labeled as normative and a sample of families in the community who had a child in a mental health treatment. Based on two to four home visits and multiple assessments, the authors concluded that among families who had been reported for physical abuse, 91% were also guilty of psychological maltreatment. The relationship was not as strong in the other direction; only 45% of families engaging in emotional abuse were also found to be physically abusive. Although the same pattern was seen in community families, there was also a signifi cant difference in the degree of overlap. As was true in the reported sample, most (93%) cases of physical abuse included psychological mal- treatment. However, only 18% of the psychological maltreatment cases included physical abuse. Whereas most cases of physical abuse or neglect include psycho- logical maltreatment, the reverse is not necessarily true, especially in a community sample. Many children may be the victims of psychological maltreatment alone. James Garbarino (2011) wrote that “the common developmentally destructive ele- ment in all forms of child maltreatment is psychological maltreatment” (p. 797). To illustrate, he asked readers to consider a child with a broken leg. If the leg were broken while the child was playing football, he would not be considered a victim of abuse. However, if the leg were broken by his father during a beating, the child would be a victim of abuse. In both cases, the physical injury is the same, but the meaning of the injury differs. A broken leg heals, but what happens to a child who lives with the knowledge that his father broke his leg?
Christina is raising two young children on her own. Unfortunately, she is having a great deal of diffi culty trying to make ends meet. In order to provide for her children, she takes a second job working night shift as a waitress. She knows her children are too young to be left alone at only 6 and 8 years of age, so she leaves them with her boy- friend, Alan. Alan has always been good to Christina and her children, but he does earn extra money by selling drugs from his home. He assures Christina that the buyers who come to his home are safe and that the children are not in any danger while they are with him.
Kelly and Chris have a 10-year-old son and a 5-year-old daughter. Although most of their parenting techniques seem to be appropriate, family members have noted that both parents are much harder on their son than they are on their daughter. Anytime the chil- dren fi ght, it is automatically assumed that their son is at fault. He is punished, normally by being sent to his room, and he is required to apologize to his little sister. When ques- tioned about this treatment, the parents assert that their son is older, so more is expected of him. Extended family members have also commented that it is the girl’s preferences for places to eat, vacation destinations, and outings that seem to be followed.
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133PSYCHOLOGICAL MALTREATMENT
DEFINING A LINE ON A CONTINUUM OF BEHAVIOR
Regardless of which specifi c defi nition of psychological maltreatment one adopts, eve- ryone must deal with where on the continuum of parental behavior an act becomes abusive. Consider, for example, the isolating subcategory. When does confi ning a child move from good parenting to poor parenting to abuse? If a father punishes his teenage son for curfew violation by grounding him for the weekend, how would you label his behavior? If I told you that the son had never been late before, had called this time to report a fl at tire, and was less than 10 minutes late, would it change your decision? What if the punishment was for a week, a month, or 3 months?
Wolfe and McIsaac (2011) laid out a “continuum of parental sensitivity and expres- sion” (p. 807) that ranged from positive, healthy parenting to poor or dysfunctional parenting to emotionally abusive or neglectful parenting. They noted that although parents whose behavior fell in the middle category might benefi t from instruction or parenting help, they would not yet qualify for Child Protective Services (CPS) interven- tion. For example, a healthy parenting style would entail rules that were appropriate for the child’s developmental age and were made to protect the child. A dysfunctional parent would make rules that were either unclear or that were applied inconsistently. The maltreating parent has rules that are arbitrary and that may exploit the child for the parent’s benefi t. The trick is to decide where exactly the family falls on this continuum.
S. Hamarman and Bernet (2000) suggest that two things should be considered when determining the severity of psychological maltreatment: parental intent and degree of harm. If intent and harm are both present, the maltreatment is severe. For example, if a mother repeatedly tells her son that she wishes he were never born because she is angry with him and wants to hurt him and this child is harmed by her harsh words, the act would be classifi ed as severe. Conversely, if there is no intent to harm and the child is not harmed, the inappropriate behavior is labeled as mild maltreatment. For instance, if during a long car trip, a parent said, “If you do not stop fi ghting, I am going to leave you both on the side of the road!” with no intent to harm the child (or leave them on the side of the road!) and the children interpreted her comment as an order to behave and not a threat, the act would be classifi ed as mild. Although this is not an ideal discipline strategy, no harm was intended, and none occurred. Finally, having only intent or only harm puts the behavior into the moder- ate category. This, of course, presumes that both intent and harm can be measured.
Areas of Agreement
Despite this dizzying array of defi nitional concerns, there is some hope that agree- ment can be reached, at least in some cases. Schaefer (1997) asked 151 participants who were either parents or mental health professionals to consider 18 categories of parental verbalizations. Of the 18, 10 were rated by 80% of the participants as never being acceptable (rejection/withdrawal of love, verbal put-downs, perfectionism, negative prediction, negative comparison, scapegoating, shaming, cursing, threat- ening, and guilt tripping). Although this falls 20% shy of perfect agreement, it does mean that there is some consensus about what sort of parental behaviors are inap- propriate. An even higher level of agreement about what constitutes maltreatment was reported by Burnett (1993) when he asked professionals and nonprofessionals to rate vignettes for psychological maltreatment. Both groups identifi ed the same nine parental behaviors as abusive (see Focus on Research 6.2 ).
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134 TYPES OF ABUSE AND THEIR EFFECTS
FOCUS ON RESEARCH 6.2
Burnett (1993) mailed 1,413 packets to citizens and social workers and asked them to rate vignettes in terms of psychological maltreatment. Based on 10 defi nitions that existed in the literature at the time, the author devised 20 vignettes with the input of professionals, 2 for each defi nition. For each type of abuse, one vignette described a single incident, and one described chronic behavior that had already had a documented impact on the child. All of the children described in the vignettes were either 8 or 9 years old; half were male, and half were female. The 10 types of abuse evident in the vignettes were: confi ning a child to a small space, severe public humiliation, “Cinderella syndrome” (making one child in the family the target of rejection or exploitation), severe verbal abuse, encouraging or coercing a child into delinquency, threatening a child, denial of psychological treatment, not allowing social and emotional growth, not providing a loving and supportive atmos- phere, and immoral parental behavior.
For instance, following are two vignettes Burnett used. The fi rst is the vignette designed to describe a chronic, harm-causing failure to provide a loving, nurturing home. The sec- ond vignette was to illustrate a single episode of singling out a child for rejection.
Since his wife died, a father lost interest in his 9-year-old son who now had to get his own
meals and wash his own clothes and has spent long hours alone at home. The father spent
long periods locked in his room. The boy’s grades dropped in school, he became more
aggressive, and he was caught recently with drugs.
Mrs. G. and Mr. R., her boyfriend, and two of her three children went on a weekend
trip. They told their other child, Donna, age 8 (their second child), that they did not want
her to accompany them. Donna was told that they were ashamed of her and that she
would have to fi nd a neighbor to house her for the weekend. (Burnett, 1993, p. 444 )
After reading the vignettes, the participants were asked to indicate if the behavior was abuse, to note how serious it was on a 6-point scale from not serious to extremely serious , and to select an intervention on a 4-point scale from no major problem to child should be removed from the family .
If participants did not respond to the original mailing, a reminder was sent out 3 weeks later. Participants who still failed to reply were sent the full packet again 6 weeks after the original mailing. After all three prompts, 833 (59%) of the surveys were returned. The response rate was higher for social workers (74%) than it was for citizens (47%).
Both social workers and citizens considered 9 of the 10 vignettes presented as defi ni- tions of action that were abusive. The only vignette not seen as abusive by either group was immoral parental behaviors. With regard to seriousness, the two groups did not differ on half of the vignettes, and there was not a consistent difference on the remaining 10 (in 5 cases, the citizens gave higher ratings of seriousness, and on the other 5, the reverse was true). Overall, citizens gave a mean serious rating to 3.54, and social workers had a mean response of 3.51. There was a larger difference when it came to intervention recommen- dations. Although there was no difference on 9 vignettes, there were 10 cases in which citizens wanted a more drastic intervention than was recommended by social workers. The
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135PSYCHOLOGICAL MALTREATMENT
Measuring Psychological Maltreatment
If professionals have this much trouble defi ning emotional maltreatment, imagine how much diffi culty they have measuring it! Can we actually measure something we cannot defi ne? Not surprisingly, there are many measures (self-report questionnaires— fi lled out by child and/or parent, interviews, observations, and proxy informants) designed to measure emotional abuse and emotional neglect. Tonmyr, Draca, Crain, and MacMillan (2011) reviewed 45 articles that examined 33 separate measures of emotional maltreatment. They concluded that while most of the measures had decent reliability (scores were consistent), none had been thoroughly evaluated in terms of validity (do they really measure what they are supposed to measure?). Part of the problem is that no “gold standard” exists for measuring emotional maltreatment. This means a researcher cannot compare their measure to an established “sure thing” to see if it is as accurate. Tonmyr et al. did note that some studies used the Child- hood Trauma Questionnaire (CTQ, Bernstein et al., 1994) as a comparison that might indicate that it is a well-respected measure. In addition to calling for more work on designing a valid measure, Tonmyr et al. stressed the fact that emotional abuse and emotional neglect should be measured separately and that both should be part of routine screening when other forms of maltreatment are being measured.
INCIDENCE
Determining how common psychological maltreatment is depends on how it is defi ned and how it is measured. Variations in defi nition and methodology lead to vastly different estimates.
National Incidence Study-4
Let us fi rst consider the information provided by the fourth NIS (Sedlak et al., 2010— see Chapter 2 for a review of the methodology). This study lists 8 codes for emotional abuse and 11 codes for emotional neglect. With regard to emotional abuse, the NIS-4 authors considered the following behaviors to be abusive:
1. Close confi nement (tying or binding). This category includes any extreme restric- tion of the child’s ability to move. In addition to tying, enclosing a child in a small space for the sake of punishment also counts as close confi nement.
2. Close confi nement: other
3. Verbal assaults and emotional abuse. This subtype of emotional abuse consists of habitual, nonphysical hostile or rejecting treatment. It includes acts of
authors further reported that responses did not differ by respondent age, parental status, or experience with child abuse. There was, however, a signifi cant effect for respondent sex. Female participants rated more acts as abusive, serious, and requiring intervention than did male participants.
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136 TYPES OF ABUSE AND THEIR EFFECTS
belittling, denigrating (defaming or disparaging), and scapegoating, as well as threatening the child.
4. Threats of sexual abuse (without contact)
5. Threats of other maltreatment
6. Terrorizing the child
7. Administering unprescribed substances
8. Other/unknown abuse. This fi nal category refers to parents who are overly punitive or emotionally abusive in ways that are not included in the other defi - nitions of abuse used by the researchers.
Emotional neglect is defi ned by the NIS-4 as one of the following 11 subtypes:
1. Inadequate nurturance/affection. In these cases, caregivers are not suffi ciently nur- turing in their interactions with the child.
2. Domestic violence. This is an interesting subtype because the negative behavior is directed at an adult in the household, not at the child directly. However, because research shows that being in the presence of violence is detrimental to children’s well-being, this type of abuse is included here. It is limited to cases of domestic violence that are either chronic or extreme.
3. Knowingly permitting drug/alcohol abuse. If parents either encourage their chil- dren to use drugs or fail to intervene if they know their children are using drugs, they are guilty of this type of emotional neglect.
4. Knowingly permitting other maladaptive behavior. Parents who are aware of their child’s involvement in maladaptive behavior, other than drug use, and do not attempt to stop the behavior are also guilty of emotional neglect.
5. Refusal to allow or provide needed care for diagnosed emotional or behavioral impairment/ problem. This subtype includes cases in which a competent professional has said that the child needs care, yet the parents have not secured services.
6. Failure to seek needed care for emotional or behavioral impairment/problem. If it should be obvious to a layperson that a child needed help but such help was not sought, parents are guilty of delay in psychological care.
7. Overprotectiveness
8. Inadequate structure
9. Inappropriately advanced expectations
10. Exposure to maladaptive behaviors and environments
11. Other inattention to development/emotional needs. This fi nal, miscellaneous cat- egory covers a general inattention to the child’s needs that does not fi t any of the above categories.
Using these defi nitions, Sedlak et al. (2010) reported that the incidence of emotional abuse according to the harm standard was 2.0 per 1,000 children in 2005–2006. This is marginally lower than the rate reported for 1993, but not different from the number reported in 1986. According to the harm standard, the rate of emotional neglect was 2.6 per 1,000. This was not signifi cantly different from the 1993 rate, but
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137PSYCHOLOGICAL MALTREATMENT
was signifi cantly higher than the rate reported for 1986. If we look at the incidence under the endangerment standard, we fi nd that the rate of emotional abuse was 4.1 per 1,000 children. This indicates a signifi cant decrease in emotional abuse endan- germent since 1993, but the rate was not different from that reported in 1986. For emotional neglect under the endangerment standard, Sedlak et al. (2010) reported an incidence rate of 15.9 per 1,000 for 2005–2006. There was a signifi cant increase in emotional neglect endangerment between all of the past three NISs (see Tables 6.2 and 6.3 ). It is not clear whether these changes represent true increases or decrease in this type of maltreatment or if they refl ect changes in our understanding and use of the terms associated with emotional maltreatment.
National Child Abuse and Neglect Data System
A different sort of data is compiled each year by the National Child Abuse and Neglect Data System (NCANDS) . Each year, data is gathered on a voluntary basis from each U.S. state and territory. The states are asked to provide case-level data that include all cases investigated by CPS that year, to indicate what type of abuse was alleged in each instance, and to specify what the fi ndings were for each case. If this information is not available, the states submit summary data. After compiling these data, the NCANDS reported that there were 55,405 cases of psychological maltreatment in 2010. Based on this report, it was calculated that 8.1% of all reports of maltreatment dealt with emotional maltreatment (U.S. Depart- ment of Health and Human Services, 2010).
The national rates of emotional maltreatment need to be interpreted with care because there are dramatic variations among states. D. Hamarman, Pope, and Czaja (2002) examined the NCANDS data for 1998 and found a 300-fold variation in the rates of emotional abuse reported by states. Pennsylvania reported the lowest rate
TABLE 6.2 Incidence Numbers for Emotional Abuse as Reported by the NIS-4 NIS-2 (1986) NIS-3 (1993) NIS-4 (2005–2006)
Harm Standard 155,200 2.5 per 1,000
204,500 3.0 per 1,000
148,500 2.0 per 1,000
Endangerment Standard
188,100 3.0 per 1,000
532,200 7.9 per 1,000
302,600 4.1 per 1,000
Source: Sedlak et al. (2010, pp. 3–4, 3–15).
TABLE 6.3 Incidence Numbers for Emotional Neglect as Reported by the NIS-4 NIS-2 (1986) NIS-3 (1993) NIS-4 (2005–2006)
Harm Standard 49,200 0.8 per 1,000
212,800 3.2 per 1,000
193,400 2.6 per 1,000
Endangerment Standard
203,000 3.2 per 1,000
584,100 8.7 per 1,000
1,173,800 15.9 per 1,000
Source: Sedlak et al. (2010).
National Child Abuse
and Neglect Data
System (NCANDS)
a voluntary, national
data collection and
analysis system that
gathers and maintains
data relevant to child
maltreatment.
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138 TYPES OF ABUSE AND THEIR EFFECTS
of only 0.37 cases per 10,000 children, whereas Connecticut reported a high of 113.02 per 10,000 children. Overall, 7% of responding states had extremely high rates (greater than 34 per 10,000), and 47% of states had very low rates (less than 3 per 10,000). This radical variation in reported incidence underscores the impact of the various legal and psychological defi nitions addressed earlier. For the purpose of comparison, the authors noted that these large differences among states were not evident for the more clearly defi ned types of maltreatment (the variation for sexual abuse was only 13-fold, and the variation for the reporting of physical abuse was 12-fold). Neglect, which is also diffi cult to defi ne, had the largest variation in report- ing among states (510-fold). This inconsistency in rates across states continues. The 2010 data range from a low of 0.1% in Massachusetts, Rhode Island, and Illinois to a high of 51.5% in Utah.
National Society for the Prevention of Cruelty to Children Data
Rates of psychological maltreatment as determined by examining reports to CPS pale in comparison to rates obtained by community samples of adults asked to report on their childhood. Although this sort of retrospective data are subject to the whims of memory and are not substantiated, the numbers are still staggering. Researchers at the National Society for the Prevention of Cruelty to Children (NSPCC) interviewed nearly 2,000 adults in 2006 and found that one third of them reported having been the victims of emotional abuse during their childhoods. Respondents reported being terrifi ed of their parents, being habitually screamed at, and being called lazy or worthless. Among the adults reporting such treatment, 33% said it went on through- out their entire childhood (Doward, 2006). Even if these claims are exaggerated, this sort of fi nding still provides evidence that the emotional abuse of children is not a rare event.
CONSEQUENCES OF PSYCHOLOGICAL MALTREATMENT
Maslow’s Theory
A number of theoretical explanations have been put forth to explain why psychological maltreatment is likely to be damaging to children. First, one can look to the hierarchy of needs proposed by Maslow. According to Maslow (1962), the goal that humans are striving to achieve is to reach self-actualization. This state is defi ned as one in which a person achieves his or her full potential. In order to reach this pinnacle, Maslow argued that one must fi rst meet lower-level needs. In his pyramid of needs (see Figure 6.1), with self-actualization at the peak, Maslow put basic needs at the base. Basic needs include physical needs for food and shelter and the need to feel safe and secure. Once these needs are met, one can focus on meeting the psychological needs of belongingness, love, and esteem. What happens in cases of psychological maltreat- ment is that some basic and most psychological needs are not met. With these defi cits, it is diffi cult if not impossible to reach one’s full potential (Maslow, 1962).
Maslow
considered the father of
humanistic psychology,
Maslow studied healthy
people and classifi ed
human needs into a
hierarchy.
self-actualization
according to Maslow,
the highest level
of psychological
development; a person’s
reaching his or her full
potential.
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139PSYCHOLOGICAL MALTREATMENT
Erikson’s Theory
A second explanatory theory is that proposed by Erikson in his psy- chosocial theory of development. Erikson suggested that humans develop by facing a series of psychological crises, or confl icts, as they go through life. For instance, Erikson said that the fi rst confl ict faced by a human is to develop a sense of trust or mistrust during the fi rst year of life. If the child’s needs are met on a consistent basis, he or she will learn to have faith in the world and trust that he or she is safe. This sense of safety will provide an advantage when fac- ing the next crisis. On the other hand, if the child learns that the world cannot be trusted, he or she will not have a confi dent basis for facing future confl icts. Moving into the next stage of life, from 1 to 3 years of age, Erikson said that children either develop a sense of autonomy or they begin to doubt themselves. If parents allow the child to make age-appropriate decisions and to feel proud of him- or herself, the child will become autonomous. Conversely, parents who cause a child to feel ashamed will lead their child toward doubt. It is obvious how psychological maltreatment can derail a child’s ability to conquer these early social confl icts. If this basis is not stable, it will have an impact on a child’s ability to face the confl icts that will mark the rest of the life span: initiative versus guilt, industry versus inferiority, identity versus role confusion, intimacy versus isolation, generativity ver- sus stagnation, and integrity versus despair (E. Erikson, 1963).
FIGURE 6.1 Maslow’s hierarchy of needs
Erikson
a psychologist who
proposed a theory
of psychosocial
development in which
people develop across
their entire life span
by confronting various
social issues.
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140 TYPES OF ABUSE AND THEIR EFFECTS
Attachment Theory
A third theory that has been used to explain the mechanism by which psychological maltreatment interferes with normal development is attachment theory. According to this theory, humans between 6 and 12 months of age should develop a strong, affec- tionate tie to a primary caregiver. If the caregiver is physically and emotionally available to the child, this tie develops naturally. Once a child has a secure attachment, he or she can use this relationship as a basis from which to explore the world. Hence, a well- attached infant has the confi dence to explore the world while keeping their caregiver in sight. Securely attached children share their new discoveries with the person they are attached to and turn constantly to that person for advice. For instance, if a stranger enters a room where a mother and infant are playing, the baby will immediately move toward the mother and look closely at her face and then determine whether there is cause for alarm. This fi rst attachment relationship also establishes a basis for all future relationships. Therefore, it is expected that securely attached infants will be more likely to have secure relationships as adults than will children who formed an insecure rela- tionship with their primary caregiver (Hart, Brassard, Binggeli, & Davidson, 2002).
Findings From the Minnesota Mother/Child Interaction Project
Whether one, none, or all of these theories accurately explains the mechanism by which psychological maltreatment harms children, more and more evidence is accumulating
that this type of maltreatment has a signifi cant negative impact on development. The researchers behind the Minnesota Mother/Child Interaction Project followed children born to high-risk mothers from the time of their birth into adulthood. They concluded that children who had been exposed to hostile, verbal abuse suffered a host of negative consequences including poor attachment, acting out in anger, showing poor impulse control, and learning problems related to being easily distracted and having low enthusiasm. These negative effects were every bit as strong as were those seen in chil-
dren who had been physically abused. Even more startling, children with parents who denied emotional responsiveness suffered from all of the symptoms listed earlier and had lower self-esteem, a tendency to engage in self-abusive behavior, and a greater likelihood of having serious psychopathology than did their nonmaltreated peers. As a group, the children who had been denied emotional responsiveness were worse off than any other group of maltreated children (Erickson, Egeland, & Pianta, 1989).
Similar to the other forms of maltreatment we have covered, psychological mal- treatment will produce different responses in different children. These responses will be partly dependent on their age, sex, and developmental level at the time that the maltreatment occurs. The impact of the abuse on its victims will also be related to the severity and chronicity of the maltreatment (Sirotnak, 2006). So, while victims are more likely to show the effects covered here, no one symptom is true of every victim, and no victim is going to have all the symptoms listed below.
Five Areas of Concern
In 1998, Hart, Binggeli, and Brassard reviewed the extant literature on the effects of emotional maltreatment on children. They divided the noted effects into fi ve
Minnesota Mother/
Child Interaction
Project
a longitudinal study
of 267 children who
were born to high-risk
mothers.
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141PSYCHOLOGICAL MALTREATMENT
different categories: (a) intrapersonal thoughts, feelings, and behavior; (b) emotional problems; (c) social and antisocial functioning; (d) learning problems; and (e) physi- cal health. Additional research conducted after Hart et al.’s examination has added support to many of their fi ndings.
Intrapersonal Thoughts, Feelings, and Behavior With regard to intrapersonal thoughts, feelings, and behavior, Hart et al. (1998) reported that researchers found evidence that child victims of psychological maltreatment had low self-esteem, created negative life reviews, and were more likely to suffer from depres- sion and anxiety than were other children. Infants who are emotionally abused are likely to have a negative affect, to be apathetic, or to cry and be irritable. Generally, they are diffi cult to calm, and they do not make good eye contact. Related to the depression, emotionally abused children were also more likely to have suicidal ideation (thoughts or fantasies about dying) and engage in suicidal behaviors. Mullen, Martin, Anderson, Romans, and Herbison (1996) reported that a history of psychological abuse was corre- lated with a signifi cant increase in suicidal attempts. The rate of attempts was 12 times higher for victims of emotional maltreatment than it was for nonabused controls, and it was considerably higher than the rate seen in children with a history of physical abuse (5 times the nonabused rate). The negative life reviews formed by these children can include themselves and the world around them. Not only do they view themselves as unworthy; they see the world as a hostile place (Pearl, 1994).
Among the studies reviewed by Hart et al. (1998), some provided evidence that the negative impact of psychological maltreatment on its victims persisted beyond childhood, even in nonclinical populations. Briere and Runtz (1990) had female college students fi ll out surveys about their family experience (including sexual, physical, and emotional abuse) and about their current functioning in terms of self- esteem, sexual behavior, and aggression. To measure the participants’ experience with psychological maltreatment, they were asked to indicate how often they had experienced the following parental behaviors in an average year prior to their 15th birthday: yells at you, insults you, criticizes you, tries to make you feel guilty, ridi- cules or humiliates you, embarrasses you in front of others, and makes you feel like you were a bad person. Self-esteem was measured by having the women rate seven statements such as “Sometimes I feel that I don’t deserve to live” and “I like myself most of the time” on a scale of 1 ( not at all true ) to 5 ( very often true ). After controlling for physical and sexual abuse experiences and other negative outcomes, the authors found a signifi cant relationship between psychological maltreatment in childhood and decreased self-esteem in college-age women. This result was replicated by Mullen et al. (1996) using a community sample of women in New Zealand, 57 of whom were the victims of self-reported emotional abuse. Mullen et al. used different measures to identify emotional abuse (parental bonding instrument) and self-esteem (Robson’s self-esteem questionnaire), but they still found a signifi cant correlation between emo- tional abuse in childhood and lower self-esteem. Wright, Crawford, and Del Castillo (2009) studied 301 college students and found a signifi cant link between emotional maltreatment and symptoms of anxiety and depression in early adulthood. In 2008, B. Allen noted that college students who had experienced the terrorizing form of psychological maltreatment were especially likely to suffer from anxiety as young adults, whereas those who were ignored by their caregivers were more likely to have symptoms of depression. Finally, Wright, Crawford, and Del Castillo (2009) reported
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142 TYPES OF ABUSE AND THEIR EFFECTS
that college students with a history of emotional abuse or emotional neglect tended to develop negative self-beliefs. These young adults had internalized the negative messages from their parents and felt shame; they saw themselves as defective. They also felt vulnerable to harm. As a result, they reported higher levels of depression and anxiety than did their nonmaltreated peers.
Harvey, Dorahy, Vertue, and Duthie (2012) interviewed a small sample ( n = 6) of adults with a history of psychological maltreatment. They found that the partici- pants suffered from feelings of shame and felt that they had failed to live up to other people’s expectations of them. Their participants also reported that they did not trust others and engaged in strategies to protect themselves from others. Although these techniques may have prevented pain, they also kept the participant’s from develop- ing close, loving relationships. Such complementary results across studies make us more confi dent about the fi ndings.
Emotional Problems When they examined emotional problems, Hart et al. (1998) found that reports of emotional instability, poor impulse control, substance abuse, unresponsiveness,
borderline personality disorder, and eating disorders were higher among victims of psychological maltreatment than they were for matched controls. Rorty, Yager, and Rossotto (1994) studied 80 women who suffered from bulimia nervosa (an eating disorder marked by cycles of bingeing and purging), and reported that the most common type of abuse history among bulimics was psycho- logical maltreatment. Reports of past experiences with emotional maltreatment were 4 times more common than were reports of physical abuse. Gavin (2011) found that participants with a history of emotional abuse reported lower satisfaction with life than did those who had not experienced such maltreatment.
Okado and Azar (2011) looked at the possibility that young adults who had experienced inappropriate emotional relationships with their own mothers would develop emotional problems that would put them at risk for abusing their future children. They assessed for extreme levels of emotional distance—both enmeshed and disengaged patterns of interaction. They found that undergraduate students who recalled either type of extreme level of emotional distance with their mother obtained higher scores on the Child Abuse Potential Inventory (CAP, Milner, 1986). This is a test designed to measure how likely it is that a person will become a perpe- trator of child maltreatment. These same students also had more unrealistic views of children as measured by the Parent Opinion Questionnaire (Twentyman, Pltokin, Dodge, & Rohrbeck, (1981,). Okado and Azar further noted that the relationship between emotional distance and risk factors for perpetrating maltreatment were mediated by emotional reactivity. Participants who reported an enmeshed or dis- engaged relationship with their own mother were more emotionally reactive than their peers who reported a normal relationship with their mothers. They were more sensitive to environmental stimuli and tended to be moody rather than emotionally stable. Work by van Harmelen et al. (2010) revealed that adults with a history of child emotional abuse had signifi cantly reduced volume in their medial prefrontal cortex (an area of the brain that is important in the regulation of emotional behavior). They suggest that emotional abuse may inhibit the growth of this brain region or cause damage to it. This defi cit may underlie the emotional reactivity noted earlier.
borderline personality
disorder
a mental disorder
marked by signifi cant
impairment in
interpersonal
relationships, problems
with self-esteem and self-
image, and impulsivity.
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143PSYCHOLOGICAL MALTREATMENT
Social and Antisocial Functioning As predicted by the preceding theories, particularly Erikson’s theory and attachment theory, these victims also suffered from a host of social problems. Reported issues ranged from attachment problems and poor social competence to noncompliance, aggression, violence, and delinquency. Researchers also found evidence of social isolation, poor empathy skills, and sexual maladjustment in victims of emotional maltreatment (Hart et al., 1998). With regard to aggression, it has been reported that this is a generalized aggression. The child is not necessarily reacting to a specifi c external event. Loeber and Strouthamer-Loeber’s (1986) review of the literature on juvenile delinquency revealed that the best predictors of delinquency were paren- tal rejection and lack of involvement. Related to social problems, some victims of emotional maltreatment are very hesitant socially, while others approach even unfa- miliar adults indiscriminately (Pearl, 1994). In my work at a local children’s shelter, it is not uncommon for children I have never met to cling to me within moments of my arrival. They will say they love me and fi ght when I try to leave. Although this may be good for my ego, it is not appropriate behavior for a child!
Learning Problems The children who were participants in the research reviewed by Hart et al. (1998) also struggled in school. On average, these children had lower mental competency, had more academic and intellectual problems, and scored lower on tests of achievement and IQ than did children in control groups. In addition, they showed signifi cant delays in the development of moral reasoning. Doyle (1997) reported that a full 62% of the adults in her study who had been the victims of emotional abuse suffered from school problems. Furthermore, 21% of the victims were kept out of school by their parents, and their parents had not arranged for alternative home schooling.
Physical Health Finally, and perhaps most surprisingly, Hart et al. (1998) noted that researchers had found evidence that psychological maltreatment had a negative impact on some chil- dren’s physical health. If parents were found to be rejecting, their children were more likely to have allergies, asthma, respiratory problems, and hypertension (abnormally high blood pressure) than were other children. Children of parents who used spurn- ing or who denied emotional responsiveness to their children had more somatic complaints and an increased risk for mortality. In cases of severe emotional maltreat- ment of infants, you may see nonorganic failure to thrive. This is a child’s failing to grow as expected when there is no known organic disease (Pearl, 1994). Some of the earliest work in this area was conducted even before professionals used the term psychological neglect. Rene Spitz (1956) spent the 1950s studying infant development in non-ideal situations. He observed children being raised in penal nurseries and in foundling homes (orphanages). The babies in the penal nurseries were cared for by their incarcerated mothers under the supervision of a nurse. The infants in the foundling homes were cared for by professional caregivers, but the infants did not have contact with their mothers. Although the foundling homes were cleaner and the children there received regular medical attention (a doctor visited daily), they did not fare nearly as well as the children in the penal nursery.
During the 5 years of observation, not one child in the penal nursery died, and there were no major infectious epidemics. In addition, most of the children met physi- cal and psychological developmental milestones on time. Conversely, 37.5% of the
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144 TYPES OF ABUSE AND THEIR EFFECTS
infants from the foundling homes died during the observation period. The surviving infants were signifi cantly underweight, and all but one was delayed in cognitive and physical development. Interestingly, the one child that was developing appropriately was described as an “angelic beauty.” Spitz (1956) noted that everyone was charmed by the child, and nobody entered the nursery without stopping to speak with or cuddle this beautiful child. The other children received only enough attention to meet their physical needs. The difference between the children who did well and those who strug- gled and even died seemed to be whether they received loving attention. This work was shocking in the 1950s and continues to be so today. It certainly underscores how potentially damaging psychological neglect can be for young children.
It is also possible that victims of emotional abuse may cause themselves physical harm. Research has shown that experiencing emotional abuse as a child increases the likelihood that an adolescent will engage in nonsuicidal self-injurious (NSSI) behavior (Glassman, Weierich, Hooley, Deliberto, & Nock, 2007). NSSI behaviors are defi ned as deliberate acts that damage the body and that are not socially sanctioned (normal piercing and tattooing would not qualify), nor are the acts intended to bring about death. The most common NSSI behavior is cutting, but other behaviors such as hair pulling, hitting, or ingesting toxins are also seen. Glassman et al. (2007) explain that the relationship between emotional abuse and NSSIs is mediated by a self- critical pattern of thinking. Apparently, the child internalizes the negative messages of their parent, thinks poorly of him- or herself, and engages in the NSSI behaviors as a form of self-punishment.
There is also evidence that children who are emotionally abused outside of their home may suffer psychological and physical consequences. In a unique study of emotional abuse, Krugman and Krugman (1984) examined children who were alleg- edly being emotionally abused by their classroom teacher. The investigation began after 17 of 27 children assigned to one male teacher began to show noticeable symp- toms of distress. The children also reported that the teacher engaged in emotionally abusive behaviors such as belittling, inducing fear, negative labeling, and yelling. Parents also observed some of these behaviors. In addition to the expected psycho- logical problems such as excessive worry about school performance, fear, and the development of a negative self-image, the children also began to manifest physical symptoms. Six of the children suffered from headaches, and fi ve reported stomach- aches. This demonstrates that not only can emotional abuse lead to physical distress, but it also can occur outside of the home. Furthermore, the physical effects of psy- chological maltreatment may persist into adulthood. Gavin (2011) reported that adults who reported a history of being psychologically abused had lower resistance to illness as adults. This link was especially strong for female participants.
Factors Related to Resiliency or Greater Harm
In attempting to assess the impact of parental behavior on child development, it is important to keep in mind that the relationship between parent and child does not occur in a vacuum. Other things going on in and around the family may mediate or exacerbate the possible effects of maltreatment. For instance, much research has found that children are more likely to be resilient in the face of maltreatment if there is an adult in their life whom they can trust and can turn to for support (see Chap- ter 10 , “Resilience”). On the other hand, living in a family where domestic violence is present can result in children suffering greater effects than would be expected
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145PSYCHOLOGICAL MALTREATMENT
from psychological maltreatment alone. T. Moore and Pepler (2006) studied 110 chil- dren whose mothers were in shelters for battered women and 100 children whose mothers were living in nonviolent relationships. They measured the interactions between mothers and children with the Confl ict Tactics Scale ( CTS, Straus, 1979), and they measured children’s behavior with the Child Behavior Checklist ( CBCL , Macmann et al., 1992). While mothers from both groups who used insults and threats had children with more problematic behaviors, there was also a signifi cant effect related to the mother’s relationship sta- tus. Children whose mothers were in a violent relationship and insulted or threatened the children had worse CBCL scores than children whose mothers were insulting or threatening but lived with nonviolent partners.
CONCLUSION
In many ways, research on psychological maltreatment is in its infancy. Unfortunately, what we have learned is starting to paint a bleak picture. Psychological maltreatment seems to have a high incidence rate, is extremely diffi cult to prove, and is associated with signifi cant negative developmental outcomes. At the same time, psychological maltreatment cases are underreported to CPS. Taken together, is seems likely that many children continue to suf- fer from this sort of maltreatment with little hope of prompt relief. This is the type of maltreatment that might be most appropriately targeted by prevention efforts. Whereas most parents realize that it is hurtful to rape or beat a child, many do not realize that words can be equally damaging.
DISCUSSION QUESTIONS
1. After reading the information in this chapter, do you think parents should be charged with psychological maltreatment alone (i.e., no other form of maltreat- ment is evident)? If so, what would be an appropriate punishment for this type of behavior?
2. Would you be more or less comfortable reporting a case of alleged psychologi- cal maltreatment to CPS as compared with a case of alleged physical abuse or neglect?
3. Which of the six subtypes of psychological maltreatment specifi ed by the APSAC would be the easiest to prove? Which would be the most diffi cult to prove?
4. Which description of psychological maltreatment did you prefer, the one from the APSAC or the one from Glaser? Why?
5. Different data sources provide varying estimates of the incidence of psychologi- cal maltreatment. Which do you think is closest to the truth?
Confl ict Tactics Scale
(CTS)
a scale that measures
psychological and
physical maltreatment
as well as nonviolent
discipline. The parent/
child version was
designed to gather
information about how
parents have disciplined
their children over the
last year. The child fi lls
out one form, and a
parent fi lls out another.
Child Behavior
Checklist (CBCL)
a 118-item scale
designed to measure
a child’s behavioral
problems and social
competencies based on
parental report.
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146
The sexual abuse of children is, unfortunately, not new. In The History of Child-hood, Lloyd deMause (1974) presents evidence that sexual behavior between adults and children was prevalent in antiquity. Sexual activity between adult males and boys was particularly common. Boy brothels and services that rented boys to men were commonplace. There is evidence in literature and art from ancient times that young girls were also used sexually by adults. Although some laws were eventu- ally passed in an attempt to restrict sexual behavior with children in ancient times,
it appears that they were not well enforced. Although the sexual abuse of children has its roots in ancient time, only recently has it become the focus of scientifi c research within the psychological literature (see Focus on Research 7.1 ). Case studies began to appear in the professional literature in the 1970s. These studies described victims and sometimes their families. While these studies were not experiments, they did lay the groundwork for later research stud- ies. Even though the fi rst published articles were mostly anecdotal, they did give information on the symptoms that might be seen in victims of childhood sexual abuse. However, these early reports were fl awed because they did not include control groups, they did not use standardized methods of assessment, and they failed to determine whether the problems seen followed the abuse or pre- dated it. It was not until the 1980s that a body of literature based on rigorous, empirical studies began to emerge (Green, 1993).
CHAPTER 7
Sexual Abuse
case study
an in-depth analysis of
one person or event. This
research method provides
signifi cant detail about
one case, but the fi ndings
cannot be generalized to
other persons or events.
control group
participants in a study
who are not exposed
to the variable being
explored.
FOCUS ON RESEARCH 7.1
In 1994, I examined the publications that were referenced in PsycLit and Psychological Abstracts for the years 1974 to 1992 (McCoy, 1994). For each year, I noted the number of articles published and what aspect(s) of sexual abuse the articles dealt with (interrater reliability for the categorization of articles into 1 of 11 categories was 80%). The articles published per year has been updated here to include data through 2012, as shown in Fig- ure 7.1 .
Prior to 1981, very little research on sexual abuse appeared in the psychological lit- erature (fewer than 15 articles per year). From 1982 through 1988, the research increased
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147SEXUAL ABUSE
steadily. After this point, the increase in articles was dramatic. By 1989, more than 400 articles were published each year. The aspect of sexual abuse that has consistently been given the most attention is victim characteristics. Each year, on average, 31% of all arti- cles published on sexual abuse dealt with impact on the victim. The second most popular topics for research were treatment and perpetrator characteristics, each accounting for approximately 18% of the articles published.
During this time, only two categories of research showed large changes in the per- centage of attention that they received. First, between 1991 and 1992, the proportion of articles about the assessment of allegations increased signifi cantly (from 6% to 16%). Second, articles on prevention peaked in 1988 and then decreased between then and 1992 (from a high of 13% to a low of 4%). Articles about victim characteristics and treatment were consistently highly frequent (31% and 18%, respectively). The other categories were less common, and stable: legal issues, 9%; exploitation, 1%; defi nition, 1%; incidence, 3%; and anatomical dolls, 2%.
It is possible that the dramatic increase in research seen in the late 1980s was spurred by the intense media coverage of high-profi le abuse cases such as the McMartin day-care case in California. The initial complaint in the McMartin case was fi led in August 1983 (see Case Example 10.1 ). By March 22, 1984, Ray Buckey and six others were indicted on 115 counts, and in January 1985, the fi rst child testifi ed during the preliminary hearings. The McMartin case became the longest and most expensive trial in the history of the U.S. legal system, costing more than $12 million. The case raised a plethora of questions about the sexual abuse of children that researchers have been struggling to answer ever since (McCoy, 1994).
FIGURE 7.1 Articles on sexual abuse referenced by PsychINFO.
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148 TYPES OF ABUSE AND THEIR EFFECTS
DEFINITION
Haugaard (2000) asserts that defi ning child sexual abuse (CSA) is an ongoing struggle, with debate raging over the proper operational defi nition of each word
in the phrase child sexual abuse. Child has been defi ned as any person younger than the age of 18 years by many professionals, but others use younger than 17 years, whereas still others choose younger than 16 years. Although there is agreement that certain acts are sexual , such as sexual intercourse, other acts are not so easily categorized. Expert opinions differ when it comes to acts such as being nude in front of a child, bathing or sleeping with a child, and massaging a child. Many of these acts fall along a
continuum between sexual and nonsexual that is related to a child’s age and the parent’s motivation. For instance, few would argue that a father should not bathe his 4-month-old daughter. However, what if the child is 4, or 10, or 12, or 14 years old? At what point does the act move from being nonsexual to sexual? Does it depend only on the age of the child, or is the father’s motivation relevant? If a father bathes his 2-year-old daughter because he fi nds it sexually arousing, it is a different situation from a father who bathes his daughter because she needs to be cleaned and the task has fallen to him. The problem is that in most cases, we can- not determine the father’s motivation (see Case Examples 7.1 ). Not only do experts debate what is meant by child and sexual ; there is also discussion about the word abuse. Some argue that the defi nition of abuse includes only cases where there is observable harm. Therefore, if there is no observable harm, there has not been abuse. Others propose that acts can be abusive even if no harm is detected. Some of the confusion and confl ict that is evident in the literature on child sexual abuse may well stem from these defi nitional problems. Researchers are aware of the prob- lem, and authors do attempt to fi nd workable defi nitions.
child sexual abuse
(CSA)
the involvement of
a child in any sexual
activity in which consent
is not or cannot be given.
CASE EXAMPLE 7.1
Consider the following scenarios. Are the actions described examples of appropriate parenting, inappropriate parenting, or sexual abuse? You do not know, of course, the moti- vation behind the parent’s actions. Assume that the parents in each case assure you that their motivation was not sexual.
1. A single dad hosts a sleepover for his 13-year-old daughter. He brings the girls snacks and checks in on them regularly. For most of the evening, he sits in the kitchen where he can keep an eye on the girls.
2. Mr. and Mrs. Jones are nudists. They never wear clothing in their own home (if they do not have company). This has been the case even while they raised their two children.
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149SEXUAL ABUSE
One broad defi nition of sexual abuse is that it includes “any sexual activity with a child where consent is not or cannot be given” (Berliner & Elliott, 2002, p. 55). Acts ranging from the forcible rape of a 5-year-old by her father to a 14-year-old being fl ashed by a stranger in a park would be included in this broad defi nition as any sexual activity. The second part of the defi nition includes not only acts in which threats or force are used to gain compliance but also acts in which a child is a seem- ingly willing participant. These acts are included as abusive because children cannot legally consent to sexual activity. (In the United States, the age of consent for sexual intercourse ranges from 16 to 18 years.) Finally, because this defi nition does not state that the perpetrator must be an adult, it also includes situations involving an older and a younger child if there is a signifi cant difference in age, size, or power. With regard to age differences, most experts consider a 5-year difference to be abusive. Some fi nd this defi nition a bit too broad for the purposes of maltreatment and limit the term to acts in which the perpetrator is a caregiver, thereby eliminating stran- ger assault. To deal with the range of seriousness, other professionals differentiate
DISCUSSION QUESTIONS
1. Are the parents described in these scenarios guilty of sexually abusing their children? 2. If the parents are guilty of sexual abuse, what would be an appropriate intervention?
For the next scenarios, discuss whether the behavior is appropriate and whether the accept- ability of the act is impacted by the sex of the people involved and/or the age of the child.
1. A parent (mother/father) bathes his or her child (son/daughter) who is 6 months old, 12 months old, 2 years old, 5 years old, 10 years old, 13 years old, or 15 years old.
2. A parent (mother/father) sleeps with his or her child (son/daughter) who is 6 months old, 12 months old, 2 years old, 5 years old, 10 years old, 13 years old, or 15 years old.
3. A parent (mother/father) showers with his or her child (son/daughter) who is 6 months old, 12 months old, 2 years old, 5 years old, 10 years old, 13 years old, or 15 years old.
4. A parent (mother/father) massages (full body, nongenital) his or her child (son/ daughter) who is 6 months old, 12 months old, 2 years old, 5 years old, 10 years old, 13 years old, or 15 years old.
DISCUSSION QUESTIONS
1. Did the gender of the parent and the child have an impact on your decisions? If so, does this amount to a double standard?
2. Most students change their responses to several of the scenarios above based on the age of the child. Compare your cutoff age with those of your colleagues. Can you come to an agreement about when it is no longer appropriate to engage in the behav- iors described in these scenarios?
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150 TYPES OF ABUSE AND THEIR EFFECTS
between contact and noncontact abuse. Acts such as fl ashing or talking sexually to a child would be categorized as noncontact sexual abuse. Contact abuse can be further broken down into penetration (oral, anal, or vaginal) and nonpenetration, but all contact abuse involves touch.
Working with a broad defi nition for child sexual abuse has had a number of consequences. First, it has led to high estimates of incidence and prevalence (see the Incidence/Prevalence section in this chapter). Second, the range of severity in cases labeled child sexual abuse is extremely broad. Instances range from very minor events to horrifi cally invasive acts. Third, this broad defi nition makes it diffi cult to determine the effects of sexual abuse. If the children labeled as sexually abused have had radically different experiences, it makes sense that it would be diffi cult to fi nd evidence that any specifi c developmental outcomes result from these experiences. Finally, broad defi nitions do not deal with the context in which the act occurred. Haugaard (2000) provides an excellent example to illustrate this point. Imagine that you are told that a father massaged the thighs of his 10-year-old daughter, and you were asked if it was an abusive act. Now, consider that you are given the additional information that the daughter had just played an intense soccer game, and the father massaged her thighs on the fi eld in full view of spectators. Is this different from a father massaging the thighs of his 10-year-old daughter in bed at night? Are both abusive?
One possible solution to the problem of a broad defi nition is to adopt a more nar- row defi nition. However, if this is done, some children who were exposed to sexual acts will be left out. Advocates worry that this sends the message that the excluded acts are not really abuse (Haugaard, 2000). As a consumer of research, you need to be very attentive to how child sexual abuse is defi ned in each research article you read so that you can appropriately interpret the results. When reading about child sexual abuse, pay careful attention to the method section of the report, and note to yourself what defi nition they used for their study.
Legal Defi nitions
All states in the United States include sexual abuse in their defi nitions of child mal- treatment. As we saw with other types of abuse, some states refer to sexual abuse
in general terms in their child maltreatment statutes, while others refer to specifi c acts. In addition, most states also address the sexual exploitation of children. Exploitation involves allowing, encour- aging, or forcing a child to engage in prostitution or pornography (National Clearinghouse on Child Abuse and Neglect [NCCAN], 2005). As an example, consider Arkansas statute §12-18-103, which defi nes sexual abuse as “sexual intercourse, deviate sexual activ-
ity, or sexual contact by forcible compulsion; attempted sexual intercourse, deviate sexual activity, or sexual contact by forcible compulsion; indecent exposure; forc- ing the watching of pornography or live sexual activity,” and which defi nes sexual exploitation as “allowing, permitting, or encouraging participation or depiction of the child in prostitution, obscene photographing, or obscene fi lming, or obscenely depicting, posing, or posturing a child for any use or purpose.” An example of a more general approach to defi ning sexual abuse is Delaware’s statute Title 16, §902; Tit 10 §901, which simply states, “Abuse includes sexual abuse and exploitation.” On the other extreme, some states get very specifi c in their statutes. Consider Florida statute
sexual exploitation
use of a child (under the
age of 18 years) for the
purpose of prostitution
or pornography.
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151SEXUAL ABUSE
§39.01, which specifi es that the “sexual abuse of a child means one or more of the following acts:
(1) any penetration, however slight, of the vagina or anal opening of one person by the penis of another person whether or not there is emission of semen, (2) any sexual contact between the genitals or anal opening of one person and the mouth or tongue of another person, (3) Any intrusion by one person into the genitals or anal opening of another person, including the use of any object for this purpose, not including any act intended for a valid medical procedure, (4) The intentional touching of the genitals or intimate parts, including the breasts, genital area, groin, inner thighs, and buttocks, or the clothing covering them of either the child or the perpetrator, not including a; an act that may reasonably be construed to be normal caregiving respon- sibility or any interaction with or affection for the child or b; an act intended for a valid medical purpose (5) the intentional masturbation of the perpetrator’s genitals in the presence of a child, (6) the intentional exposure of the perpetrator’s genitals in the presence of a child, or any other sexual act intentionally perpetrated in the pres- ence of a child, if such exposure or sexual act is for the purpose of sexual arousal or gratifi cation, aggression, degradation, or similar other purpose, (7) the sexual exploi- tation of a child, including allowing, encouraging, or forcing a child to solicit for or engage in prostitution, or engage in a sexual performance.
Sadly, even with this degree of detail, questions will remain. For instance, in Section 6, the act is only illegal if the perpetrator’s motive was tied to the child’s presence. How do we measure another’s motive for engaging in a particular sexual act? Finally, some states such as Nevada (§432B.100) highlight age of consent by stating that sexual abuse includes statutory sexual seduction (unlawful sexual intercourse with a person under the age of consent).
Not only do the child sexual abuse laws vary by state, they change over time to refl ect new behaviors and technologies. For instance, in recent years, the laws that were designed to punish adult perpetrators who produced and distributed child por- nography have been used to punish teenagers who take nude pictures of themselves and send them to another person via cell phone or e-mail. As times change, sates are being forced to reexamine and clarify their legal statutes (see Legal Example 7.1 ) .
LEGAL EXAMPLE 7.1: SEXTING
The strict laws against child pornography were designed to protect children from adult perpetrators. However, in recent years, these laws have been used against adolescents who engage in sexting—the exchange of sexually explicit text or pictures via electronic means; usually cell phones. Certainly, teenagers have embraced the technology of texting. Ado- lescents from 14 to 17 years of age send a staggering 3,339 text messages per month. This averages more than 100 texts per day! Female adolescents send more messages per month (4,050) than do male adolescents (2,539). Although some parents and teachers may object to this amount of texting, it is perfectly legal. The problem is that some teens also engage in sexting, which may cross legal boundaries (Srinivas, White, & Omar, 2011).
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152 TYPES OF ABUSE AND THEIR EFFECTS
How common sexting is among teenagers is a debated topic. Some studies have reported that sexting is very normative in adolescence. In one study, 39% of teens (14 to 17 years old) said they had sent sexually explicit material and 28% had received sexually explicit material (Srinivas et al., 2011). Another study reported that 71% of girls and 67% of boys had sent sexually explicit material (texts or images) to their boyfriend or girlfriend (Ostrager, 2010). Focusing only on pictures, one study reported that one in fi ve teenagers admitted to sending nude or seminude pictures of themselves electronically. Furthermore, many (44% of girls and 36% of boys) knew that it was possible for the images to be shared with others (beyond the person they had sent them to) and they also indicated that this was possibly acceptable. The reasons the teens gave for sexting were that it was fun or a form of fl irtation (Srivanas et al., 2011). These very high numbers have been challenged by other researchers. The studies cited here have been criticized for using biased samples and not clearly defi ning sexually explicit. Many studies included “seminude” pictures in their numbers of explicit exchanges. This may mean that teenagers who sent pictures of themselves in a bathing suit might have said yes to having sent sexually explicit materials even though what they sent would not be illegal. K. Mitchell, Finkelhor, Jones, and Wolak (2012) interviewed a representative sample of 1,560 children aged 10 to 17 years and their parents. They found that 9.6% ( n = 39) of the children admitting to creating or receiving nude or seminude pictures, (2.5% admitted to creating or appearing in pictures, and 7.1% said they had received such pictures). When the researchers tightened the defi nition of sexually explicit to include only pictures that showed breasts, genitals, or buttocks, only 1% of the children had created pictures that met the criteria, and only 6% of the partici- pants had received images that were explicit.
Although the incidence of sexting is debated, the fact that it can have very negative consequences is a reality. The problem is that no matter what the teenagers’ intentions were, the act is illegal if sexually explicit pictures of minors are created, possessed, or dis- tributed. The pornography laws strictly prohibit the involvement of minors in material that is sexually explicit. Across the nation, teenagers who sext are being charged with the creation, possession, or distribution of child pornography and are facing harsh conse- quences including jail time, fi nes, registration as sex offenders, and the loss of scholarships and respect (Ostrager, 2010). Wolak, Finkelhor, and Mitchell (2012) estimated that in 2008 and 2009, law enforcement offi cers in the United States dealt with approximately 3,477 cases of sexual images of minors produced the minors themselves.
Take, for example, the case of Phillip Alpert, whose girlfriend sent him nude pictures of herself when she was 16-years-old and he was 17-years-old. After they broke up, Phillip sent the pictures out as a mass e-mail. He was subsequently convicted of transmitting child pornography. As a result, Phillip will have to register as a sex offender until he is 43 years old. This means he must register every 6 months and that he cannot live near any place where children gather (schools, parks, beaches, churches, playgrounds, etc.). Phillip says the restrictions make it impossible for him to live in any city (Mabrey & Perozzi, 2010).
Although Phillip sent the pictures in anger, it is also considered a crime when pictures are sent voluntarily. In Iowa, Jorge Canal, an 18-year-old, sent a picture of his penis to a female friend who was 14 years old. The girl admitted that she had asked for a picture of his penis 3 or 4 times. In addition to the sexually explicit photo, Jorge also sent a picture of his face. The girl did not erase the pictures, and when her parents found them, they
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153SEXUAL ABUSE
INCIDENCE AND PREVALENCE
It should not surprise you to know that it is extremely diffi cult to assess the incidence or prevalence of childhood sexual abuse. Not only do defi nitions vary widely, but this type of maltreatment, even more than others, also occurs in secret. Frequently, only the perpetrator and the victim know what is occurring. Because there are sel- dom any outward, physical signs of sexual abuse, it is feared that many cases go unrecorded. Based on interviews with adults, researchers conclude that fewer than half of child victims disclose sexual abuse at the time it occurs, and many never tell (Berliner & Elliott, 2002). The evidence to support this secrecy is compelling. For instance, Lawson and Chaffi n (1992) interviewed children who had sexually transmitted diseases (STDs) and reported that 43% of them did not acknowledge sexual contact. Children may not tell about being abused for a host of reasons. In some cases, the perpe- trator threatens the child or the child’s loved ones with harm if the child tells of the abuse. In other cases, children stay quiet in order to protect the perpetrator, for whom they may have strong feelings. Some victims will stay silent in order to keep the family intact. They may fear that they will be blamed for tearing the family apart by removing the perpetrator, who may be loved and respected by other members of the family. Children who are very young or mentally delayed may lack the necessary language skills to convey to someone what has happened, and some may not even realize that what is happening is wrong. Still others may fear that they would not be believed if they told anyone. As a result of all of these factors, it is normal that children will not tell someone when they are being sexually abused.
contacted the police. Jorge was convicted for distributing obscene material to a minor. This conviction was upheld by the Iowa Supreme Court. Jorge was fi ned $250, given 1 year of probation, and he has to register as a sex offender (Schulte, 2009).
Although there is a consensus that sexting is wrong, many feel the punishment is disproportionate to the behavior. Because adolescents are often immature and impulsive, it seems overly harsh to hold them accountable to adult standards. It has been suggested that education, therapy, and community service would be more appropriate consequences for sexting than would jail, fi nes, or registration as an offender. There is also concern that putting “sexters” on the sex offenders registry will overload the system and make it even more diffi cult for law enforcement offi cers to monitor all of the perpetrators. Many feel that it would be better to focus on more severe acts (Ostrager, 2010).
Several states (Florida, Nebraska, Texas, Utah, and Vermont) have recently changed their laws to treat sexting differently than other sexual images of children, and many other states are considering such legislation. For instance, in Vermont, it is now legal for teenagers from 13 to 18 years of age to exchange nude pictures. However, it is still a crime to forward such pictures (Mabrey & Perozzi, 2010). In Florida, the fi rst offense of sexting is now a noncriminal offense punishable by 8 hours of community service and a $60 fi ne. The second offense is a fi rst-degree misdemeanor and the third offense is a third degree felony (CS/CS/HB 75: Offense of Sexting).
sexually transmitted
diseases (STDs)
diseases that are most
commonly spread via
sexual contact; also called
venereal disease (VD)
or sexually transmitted
infections (STIs).
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154 TYPES OF ABUSE AND THEIR EFFECTS
Incidence
The National Incidence Study-4 (NIS-4; see Chapter 2 for a description of the methods used in this national survey) defi nes sexual abuse as any one of the following categories of behavior. First, acts of intrusion are considered sexual abuse. This means that any
penetration of the child’s mouth, anus, or genitals with a penis or penetration of the anus or genitals with fi ngers constitutes abuse. The second category, molestation with genital contact, includes all acts where genital contact occurred without penetration. Third, exposing children to sexual acts or sexually explicit material is considered a form of sexual abuse. Fourth, parents who fail to monitor their child’s
voluntary sexual behavior may be guilty of maltreatment. The fi nal category consists of attempted sexual abuse or threatened sexual abuse (Sedlak et al., 2010).
Based on the harm standard, the NIS-4 report indicated that signifi cantly fewer children were sexually abused in 2005–2006 than were in 1993, but the number of victims was not signifi cantly different from the 1986 fi ndings. Under the endanger- ment standard, the number of sexual abuse victims was also signifi cantly lower than the number reported in 1993, but not signifi cantly different from the 1986 estimate (See Table 7.1 for incidence estimates; Sedlak et al., 2010).
Although the National Incidence Study data is generally considered the offi cial estimate of child sexual abuse, there are a number of other reports dealing with the incidence of sexual abuse, and many of those provide much higher estimates. For example, a poll conducted by Gallup, Moore, and Schussel in 1995 reported a rate of child sexual abuse that was signifi cantly higher than the incidence reported by the NIS. The Gallup researchers surveyed 1,000 parents selected as a representative national sample. In addition to many other questions on child rearing, the parents were asked about their child’s experiences with sexual abuse in the last year. They were asked whether their child had been forcibly touched in a sexual manner or had been forced to touch in a sexual manner an adult or an older child in the past year. If they said no, they were asked whether their child had ever had such an experience. The Gallup Poll reported an incidence rate of 19 per 1,000 children and a prevalence rate of 57 per 1,000. Interestingly, the Gallup poll found similar rates of reported sexual abuse for boys and girls. They also found two peaks with regard to victim age. Children seemed especially vulnerable from 5 to 8 years of age and from 13 to 17 years of age. When parents were asked to report on their own experiences with child sexual abuse, 30% of mothers and 9% of fathers said that they were victims.
Finkelhor, Turner, Ormrod, and Hamby (2010) conducted more-recent telephone surveys. They interviewed children between the ages of 2 and 17 and their caretakers.
molestation
the act of subjecting
someone to unwanted or
improper sexual activity.
TABLE 7.1 Incidence Numbers for Sexual Abuse as Reported by the NIS-4 NIS-2 (1986) NIS-3 (1993) NIS-4 (2005–2006)
Harm Standard 119,200 1.9 per 1,000
217,700 3.2 per 1,000
135,300 1.8 per 1,000
Endangerment Standard
133,600 2.1 per 1,000
300,200 4.5 per 1,000
180,500 2.4 per 1,000
Source: Sedlak et al. (2010, pp. 3–5, 3–15).
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155SEXUAL ABUSE
They talked with 2,030 children in 2003 and 4,046 children in 2008. Like the authors of the Gallup poll, they reported higher levels of sexual victimization than did the NIS-4. In 2003, they found that 3.3% (33.3 per 1,000) of the children in their sam- ple had been sexually victimized and that number dropped to 2.0% (20 per 1,000) in 2008. However, it should be noted that Finkelhor et al. used a broad defi nition of sexual victimization that included assault by a peer and statutory rape. The rate of sexual victimization by a known adult was 0.3% (3 per 1,000) in 2003 and 0.2% (2 per 1,000) in 2008; estimates only slightly higher than those reported in the NIS-4. Taken together, these studies illustrate that rates of sexual abuse will vary based on how sexual abuse is defi ned and how it is measured.
Prevalence
Another way to assess how frequently child sexual abuse occurs is to focus on adults rather than on children. Instead of determining how many children are currently being abused, researchers ask how many adults were abused when they were children. This shifts the measure from one of incidence (cases per year) to one of prevalence (proportion of people in a population who have ever been victims). These retro- spective studies ask adults to report on their own childhood experiences. Finkelhor (1994) summarized the results from 19 such studies and reported that between 2% and 62% of women reported a history of child sexual abuse, as did 3% to 16% of men. This wide discrepancy refl ects a variation in defi nition (contact versus noncon- tact, age at which childhood ended, etc.) as well as different sampling techniques. Focusing on the studies with better methodologies, Finkelhor suggested that the rate for women is likely at least 20%, and the best estimate for men is between 5% and 10%. If the rates of abuse that are reported by adults are accurate, it would mean that there are approximately 500,000 new cases per year. If Child Protective Services (CPS) is aware of 150,000 cases, and some unknown number is handled exclusively by law enforcement (if the abuser is not a family member, the accusations would be handled by law enforcement, not CPS), then how many are going undetected? It seems that many cases, at least half (and probably more), are not being addressed.
Although it is possible that people may overreport past experiences with child sexual abuse to gain attention or to see themselves as a “survivor,” there is no evi- dence suggesting that fabrication is a signifi cant problem with this type of research. In fact, underreporting due to shame, embarrassment, or forgetting is considered the more likely problem. One researcher (Williams, 1994) did a follow-up study of 129 women who had been treated at an emergency room for sexual abuse as young children. When Williams interviewed the victims 17 years later (without telling them why they were contacted), 38% of the women did not disclose the abuse. Therefore, the rates of child sexual abuse may be even higher than those reported in retrospec- tive studies.
Clinical Populations
Rates of child sexual abuse among clinical populations are gen- erally found to be signifi cantly higher than rates for the general population. Estimates of between 44% and 50% are reported among female psychiatric inpatients and outpatients. However,
clinical population
a group of people defi ned
by their association
as patients within a
treatment facility.
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156 TYPES OF ABUSE AND THEIR EFFECTS
this is not always the case, because others have reported rates among clinical popu- lations that are similar to rates in the general population (16% to 22%). Briere and Zaidi (1989) speculated that this wide range of results might be attributable to how carefully the patients were assessed for a history of child sexual abuse. They noted that patients might not spontaneously tell about child sexual abuse if they were not asked directly about it. Further, clinicians may not make note of child sexual abuse even if the patient had mentioned it. To test the impact of direct inquiry on rates of child sexual abuse in a female clinical population, they compared the charts for 50 nonpsychotic women from a psychiatric emergency room that were pulled at random with 50 charts written by clinicians who were told to ask specifi cally about child sexual abuse. The two samples did not differ signifi cantly with regard to age, race, marital or employment status, education level, or income. Among the random sample of charts, the documented rate of child sexual abuse was 6%, and among the queried group, it was 70%. Therefore, when assessing the incidence literature, it is clearly important to pay particular attention to how child sexual abuse was assessed.
Change in Rates Over Time
It should also be noted that the reporting of child sexual abuse has changed over time. We saw a sharp increase in reports of child sexual abuse in the late 1980s and early 1990s. This increase, probably in response to media attention at that time, was followed by a decline. Between 1994 and 2001, the majority of states saw a decrease in reports of child sexual abuse of almost 30%. Also, the NIS-4, as noted earlier, reported signifi cantly lower incidence numbers for sexual abuse in 2005–2006 than they did in 1993 (Sedlak et al., 2010). There are several ways to interpret this change. First, it may refl ect a tendency to overreport child sexual abuse in the late 1980s that corrected itself by the mid-1990s. Second, it may be that there has been a true decline in cases of child sexual abuse in the last decade. Although this may seem overly opti- mistic, it is true that this period saw a decrease in other crime rates as well. It could also be that the prevention efforts that began in the late 1980s were successful. Third, it could be that more stringent criteria were adopted for investigation, and as a result it only appears that there are fewer cases of child sexual abuse (Berliner & Elliott, 2002). However, evidence is beginning to accumulate that this pessimistic interpreta- tion is not true. Self-reports of abuse by adults and children in community samples have also started to refl ect a trend toward a decrease in the incidence of child sexual abuse. Although the research in this area is still limited (e.g., only a small number of studies have been conducted, and they have limited samples), the preliminary results are promising (L. Jones & Finkelhor, 2003).
PERPETRATORS
Only a minority of perpetrators (10% to 30%) are strangers (Finkelhor, 1994). Despite the fact that we are careful to warn our children about strangers who may attempt to hurt them, the far greater risk comes from family and friends or acquaintances. Approximately 10.4% of perpetrators are close family members (parent, stepparent, or sibling). In this close family group, the most likely perpetrator is a stepparent, usu- ally the stepfather. It is estimated that stepparents are 10 times more likely to offend
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157SEXUAL ABUSE
than are natural parents. When the victim is female, the abuser is a family member in one third to one half of all cases. Intrafamily abuse is less common when the victim is male. Only one tenth to one fi fth of male victims are abused by family members. Acquaintances are the most frequent perpetrators of sexual abuse for boys and girls. Across studies, about 47.8% of perpetrators are known to the victim but are not close family members. Although familial abuse is less common than abuse by other per- petrators, it is more likely to involve severe and recurrent abuse than is abuse at the hands of other perpetrators (Fergusson & Mullen, 1999).
The age of perpetrators can range from quite young (even younger than their victims in some extreme cases) to old age. About one third of all perpetrators are under the age of 18 at the time they abuse. The majority of perpetrators are between the ages of 15 and 45 (Fergusson & Mullen, 1999; see Table 7.2 for perpetrator ages reported by the NIS-4.)
The vast majority of perpetrators (as many as 90%) are male (See Table 7.3 for NIS statistics on perpetrator sex). Although most agree that males are far more likely to be perpetrators, it is also believed that abuse by female perpetrators is less likely to be reported than is abuse by a male perpetrator (Finkelhor, 1994). Fergusson and Mullen (1999) report that when the victim is female, nearly all (92% to 99%) of the perpetra- tors are male. When the victims are male, between 63% and 86% of the perpetrators are male. ChildLine is a free and confi dential hotline in the United Kingdom that provides counseling for any children that call. In 2008 and 2009, the counselors received 16,094 calls from child sexual abuse victims. Among female callers, 28% did not identify the sex of the perpetrator, 67% of girls identifi ed a male abuser, and 6% said they were abused by a female. Male children also frequently declined to identify the sex of the perpetrator (30%). Of males, 34% said their abuser was a male, and 36% identifi ed a female abuser (National Society for the Prevention of Cruelty to
TABLE 7.2 The Age of Perpetrators of Sexual Abuse Reported in the NIS-4 <26 YEARS 26–35 YEARS > 5 YEARS UNKNOWN
Biological Parent 5% 35% 25% 35% Nonbiological Parent or Partner * 36% 48% 11% Other Person 30% 14% 29% 29%
Source: Sedlak et al. (2010).
Note: * = fewer than 20 cases with which to calculate estimate; estimate too unreliable to give (Sedlak et al., 2010, pp. 6–12).
TABLE 7.3 The Sex of Perpetrators of Sexual Abuse by Relationship to Victim PERCENTAGE OF MALE
PERPETRATORS
PERCENTAGE OF FEMALE
PERPETRATORS
Biological Parent 80% 22% Nonbiological Parent or Partner 97% 3% Other Person 86% 6%
Source: Sedlak et al. (2010, pp. 3–5, 3–15).
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158 TYPES OF ABUSE AND THEIR EFFECTS
Children [NSPCC], 2009). These data may indicate that more males are being abused by females than are seen in cases that come to the attention of CPS. Lately, the media has been giving a great deal of attention to sexual abuse between female teachers and male students (see Case Example 7.2 ). It will be interesting to see if this has any impact on reporting practices.
CASE EXAMPLE 7.2
One of the best-known female perpetrators of child sexual abuse is Mary Kay LeTourneau. Ms. LeTourneau was a 36-year-old teacher when she admitted to having sex with one of her former students, a boy who had just turned 13 years old at the time the affair started. Although both the boy, Vili Fualaau, and LeTourneau maintained that the sex was consensual, children cannot legally consent to sex in the State of Washington until they are 17 years old. Prior to their relationship becoming sexual, Vili had been a student in LeTourneau’s class for both second and sixth grades. The two had become close, with Vili frequently confi ding in LeTourneau. Vili even spent the night with his teacher when his mother had to work late. During this time, LeTourneau was experiencing marital and fi nancial diffi culties, and her father was suffering from cancer. Toward the end of his sixth- grade year, Vili began to write love letters to LeTourneau and asked her to have sex with him. Although she originally refused, after having a fi ght with her husband one night, LeTourneau began an 8-month sexual relationship with Vili that was revealed when she became pregnant by him. LeTourneau gave birth to a daughter, her fi fth child and Vili’s fi rst, and named her Audrey (G. Olsen, 1999; Robinson, 2001).
LeTourneau pleaded guilty to second-degree child rape (Washington’s term for statu- tory rape) and was sentenced to 7.5 years in prison. However, the judge in the case was lenient in the face of testimony that LeTourneau was suffering from manic depression and that she showed remorse and promised that it would not happen again. Not even Vili’s mother pushed for serious punishment. In the end, all but 6 months of LeTourneau’s sentence was suspended. After early release for good behavior, LeTourneau served only 3 months in prison. She was required to take part in a 3-year sexual deviancy treatment program, and she was forbidden to see Fualaau. What makes this case even more shock- ing is that just 4 weeks after her release, LeTourneau was found with Vili. At that time, she was sent back to prison to serve her entire 7.5-year sentence. It was also at that time that the public learned she was pregnant again (Miller-Perrin & Perrin, 1999). While in prison, LeTourneau gave birth to her second child with Vili, a daughter named Alexis. Her hus- band, Steve, also divorced her while she was in prison. LeTourneau did not follow court orders while in prison and continued attempting to contact Vili. At one point, she spent 6 months in solitary confi nement for this offense (Montaldo, 2005).
In the meantime, Vili’s family sued the school district for failure to protect him, but the jury found in favor of the school. Fualaau was not awarded any damages. LeTourneau was paroled in 2004, and just 2 days later, Vili, who was then 21, asked the court to remove the no-contact rule. The court did this, and Mary Kay and Vili were married on May 20, 2005 (Montaldo, 2005).
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Perpetrators of child sexual abuse are rarely violent. Instead of using force, they engage in an elaborate grooming process that allows the abuse to happen without detection. Perpetrators fi rst identify a child they see as vulnerable. Offenders look for children who seem lonely and in need of attention. It is common for perpetrators to target children who do not have good relationships with their parents and who do not seem to have friends. Abusers may also be drawn to children who have been victimized before (Craven, Brown, & Gilchrist, 2006).
Grooming Victims
In order to have contact with the child, the perpetrator needs to begin by grooming the environment. They fi rst become part of the community and obtain positions of trust that give them access to children (e.g., coaches, teachers, leaders in children’s groups or organizations). If the abuser is part of the family, he or she already has access to the child and do not need to do much work to groom the environment. With the onset of online communications, some perpetrators who are outside of the family are also able to skip this step and connect directly with the child. Because chil- dren are often completely unmonitored when they are online, an offender has direct access to the child without having to work around parents (Shannon, 2008; see Focus on Research 7.2 ). The perpetrator then works on developing an exclusive relation- ship with the child while also distancing the child from other people. For instance, some abusers may encourage a child’s mother to spend time out of the house or to use drugs and alcohol. If the child is isolated, he or she does not have anyone to tell about what is occurring (Craven et al., 2006).
In 2011, Mary and Vili Fualaau appeared on the Today Show for an update on their relationship . They had been married for 5 years and were raising their daughters, now 12 and 13 years old. Mary also reported that she was reconciled with her four children from her fi rst marriage and that she had just welcomed her fi rst grandchild (born to her son who is just 1 year older than her current husband). Ms. Fualaau said that she and Vili have told their daughters about how they met and the subsequent legal problems. She added that she would not want her daughters to be sexually active yet even though they are near the age their father was when they were conceived. The Fualaaus still live in Seattle and report that they are treated well by their neighbors (McGraw, 2011).
DISCUSSION QUESTIONS
1. Was LeTourneau’s original punishment suffi cient? 2. Would the legal response have been different if LeTourneau was a male teacher and
Vili was a female student? 3. Is it possible for a child of 13 years and an adult woman to be in love? 4. Does the fact that Mary Kay and Vili are now married mean that their prior relation-
ship was not abusive?
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160 TYPES OF ABUSE AND THEIR EFFECTS
After the perpetrator has access to the child, he or she begins grooming the child for sexual behavior. The grooming of the child may be similar to what is seen in adult courtship. Interfamilial abuse often involves the elevation of the child to an adult level. For example, a grown man may begin to treat his young daughter as if she is an adult woman he wishes to date. Men who sexually abuse boys may use a very different approach—they may interact with the victim at the child’s level. In these cases, the men may play childish games with the victim and pretend to share their interests. Either way, the relationship brings attention and affection to the child. The focus at this time is to build a trusting relationship. Sexual behavior is introduced gradually (Craven et al., 2006). Offenders may introduce “dirty talk” or show the child pornography. This type of activity opens the door to sexualizing the relationship (Shannon, 2008). Initial touching is usually nonsexual. Offenders may begin by tickling the child or touching them in nonsexual ways while both are clothed. The touching then proceeds to sexual areas through clothing, then under clothing, then without clothes. During this progression, the abuser may also arrange to “accidently” see the child naked or have the child see him without clothes (Craven et al., 2006). The perpetrator may use bribes or treats to encour- age the child to comply and to keep the sexual behavior secret. The use of bribes is
FOCUS ON RESEARCH 7.2
Burgess, Mahoney, Visk, and Morgenbesser (2008) published an article titled “Cyber Child Sexual Exploitation.” They noted that the ICAC (Internet Crimes Against Children) is charged with attempting to stop the online sexual exploitation of children. This exploita- tion can take the form of solicitation, pornography, the prostitution of children, exposing children to sexual material, or engaging children in sexual conversations. Unfortunately, children are often the victims of inappropriate sexual overtures when they are online. In a study of children between the ages of 10 and 17 years, it was found that 14% had been approached in a sexual way online and that 4% of those reported that the approach was aggressive. Of children, 34% reported that they had seen sexual material online that they did not want to see.
When Burgess et al. (2008) reviewed 258 cases on online sexual exploitation, they noted that offenders tended to be people in positions of authority (e.g., teachers, prin- cipals, clergy, health professionals, police offi cers). The found that most offenders were male (94.8%), and they ranged in age from 18 to 72 years (53.4% were between 30 and 49 years). The cases were reported to authorities from a variety of sources. In some cases, computer technicians came across the images while working on the offender’s computer and reported the images to the police. In other cases, the sexual images were found via AOL monitoring. In one case, a maintenance worker saw the images on a screen when he was fi xing a leak in an offi ce.
If you suspect child sexual exploitation, you can report it to the CyberTipline that is supported by the National Center for Missing and Exploited Children (800-843-5678). You may also report online at www.missingkids.com/cybertipline.
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believed to be more common than the use of threats to ensure the child’s coopera- tion (Craven et al., 2006).
Although the grooming of the child may be evident in hindsight, many of the early phases of grooming are impossible to distinguish from the behavior of caring adults. Paying attention to a child, giving small gifts and attention, earning the trust of caregivers, and assuming leadership roles in clubs for children are all things that many good, loving, nonabusive adults will do to help a child. The true difference is in the motivation behind the behaviors, which is extremely diffi cult to discern.
VICTIMS
Victims of child sexual abuse are more likely to be female than male. Only 20% of child sexual abuse cases reported to CPS involve males (Finkelhor, 1994). After reviewing the literature, Fergusson and Mullen (1999) concluded that depending on how child sexual abuse is defi ned, the rate of abuse for girls is between 1.8 and 3.4 times higher than the rate for boys. This rate is smallest (1.8 times higher for girls than for boys) when abuse is defi ned as intercourse, the most severe type of child sexual abuse.
Berliner and Elliott (2002) found that the peak age of vulnerability to child sex- ual abuse seems to be between the ages of 7 and 13, with the age of onset being later for male victims than for female victims. The median age at the onset of sexual abuse is between 10 and 11 years of age. Prior to this peak, there is also evidence for a sharp increase between the ages of 4 and 8 years. Fergusson and Mullen (1999) also found evidence that rates generally increase from the age of 4 to 11 and then level out before decreasing around the age of 14 and increasing again around the age of 17. However, the sexual abuse of children under the age of 6 years is probably reported at a lower rate than abuse at other ages (Finkelhor, 1994). Young children may not have the ability to tell (they do not have contact with adults beyond their family, they do not know the necessary words, etc.), or they may not even realize that what is happening to them is wrong or unusual.
Socioeconomic status does not seem to be as big of a risk factor for child sexual abuse as it is for other forms of maltreatment. For instance, the NIS-4 reported that low-income families had a rate of neglect of 16.1 per 1,000, whereas non-low-income families had a rate of 2.2 per 1,000; a dramatic difference. The numbers for sexual abuse, although still worse for low-income families, were closer than they were for neglect (0.6% per 1,000 for non-low-income families and 1.7 per 1,000 among low-income families). Although more cases of child sexual abuse from lower classes come to the attention of CPS, this difference is not seen in retrospective studies (Finkelhor, 1994). It is possible that abuse among lower class families is simply more commonly detected and reported because the families have more contact with social service agencies.
Lack of parental supervision and parental involvement does seem to increase the risk that a child will become the victim of sexual abuse. If parents are emotionally unavailable for their children, the children may look for attention elsewhere (Finkel- hor, 1994). In addition, children who live without one of their biological parents are at an increased risk for being the victims of sexual abuse (Berliner & Elliott, 2002). This risk comes both from being raised by a single parent who may not be able to be as attentive as parents in a two-parent household and from being exposed to parental dating partners who enter the child’s world (See Case Example 7.3).
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162 TYPES OF ABUSE AND THEIR EFFECTS
CASE EXAMPLE 7.3
In 1989, K. V. was 10 years old. Both she and her brother lived with their father and step- mother and had overnight visitation with their mother, who lived with her boyfriend, D. R. H. On May 2, 1989, both K. V. and her brother told their father that D. R. H. had physically abused their mother. K. V. also said that D. R. H. had touched her breasts and that he had put his fi nger in her vagina, and he warned her not to tell. K. V.’s father called the police, and the prosecutor sent K. V. for a medical exam. Dr. Smith conducted the exam and noted that K. V. was sad and cried, but she did not appear to be in any acute stress. There were no abnormal scars or scratches on her skin; there was no scarring in the vagi- nal, anal, or breast area; and her general physical exam was normal. Dr. Smith did note that K. V.’s hymenal ring appeared to be broken. Smith concluded that this injury was con- sistent with digital penetration. Dr. Smith testifi ed to his fi ndings at trial. K. V.’s previously recorded statements about the alleged abuse were also presented, along with corroborating testimony from K. V.’s mother. K. V.’s mother stated that D. R. H. had admitted to her that he had fondled K. V. and that he wanted to rape her. Based on this testimony, D. R. H. was found guilty and sent to prison.
D. R. H. appealed his conviction. After visiting D. R. H. in jail, K. V.’s mother recanted her statements, as did K. V. D. R. H.’s lawyer requested a second genital exam to be con- ducted by a doctor selected by the defense. K. V. refused a second exam and stated that she did not need to be examined because nothing had happened to her. The appeals court agreed with D. R. H., and the conviction was overturned pending a second exam.
The Supreme Court of New Jersey reviewed the case and concluded that the courts could not compel a second exam. It argued that the court had an interest in protecting a child witness and that the exam could be traumatic for her. The supreme court argued that D. R. H. was not challenging Dr. Smith’s fi nding, only his interpretation of those fi ndings. The court said that the defense expert was free to offer a different interpretation of the fi ndings from the existing exam. The court ruled that any harm done to the defendant because his expert had not personally conducted the exam was not suffi cient to override the court’s desire to protect the witness. Previous rulings had protected children from multiple psychological examinations, and the court felt that similar reasoning applied to physical exams ( State v. D. R. H. , 1992).
DISCUSSION QUESTIONS
1. Do you think K. V. was sexually abused by D. R. H.? If so, why did she recant? 2. Was the appeals court right to order a second medical exam, or was the state supreme
court right to say it was more important to protect K. V.? 3. Should K. V.’s mother be charged with anything? Should she have visitation with
K. V. and her brother?
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Some researchers have also proposed a link between physical and/or cognitive disability and child sexual abuse. Children with a disability have an incidence rate that is 1.75 times greater than the rate for nondisabled children (Berliner & Elliott, 2002). However, some feel that the evidence for this link is not suffi ciently strong to establish disability as a risk factor. It may be that disabled children are at a greater risk because they are needier or because they are less able to defend themselves or to seek help, but it is also possible that disabled children have more contact with service providers who are, in turn, more likely to detect and report abuse.
There is also a relationship between compliance (the tendency to go along with requests from others) and child sexual abuse. Researchers found that adults, both men and women, who had suffered sexual abuse as children obtained signifi cantly higher scores on a compliance scale as adults than did those without a history of sexual abuse. However, it is not evident from the data collected that they were more compliant when they were children (Gudjonsson, Sigurdsson, & Tyrggvadottir, 2011).
EXTRAFAMILIAL CHILD SEXUAL ABUSE
The sexual abuse of children can occur within the family or in an extrafamilial set- tings. Sadly, any time a child is placed in the care of an older person, the possibility of sexual abuse is present. Recent decades have seen a great deal of media and research attention given to sexual abuse within churches, in day-care centers, and in schools.
Religious Settings and Churches
In some ways, the most shocking setting for child sexual abuse may be churches and faith communities. People look to religious leaders to be models of morality, so sexual assaults against children by those with religious authority have been particu- larly hard to accept. Although child sexual abuse occurs across all faiths, the Catholic Church has garnered the most attention.
The most extensive study of child sexual abuse within the Catholic Church was conducted by a group of researchers at John Jay College (2004). The research was commissioned and funded by the United States Conference of Catholic Bishops. The researchers were charged with describing both the nature and the extent of child sexual abuse within the church. Their 251-page report, titled The Nature and Scope of Sexual Abuse of Minors by Catholic Priests and Deacons in the United States 1950–2002 , can be found online at www.usccb.org/issues-and-action/child-and-youth-protection/ upload/The-Nature-and-Scope-of-Sexual-Abuse-of-Minors-by-Catholic-Priests-and- Deacons-in-the-United-States-1950-2002.pdf.
The researchers at John Jay College (2004) concluded that there were allegations of child sexual abuse against 4,392 priests and deacons between the years of 1950 and 2002. This represents between 4% and 4.3% of all priests and deacons during that time. The rate of abuse did not vary signifi cantly across the different regions of the United States (3% to 6%). The victims were most likely to be between the ages of 11 and 14 (50.9%), and the majority (81%) were male.
It appears that the rate of abuse cases was highest in the 1970s and the 1980s. However, church offi cials were not aware of most of these cases when they were occurring. About one third of the allegations covered in the document produced by
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164 TYPES OF ABUSE AND THEIR EFFECTS
researchers at John Jay College were not reported until 2002. A further third were reported after 1993. Therefore, prior to 1993, the Catholic Church was aware of only one third of these cases. At the time of the report, the police had been notifi ed about 1,021 priests (24%) and 384 (8.7%) were charged criminally (John Jay College, 2004). These criminal charges led to 6% of all priests reported to police being convicted and 2% serving sentences (John Jay College, 2004).
Using some of the data from the report produced by John Jay College, Mer- cado, Tallon, and Terry (2008) cautioned people against assuming that all priests who offended were the same. Although the priests who had many victims got the vast majority of the media attention, they were not the most common offenders; in fact, they were the rarest. Mercado et al. reviewed 3,674 cases and reported that most offenders had one ( n = 1,915) or 2 to 3 victims ( n = 1,082). Fewer offenders had 4 to 9 victims ( n = 540), and the smallest number of offenders had 10 or more victims ( n = 137). They noted that the offenders differed in more ways than the number of victims each had. Those with religious authority with 10 or more victims began offending earlier in their life, they were more likely to have younger victims, and those victims were more likely to be male (90.6% were male compared to 66.4% of victims whose perpetrator had only 1 victim). These offenders with the most vic- tims were also the most likely to be charged and convicted, although this was rare across all categories of offenders (e.g., 9.25% of offenders with 10 or more victims were convicted compared to 3.34% of those with only 1 victim). Those with 10 or more victims were also more likely to receive treatment interventions that included everything from administrative leave, to retirement, to medical leave, to suspension. However, priests with the highest number of victims were no more likely to be trans- ferred across dioceses than were the other offenders.
Another line of research has focused on comparing religious and non-religious offenders. Many perpetrators of child sexual abuse defi ne themselves as religious even if they are not employed in a religious setting (Vieth, 2012). Abel and Harlow (2001) surveyed 3,952 male sexual offenders and found that 93% of them described themselves as religious. Furthermore, research suggests that “religious” offenders may have more victims, younger victims, and be more likely to use force than are nonreligious offenders (Vieth, 2012).
Looking only at persons with religious careers, Saradjian and Nobus (2003) examined the cognitive distortions of 14 religious professionals (11 Catholic priests, 1 Protestant vicar, and 2 Christian missionaries) who were in treatment for sexually abusing children. They found that these religious men engaged in many of the same cognitive distortions that have been reported for nonreligious offenders (e.g., no vio- lence means no harm, no penetration means it was not really sex, no one will fi nd out, all teenage boys want sex, if I am nice/helpful in other ways it will counteract the abuse, etc.). They also found, however, that many of the religious perpetrators had distorted cognitions that invoked their faith. For instance, one priest said, “As a priest, everything is alright” (Saradjian & Nobus, 2003, p. 911). Another said, “God has called me to be a priest. I believe this fully. When he called me, he knew what I was like, what my needs were, and how I could have them met” (Saradjian & Nobus, 2003, p. 912). As a fi nal example, one man refl ected on not being caught by saying, “How could it be that bad if He (God) allows it?” (Saradjian & Nobus, 2003, p. 912). When perpetrators are members of the clergy, they may think that God will protect the children they victimize or that by doing other good works, they will be forgiven for their molestation of children (Vieth, 2012). Although it is likely that religious
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165SEXUAL ABUSE
beliefs could inhibit many believers from offending, for these perpetrators, their faith actually facilitated their offending.
Dale and Alpert (2007) write that the sexual abuse by priests was worsened by the lack of a signifi cantly punitive response by the church authorities. Instead of exposing priests to secular law and taking away their privileges and responsibili- ties within the church, cases were dealt with internally and quietly; often, priests returned to work that involved contact with children. Dale and Alpert further argue that church authorities pressured victims and their families to remain silent about the abuse. For the victims this meant a second betrayal. They were abused by a priest and then not helped by the greater faith community. One victim wrote, “I learned, too, that my abuser had not been the only priest to harm a child. A number of priests had preyed on children, many younger than I had been. Many bishops didn’t seem to recognize that wolves disguised as priests had attacked the sheep within their fl ocks, and some bishops covered up their offenses. I was devas- tated, enraged, hurt, and disgusted, but I did not let this crisis impede my healing” (Plante & McChesney, 2011, p. 4). Being sexually abused within the church and then not receiving appropriate support from the larger church community can have an impact on the victims’ faith. Children who were molested by members of the clergy report that they attend church services less often and that they have trouble trusting God (Vieth, 2012).
The public outcry and media scrutiny that began in the mid-1980s forced the Catholic Church to revise its response to allegations of sexual abuse. In 1992, the United States Conference of Catholic Bishops offered Five Principles to be followed in light of allegations: less secrecy, prompt response, removing alleged perpetrators from contact with potential victims and having them evaluated and treated, full compliance with civil law, and reaching out to victims and their families (Frawley- O’Dea, 2004). Although a step in the right direction, the Five Principles were criticized for giving bishops too much discretion in determining when allegations were supported with suffi cient evidence and they did not fully address how to deal with adult survivors who made allegations of past abuse. Vieth (2012), an expert on child abuse, says that religious personal should be aware of basic information about child sexual abuse and the defi nition of pedophilia as provided by the Diag- nostic and Statistical Manual of Mental Disorders , Fourth Edition ( DSM-IV ; American Psychiatric Association, 1994). However, this is not suffi cient. Anytime a member of a religious organization is confronted with a sex offender, they should seek the advice of a mental health professional with an expertise in dealing with perpetrators of sexual abuse. In response to these criticisms, the Ad Hoc Committee on Sexual Abuse created a standardized approach to CSA allegations in 1993. In 2002, the Vatican changed these regulations to tighten the defi nition of sexual abuse, include a statute of limitations, and require a due process that conformed to Cannon Law (Frawley-O’Dea, 2004).
Certainly, child sexual abuse occurs across many, if not all, faiths. Although the media has focused on clergy within the Catholic Church, cases of child sexual abuse are found within many religious traditions and are especially problematic in institu- tions with powerful leaders and a tendency to handle allegations internally instead of turning evidence over to the secular authorities. For example, leaders of faith traditions including Pentecostals, Hasidic Judaism, the Fundamentalist Church of the Jesus Christ of Latter-Day Saints, and American Southern Baptists have all been found guilty of child sexual abuse (Speckhardt, 2011).
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166 TYPES OF ABUSE AND THEIR EFFECTS
Day-Care Centers and Preschools
Interest in sexual abuse in day-care centers rose dramatically in 1983 following the much-publicized case of alleged sexual abuse at the McMartin preschool. The investi- gation and trials related to these allegations lasted more than 7 years and ended with two deadlocked juries (McCord, 1993). Although many questions remain regarding this case, it dramatically increased the attention given to child sexual abuse in day- care settings. (See Chapter 11, “Forensic Interviewing of Children,” for a thorough review of this case).
Researchers attempted to describe sexual abuse in day care centers and to identify risk factors associated with day care providers. Faller (1988) interviewed 48 children who had been sexually abused in a day-care setting (either public or home based). In cases of abuse in home day-care centers, the abuser was not necessarily the primary caregiver. Margolin (1990) noted that the husband of the caregiver is often the per- petrator in this setting. Faller reported that half the children in her study had been abused by a single perpetrator, but the other half had more than one abuser. The average number of perpetrators per child was 2.8 with a range from 1 to 8. When there was only one abuser, the sexual abuse was generally kept secret from the other workers. However, in cases with multiple abusers, it seemed that all adult workers knew about the abuse, although the level of involvement varied among workers. With regard to perpetrator sex, 47.9% of the children were abused only by men, 2.1% were abused only by women, and 50% were abused by both men and women.
The average age of victims at the time the abuse began was 3.9 years and the range was from 1 to 9 years (a child in an aftercare program). Two thirds of the vic- tims were 3 or 4 years old when the abuse began. Overall, 37.5% of victims were boys and 62.5% were girls. However, it was noted that the rate of abuse did not vary by sex in day-care centers. The higher rate for female victims was attributed solely to home day cares, where 90% of the victims were female. The children were most com- monly subjected to acts of fondling and oral sex. Still, 20% of the reported acts did involve intercourse. The children were also threatened. Threats were used rarely to induce compliance, but they were used to ensure that the victims remained silent about the abuse. The most common threats involved threats of harm, or even killing, the child or the child’s loved ones (Faller, 1988).
Not surprisingly, the children suffered from an array of symptoms follow- ing the abuse. The impact of sexual abuse was measured by interviewing the child victim and their parents about problems and symptoms following the abuse experi- ence. The focus was on identifi able behaviors. On average, the children exhibited 3.7 symptoms. It was noted that children abused by multiple perpetrators had more symptoms (5.7) than did children abused by only one perpetrator (2.1). There were only 2 children who did not have any negative symptoms. The most common prob- lems involved inappropriate sexual behaviors and emotional problems, but children also suffered from phobias, sleep disturbances, behavioral problems, and physical problems (Faller, 1988). Other researchers have noted that victims of sexual abuse in daycare centers have better outcomes if they come from cohesive families that are able to offer support, had parents who responded positively to them, and who had the opportunity to receive therapy (Finkelhor & Kendall-Tackett, 1993).
Many day-care centers attempt to protect the children they serve by running background checks on employees. However, one study noted that only 8% of day- care perpetrators had a prior conviction for sexual misconduct. This fi nding suggests
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167SEXUAL ABUSE
that criminal checks are not suffi cient to keep children safe (Finkelhor, Williams, & Burns, 1988). Schumacher and Carlson (1999) identifi ed some factors associated with lower risk. They found that day cares with large staffs were associated with less severe abuse and shorter duration of abuse. On the other hand, they noted that day cares run by multiple members of the same family were associated with greater risk.
Similar to what has been seen within faith communities, day-care centers have also be accused of failing to report suspected maltreatment within their organiza- tion. Day-care workers provided a host of reasons for failure to report: loyalty to coworkers, not knowing they were mandated reporters, and being fearful of legal consequences if they were wrong about their allegations (Schumacher & Carlson, 1999). Clearly, these workers were not fully aware of the mandated reporting laws. A possible point of intervention might be to require education about mandated report- ing for all day-care workers.
Schools and Sports Teams
Children are also victimized within their schools. Hundreds of cases per year across the United Stated involve allegations of sexual abuse by teachers, bus drivers, and coaches. People hired by the school districts to educate and protect children exploit their position to take advantage of the students in their care (Shoop, 2004).
When students interact with school personnel, there is a clear imbalance of power. The students are generally expected to obey the authority fi gures without question. Unfortunately, in cases of CSA, this can lead to acquiescence; children do not actively resist the abuse. Instead, they appear to go along with what is happen- ing. Also, many of these victims really like the person who becomes the perpetrator; they may even have a crush on them. Although this does not change the fact that what is happening is still very much an abusive act, it may make prosecutors leery about bringing the cases to court (Shoop, 2004).
Teachers, like most pedophiles, count on the child to stay silent about the abuse. Some children, especially the very young, will not know that what is happening is wrong. Others will feel too guilty or ashamed to tell anyone. Many abusive teachers work to make sure the child feels responsible for what is occurring. They may com- municate to the child the message that because the child is so special, or pretty, or amazing, there is no way the adult could resist them. Disabled children are particu- larly vulnerable to sexual abuse in school settings just as they are at home (Shoop, 2004).
Teachers, like other pedophiles, carefully select their victims. They look for stu- dents who do not have many friends and who have low self-esteem. They may also target students who are vulnerable because they have suffered a recent loss. Teachers may also focus on children who either need extra help in their subject area or are gifted in their class. Both low- and high-achieving students provide an excuse for the teacher to spend extra, often individual, time with the child. The teacher could get close to the student under the guise of providing tutoring or challenging a gifted student (Shoop, 2004).
Once a child has been targeted, the teacher may begin testing the child. Dur- ing this phase, he or she may brush against the child or give the child a prolonged hug. If the child reports such actions to an authority fi gure, the teacher would have plausible deniability. However, if the child does not report, the teacher may move
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168 TYPES OF ABUSE AND THEIR EFFECTS
on to sexual jokes and conversations. Interestingly, high school females recognize that certain teachers are inappropriate even if they do not report them. When asked to identify which teacher, if any, was a letch, the majority of students identifi ed the same teacher (Shoop, 2004). Certainly not all teachers who behave inappropriately will go on to be abusive, but if all teachers were reported at this stage, it might pre- vent some abuse cases.
If the teacher is not stopped at the testing stage, he or she may move on to grooming and to actual abuse. The teacher’s behaviors become more obviously inap- propriate. He or she isolates the student from family and friends and tries to make the student feel special. Over time, sexualized conversations lead to sexual acts (Shoop, 2004).
Within schools and in organizations outside of schools, coaches have been also taken advantage of children. In one study, it was noted that over an 18-month period, more than 30 cases of sexual abuse by coaches that resulted in arrest were reported by major U.S. newspapers (Nack & Yaeger, 1999). Because only a small percentage of cases lead to arrests, this is likely only the tip of the iceberg.
Coaches, like other abusers, give their victims special attention. They make the child feel special. There is some evidence that coaches prey on many children, so each one has more than one victim. Some coaches who have been convicted of child sexual abuse admit that they became coaches because it gave them access to children.
One coach, Norman Watson, admitted that he had sexually abused hundreds of children while a Little League coach. Watson continued to coach, and molest children, even while he was on probation for an earlier molestation case. Not only had Watson been convicted of child sexual abuse; he had also spent more than 5 years in treatment for molesting children. Despite this background, he continued to coach. When the full story of his molestation fi nally came to light, he pled guilty to 39 counts and received an 84-year sentence. Like most coaches who offend, Wat- son was a gifted coach and a very personable man with strong interpersonal skills. Also, like many offenders, he was single, White male, with a normal to above normal IQ. In addition to coaching the children, he offered to babysit, he took the children on outings, and he bought them gifts. Watson was so popular as a coach that when a parent noted his name on the sex offender registry and reported it to the board president, Watson was allowed to continue coaching after promising the board that he had changed (Nack & Yaeger, 1999).
More recently, the child sexual abuse scandal at Penn State University highlighted the problem of sexual molestation by coaches (see Chapter 3 , Case Example 3.3 ). These cases illustrate the fact that you will not know pedophiles when you see them. Adults who appear concerned and committed to children can be guilty of child sex- ual abuse. Parents need to be vigilant about protecting their children, and when allegations arise, they need to be taken seriously and carefully investigated to prevent further harm.
CHILD SEXUAL EXPLOITATION
Sexual exploitation is a term that is not used consistently; defi nitions vary across the fi eld. Some consider the term synonymous with child abuse. For others, child sexual exploitation is a form of child sexual abuse that generally involves money. In other words, the motive is, at least partially, fi nancial gain. Some refer to these behaviors
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169SEXUAL ABUSE
as the commercial sexual exploitation of children (CSEC; K. Mitchell, Jones, Fin- kelhor, & Wolak, 2011). I use the term here to include child pornography, child prostitution, and the sex traffi cking of children. Perpetrators of child sexual exploita- tion can be members of the child’s family or outsiders. One review of known images of child pornography revealed that 70% of all photographs were taken by close rela- tives or by family friends (Cooper, 2009).
Child Pornography
Child pornography is the visual depictions of minors (those younger than 18 years of age) in lewd or erotic ways. The term is limited to images that are designed to illicit arousal, so educational photographs or family pictures that include a nude child in a nonerotic setting would not be considered pornography. Child pornography is a seri- ous problem that has worsened with the growth of the Internet. The National Center for Missing and Exploited Children estimates that there are more than 12 million por- nographic images of children available. It is further estimated that 20,000 new images are added to the Internet each month (Cooper, 2009). In 2006, there 569 arrests in the United States for Internet-facilitated CESC. O these cases, 36% involved buying or selling access to children for the purposes of producing pornography, and 64% were related to the purchase or selling of existing images (L. Mitchell et al., 2011).
Child Prostitution
Child prostitution involves minors who engage in sexual acts for money. Because prostitution is illegal in most parts of the United States, responses to child prostitutes have traditionally been punitive. Recent efforts have been directed toward seeing children who engage in prostitution as victims, not criminals (Lowe & Pearce, 2006). Because children with a history of being maltreated are more likely to run away from home and are more likely to use drugs and alcohol, they are at a heightened risk for engaging in prostitution. Although it may appear that the children are choosing to engage in prostitution, there is generally more to the story.
Sex Traffi cking
Closely related to child prostitution is sex traffi cking, which is defi ned as organized and forced/coerced sexual slavery of unwilling persons. Due to the secretive nature of sex traffi cking, it is diffi cult to estimate how frequently it occurs. Incidence estimates vary widely across studies and many experts assume that reported numbers dramati- cally underestimate the true prevalence. Although some sexual traffi cking occurs across international borders, most is domestic. Traffi ckers (also referred to as pimps) target their victims, looking for children living in poverty who are isolated and who come from troubled families. They also target those who are young. The average age at entrance into sex traffi cking is estimated to be 13 years. Some offenders, labeled as fi nesse pimps, lure their victims with kindness and promises. Other perpetrators engage in intimidation, threats, and aggression and are known as guerilla pimps (McClain & Garrity, 2011).
In 2000, the United States Congress passed the U.S. Traffi cking Victim Protection Act (TVPA). In passing this legislation, the federal government recognized traffi cking
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170 TYPES OF ABUSE AND THEIR EFFECTS
as a form of slavery wherein the children forced to perform sexually for money were victims, not criminals. The act also provides substantial penalties for those who use children in this manner. In order for the victims to receive benefi ts under this act, they must prove or admit to being traffi cked, and they must be willing to participate in the prosecution of their perpetrators (Pierce, 2012). The act must be reauthorized every two years. The U.S. Congress failed to reauthorize the act in 2011, but it did pass the Senate by a vote for 95–3 on Feb. 12, 2013.
A thorough examination of child sexual exploitation is beyond the scope of this book. In fact, there are many excellent books devoted entirely to this topic. Inter- ested readers are encouraged to check out Medical, Legal and Social Science Aspects of Child Sexual Exploitation – A Comprehensive Review of Pornography, Prostitution and Inter- net Crime edited by Sharon Cooper, Richard Estes, Angelo Giardino, Nancy Kellog, and Victor Vieth (2005). The two volumes of this book cover the historical back- ground, the impact of sexual exploitation on children, forensic analysis of images, the prosecution of offenders, the importance of education, and many more aspects of exploitation (M. Wilson, 2007).
CONSEQUENCES OF SEXUAL ABUSE
Despite a good deal of attention and research paid to the problem in the last 20 years, there is still little to no evidence to suggest that there is a set of symptoms unique to victims of sexual abuse (Finklehor, 1990). Instead of sexual abuse leading to a particular set of negative consequences, it seems to put victims at risk for developing any of a large number of negative outcomes. However, no one symptom is seen in the majority of victims.
Meta-Analyses
A number of meta-analyses have been done to summarize the research on sexual abuse and the possible consequences for victims. In 1993, Arthur Green, a medical doc-
tor, published an article detailing the short- and long-term effects of child sexual abuse. He found evidence to suggest that sexual abuse victims are more likely to suffer from a range of problems including anxiety disorders, dissociation, hysterical symptoms, depression, low self-esteem, and dis- turbances in sexual behavior than are their nonabused peers when they are children. As adults, these victims continue to
be at risk for anxiety disorders, depression, low self-esteem, suicidal behavior, sub- stance abuse, borderline personality disorder, multiple personality disorder, sexual dysfunction, revictimization, and sexual offending. Green does, however, caution that many of these research studies are still plagued by signifi cant methodological fl aws including imprecise defi nitions for sexual abuse, insuffi cient information about the severity of abuse suffered by the participants in the study, failure to identify the perpetrator, use of assessment instruments that are not specifi c to sexual abuse, insuf- fi cient validation of sexual abuse history (e.g., relying solely on self-report in some cases), and poorly constructed control groups in some cases. Finally, all data must be interpreted in terms of where the sample for the study came from. If participants are
meta-analysis
a statistical technique
that allows researchers
to combine the results of
several different studies.
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selected from a treatment facility, they are likely to have more negative symptoms than would victims who are not seeking treatment. Keep these cautions in mind as you read about the research on the consequences of sexual abuse.
Paolucci, Genuis, and Violato (2001) conducted a more focused meta-analysis on the effects of child sexual abuse. They opted to focus on only six specifi c outcomes: post- traumatic stress disorder, depression, suicide, sexual promiscuity, victim–perpetrator cycle, and poor academic performance. Looking only for studies that included empir- ical data, had control groups, used standardized psychometric measures, and had a sample size of at least 12, Paolucci et al. identifi ed 37 studies that had been pub- lished between 1981 and 1995 dealing with the impact of child sexual abuse on at least one of their six measures of interest. The defi nition of child sexual abuse used by the authors was any unwanted sexual contact (not limited to penetration) that occurred while the victim was legally a child and the perpetrator was in a position of relative power as compared to the victim. Taken together, the studies they reviewed covered 25,367 participants, 9,230 of whom had a history of child sexual abuse. As is common in meta-analyses, the authors calculated a measure of effect size for each variable. (If you are not familiar with effect sizes, see Focus on Research 7.3 for a brief overview.) The authors found that a history of child sexual abuse signifi cantly increased a child’s risk for all six of the variables studied. The effect sizes were as follows: posttraumatic stress disorder, d = .40; depression, d = .44; suicide, d = .44; sexual promiscuity, d = .29; victim–perpetrator cycle, d = .16; and poor academic per- formance, d = .19. Surprisingly, the authors did not fi nd any signifi cant differences in outcome based on the victim’s gender, socioeconomic status, or age at the time of abuse; the number of incidents; or the relationship between the perpetrator and the victim. This is different from what others have reported.
FOCUS ON RESEARCH 7.3
An effect size is a measure of the magnitude of an effect. It tells you how big an effect is. There are a number of different measures of effect size, but they are similar. Generally, you calculate the mean difference between the two groups you are comparing. In a meta- analysis on child sexual abuse, you take the mean (or average) score for the abused group, and then subtract the mean score for the control (nonabused) group. This mean difference is then divided by the standard deviation ( SD ) of either group. The standard deviation of a group of scores measures the average deviation of scores around the group’s mean. Therefore, the SD refl ects how much variation there is among scores in a group. A small SD means that that scores are similar to each other, whereas a large SD means that the scores vary widely. Two common measures of effect size are J. Cohen’s (1988) d and Glasser’s delta. Cohen’s d allows you to use the SD from either the control group or the experimen- tal group; Glasser’s delta requires division by the SD of the control group.
In order to understand a meta-analysis, you need to know not only what an effect size is but also how to interpret it. There are, as you might have guessed, numerous ways to do this. The most straightforward to is follow Cohen’s (1988) guidelines. He suggested that d = .2 constituted a small effect, d = .5 indicated a medium effect, and d = .8 meant a large effect. Another way to interpret d scores is to think of them as indicating the percentage
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172 TYPES OF ABUSE AND THEIR EFFECTS
For instance, Roland, Zelhart, and Dubes (1989) found that for female college stu- dents, those who were victimized by a father or stepfather showed signifi cantly more
elevations on the Minnesota Multiphasic Personality Inventory ( MMPI, Hathaway, McKinley, & Butcher, 1942–1990) than did those who were not abused and those who were abused by someone in a different role. The MMPI is one of the most widely used per- sonality tests. It consists of 567 true/false questions and 10 clinical scales: hypochondria, depression, hysteria, psychopathic deviance, masculinity/femininity, paranoia, obsessive-compulsive behavior, schizophrenia, hypomania, and social introversion. In addition, it has a scale designed to measure whether the respondent is being honest. Even when the relationship to the perpetrator is not considered, a number of studies have shown that both men and women with a history of child sexual abuse have elevated MMPI
scores. This is evidence of a general level of psychological distress among victims (Polusny & Follette, 1995). Wind and Silvern (1992) replicated Roland et al.’s fi nding that child sexual abuse was particularly damaging if the perpetrator was a father fi g- ure, and they found evidence that victims’ depression levels were also related to both the frequency and the duration of the abuse. Therefore, for any specifi c symptom it is important to consider whether it is related more strongly to a subset of child sexual abuse victims than it is to all victims.
Depression
Among adult victims of child sexual abuse, the most commonly reported symptom is depression (Briere & Runtz, 1993; Kendall-Tackett, 2012). Evidence from both clinical and community samples supports a relationship between child sexual abuse and subse- quent depression. This connection is evident across a variety of measures for depression
of nonoverlap between the groups. For instance, if the distribution of depression scores for the abused group completely overlapped the distribution of scores for the nonabused group, the d would be 0, indicating that there is no difference in the scores of the two groups—percentage of nonoverlap = 0. A d of .2 (a small effect) means that 14.7% of the distribution of one group does not overlap the distribution of the second group. A d of .4 (a medium effect) means that 33% of the distribution of the one group does not overlap the other distribution of scores. A d of .8 (a large effect) means that the percentage of nonoverlap is 47.4%.
Other researchers opt to report r as a measure of effect size. This statistic tells you how much of the variance in what you are measuring is accounted for by your independent variable. According to J. Cohen (1988), an r = .1 is a small effect, an r = .3 is a medium effect, and an r = .5 is a large effect.
At this point, it may be obvious to you why most psychology students are required to take at least one course in statistics!
Minnesota Multiphasic
Personality Inventory
(MMPI)
a 576-item, true/false
questionnaire that
provides scores on 10
clinical scales and 1
scale designed to assess
whether the participant
was truthful.
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including the Beck Depression Inventory (BDI) , the depression scale of the MMPI, and clinical interviews leading to a diagnosis of major depression according to criteria of the DSM-IV. Although nearly all studies report that being sexually abused increases the risk for the development of depression, the degree of risk varies widely. Studies fi nd that between 13% and 88% of child sexual abuse vic- tims experience depression, as compared with between 4% and 66% of nonabused control participants (Polusny & Follette, 1995).
Although depression is a common fi nding, it is not a universal one. For instance, Fromuth and Burkhart (1989) studied 582 college males (253 from a Midwestern university and 329 from a Southeastern university). They did not fi nd a correlation between child sexual abuse and depression among their Southeastern sample, and only a small correlation for their Midwestern sample. The nonsignifi cant fi nding for their Southeastern sample and the small effect found in the other sample may be attributable to the fact that Fromuth and Burkhart included noncontact abuse in their defi nition of child sexual abuse. Because this is generally a less damaging type of abuse, it may have masked the effects of contact abuse. In addition, the exclusion of women, who are more likely to suffer from depression, may also account for their fi ndings. However, the difference between no effect and a small one seen in two similar samples (both male college students) speaks to the need for multiple studies on diverse samples before making strong conclusions.
Self-Destructive Thinking and Behavior
Given the apparent relationship between child sexual abuse and depression, it makes sense to explore whether child sexual abuse victims are at greater risk for suicidal behavior. Not surprising, evidence exists to show that in both community and clini- cal samples, victims of child sexual abuse are at an increased risk for suicidal ideation and suicidal behavior. A meta-analysis of 177 studies that covered 65,851 participants found a statistically signifi cant relationship between a history of child sexual abuse and both suicidal and non-suicidal self-injury (Maniglio, 2011b). Whereas actual sui- cide attempts or suicides are labeled as suicidal behavior, suicidal ideation consists of thoughts or fantasies about suicide or wanting to take one’s life. Suicidal ideation may be driven by negative emotions. You, Talbot, He and Conner (2012) assessed depressed women with a history of child sexual abuse. They found that negative emotions including shame and guilt were associated with suicidal ideation. Among community samples, the rate of suicidal ideation has been reported to be 32% among victims of contact sexual abuse and 36% among victims of childhood rape. This compares to a rate of 20% among nonabused peers. This same pattern holds true for suicide attempts. Among victims of contact abuse, 16% attempted suicide, as did 18% of childhood rape victims and 6% of nonabused control participants (Polusny & Follette, 1995). This fi nding holds true among clinical populations as well. At a crisis counseling center, Briere and Runtz (1988) found that 51% of patients who reported a history of child sexual abuse also had made a previous suicide attempt, as compared to 34% of patients who were not the victims of child sexual abuse. These results were replicated by Briere and Zaidi (1989) when they examined the charts of 50 nonpsy- chotic female patients at a psychiatric emergency room. The rate of suicidal ideation was 77% for child sexual abuse victims and 33% for nonvictims. Likewise, 66% of the
Beck Depression
Inventory
a 21-item, multiple
choice, self-report
measure that assesses the
severity of depression.
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174 TYPES OF ABUSE AND THEIR EFFECTS
child sexual abuse victims had previously attempted suicide, as compared with 33% of patients who were not victims of child sexual abuse.
Cankaya, Talbot, Ward, and Duberstein (2012) reported that the relationship between the perpetrator and the victim is important in predicting suicidal behavior in depressed women with a history of child sexual abuse. They examined an outpa- tient sample (N = 106) of women who were seeking treatment at a community mental health center. In order to be included in the study, the women had to be suffering from major depressive disorder and report a history that included child sexual abuse. They found that suicide attempts were much more likely if the woman had been abused by a parent or by a parent fi gure than if she had been abused by a nonparent.
In addition to an increase in suicidal ideation and suicide attempts, a link between child sexual abuse and self-mutilation has also been demonstrated. Self- mutilation includes acts, such as cutting or burning, that are not intended to be life threatening but involve deliberate physical harm to one’s body. Research deal- ing with clinical samples has shown that child sexual abuse, especially if it has an early onset, will increase the risk that a child will engage in self-mutilating behavior (Polusny & Follette, 1995). In the Briere and Zaidi (1989) study mentioned earlier, the rate of self-mutilation was 17% among women with a history of child sexual abuse and 0% among those with no history of child sexual abuse.
Anxiety
Most of the published literature shows that victims of child sexual abuse are more likely to be anxious than are their nonabused peers. This increase has been noted across
a variety of measures including structured clinical interviews, the Beck Anxiety Inventory, and the psychasthenia scale of the MMPI, which is associated with anxiety. Victims of child sexual abuse are up to 5 times more likely to be diagnosed with some type of anxiety disorder than are nonvictims (Berliner & Elliott, 2002). This anxiety may stem from hypervigilance. Expecting that something bad will happen and interpreting things that are neutral, or even positive, as evidence of danger, a victim who sees the world as a dangerous place may be constantly on guard. Living in a world that is consistently perceived as threatening increases anxiety levels to a maladaptive level. Although vigilance is appropriate and adaptive when walking alone at night in a strange city, it is not a productive response if it is chronic. Constant vigilance wears a person out and makes his or her miss out on enjoying what is going on in the world. Victims may
also experience anxiety because they are preoccupied with control. With a history of being victims with no control, they continually worry about how much control they have (Briere & Runtz, 1993). Although general anxiety seems to be high among CSA victims, it has been noted that this is true only of chronic anxiety, not acute anxiety, and that victims are not more likely, as a group, to show more specifi c fears.
Posttraumatic Stress Disorder
A history of child sexual abuse seems to be associated with an increased risk for devel- oping posttraumatic stress disorder (PTSD), especially if the abuse included contact
hypervigilance
excessive watchfulness
or wariness; constant
scanning of the
environment for signs of
danger.
Beck Anxiety Inventory
a 21-item scale designed
to measure anxiety and
to discriminate between
anxiety and depression.
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(see Chapter 4 for a description of PTSD). Reports in the literature indicate that the rate of post-traumatic stress disorder among child sexual abuse victims is between 33% and 86%. Much of this variation is likely due to how child sexual abuse is defi ned. Saunders et al. (1992) studied a community sample of 391 women, 131 of whom had suffered some sort of childhood sexual assault. They found that rates of PTSD varied signifi cantly with the type of sexual abuse that had occurred. None of their nonvic- tims hadPTSD, as compared with 11.4% of the noncontact victims having a history of PTSD, 33.3% of molestation victims, and 64.1% of the rape victims. The rate of PTSD is also much higher among clinical samples (72%) than it is among community samples (8.8% to 17.9%), according to Polusny and Follette’s (1995) review of the literature. The rate of PTSD among sexually abused children is higher than the rate seen among children who suffer from other types of maltreatment (Berliner & Elliott, 2002).
For victims of child sexual abuse, fl ashbacks seem to be especially prominent. The person suffering from fl ashbacks has recurring, intrusive thoughts about the event. These memories may be very vivid and may include visual, auditory, and tactile sensations. The memories can be triggered by a variety of stimuli including sexual situations (personal or in the media), abusive behavior, or even disclosing their own abuse (Briere & Runtz, 1993). Because these recollections are painful for victims, they may go out of their way to avoid possible triggers. In doing this, they place limitations on their daily life.
Substance Abuse
Victims of child sexual abuse are also at an increased risk for the abuse of substances, both legal and illegal (Maniglio, 2011a). Again, this outcome is especially likely if the abuse included contact. Among community samples, between 15% and 22% of sexual abuse victims have a problem with substance abuse or dependence, as com- pared with 4% to 7% of control participants. Drug-related problems are even higher among clinical samples. Between 21% and 57% of sexual abuse victims in clinical settings are reported to have substance abuse problems, as compared with between 2% and 27% of patients who have not experienced child sexual abuse (Finkelhor, 1994). Based on the results of numerous studies, it can be concluded that the rela- tionship between child sexual abuse and adult substance abuse is between moderate and strong (Fergusson & Mullen, 1999). It has been theorized that victims may be using substances as way of dealing with the memories of the abuse.
Personality Disorders
Victims of child sexual abuse are more commonly diagnosed with personality dis- orders, particularly borderline personality disorder, than are nonabused children. Cutajar et al. (2010) examined the medical records of 2,759 victims of sexual abuse who had been abused between 12 and 43 years earlier. The rate of personality dis- orders among the sexually abused participants was 3.6%. This rate was signifi cantly higher than the rate seen in the comparison group of nonabused participants (0.7%). The most commonly seen disorder was borderline personality disorder (BPD). This personality disorder is marked by instability in a range of personality areas includ- ing interpersonal relationships, mood, behavior, and self-image. According to the DSM-IV (American Psychiatric Association, 1994), a person must have at least fi ve
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176 TYPES OF ABUSE AND THEIR EFFECTS
of the following symptoms to be diagnosed with borderline personality disorder: a pattern of unstable and intense relationships; impulsiveness that is potentially self- damaging; affective (emotional) instability; inappropriate, intense anger; recur- rent suicidal or self-mutilating threats or behaviors; identity disturbance; feelings of emptiness or boredom; and frantic efforts to avoid abandonment. Among clinical populations, between 67% and 93% of patients diagnosed with borderline personal- ity disorder or were noted as having borderline traits have a history of child sexual abuse (Briere & Runtz, 1993).
Eating Disorders
There is some confl ict in the literature regarding the relationship between child sexual abuse and the development of eating disorders. Many researchers report that approxi- mately one third of people with eating disorders (between 24% and 69% across studies) have a history of child sexual abuse, and others argue that the rate of child sexual abuse among patients with eating disorders is not higher than the rates seen in well-
constructed control groups. Many authors assert that a history of child sexual abuse is more strongly associated with bulimia (binge- ing and purging) than it is with anorexia (Briere & Runtz, 1993), and others question whether there is any connection at all. Pope and Hudson (1992) reviewed the literature on the relationship between child sexual abuse and bulimia and concluded that the “current evi- dence does not support the hypothesis that childhood sexual abuse is a risk factor for bulimia nervosa” (p. 455). Pope and Hudson began their report by noting that a prospective study is lacking in this area. An ideal way to answer the question of whether child sexual abuse increases the risk of developing bulimia would be to identify a large group of child sexual abuse victims and follow them across their life span, periodically assessing them for eating disorders and measuring
for other factors that may contribute to eating disorders. Lacking this sort of evidence, Pope and Hudson reviewed six retrospective studies that made use of control groups. Four of these six studies found no difference between the rate of child sexual abuse among bulimic patients and the rate seen in their control groups. One of the two studies that reported a signifi cant difference (R. Hall, Tice, Beresford, Wooley, & Hall, 1989) did not control for the gender of participants in their groups. Whereas 98% of their eating-disorder group was female, only 85% of their control group was female. Because sexual abuse is more common among females, this is a signifi cant confound. When participant gender was controlled for, there was no difference in child sexual abuse rates between the groups. In the other study that showed signifi cant differences (Steiger & Zanko, 1990), the rate of child sexual abuse was similar in patients with eating disorders and those with other psychiatric problems (21% of anorexics, 36% of bulimics, and 33% of psychiatric comparisons had a history of child sexual abuse), but the rate was signifi cantly higher than that of the nonpsychiatric control group (9%). Pope and Hudson question this fi nding, because 9% is a very low rate of child sexual abuse according to nearly all incidence studies. Because some of the participants in the control group were hospital staff, and therefore known to the authors, Pope and Hud- son suggest that underreporting of abuse may have occurred for this group.
In reviewing retrospective studies without control groups, Pope and Hudson (1992) found that the rates of child sexual abuse among bulimics did not differ from
bulimia
an eating disorder
characterized by cycles of
bingeing and purging.
anorexia
an eating disorder
characterized by the
relentless pursuit of
thinness through
starvation.
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177SEXUAL ABUSE
overall rates of child sexual abuse among the general population. Pope and Hudson speculated that the relationship between child sexual abuse and bulimia may be an illusory correlation. Because both are relatively common, especially among females, they will frequently co-occur. However, it is not true that one is causally linked to the other.
Dissociation and Memory Impairment
Dissociation, or a separation of specifi c mental structures from the mainstream of consciousness, is also seen in some child sex- ual abuse victims. Participants who have a history of child sexual abuse have higher scores on the Dissociative Experiences Survey (Bernstein & Putnam, 1986) than do nonabused children (Briere & Runtz, 1993). Psychologists theorize that this may be a way for the mind to defend against full awareness of the abuse. By avoid- ing a full realization of one’s victimization, the survivor is able to reduce the negative feelings associated with the trauma. The forms of dissociation that may be seen include psychic numbing, depersonalization, disengagement (“spacing out”), and amnesia (Berliner & Elliott, 2002). The dissociation is especially likely to occur during times of stress.
Repressed Memory At the extreme end of memory impairment is the controversial topic of memory repression. Repression is one of the mind’s defense mechanisms proposed by Sigmund Freud. Freud stated that the mind, in order to protect itself, could reject unacceptable thoughts, desires, or memories by forcing them into the unconscious. The mind is able to bury the traumatic experience so completely that the person is no longer consciously aware of the memory. Freud did speculate that it required signifi cant psychic energy to keep a buried memory hidden (Freud, 1949). A good analogy is to imagine the effort it takes to keep a beach ball under water: one can do it, but it takes a great deal of work. In addition, while a victim may not recall the event, aspects of it may “leak” into the conscious mind. So, theoretically, a woman who was repressing memories of child sexual abuse may be afraid of men, anxious, or unable to enjoy a normal sexual relationship. The goal of psychotherapy would then be to help such persons recall the memory and deal with it directly so they could move forward with their lives (Madison, 1961). Freud himself was somewhat confl icted in his writings about repression. He fi rst wrote that his patients were recovering true memories of abuse, but he later wrote that the patients were recalling childhood fantasies (Masson, 1985).
The debate about the possibility of the mind to repress, and later recover, memo- ries is a fi erce one. Entire books have been written on the topic, and passions run high on both sides. I will present just a brief overview of the debate here. I would encour- age the interested reader to consider exploring The Myth of Repressed Memory: False
dissociation
the separation of some
mental processes from
conscious awareness.
Dissociative Experience
Survey
a 28-item self-report
measure designed to
be a screening test for
dissociative identity
disorder (DID), formerly
called multiple personality
disorder (MPD).
repression
a defense mechanism
in which painful or
unacceptable memories
or fears are rejected by
the conscious mind
and are buried in the
unconscious.
Freud
a Viennese physician
who developed the
psychoanalytic theory
that stresses the
importance of the
unconscious mind and
the constant confl ict
within each person’s
personality.
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178 TYPES OF ABUSE AND THEIR EFFECTS
Memories and Allegations of Sexual Abuse , by Elizabeth Loftus and Katherine Ketcham (1994), and Trauma and Recovery: The Aftermath of Violence From Domestic Abuse to Political Terror, by Judith Herman (1992).
It would be ethically impossible to test the theory of repression empirically. In order to do so, we would need to randomly assign a group of children to sexual abuse and a group to nonabuse. After videotaping the abuse for appropriate documenta- tion, we would threaten the abused children to maintain secrecy and never speak to them about what happened. Then, the children from both groups would need to be interviewed carefully over their life spans to see if they recalled the event. Even this is not perfect because some may recall the abuse but refuse to admit it. Still, if it turned out that some of the abused children went through a period when they apparently had no memory of the abuse and were later able to recover an accurate memory of it, then the theory would be supported with strong evidence. Because research such as this will not and should not be conducted, we have to make generalizations from research that is ethically permissible. Unfortunately, there is much disagreement about how the available information should be interpreted.
Many practicing clinicians express a belief in the construct of repressed memory. When Dammeyer, Nightingale, and McCoy (1997) asked clinicians, “Do you believe that repressed memory exists?” the average response among clinicians holding a PhD in clinical psychology was 7.28 on a scale from 1 ( defi nitely no ) to 10 ( defi nitely yes ). Whereas these PhD clinicians indicated a moderate preference for belief, other clini- cians were even more accepting of repression. The average response of participants with a PsyD (doctorate of psychology) was 8.13, and the average response among therapists with an MSW (master of social work) was 7.85.
Certainly, clinical examples of recovered memory cases are prevalent. Clients, generally women, enter therapy for a range of problems including depression, low self-esteem, and sexual dysfunction and deny any history of child sexual abuse. How- ever, over the course of therapy, the client recalls memories of past sexual abuse. The memories cause a great deal of distress, and the therapists, who are trained in interpreting human behavior, believe that their clients are genuine. In addition, many cite Williams’s (1994) study as good evidence for repressed memory. Williams obtained the emergency room records for girls who had been treated for sexual abuse between 1973 and 1975. In 1990 and 1991, she was able to contact and interview 129 of these women. When the women were contacted, they were told only that the study was about the lives of women who had received medical care at the city hospital. Each woman was interviewed in person for approximately 3 hours. Of these women, 38% did not report the abuse that had been documented between 1973 and 1975. Because the women were willing to report other negative events, the research- ers felt confi dent that it was a lack of recall, not an unwillingness to tell, that led to this failure to report. The women who did not recall the abuse were, on average, younger at the time of abuse than those who did recall the abuse. This, of course, is not evidence for recovered memory. It is simply evidence that abuse can be forgot- ten, or that it can be repressed. Williams went on to report that 16% of the women who did recall the abuse said there was a time in their life when they had not remem- bered the abuse. This, if the self-report is accurate, is evidence for the repression and recovery of memories.
Other psychologists remain skeptical about repressed and recovered memories. Dammeyer et al. (1997) found that experimental PhDs were close to the middle of the 1–10 scale when it came to belief in repressed memory (6.01), indicating neither
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179SEXUAL ABUSE
strong belief nor strong disbelief. In other words, many psychologists argue that we simply do not know if this is possible. Further, there is strong evidence that it is pos- sible to create false memories for negative childhood events, even among healthy adults. Researchers have found that by asking repeated, leading questions, false memories can be created in children and adults (see Chapter 10 ). In addition, tech- niques such as imaging, journaling, dream work, and hypnosis that are used by some therapists are especially likely to lead to the recovery of false memories. Skeptics also point out that the so-called recovered memories are odd in that they do not fi t with what we know about how memory works. The recovered memories tend to be overly detailed, to include memories from very young ages, and to be bizarre (memories of satanic cults, animal sacrifi ce, etc.). Real memories tend to get blurry with age, and humans do not have memories from their infancy (we all suf- fer from infantile amnesia ). The extreme memories of murder or torture that are recovered are not supported by physical evidence. If children were being murdered, scarred, or mutilated, then there should be missing children that fi t the descriptions of the mur- dered children, and there should be adults who carry the marks of this sort of abuse. Despite years of investigation, the Federal Bureau of Investigation (FBI) has not been able to fi nd such physical evidence. Finally, skeptics point out that patients who recover a memory of abuse do not get better as the theory would predict (e.g., by addressing the “buried” problem, they should be able to move on). In fact, many patients get much worse (Loftus & Ketcham, 1994). For these reasons, many argue that therapists should be extremely careful in pursu- ing repressed memories. In court cases across the country, both sides of this debate have been argued repeatedly. On one hand, there have been convictions based on recovered memory testimony, and on the other hand, therapists have been success- fully sued for implanting false memories.
Cognitive Distortions
Everyone makes assumptions about themselves and the world around them. Many of these assumptions are based on experiences during childhood, when one is fi rst learning about themselves and others. Being the victim of child sexual abuse can change a child’s thought processes. Being victimized leads some children to overes- timate the amount of danger in the world and to underestimate their self-effi cacy. Because they were abused at a time when they were not able to resist, many victims have low self-esteem and see themselves as helpless in the face of chronic danger (Briere & Runtz, 1993). Although some victims suffer from self-blame, it appears that most victims do not; they place blame appropriately on the perpetrator (Berliner & Elliott, 2002).
Another important aspect of cognition is the sort of attribu- tions a person makes to explain events. Among victims of child sexual abuse it is common to see internal/stable attributions of negative events. In other words, if something bad happens, vic- tims are likely to think that they caused of the bad thing (internal) because of something that is always true of them (stable). Con- versely, they attribute positive events to external and nonstable causes such as luck (Briere & Runtz, 1993). This is the reverse of
infantile amnesia
the inability of adults
to remember much, if
anything, about the fi rst
3 years of their life.
self-effi cacy
a person’s belief that he
or she is capable of doing
what is necessary to
produce the desired result
in a given situation.
attributions
determinations about
what caused an event or
a condition; explanations
for one’s own behavior or
the behavior of others.
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180 TYPES OF ABUSE AND THEIR EFFECTS
the type of thinking that most nonvictims engage in as they interpret the world around them. Most people take credit for positive events and blame negative events on things beyond their control (e.g., “I got a good grade on my psychology test because I am smart. I got a bad grade on my biology test because my professor is crazy and nitpicky.”)
Social Functioning
Victims of child sexual abuse are, as a group, less socially competent than are their nonabused peers. They are less able to trust than are nonvictims and are therefore less able to form secure relationships. Children who have been victimized may also see themselves as being different from their peers, and this difference makes them feel that they do not fi t in with other children (Finkelhor, 1994). They are likely to have diffi culty forming and maintaining intimate relationships. As adults, female victims are more likely to remain single, and if they do marry, they are more likely to separate or divorce than are their nonabused peers (Kendall-Tackett, 2012). Female victims of child sexual abuse report that they do not have many friends, and they are less likely to fi nd the relationships they do have to be satisfying than are nonabused women (Finkelhor, 1994).
Sexualized Behavior
Children who are victims of child sexual abuse are more likely to have sexual behav- ior problems than are their nonabused peers or children who are the victims of other types of maltreatment. Although sexual curiosity and sex play are common among children, victims of child sexual abuse are more likely to engage in behaviors associ- ated with genital sexual activity such as simulating intercourse or inserting objects into the vagina or the anus. Sexual play and exploration in nonabused children typically appears between the ages of 4 and 7 years, but it may be evident as early as 2 years. Normal sexual play includes masturbation, some looking at and touching of others’ genitals, and drawings of genitals. What is not generally seen in nonabused children is insertion of objects, insertion of the fi nger or the penis, or oral–genital contact. High levels of abnormally sexualized behavior are associated with abuse that is more intrusive, abuse committed by a greater number of perpetrators, and abuse that is accomplished with threats of harm. However, this does not mean that all chil- dren who act out sexually have been abused. Children who suffer from behavioral disorders such as oppositional defi ant disorder or conduct disorder may also engage in developmentally inappropriate sexual acts such as performing fellatio or cunnilin- gus. Other experiences, such as visual exposure to sexual material or acts, have also been associated with inappropriate childhood sexual behavior (Kuehnle & Sparta, 2006). So, although children with a history of CSA are more likely than others to act out sexually, you cannot assume that sexual abuse is at the root of all inappropriate sexual behavior in childhood.
Among seriously mentally ill children, female child sexual abuse victims are more likely than others to be hypersexual, and male victims are more likely to expose their genitals to others or use sexual coercion than are children who were not abused (Adams, McClellan, Douglass, McCurry, & Storck, 1995). Adams et al. (1995)
hypersexual
excessively or unusually
interested in sexual
matters.
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181SEXUAL ABUSE
reviewed the charts of 499 children from a psychiatric hospital. The children were categorized as having no inappropriate sexual behaviors or being hypersexual, expos- ing, or victimizing. Of these children, 41% had shown some type of inappropriate sexual behavior, and 16% had victimized others. A history of sexual abuse was related to inappropriate sexual behavior. Of the children with a history of sexual abuse, 81% behaved inappropriately, as compared with 36% of children who were not sexually abused. So, although child sexual abuse is associated with sexual misbehavior, it is neither a necessary (36% of nonabused were inappropriate) or a suffi cient (18% of children with a history of child sexual abuse were not inappropriate) link. The chil- dren who victimized others were likely to have been the victim of chronic abuse by a greater number of abusers. They were also more likely to be male; only slightly more than a quarter were female. On the other hand, children in the hypersexual group were more likely to be female. The authors conclude by saying that children in psy- chiatric settings should be carefully screened for sexually inappropriate behaviors, especially if they have a history of sexual abuse.
As adults, victims of child sexual abuse are more likely to suf- fer from sexual dysfunction or to be preoccupied with sex (Zwickl & Merriman, 2011). Women who have a history of sexual abuse report more negative feelings about sex and less sexual satisfac- tion. Compared to nonabused women, these women experience fewer orgasms and lower levels of sexual responsiveness (Colan- gelo & Keefe-Cooperman, 2012). Victims are also at a greater risk for engaging in unsafe sexual behaviors and of being revictimized as adults (Berliner & Elliott, 2002). Senn, Carey, Vanable, Coury- Doniger, and Urban (2006) assessed child sexual abuse and risky sexual behavior among adults attending a sexually transmitted disease clinic. They reported that child sexual abuse victims had a higher number of sexual partners in the previous 3 months and over their lifetime. They also found that patients with a history of child sexual abuse were more likely to have exchanged sex for money or drugs. These behaviors were even riskier in light of the fi nding that participants with a child sexual abuse history reported more episodes of unprotected vaginal and anal intercourse. Not surprisingly then, adults with no history of child sexual abuse had a lower lifetime incidence of sexually transmitted diseases (69%) as compared to those who had a history of child sexual abuse (83%). Females with a history of child sexual abuse are also at a slightly higher risk for teenage pregnancy than are nonvictims (Tyler, 2002). Victims of child sexual abuse may engage in numer- ous, short-term sexual relationships in order to meet their needs for closeness and intimacy.
Controversy in the Professional Literature Regarding the Impact of Child Sexual Abuse
Like most aspects of sexual abuse, there is disagreement among professionals about the effects of child sexual abuse on later development. Despite the research reviewed here, there are researchers who argue that the effects of child sexual abuse are not typically intense or pervasive. In fact, a meta-analysis conducted by Rind, Tromov- itch, and Bauserman (1998) made this claim and triggered a storm of controversy (see Focus on Research 7.4 ).
sexual dysfunction
any problem during the
sexual response cycle
from desire to arousal to
orgasm that prevents the
achievement of sexual
satisfaction.
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182 TYPES OF ABUSE AND THEIR EFFECTS
FOCUS ON RESEARCH 7.4
In 1998, Rind, Tromovitch, and Bauserman published an article titled “A Meta-Analytic Examination of Assumed Properties of Child Sexual Abuse Using College Samples” in the prestigious journal Psychological Bulletin. Rind et al. stated that past reviews of the litera- ture in this area had been fl awed. They criticized qualitative literature reviews for relying largely on clinical and legal samples. Their argument was that these samples represented the worst-case scenarios. They further stated that people suffering from a clinical disorder are searching for an explanation for their current problems and may, therefore, be pre- disposed to blaming them on past child sexual abuse experiences. Further, if a therapist believes that child sexual abuse generally leads to negative outcomes, this idea may be transmitted to patients. Further, these studies do not examine other factors, such as fam- ily environment, that may lead to negative outcomes. In other words, even if the person is suffering, it is not clear that the child sexual abuse was the cause. Rind et al. are more supportive of past quantitative reviews that rely on more nonclinical samples and that use meta-analysis to determine effect sizes. They point out that the quantitative reviews show fairly small effect sizes for negative outcomes following child sexual abuse. However, even these studies did not examine gender or family environment as carefully as Rind et al. thought was necessary.
Rind et al. (1998) therefore opted to conduct their own meta-analysis. They chose to focus on studies that examined the functioning of child sexual abuse victims who were college students at the time of the study. They made this decision because the largest number of nonclinical, nonlegal samples was from college populations. In addition, they noted that more than half of all people in the United States have some college experience. Finally, the work with college students was most likely to include data on other variables that might explain negative outcomes (e.g., issues related to their family environment). Although they acknowledge that college samples might be criticized because symptoms may have yet to appear or because persons able to attend college may be better able to cope than are nonstudents, they defended their choice with past research. They noted that other researchers had found no age differences in symptoms among adult victims and that past studies had reported that college samples were similar to other nonclinical populations.
Rind et al. (1998) went on to identify 59 studies that reported data for college sam- ples. The studies had to have a control group, a distinct child sexual abuse group (i.e., sexual abuse victims could not be grouped with victims of other types of abuse), and enough data provided so that an effect size could be calculated, and they had to report on at least 1 of 18 dependent measures of interest (alcohol problems, anxiety, depression, dissociation, eating disorders, hostility, interpersonal sensitivity, locus of control, obses- sive-compulsive symptomatology, paranoia, phobia, psychotic symptoms, self-esteem, sexual adjustment, social adjustment, somatization, suicidal ideation and behavior, and general psychological adjustment). Of the 59 studies identifi ed, 36 were published, 21 were unpublished dissertations, and 2 were unpublished master’s theses. The defi nition of child sexual abuse varied across studies, but most used an age discrepancy of at least 5 years to denote abuse, whereas only 20% focused on unwanted contact as the defi nition of
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183SEXUAL ABUSE
abusive acts. Of these studies, 73% included both contact and noncontact abuse, whereas the others used only contact abuse. For most studies, “child” was defi ned as 16 years of age and younger.
They found that child sexual abuse victims were more likely to report psychological problems than were nonabused students. The overall effect size, however, was small ( r = .09, 95% confi dent interval [CI]: .08 to .11). In other words, less than 1% of the variation in adjustment was accounted for by sexual abuse history. The effect sizes for the 18 specifi c symptoms ranged from .04 to .13. Although all but one, locus of control, were signifi - cantly different (child sexual abuse victims had higher rates than did nonvictims), all of the effects were small. The authors also noted that female victims tended to report more symptoms than did male victims.
The authors went on to examine whether these symptoms resulted from sexual abuse or from other factors. As expected, they found that participants who had suffered sex- ual abuse were also more likely to come from nonideal family environments (FEs). After controlling for nonsexual abuse or neglect, adaptability, confl ict and pathology, family structure, support/bonding, and traditionalism, they concluded that even the slight dif- ference seen between child sexual abuse victims and nonvictims disappeared when family environment was controlled for statistically.
Finally, Rind et al. (1998) summarized by saying that these results can be explained by the defi nition of child sexual abuse used by most researchers. They argue that not all sexual experiences between adults and children should be labeled as sexual abuse. Their suggestion was that children and adolescents should be dealt with separately, and that willingness (or lack thereof) and positive versus negative reactions should also be con- sidered. So, if a child willingly has a sexual experience with an adult and has a positive reaction to it, it should be labeled with the value-neutral term adult–child sex . If the child is unwilling or reacts negatively, then the term child sexual abuse is appropriate. The same pattern would hold true for the terms adult–adolescent sex and adolescent sexual abuse . They argued for the separation of children and adolescents because adolescents have more sex- ual interests, they are more likely to know whether they want to engage in a particular act, and they are better able to resist encounters they do not want, plus adult–adolescent sex has historically been common and even sanctioned in many cultures.
This article caused a storm of controversy after it was picked up by the popular journal. Although it originally had little impact beyond the scientifi c community, this changed when it was referenced on the web page of North American Man/Boy Love Association (NAMBLA, a pedophilia advocacy group) as scientifi c support for its views. In 1999, Dr. Laura attacked the American Psychological Association on her radio show for daring to publish the article (Ondersma et al. 2001).
In 2001, two articles were published in Psychological Bulletin responding to Rind et al.’s (1998) article. The fi rst was by Ondersma et al. (2001), who raised some concerns about the methodology used by Rind et al. and major concerns about how the data was presented and interpreted. Regarding the methodology, Ondersma et al. criticized the defi nition of child sexual abuse used by Rind et al. By using defi nitions that included both contact and noncontact abuse, Rind et al. may have obscured consequences of contact abuse. Secondly, they objected to Rind et al.’s partialization of family environment based solely on self- reported, retrospective, quasi-experimental data. They noted that this type of analysis does
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184 TYPES OF ABUSE AND THEIR EFFECTS
not take into account the fact that the experience of child sexual abuse may be what led to the more negative reports regarding family environment.
Ondersma et al. (2001) are clear, however, that the methodological problems pale in comparison to the way the data were presented and interpreted. The fi rst problem was in how narrowly the authors defi ned “harm.” They looked only at long-term psychological effects. Although this may be an appropriate defi nition for a study, one cannot conclude from this type of defi nition that there is no harm. They did not consider short-term harm, medical harm (e.g., sexually transmitted disease, injuries), rate of revictimization, how much time abused children spent in therapy, and so on. Also, just because something does not cause long-term harm, it does not follow that it is not abuse. As a point of compari- son, Ondersma et al. propose this question: If a rape victim has no measurable negative effects a year after the event, should we call the event “unilaterally consenting adult–adult sex” instead of rape (p. 711)? Second, Ondersma et al. note that just because effect sizes are small, it does not mean that they are clinically insignifi cant. As a means of compari- son, Ondersma et al. noted that the relationship between taking an aspirin each day and the prevention of future heart attacks is smaller than the effect sizes reported by Rind et al. ( r = .03), yet given that second heart attacks are relatively common (as is child sex- ual abuse), this translated into patients who take aspirin having only half as many heart attacks as patients who were not on aspirin therapy. Third, despite Rind et al.’s claim that symptom rates between college students and members of community samples are similar, Ondersma et al. caution generalizing from this high-functioning group to all child sexual abuse victims. Fourth, in asking whether the sex was wanted implies that a child is capable of consenting to sex with an adult. In order to give consent a child would need to be fully aware of what was being asked, and fully free to say no to the request. It has been argued by many that children are not capable of this with regard to sexual decisions. In conclusion, Ondersma et al. argue that Rind et al. went beyond scientifi c fi ndings to questioning moral values about child sexual abuse.
A second response to Rind et al. (1998) was published in the same issue of Psychologi- cal Bulletin. Dallam et al. (2001) seconded many of the arguments presented by Ondersma et al. (2001), including the use of a college sample and the inclusion of noncontact abuse, and backed up their statements with considerable research. Dallem et al. went on to ques- tion the statistics used by Rind et al. Although the level of statistical analysis used by Dallem et al. is advanced, the conclusion was that Rind et al. used very conservative sta- tistical methods and failed to make necessary statistical corrections. As a result, the data presented by Rind et al. underestimated the effects of child sexual abuse. Dallem et al. were especially critical of the analysis based on gender. They argued that if base rates (e.g., how common something is in a given population) were incorporated properly, the global effect sizes for males and females were nearly identical.
Perhaps it is not surprising to know that Rind, Tromovitch, and Bauserman (2001) published an article in the same issue of Psychological Bulletin defending their original article and addressing the criticisms from Ondersma et al. (2001) and Dallem et al. (2001). In addition to being instructive about the possible effects, or lack thereof, of child sexual abuse, this series of articles points to many of the diffi culties inherent in this type of research. I would urge the interested student to read all of the original works with an eye toward understanding the scientifi c method, the relationship of science to morality and
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185SEXUAL ABUSE
the law, and how diffi cult it is to conduct objective work in a fi eld that is as emotionally charged as childhood sexual abuse.
DISCUSSION QUESTIONS
1. In what ways is it easier to determine that sexual abuse has occurred as compared to other types of maltreatment? In what ways is it more diffi cult?
2. Compared to the other types of maltreatment covered so far, would you be more or less comfortable reporting suspicions of child sexual abuse to Child Protective Ser- vices?
3. Do you favor a broad or a narrow defi nition of sexual abuse? Why? 4. The estimates of sexual abuse vary, depending on the method used to collect data.
Which estimates to you think professionals should put the most faith in? 5. Do you think that the estimated rate of sexual abuse for boys may be low because
of underreporting? If so, do you think this is related to the fact that sex between a young boy and a woman is not considered as problematic as sex between a young girl and a man?
6. Given the controversy surrounding some research fi ndings in this area, should researchers be limited to presenting only their data with no commentary on it?
Disagreement Concerning Whether Child Sexual Abuse Is Experienced as Traumatic When It Occurs
In 2009, Dr. Susan Clancy from Harvard University published a book titled The Trauma Myth: The Truth About the Sexual Abuse of Children and its Aftermath. Clancy based her work on interviews with more than 200 survivors of sexual abuse whom she recruited by putting advertisements in the local papers. Of her participants, 65% were female and 35% were male. Although almost all of the participants reported that the sexual abuse they experienced as children had damaged them in some way (e.g., they had symptoms of depression and PTSD, they had relationship and sexual problems, they suffered from low self-esteem, and they had problems with alcohol and drugs), these problems were not caused by trauma. Clancy reported that very few (fewer than 10%) of the victims she interviewed experienced the abuse as traumatic. When they were being abused, they were not afraid or shocked; they did not feel forced; and no violence was involved. Over and over, her participants said they were not overwhelmed and they were not hurt physically.
When Clancy (2009). asked the participants in her study what they did feel dur- ing the experience, most noted that they felt confused or surprised. They also said they had the feeling something was wrong, but they went along with the perpetrator anyway. Fewer than 5% of participants said they tried to stop the abuse from hap- pening. There were many reasons given to explain why they did not say no. The participants noted that adults frequently asked them to do things they did not want to do, so that was not an unusual circumstance. They did not understand that sexual behavior was a very different kind of event. In addition, the perpetrator was gener- ally someone they loved and trusted; they wanted to make him happy. Also, many
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186 TYPES OF ABUSE AND THEIR EFFECTS
said they were rewarded with toys, affection, and love. Some of the participants also noted that they experienced sexual pleasure from the encounters.
The question then becomes, Why does sexual abuse cause negative outcomes if the child does not experience it as traumatic? Clancy (2009) said that as the children grow and learn about sexuality, they realize that what happened to them was sexual abuse and that it was terribly wrong. These teenagers and young adults then suffer from the betrayal they only now understand. They feel manipulated and gullible. Furthermore, because child sexual abuse is “supposed to be traumatic,” they think there is something wrong with them for the way they reacted. They don’t under- stand why they did not fi ght the abuse or why there were aspects of the encounters they enjoyed. They suffer from a great deal of self-blame and guilt for not fi ghting or trying to get help; they feel ashamed. Clancy said that we must let children know that the abuse was never their fault; no matter what they felt or did. We also need to let victims know that it is common for children to experience sexual abuse and not fi nd it traumatic when it is happening. Not being traumatized does not mean there is anything wrong with them—it simply means that they had not reached a devel- opmental level where they were capable of fully understanding what was being done to them (Clancy, 2009).
Critics fear that Clancy (2009) was saying that child sexual abuse is not wrong or that it does not hurt children. This is not at all what Clancy is doing. She is pointing out that the current trauma model is not appropriate for most victims, and pro- fessionals need to listen more carefully to what the victims are saying about their experiences. Having a better understanding of what victims go through will lead to better treatment options.
The Impact of Abuse on Boys as Compared to Girls
Although most researchers acknowledge that boys make up between one quarter and one third of abuse victims, much less research has been devoted to them. Although boys have received more attention in recent decades, the literature is still lacking. From what is known, it seems that boys, like girls, suffer both short- and long-term consequences as a result of child sexual abuse experiences. What may surprise you is to know that researchers have found more similarities than differences between male
and female responses to child sexual abuse. Boys show the same stress-related responses after disclosure as do girls. They are fear- ful, they have problems sleeping, and they are distracted. Boys also seem to self-report the same number of symptoms that girls report. It had been expected that boys might show less negative outcomes because they were more likely to be abused by people outside of their families than were girls. Perhaps, because the majority of per-
petrators are male, the added stigma regarding issues of homosexuality serves to increase symptoms in boys (Finkelhor, 1990).
Although male and female responses to sexual abuse are similar, they are not identical. Boys are more likely to have externalizing symptoms such as aggression, whereas girls are more likely to have internalizing problems such as depression. Men who were victims of child sexual abuse are also more likely to report a sexual interest in children (25%) than are female victims (3%) or men who were not victims (9%). Finally, both male and female victims are at risk for developing some type of psycho- pathology, but male victims are most likely to develop substance abuse problems,
disclosure
the act of revealing;
telling someone else or
making known what has
previously been hidden.
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187SEXUAL ABUSE
while female victims suffer from affective disorders, anxiety disorders, and substance abuse (Finkelhor, 1990).
Consequences Over Time
The good news is that many sexually abused children do recover over time. Most longitudinal research shows that symptoms decrease in number and severity over time for many children. Unfortunately, however, a minority of child victims show a worsening of symptoms with time. One factor that has been associated with worsen- ing symptoms is the involvement in a long, drawn-out criminal trial. On the other hand, family support is consistently associated with more positive outcomes. Also necessary for healing is the protection from further abuse. The good news is that vic- tims of child sexual abuse are less likely to be reabused than are victims of other types of maltreatment. The bad news is that some, between 15% and 19%, are likely to be reabused and that those who are not abused again are often safe from abuse because they were removed from the presence of the abuser (Finkelhor, 1990). Although this ends the abuse, if it disrupts the family, it introduces a new set of confl icts that the child must face (being blamed for tearing the family apart, a decrease in family income, missing the abusive parent, etc.).
Victims With No Symptoms
One of the puzzling realities of the sexual abuse research is that almost all studies fi nd a substantial group of victims who appear not to have any symptoms. Generally between one quarter and one third of victims do not seem to experience any negative impact from their experiences. Although some have argued that this refl ects a lack of suffi ciently sensitive measures (they have symptoms, but we cannot detect them), even very thorough clinical assessments have failed to fi nd symptoms in all victims. Another explanation is that victims may be asymptomatic at the time of assessment, perhaps because they are in denial, but they may suffer negative effects at some later date. However, it is also possible that some victims will not have any negative effects. These resilient victims do seem to be those who have suffered less serious forms of abuse and who have the resources and support necessary to cope with the situation (Finkelhor, 1990).
CONCLUSION
What seems to be lacking is “sexually abused child syndrome.” Evidence does not exist to indicate that a sexually abused child will show a certain list of symptoms. Instead, child sexual abuse seems to increase the chances that a child will suffer from any of a large variety of symptoms as addressed earlier. The problem with this is that the previously described symptoms can also be seen in children who have not been sexually abused. So, even though sexually abused children are more likely to be depressed than are nonabused children, if we look at the entire population of chil- dren who are depressed, the majority of them will not have a history of child sexual abuse. Also, a substantial minority of children will not show any symptoms at all (Fer- gusson & Mullen, 1999). Because of this, it is often extremely diffi cult to determine
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188 TYPES OF ABUSE AND THEIR EFFECTS
whether a particular child is the victim of sexual abuse. In a small number of cases, a child will have a sexually transmitted infection or a pregnancy that can provide evidence of abuse. In most cases, however, either there is no medical evidence or the medical evidence that is available is controversial. Experts for the prosecution testify that the fi ndings are evidence for abuse, and experts for the defense say that physical fi ndings can be explained by a nonabusive past experience (see Case Example 7.3 ). In the vast majority of cases, the determination is based largely on the child’s report. For this reason, professionals must be very careful in interviewing children about sus- pected abuse. If the result of the interview will form the basis for a diagnosis and/or legal action, it is imperative that the information gleaned be as accurate as possible. Getting accurate information from children, without suggesting erroneous informa- tion, is more complex than one might expect, especially with young children. (See Chapter 10 for more information on interviewing children.)
DISCUSSION QUESTIONS
1. In what ways is it easier to determine that sexual abuse has occurred as com- pared to other types of maltreatment? In what ways is it more diffi cult?
2. Compared to the other types of maltreatment covered so far, would you be more or less comfortable reporting suspicions of child sexual abuse to Child Protective Services?
3. Do you favor a broad or a narrow defi nition of sexual abuse? Why?
4. The estimates of sexual abuse vary, depending on the method used to collect data. In which estimates do you think professionals should put the most faith?
5. Do you think that the estimated rate of sexual abuse for boys may be low because of underreporting? If so, do you think this is related to the fact that sex between a young boy and a woman is not considered as problematic as sex between a young girl and a man is?
6. Given the controversy surrounding some research fi ndings in this area, should researchers be limited to presenting only their data and no commentary on it?
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189
DEFINITION
Fetal abuse is an umbrella term that has been used to describe a wide variety of behaviors. What the actions have in common is that they cause harm, usually accidental harm, to a fetus. Mothers can be guilty of fetal abuse by ingesting chemicals, such as drugs or alcohol that harm their fetus or by the much less common means of direct physical assault (see Case Example 8.1 ). People other than the mother can also be guilty of fetal abuse via physical assault. For example, a man who beats his pregnant partner, especially around the abdomen, can be guilty of fetal abuse.
CHAPTER 8
Fetal Abuse
fetal abuse
behaviors that put the
fetus at risk for harm.
CASE EXAMPLE 8.1
D. R. had a diffi cult childhood. She was shuffl ed among various foster homes and occa- sionally sent back to attempt living with her biological parents. Her father had physically and sexually abused her, and her mother told her that when she was carrying her, she had tried to induce an abortion by doing things such as jumping off furniture and drinking to excess. When D. R. was 15 years old, she was impregnated by her 18-year-old boyfriend. D. R. declined terminating the pregnancy at 18 weeks because the boyfriend wanted the baby. However, the boyfriend quickly grew disillusioned with the idea of becoming a father. The couple requested an abortion at 25 weeks, but the request was denied. Hours later, D. R. was taken to the doctor’s offi ce due to atypical bleeding. On questioning, D. R. revealed that she had been punching the fetus through the abdominal wall whenever she felt it moving. She denied that she was trying to cause an abortion, but admitted feeling angry at the fetus because it was purposely destroying her life (Condon, 1986).
CASE POINT
Although very rare, there are documented cases of direct assault on the fetus by the mother.
DISCUSSION QUESTIONS
1. Should D. R. have been found guilty of fetal abuse? If so, what sort of punishment would have been appropriate?
2. If D. R.’s child was born alive, should Child Protective Services do anything to protect the child, or should it wait until allegations of child maltreatment were brought to its attention?
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190 TYPES OF ABUSE AND THEIR EFFECTS
The very concept of fetal abuse is problematic because fetuses are not legally con- sidered “persons” until they are born alive, and they are not, therefore, entitled to constitutional protection (Reutter, 2005). In particular, fetuses have not been granted rights hostile to their mother. Since Roe v. Wade (419 U.S. 113, 1973) it has been the case that before a fetus is viable, the woman’s liberty of personal privacy takes prec- edence over the state’s right to interfere. However, as you will see, more and more states are attempting to protect fetuses by criminally prosecuting women who use drugs while pregnant. Although the term fetal abuse is controversial, and a concise defi nition is elusive, some term is needed to describe these types of behavior. If pro- fessionals are to become aware of and vigilant about a problem, it needs to be named (Condon, 1986). Therefore, despite the debate over the validity of the term fetal abuse , I use it here to describe behaviors engaged in by pregnant women that put their fetuses at risk.
INCIDENCE
It has proved extremely diffi cult to determine the incidence of drug use during preg- nancy. Focusing on illegal drugs, the National Survey on Drug Use and Health (2008 reported that 4% of pregnant women had used an illicit drug in the last month. There are approximately 6 million pregnancies each year in the United States, so this translates to 240,000 exposed fetuses. Fetuses can also be harmed by legal substances such as alcohol and nicotine. The Centers for Disease Control and Prevention (CDC; 2012a, 2012c) estimated that 7.6% of pregnant women drank alcohol in the previous 30 days (approximately 456,000 pregnancies) and that 12.8% had smoked cigarettes
within the previous 30 days (approximately 768,000 pregnancies). Using data from the National Institute on Drug Abuse (NIDA) , Chasnoff and Lowder (1999) estimated that more than 1 million children are prenatally exposed to drugs (legal and/or illegal) each year (keep in mind that many women use multiple drugs during pregnancy). Other studies have attempted to determine incidence by testing all patients at selected hospitals or clinics. Researchers in Detroit screened 3,010 newborns at one hospital and found that 44% of them had been exposed to drugs prenatally (Ostrea, Brady, Gause, Raymundo, & Stevens, 1992). Chasnoff, Landress, and Barrett (1990) tested pregnant mothers during their fi rst pre- natal visit and found that 13.8% tested positive for drugs. Clearly, the estimates vary dramatically based on the sample tested and the method of assessment used. Although we do not have a clear
understanding of the number of children exposed to drugs prenatally, there is suf- fi cient data to consider it a signifi cant problem.
CAUSES OF FETAL ABUSE
Very little research has been done to determine what factors cause women to use sub- stances while pregnant. Certainly, addiction is the most likely explanation. Although women may wish to protect their fetuses, they may not be able to control their
National Institute on
Drug Abuse (NIDA)
an organization
dedicated to bringing
the power of science to
bear on issues of drug
abuse and addiction by
supporting research and
disseminating research
fi ndings related to drug
prevention, treatment,
and policy.
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191FETAL ABUSE
substance use during their pregnancy. The causes of addiction vary and are beyond the scope of this book, but what is relevant to the current discussion is that use of drugs by pregnant women is not believed to be directed toward the child. In other words, the mothers are not trying to harm their fetuses when they ingest drugs.
In many cases, there may be additional contributing factors when it comes to drug use during pregnancy. Kent, Laidlaw, and Brockington (1997) studied fi ve women who were referred because of fetal abuse. Although the sam- ple was very small, they did note several similarities that may be contributing factors for fetal abuse. All fi ve of the women suffered from depression, and three of them had previously struggled with postpartum depression. All fi ve women had mixed feelings about their pregnancies, and four had considered terminating the preg- nancy. Two of the women actually denied the pregnancy for some time. Finally, three of the fi ve women had signifi cant diffi culties in their personal relationships. Although one cannot generalize from such a small sample, this research suggests that future work should examine factors beyond addiction when attempting to understand what causes fetal abuse.
More research has been conducted specifi cally on the use of alcohol during preg- nancy. Skagerstrom, Chang, and Nilsen (2011) reviewed 14 studies and concluded that the most consistent predictors of alcohol use during pregnancy were drinking alcohol before becoming pregnant and having a history of being abused or being exposed to violence. O’Brien (2012) added that mothers who were in school while pregnant were less likely to consume alcohol. On the other hand, pregnant teens who felt “pushed around” were more likely to drink alcohol as were pregnant women who had not decided on a feeding plan for their infant shortly before their due date.
A different causal mechanism may be in play when dealing with the rare cases of direct physical assault on the fetus by punching the anterior abdominal wall. While this is not a common cause of fetal abuse, Condon (1987) argues that this sort of behavior may be caused by the perception that the fetus is attacking or depriving the mother. To research this question, Condon had 112 pregnant women and their partners fi ll out a survey that included questions about feelings toward the fetus. In response to the phrase “Over the past 2 weeks, when I think about my developing baby, my thoughts . . .,” 21% of women and 8% of men chose the answer “are a mixture of tenderness and irritation” versus answers that described feelings as either always or mostly tender and loving. More directly, 8% of women and 4% of men said they had occasionally wanted to hurt or punish the developing baby. It is impor- tant to note, however, that none of these participants was believed to have actually attempted any sort of assault on their fetuses.
EFFECTS OF DRUGS ON PRENATAL DEVELOPMENT
There is little doubt that the use of certain substances during pregnancy is not ideal for the developing fetus. When pregnant women ingest drugs or alcohol, they pass these substances on to the fetus. Medical research has shown that the substances remain active for a longer period in the fetus than they do in the mother, thereby increasing the risk posed to the fetus (Merrick, 1993). It is very diffi cult, however, to determine empirically exactly what impact a specifi c drug has on a developing
postpartum depression
prolonged sadness,
crying spells, impatience,
or mood swings
following the birth of
a child; may include
mixed feelings about
motherhood and/or an
inability to care for the
newborn.
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192 TYPES OF ABUSE AND THEIR EFFECTS
organism. The research in this fi eld is plagued by methodological problems. First, many women are polydrug users. If a mother is ingesting more than one drug and her baby is born with a prob- lem, it is impossible to know which drug, if any of them, caused
the problem. Furthermore, drugs can interact with each other causing effects that are different from those caused by either drug alone. For instance, taking cocaine and consuming alcohol at the same time is more harmful for the fetus than is the use of each drug on its own (W. Chen & Maier, 2011). In addition to drug use, many of these mothers have poor nutritional habits, they are likely to live in poverty, many are homeless, and often they receive little or no prenatal care. If a negative fetal out- come is noted, it could have been caused by any of these things, a combination of them, or something else that is unknown. One study done in New York City reported that 58% of substance-abusing mothers received no prenatal care at all (Merrick, 1993). Because the use of one drug alone during an otherwise optimal pregnancy is a rare (or nonexistent) occurrence, it is diffi cult to make strong causal statements about the impact of a drug on fetal development. This question is further complicated by
the fact that a drug will likely have an impact on the developing organism differently, depending on how far along the mother is in her pregnancy when she ingests the drug. Many drugs have a dra- matic negative impact early in pregnancy, but minor or no effects if ingested in the third trimester (Niccols, 1994). Research that is conducted on children who were prenatally exposed to drugs when they are not newborns to determine long-term effects is further confounded by mixing prenatal exposure to drugs with postnatal experiences in a drug-using household. Even with these signifi cant limitations, there is evidence that some drugs, especially alcohol, have a defi nite long-term negative impact on children who are exposed prenatally (Merrick, 1993).
Although nowhere near an exhaustive list, the research on the impact of selected drugs on prenatal development is presented in the following sections.
Alcohol
It is well established that prenatal exposure to alcohol can harm a fetus. Drinking during pregnancy is the leading cause of prevent- able fetal death, fetal malformations, and neurodevelopmental problems (Aliyu et al. 2011). Maternal alcohol consumption sig- nifi cantly increases the risk of spontaneous abortion (Chiodo et al., 2012). Aliyu et al. (2011) examined 1,221,310 births and found an association between maternal alcohol consumption during preg- nancy and placental abruption. Mothers who drank alcohol were 33% more likely to suffer this complication. In addition, moderate drinking has been associated with both low birth weight and neo- natal asphyxia (Meyer-Leu, Lemola, Daeppen, Deriaz, & Gerber, 2011). Although professionals do not know how much alcohol can be consumed before harming a fetus, it is known that some infants born to mothers who consume alcohol during pregnancy will have fetal alcohol syndrome (FAS). It is a challenge to know how much
polydrug
multiple, different drugs.
alcohol
an intoxicating
beverage containing a
chemical produced by
yeast fermentation or
hydration of ethylene.
placenta abruption
the condition in which
the placenta separates
from the uterine wall
prior to birth; this can
result in severe bleeding.
neonatal asphyxia
a signifi cant decrease in
oxygen and an increase
in carbon dioxide that
can lead to loss of
consciousness and death.
fetal alcohol syndrome
(FAS)
a series of birth defects
resulting from a mother’s
consumption of alcohol
during pregnancy.
Symptoms include
mental retardation, low
birth weight, head and
face abnormalities, and
growth defi ciencies.
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193FETAL ABUSE
alcohol was consumed, because the data are always an estimate and rely on self-report measures. To make matters more compli- cated, some children born to alcoholics do not have fetal alcohol syndrome, so experts cannot know when a baby will be born with fetal alcohol syndrome. After conducting a meta-analysis of studies on alcohol use during pregnancy, O’Leary and Bower (2012) con- cluded that there is no strong evidence to link low levels of alcohol exposure to fetal harm. However, both heavy and moderate alco- hol consumption were associated with a host of negative fetal outcomes. Because the line between low and moderate consump- tion is not totally clear, their recommendation is that all mothers abstain from alcohol during pregnancy.
It is estimated that between 0.2 and 1.5 per 1,000 live births in the United States involves fetal alcohol syndrome (CDC, 2012b). This disorder is marked by pre- and postnatal growth defi ciencies, dysfunction in the central nervous system, dysmorphic features including a fl at nasal bridge, withdrawal symptoms at birth, heart problems, and mental retardation (S. Day, 2012; Merrick, 1993). In 1981, researchers estimated that fetal alcohol syndrome was the third most common cause of mental retardation in the United States; Down syndrome was fi rst and spina bifi da was second (Little & Streissguth, 1981). By 1994, fetal alcohol syndrome had moved into fi rst place as the most common known cause of men- tal retardation. The retardation seen in children with fetal alcohol syndrome generally involves IQs in the range of 60 to 65 (CDC 2012b; Niccols, 1994).
Some children who are exposed to alcohol prenatally do not show full-blown fetal alcohol syndrome but still suffer from fetal alcohol effects (FAE). Children with fetal alcohol effects have a higher than normal rate of perinatal mortality, low birth weight, and a lower than average IQ (Little & Streissguth, 1981). The preva- lence of fetal alcohol effects is thought to be three to four times higher than the rate of full-blown fetal alcohol syndrome (Niccols, 1994).
Cocaine
Whereas there is general agreement about the effects of alcohol on fetuses, the impact of cocaine on development is far more controversial. Despite the fact that women who use cocaine have been the ones most likely to be prosecuted for fetal abuse, it is not clear exactly what cocaine does to a fetus. For instance, there is no agreement as to whether cocaine causes congenital abnormalities (Merrick, 1993). In the late 1980s, the popular media inundated the public with dire messages about “crack babies,” children pre- natally exposed to cocaine. The media exaggerated preliminary research reports that were based on small samples and studies that did not include control groups. It was reported extensively that these children were at signifi cant risk for spontaneous abortion,
dysmorphic
an abnormality of the
structure of part of the
body that results from a
developmental defect.
Down syndrome
a chromosomal
abnormality (an
extra copy of the 21st
chromosome) that results
in mental retardation,
abnormal facial features
(fl attened nasal bridge,
widely spaced and
slanted eyes), slowed
growth, and other
physical problems.
spina bifi da
a congenital abnormality
in which the fetus’s
spinal cord does not
form properly, leaving
part of the spinal cord
unprotected.
fetal alcohol effects
symptoms present in a
child that are associated
with maternal alcohol
consumption during
pregnancy but which do
not meet the diagnostic
criteria for fetal alcohol
syndrome.
perinatal
occurring shortly before
or shortly after birth.
cocaine
a crystalline alkaloid that
comes from coca leaves.
It is used illicitly as a
stimulant and to induce
euphoria.
congenital
a condition that is
present at birth.
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194 TYPES OF ABUSE AND THEIR EFFECTS
sudden infant death syndrome, growth problems, and a host of serious neurobehavioral abnormalities. Both the public and policy makers responded swiftly to these fears by creating poli- cies and passing new laws, yet more careful research that followed did not support these early, dire predictions. In fact, published in 1993, a special section in the journal Neurotoxicology and Teratol- ogy concluded that the existing data proved few, if any, negative effects from prenatal exposure to cocaine (Ondersma, Simpson, Brestan, & Ward, 2000). A meta-analysis of well-designed studies that was published in the Journal of the American Medical Association in 2001 reported similar fi ndings. The authors concluded that
after controlling for confounders [other variables such as poverty that might account for negative outcomes], there was no consist- ent negative association between prenatal cocaine exposure and physical growth, developmental test scores, or receptive or expres- sive language. Less optimal motor scores have been found up to age 7 months but not thereafter, and may refl ect heavy tobacco exposure.
(Frank, Augustyn, Knight, Pell, & Zuckerman, 2001, p. 1613)
This does not, however, mean that other researchers have not found evidence of negative effects of prenatal cocaine exposure. There does seem to be some consensus that use of cocaine during pregnancy is linked to smaller head circumference at birth and through the age of 24 months (although the difference in head circumference between cocaine-exposed and nonexposed infants decreases by 18 months of age), a higher rate of miscarriage, a greater likelihood of prenatal strokes, problems with self-regulation particularly when stressed, diffi culties with habituation, kidney disor- ders, and breathing disorders (Merrick, 1993). Long-term studies are still lacking, but those that exist point to small or nonexistent differences between children exposed to cocaine prenatally and those who were not. For instance, some research shows no IQ differences by 4 to 6 years of age, whereas other work points to very small defi cits (3.26 points). However, even small impairments can be problematic if they persist. Researchers at the NIDA have documented defi cits in arousal, emotional regulation, and the ability to sustain attention in children prenatally exposed to cocaine. They have also found that these problems are having an impact on school performance; children who were exposed to cocaine before birth were more likely to repeat a grade and to require special education classes than were their nonexposed peers. Minnes et al. (2010) reported in increase in externalizing behaviors among children prena- tally exposed to cocaine. Of course, it is not clear whether long-term effects are the result of prenatal exposure or postnatal factors (such as being raised in a home where drugs were used). Overall, the current consensus seems to be that cocaine can a nega- tive impact on fetal development, but not all children are harmed, and the problems that may occur are not generally devastating (Ackerman, Riggins, & Black, 2010; Bandstra, Morrow, Mangoor, & Accornero, 2010; Ondersma et al., 2000; Terplan & Wright, 2011). Perhaps the current state of knowledge about the effect of prenatal exposure to cocaine is best summed up by the title of an article written by Alan I. Leshner (1999), director of the National Institute on Drug Abuse: “Research Shows Effects of Prenatal Cocaine Exposure Are Subtle but Signifi cant.”
sudden infant death
syndrome
the unexplained and
unexpected death of an
infant (younger than
1 year old) who was
apparently healthy;
generally occurs during
sleep.
neurobehavioral
the study of the way the
brain affects emotion,
behavior, and learning;
the assessment of a
person’s neurological
status by observing his or
her behavior.
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195FETAL ABUSE
Methamphetamine
The highly addictive drug methamphetamine (MA) is the most commonly abused amphetamine. The use of methampheta- mine increased substantially between 1992 and 1998 and has remained steady since then. By 2002, it was estimated that 5.3% of the population in the United States (over the age of 12) had used methamphetamine at least once and by 2006, the director of NIDA reported that approximately 10 million people in the United States had used methamphetamine at least once (NIDA, 2006). With regard to pregnancy, a study of 1,632 mothers by Arria et al. (2006) found that 5.2% had used methamphetamine during their pregnancy (as deter- mined by self-report and/or a positive meconium screen). It is now estimated that methamphetamine is used more often by pregnant women than is cocaine (Terplan & Wright, 2011).
In animal studies, a number of negative fetal outcomes have been linked with prenatal exposure to methamphetamine, including “offspring mortality, retinal eye defects, cleft palate, rib malformations, decreased rate of physi- cal growth, and delayed motor development” (Arria et al., 2006, p. 294). However, one must be careful in generalizing from animal studies in order to understand human outcomes. Unfortunately, little research exists with human participants, and what does exist is limited by poor methodology including small samples, lack of control groups, and problems with confounding variables. With this is mind, the extant literature does suggest that human fetuses exposed to methampheta- mine are at increased risk for “clefting, cardiac anomalies, fetal growth retardation, behavioral problems, and cranial abnormalities” (Arria et al., 2006, p. 294). These infants are also at a greater risk for postnatal death, and they are more likely to have a low birth weight than are nonexposed infants (NIDA, 2006; Santrock, 2007). A study that began in 2002 to examine the impact of methamphetamine use on fetal development has found an association between maternal use of methampheta- mine and fetal growth restriction. Infants whose mothers used methamphetamines while pregnant were 3.5 times more likely to be small for gestational age than were nonexposed infants (L. Smith et al., 2006). However, by three years of age, there were no psychological differences noted between exposed and nonexposed infants (Terplan & Wright, 2011). This does not mean that no long-term effects have been seen. Roussotte et al. (2011) studied children who ranged from 7 to 15 years of age. They found that children who were prenatally exposed to methamphetamine had abnormally low brain activation during a visual-spatial task that assessed working memory.
Marijuana
Despite the fact that marijuana is the most commonly used illicit drug by women of childbearing age (Kuczkowski, 2005), little research has examined the impact of this drug on fetal develop- ment. It is estimated that between 3% and 16% of pregnant women use marijuana (Keegan, Parva, Finnegan, Gerson, & Belden, 2010). Work that does exist links prenatal exposure to marijuana with
methamphetamine
(MA)
a potent, highly addictive
central nervous system
stimulant that causes an
increase in energy and a
decrease in appetite.
cleft palate
a congenital condition
that results in a crack in
the roof of the mouth.
marijuana
the dried leaves and
female fl owers of the
hemp plant that are
used as an intoxicant. It
can be smoked or eaten
and it produces mild
euphoria and possibly
distorted perceptions.
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196 TYPES OF ABUSE AND THEIR EFFECTS
premature birth, small birth size, poor habituation to visual stimuli at birth, an increased startle response at birth, and a high pitched cry (NIDA, 2012). Despite early defi cits, by 12 months, no differences were seen in visual or motor perfor- mance when babies who were prenatally exposed to marijuana were compared to nonexposed infants (Brick, 2005). One must interpret this result carefully though, because in other domains, problems have not been detected at a given age and then did appear later. For instance, defi cits in verbal skills and lower memory scores were evident at 48 months of age in children prenatally exposed to marijuana, even though no shortcomings in these areas had been noted at 36 months (Chasnoff & Lowder, 1999). Other long-term effects have also been documented. For instance, preschool children who had been exposed to marijuana prenatally made more information-processing errors due to problems with sustained attention than did their nonexposed peers (NIDA, 2012). In addition, both memory and learning diffi culties have been noted at 11 years in children who were exposed to marijuana prenatally. Researchers do note that these results should be viewed with caution because very little work has been done in this area (Santrock, 2007).
Nicotine
More than 30% of women who are of childbearing age smoke cigarettes (Kuczkowski, 2005), and many continue to smoke during pregnancy. In 2006, estimates were that between 18% and 25% of pregnant women continued to smoke (Huizink & Mulder, 2006; H. Jones, 2006). By 2010, that rate had declined to between 12% and 15% (Keegan et al., 2010). The women who smoked while pregnant tended to be poor, young, single, and poorly educated (Huizink & Mulder, 2006; Keegan et al., 2010).
Pregnant women are advised to avoid cigarettes because exposure to nicotine has been linked with low birth weight, premature delivery, respiratory problems, and sudden infant death syndrome (Brick, 2005; Santrock, 2007). Newborns prenatally exposed to nicotine also showed heightened tremors and startles, and they were more excitable than nonexposed infants (Huizink & Mulder, 2006). In addition, children whose mothers smoked during preg-
nancy had poorer language skills and lower cognitive functioning at both 36 and 48 months when compared with nonexposed peers (Chasnoff & Lowder, 1999). These fi ndings may be linked to a heightened rate of attention defi cit hyperactivity disorder (ADHD) in children who were exposed to nicotine before birth (Santrock, 2007). A number of well-designed studies have shown a dose-response relationship between cigarette smoking and ADHD (Huizink & Mulder, 2006). This means that the greater the prenatal exposure, the more likely it is that the child will show symptoms of attention defi cit hyperactivity disorder. Prenatal exposure to nicotine has also been linked to disruptive behavior. Infants from 12 to 24 months who were prenatally exposed to nicotine showed high and increasing levels of disrup- tive behavior, they had lower social competence, they were more aggressive, and they showed more stubborn defi ance than their nonexposed peers. By the age of 7 years, the children whose mothers smoked while pregnant were twice as likely to be diagnosed with oppositional defi ance disorder (ODD), which often leads to conduct disorder. As a caution, when long-term consequences of nicotine exposure are assessed, it is important to note that damage may be due, in part or whole, to postnatal exposure if the child is raised in a smoking environment.
nicotine
a toxic, addictive
substance derived from
tobacco that acts as a
stimulant.
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197FETAL ABUSE
Heroin
Use of heroin during pregnancy may lead to smaller body size and head circumference at birth, premature birth, low birth weight, or even prenatal or perinatal death (Brick, 2005; Nichtern, 1973; Wal- ton-Moss, McIntosh, Conrad, & Kiefer, 2009). Some infants born to mothers who use heroin (25% in one sample) will go through withdrawal symptoms after birth. The common symptoms seen include tremors, irritability, disturbed sleep cycles, and abnormal crying (Nichtern, 1973; Santrock, 2007). Effects documented later include behavioral problems at 12 months of age and defi cits in attention during preschool years (Santrock, 2007).
Even treatment for heroin can be problematic for fetuses. Methadone is commonly used to treat heroin addiction, but it is also an opiate narcotic. Fetuses exposed to methadone have problems with both fi ne and gross motor skills at birth, and the fi ne motor problems are still evident at 5 years of age. In addi- tion, at age 5, children exposed to methadone as infants are more active, and this activity is frequently off-task (Brick, 2005). A new treatment for heroin, buprenorphine, may be a safer option for pregnant women. Newborns exposed to buprenorphine before birth had shorter hospital stays and needed less morphine to deal with withdrawal symptoms than did newborns who had been exposed to methadone (H. Jones, 2006). To better protect fetuses, more research is needed to develop treatment options that are safe for mother and baby.
RESPONDING TO FETAL ABUSE
Although there is debate about how serious the effects of some drugs, such as cocaine, can be for a fetus, there is agreement that many drugs, both legal and illegal, can have a negative impact on fetal development. The next questions are, What, if anything, should be done to protect children from prenatal exposure to drugs? and Should the response to substance use/abuse during pregnancy be therapeutic or punitive?
Treatment
In the late 1980s, when the media began to pay close attention to the effects of drugs on fetal development, treatment programs were not readily available for pregnant women. The initial response of the federal government was generally therapeutic. States were mandated to increase the proportion of their drug treatment funding that was designated to aid pregnant women and women with children (from 5% to 10%). Congress also ruled that pregnant women should have priority access to a range of services. Shortly after these guidelines were established, budget cuts made them nearly impossible to implement. For instance, if a larger percentage of a shrinking budget was earmarked for pregnant women, it meant that other populations, such as people on probation, would be underserved. From 1992 to 1995, this therapeutic approach shifted to a more punitive approach. In one study, 45% of responding
heroin
a highly addictive
narcotic derived from
morphine; it decreases
the ability to perceive
pain.
methadone
a synthetic narcotic that
is used to relieve pain
and as a heroin substitute
during treatment for
heroin addiction.
buprenorphine
a medication used during
the treatment of heroin
addiction that prevents
the experience of
withdrawal symptoms.
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198 TYPES OF ABUSE AND THEIR EFFECTS
states (responses were gathered from 46 states) mandated criminal prosecution for substance abuse by a pregnant woman in 1992, and by 1995, this number had jumped to 71%. In addition, the identifi cation of a positive neonatal toxicology test was defi ned legally as abuse or neglect by 14% of states in 1992, and by 35% in 1995 (Chavkin, Breitbart, Elman, & Wise, 1998; see the Criminal Prosecution section later in this chapter)
Mandated Reporting
The fi rst step in punishing a behavior is to bring it to the attention of the authorities. To this end, states began to mandate the reporting of drug use during pregnancy. Doctors who knew, via self-report or positive toxicology reports, that their patients were using substances while pregnant were mandated to report this to authorities. There is some evidence that mandatory reporting practices with regard to fetal abuse are not being enforced equally across racial groups. Chasnoff, Landress, and Barrett (1990) examined the reporting practices for 5 public health clinics and 12 private obstetrical offi ces in Pinellas County, Florida. During the study, they screened all of the women seeking care (380 women from the public clinics and
335 women from the private offi ces) for alcohol, opiates, cocaine (and its metabolites), and cannabinoids. Of the 715 women, 14.8% had a positive toxicology report. There was no signifi cant difference between the percentage of positive tests from the pub- lic clinics (16.3%) and the percentage (13.1%) from the private clinics. Broken down by specifi c drug type, only cocaine use var- ied by setting; it was signifi cantly more common among women
using the public clinics. The overall drug use by Caucasian women was 15.4%, and the overall use by African American women was 14.1%. However, there were racial differences with regard to the use of specifi c drugs. Cocaine use was more com- mon among African American women (7.5% versus 1.8% for Caucasian women), and the use of cannabinoids was more common among Caucasian women (14.4% versus 6.0% for African American women). What was most interesting about the study is that even though Florida had a law that required reporting all women who used illicit drugs during pregnancy, this is not what occurred. African American women were far more likely to be reported for positive toxicology tests than were Caucasian women. During the 6 months of the study, 48 Caucasian women were reported for drug use and 85 African American women were reported. Despite the fact that analysis of all urine samples revealed equal rates of drug use by women of both races, African American women were signifi cantly more likely to be reported than were Caucasian women. One possible explanation was that African American
women were more likely to use the public clinics. However, even when the setting was controlled for, the racial bias was still evi- dent. The study also found that poor women were more likely to be reported for drug use than were more affl uent women. Because doctors (unlike these researchers) do not test every woman who comes to them for care, the bias may be in the doctors’ expecta- tions of who is likely to use drugs. This would, in turn, have an impact on whom they would test. It is important to keep the potential of racial bias in mind when implementing strategies to intervene in cases of alleged fetal abuse.
cannabinoids
the chemical compounds
that are the active
components of
marijuana.
racial bias
a negative opinion,
attitude, or response
toward a group of people
who share a common
physical attribute such as
skin color.
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199FETAL ABUSE
Criminal Prosecution
Shortly after the implementation of mandatory reporting laws for fetal abuse, pros- ecutors began to arrest women and charge them with crimes related to pregnancy. By 1992, 167 women from 24 states had been charged criminally for behaviors ranging from the ingesting of illegal drugs to taking legal drugs to failure to follow doctor’s orders while pregnant (Merrick, 1993). The outcomes of these cases varied widely. The cases presented here, and the legal issues related to their prosecution, are some of the most well known. These charges are fundamentally different from other child maltreatment charges because the rights of a fetus are not clear. Because fetuses are generally not considered legal persons or children, it is not obvious that harming a fetus or putting a fetus at risk is a violation of the child maltreatment laws. Further, even if fetuses have legal rights in some arenas (e.g., a person can be charged with harming a fetus after assaulting a pregnant woman), it is controversial as to whether a fetus can have rights hostile to the mother. Due to the unique relationship between a fetus and the woman carrying the fetus, the Illinois Supreme Court ruled in 1988 that a child could not sue its mother for prenatal injury. In this case ( Stallman v. Youngquist ), the mother was charged with negligent driving while pregnant, not drug use, but the principle is similar. When fetuses have been granted rights, it was gen- erally when they were harmed near the end of pregnancy, after the age of viability. Therefore, even though drug use is more likely to cause harm early in the pregnancy, laws focus on drug use at the end of pregnancy (see Case Example 8.2).
CASE EXAMPLE 8.2
State v. Johnson
Because it is problematic to charge women with harming their fetuses, a Florida court attempted to charge a woman with hurting her child in the moments after birth, before the umbilical cord was cut.
In October of 1987, an African American woman, Ms. Jennifer Johnson, gave birth to a baby boy in Florida. Because Johnson told her doctor that she had consumed cocaine the night before delivering her son, she and the baby were given toxicology tests. Both mother and baby tested positive for cocaine metabolites. Ms. Johnson was not prosecuted at this time, and she went on to become pregnant again. In December of 1988, Johnson gave birth to a second child, a daughter. Again, she admitted to using cocaine during the pregnancy and on the day of delivery (Merrick, 1993). Johnson had previously tried to get treatment for her drug addiction but was turned away (Pollitt, 1990).
During the deliveries of both children, between 60 and 90 seconds elapsed between the child emerging from the birth canal and the umbilical cord being cut. Based on this, Ms. Johnson was charged with delivering a controlled substance to her minor children. Expert testimony as to whether drugs could have passed via the umbilical cord, after birth, confl icted. Whereas experts for the prosecution argued that this was possible, the defense’s experts contested this opinion. In addition, neither child showed signs of cocaine addiction, and both were considered to be healthy newborns. Regardless, Johnson was convicted, and
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200 TYPES OF ABUSE AND THEIR EFFECTS
her conviction was upheld by the appellate court. However, the Supreme Court of Florida unanimously reversed the ruling of the lower courts. The justices ruled that the legislature had not intended the statute regarding the delivery of drugs to minors to include the pass- ing of drugs via the umbilical cord. They further argued that this sort of prosecution violated Florida’s policy of keeping families together (Merrick, 1993, Sagatun & Edwards, 1995).
DISCUSSION QUESTIONS
1. What criteria were used to try to establish maltreatment in this case? Do you think the criteria were infl uenced by political or cultural forces?
2. Was this prosecution an appropriate use of the law prohibiting the passing of drugs to minors?
3. If this was not a good use of existing law, should a new law be written to cover this sort of circumstance?
State of Wyoming v. Pfannenstiel
The case of State of Wyoming v. Pfannenstiel was the fi rst time a woman was charged with child abuse for drug use during pregnancy. Diane Pfannenstiel was 29-years-old and pregnant when she sought assistance because she was the victim of domestic violence. In the course of her treatment, it was noted that she had alcohol in her system. She was subsequently arrested and charged with child abuse by the state of Wyoming. The state trial judge ultimately dismissed the charges because it was not proved that the fetus had been injured (Stone-Manisa, 2009).
DISCUSSION QUESTIONS
1. Should Diane Pfannenstiel have been charged with child abuse? 2. What message, if any, does this case send to women who are being abused about
seeking help? 3. Would the judge’s decision been different if the fetus was later born with fetal alco-
hol syndrome?
People v. Stewart
Other states also tried to bend existing laws to make them cover fetal abuse. One of the more creative uses of law to punish women who use drugs while pregnant was
seen in the case of Pamela Rae Stewart in California. Ms. Stewart was receiving prenatal care and was told by her obstetrician to avoid street drugs and sexual intercourse during her preg- nancy and to stay off her feet because of misaligned placenta. She did not follow this advice, and subsequently gave birth to a brain-damaged son, who died 6 weeks after his birth. Stewart was charged with failure to deliver support to her child based on a criminal statute that had not been used in years but was originally intended to punish men who failed to provide for children they had fathered. In the end, the judge did dismiss the case, and Stewart spent only a week in jail (Bhargava 2004; Pollitt, 1990). An interesting side note to this case is the role played by Stewart’s husband. He was present when the doctor told her of the restrictions, yet he used drugs with her, had sex with her, and even beat her while she was pregnant. He was never charged with anything, not even domestic violence (Pollitt, 1990).
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201FETAL ABUSE
DISCUSSION QUESTIONS
1. What criteria were used to try to establish maltreatment in this case? Do you think the criteria were infl uenced by political or cultural forces?
2. Was the judge right to dismiss the charges in this case? 3. Do cases such as this worry people about a possible “slippery slope”? (If failing to
follow doctor’s orders can be prosecuted, where will it end? Could a woman be pros- ecuted for gaining too much weight or for failing to take folic acid as prescribed?)
4. Should Stewart’s husband have been charged with a crime? If so, what charges would have been appropriate?
Whitner v. State
Other women have been prosecuted under existing child abuse laws, with the prosecu- tion’s argument being that the term child includes fetuses.
On April 20, 1992, Cornelia Whitner pled guilty to criminal child neglect for causing her infant son to be born with cocaine metabolites in his system. Even though her son was born healthy, Whitner pled guilty and was sentenced to 8 years in prison. Although Whitner did not immediately appeal this verdict, she later fi led an appeal claiming ineffec- tive counsel. At the time of her plea, Whitner did not realize that the statute under which she was being prosecuted might not apply to drug use during pregnancy. At the time of her conviction, the South Carolina law included only the term child , with no references to fetuses. The appeals court upheld the conviction and maintained that the term child included viable fetuses. They referred to an earlier case, State v. Horne (1984), in which a male defendant was convicted of manslaughter after he stabbed his pregnant wife in the stomach, causing the death of a 9-month fetus. The dissenting justices argued that the use of the word child was ambiguous and that previous bills to make fetal abuse illegal had failed in the state legislature. Whitner served her full 8-year sentence before being released.
DISCUSSION QUESTIONS
1. Do you agree with the courts that Whitner was guilty of child abuse? 2. What criteria were used to establish maltreatment in this case? Do you think the
criteria were infl uenced by political or cultural forces? 3. If Whitner is guilty, was her sentence appropriate? If not, what sort of punishment
or intervention would you suggest? 4. Was the South Carolina appellate court right to say that a fetus is included in the
term child ?
State v. McKnight
Once the Whitner case established that the child maltreatment laws in South Carolina covered fetuses, prosecutors were set to move ahead with further prosecutions.
Regina McKnight of Conway, South Carolina, was the fi rst woman in the United States to be convicted of homicide for using crack cocaine during her pregnancy. Ms. McKnight gave birth on May 15, 1999, to a stillborn baby boy at 8.5 months gestational age. At the time of delivery, both mother and newborn tested positive for cocaine. Ms. McKnight, an
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202 TYPES OF ABUSE AND THEIR EFFECTS
African American, was 22 years old. She was a homeless, unemployed addict, the mother of three, and possibly suffering from a mental handicap—with an IQ of 72 (Herbert, 2001). She had started to use drugs after her mother, whom she had lived with, was killed in an automobile accident in 1998. In South Carolina, women are given toxicology tests if they have had no prenatal care or if the fetus dies with no explanation. When McKnight’s test results were positive, a report was made to the Horry County Police Department. The case went to jury trial in May of 2001 (Bhargava, 2004).
The doctors who testifi ed at the trial disagreed about the cause of fetal death. Although existing medical research showed a link between cocaine use and fetal death in cases in which there is placenta abruption or ruptured membranes, neither of these were present in McKnight’s case. The defense further argued that the State failed to rule out more com- mon causes of fetal death that were present in the case (syphilis, hypothyroidism, poverty, and the use of alcohol and tobacco). The jury in McKnight’s case deliberated for just 15 minutes before rendering a verdict of guilty. McKnight was sentenced to 12 years in jail (Bhargava, 2004).
In 2002, the South Carolina State Supreme Court upheld McKnight’s conviction. They maintained that it was appropriate to use the state’s homicide laws to prosecute women who experience stillbirths if the women had engaged in behaviors that heightened the risk to their fetuses. The U.S. Supreme Court declined to review this decision (Paltrow & Newman, 2008).
In 2008, the case was again appealed to the South Carolina State Supreme Court on different grounds. This time, McKnight’s lawyers argued that she had not received a fair trial due to ineffective counsel. Specifi cally, it was argued that McKnight’s attorney did not solicit appropriate medical experts to challenge the fi ndings of the prosecution’s experts. On May 11, 2008, the court ruled unanimously that McKnight had not received a fair trial. The court ruled that a factual error was made when the trial court accepted that there was a causal link between McKnight’s use of cocaine and the stillbirth of her son. Further, the court noted that the medical evidence presented at trial that linked cocaine use and fetal harm was both outdated and inaccurate (Paltrow & Newman, 2008). McKnight was released after serving 8 years of her 20-year sentence (Greene, 2008).
DISCUSSION QUESTIONS
1. Was the jury right to convict McKnight of homicide? 2. What criteria were used to establish maltreatment in this case? Do you think the
criteria were infl uenced by political or cultural forces? 3. Was McKnight’s sentence fair? If not, what punishment or intervention would you
suggest? 4. The South Carolina State Supreme Court ruled twice on this case. Do you agree with
these decisions? 5. If the U.S. Supreme Court heard this case, do you think it would agree or disagree
with the lower courts? Why?
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203FETAL ABUSE
Although states continue to move forward with criminal prosecution of alleged fetal abuse, there are still many unanswered questions, legally and morally. The debate about whether this is an appropriate response to drug use during pregnancy is a heated one (see Debate 8.1 : Should Cases of Alleged Fetal Abuse Be Prosecuted Crimi- nally?). When prosecutions for fetal abuse began, fetuses were not mentioned in child abuse and neglect laws. However, by 2012 at least 12 states had changed their child maltreatment laws to specifi cally mention fetuses. For example, Illinois Comp. Stat. Ch. 325, §5/3 defi nes a neglected child in part as “a newborn infant whose blood, urine, or meconium contains any amount of a controlled substance or a metabolite thereof.” In a similar manner, Indiana Code §31-34-1-1 includes the following in its defi nition of child neglect:
The child is born with Fetal Alcohol Syndrome, or any amount, including a trace amount, of a controlled drug or a legend drug in the child’s body. The child has an injury, abnormal physical or psychological development, or is at a substantial risk of a life- threatening condition that arises or is substantially aggravated because the child’s mother used alcohol, a controlled substance, or a legend drug during pregnancy. (emphasis added)
As a fi nal example, South Dakota Ann Laws §26-8A-2 defi nes an abused or neglected child in part as one “who was subjected to prenatal exposure to abusive use of alco- hol, marijuana, any controlled drug, or a substance not lawfully prescribed by a practitioner.” It will be up to the courts to determine what is meant by “abusive use.”
legend drug
a drug that is approved
by the Federal Drug
Administration (FDA)
and that requires a
prescription.
DEBATE 8.1: SHOULD CASES OF ALLEGED FETAL ABUSE BE PROSECUTED CRIMINALLY?
YES
There are many who argue strongly that fetal abuse should be prosecuted in court because it is a crime. First, the use of illegal substances is already a criminal act. Second, many states now include viable fetuses in their child abuse statutes, which makes using any drugs that may harm the fetus during the end of a pregnancy a crime. Our court systems are set up to deal with crimes. From a justice perspective, this makes prosecution the right thing to do (Ondersma et al., 2000). In states that do not have laws protecting fetuses, prosecu- tion is still appropriate because the fetuses become children when they are born alive. If they have injuries because of what they were exposed to prenatally, then a child has been harmed. Logli (1998) also points out that it is already well established, in both criminal and civil courts, that fetuses can be protected from people other than their mothers. Given that fetuses have legal rights in some contexts, they are valuable entities that deserve to be protected in all cases.
Logli (1998) further argues that using drugs, even legal ones, is not a right that women have. Additionally, if women chose to carry a pregnancy to term, then society can and should require them to do a good job.
Some opponents of prosecuting fetal abuse argue that such laws or prosecutions may prevent women from seeking prenatal care, but Logli (1998) says this is a weak argument.
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204 TYPES OF ABUSE AND THEIR EFFECTS
Arguably, the same logic could be applied to all current child maltreatment laws. One could say that because it is illegal to physically abuse your child, parents are less likely to bring them for medical care where the abuse could be discovered. Therefore, child mal- treatment should not be illegal. If this argument is not valid, neither is the one regarding fetuses.
Prosecuting fetal abuse also opens the door to removing any children born alive if the mother is found guilty. This would serve to protect children from being raised in a home where substance abuse is occurring. It has been reported that households where substance abuse occurs are likely to have other problems including domestic violence, criminal activity, poverty, and stress, none of which are good for children. Although not all women who use substances are going to maltreat their born children, substance abuse is certainly a risk factor for child maltreatment, especially considering the signifi cant taboo and risk of being caught during delivery when a woman uses drugs near the end of her pregnancy (Ondersma et al., 2000).
For all of these reasons, fetal abuse should be prosecuted in court.
NO
On the other side of the debate, many argue equally vehemently that women who use drugs while pregnant should not be prosecuted criminally. One obvious place to start is that the laws of most states do not include fetuses in their child abuse statutes. The statutes governing child maltreatment refer specifi cally to children, which means they are in effect only after a child has been born (Paltrow, 1991).
Although a simple solution to this point is to pass laws that include fetuses, as some states have done, there are still signifi cant concerns. One argument is that substance abuse is considered a mental disease. The U.S. Supreme Court ruled in 1925 that addiction was a disease (Paltrow, 1991). The use of the drug is, therefore, not under the complete control of the addict. Not only is it true that a person should not be punished for something she can- not control; it is also true that laws will not change behavior that is not under a person’s control. If an addict is not in control of his or her substance-using behavior, it is unlikely that he or she could choose to stop using a drug even if the addict knew he or she might be punished for engaging in that behavior. Perhaps it would be more effective, and more humane, to treat the addict than to punish her for her disease.
A practical argument is one of cost. Although the estimated incidence of children who are parentally exposed to drugs ranges dramatically, even the lowest estimate of 380,000 incidents per year is daunting (Merrick, 1993). If all of these women were to be charged, tried, and punished, the cost would be astronomical. In addition to court and prison costs, the foster care system would need a substantial increase in funding to care for the children whose mothers were incarcerated. There are also intangible costs associ- ated with separating the child from the mother. Unfortunately, our foster care system is not perfect, and there have been cases where family relationships have been disrupted because of drug use, but a healthy, alternative home was not established for the newborn (Paltrow, 1991).
With regard to constitutional issues, it has been argued that these laws violate the Fourteenth Amendment, which guarantees equal protection under the law. Because any laws that deal with issues related to pregnancy can only be used against women during
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205FETAL ABUSE
their childbearing years, they cannot apply to everyone (Merrick, 1993). A second con- stitutional argument against the prosecution of fetal abuse is that it violates the mother’s fundamental right to privacy. In addition, the U.S. Supreme Court ruled in Ferguson v. The City of Charleston (2001) that if mothers are tested randomly for drugs when they deliver babies, their Fourth Amendment rights have been violated (the right to be free of unreasonable search). Finally, the Eighth Amendment guarantees that only conduct may be punished, not status. However, the prosecution of fetal abuse is not about punishing women for using drugs, because other laws govern the use of illegal substances. These women are being prosecuted for using drugs while they are pregnant (Paltrow, 1991).
There is also signifi cant concern that laws like these would not be applied fairly even within the group of pregnant women. Research already exists that provides convincing evidence that women who are poor and/or members of minority groups are more likely to be reported for using drugs while pregnant (Chasnoff et al., 1990).
Even those who focus on the well-being of the child, as opposed to the rights of the mother, have expressed concerns about the criminal prosecution of fetal abuse. The concern is that if women know they will be arrested if they admit to using drugs while pregnant, they may keep this information from their doctors or refuse to seek medical care at all. For example, following the very well publicized prosecution of Melanie Green for allegedly inducing the death of her newborn via prenatal drug use, the Prenatal Center for Chemical Dependence at Northwestern University began to receive calls from women who were afraid that they would be arrested if they came in for help. Women who in the past would have received care from this facility stopped seeking services to avoid arrest. In the extreme case, a drug-using mother may opt to terminate a pregnancy rather than attempt to carry and deliver a baby while she is struggling with drug addic- tion. Another concern regarding fetal health is that if women are jailed prior to giving birth, the fetus may be damaged by being carried and delivered within the prison sys- tem (Norton-Hawk, 1998). These concerns have led the major national health groups, including the “American Medical Association, the American Academy of Pediatrics, the American Public Health Association, the American College of Obstetricians and Gynecol- ogists, and the American Society of Law and Medicine” (Paltrow, 1991, p. 88), to oppose such criminal prosecution.
A fi nal concern is that this approach punishes women addicts who may have des- perately wanted to get help but were turned away from treatment centers (Norton-Hawk, 1998). The United States does not currently have a suffi cient number of drug treatment facilities available for those who seek care. In addition, the majority of the existing pro- grams will not accept patients who are currently pregnant. Other programs do not accept Medicaid, so poor women have no way to pay for treatment (Merrick, 1993). An additional problem is that the programs that do accept pregnant women may not allow these moth- ers to bring other children with them. This forces the women to choose between caring for their children or their fetuses. Finally, even programs that will accept pregnant women may be fl awed because they were originally designed to treat male addicts. As such, pro- grams frequently fail to address issues, such as prior victimization, that are nearly universal among female addicts (Paltrow, 1991).
For all of these reasons, criminal prosecution is not the best response to drug use dur- ing pregnancy.
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206 TYPES OF ABUSE AND THEIR EFFECTS
As states change their maltreatment laws to include fetuses, charges against pregnant women continue to be pursued. For instance, since 2006, more than 60 women in Alabama have been charged with “chemical endangerment” for using drugs while pregnant. Judges such as Mitch Floyd in Marshall County run for judicial positions on platforms of being tough on pregnant women who endanger their fetuses. The specifi c situations charged cover a range of circumstances. In 2011, Rennie Gibbs was charged in Mississippi for using cocaine during her pregnancy in 2006. Ms. Gibbs gave birth at 36 weeks to a stillborn infant. In a very different scenario, Bei Bei Shau of Indiana was charged with homicide following an unsuccessful suicide attempt. Ms. Shau attempted to end her life by ingesting rat poison. She survived the attempt, but her fetus did not (Pilkington, 2011).
Public Support for Prosecution There does seem to be a good deal of public support for the criminal prosecution of fetal abuse. In one survey (McCoy, 2003), 98% of the participants said that women who use drugs while pregnant should be prosecuted. Seventy-fi ve percent of the par- ticipants indicated that they would be in favor of prosecution in any case—illegal or legal drugs. However, when participants were asked to indicate what sort of punish- ment, if any, they thought should be the result of a guilty fi nding, they were much gentler than the courts have been. Only 17.1% of participants recommended jail time, and most of those (10.4%) recommended sentences of less than 1 year. This does not mean that the participants did not think any sanctions were necessary. Only 3.7% of participants endorsed no sanctions at all for guilty women. Interven- tions that were more therapeutic than criminal were recommended most often (participants could select more than one option): 54% endorsed court-ordered coun- seling, 57% were in favor of court-ordered inpatient treatment, 42% recommended court-ordered outpatient treatment, and 65% wanted to see court-ordered parenting education (McCoy, 2003).
Civil Commitment
Yet another legal response to drug use during pregnancy is civil commitment. More than half of the states in the United States have laws that allow for the involuntary
commitment of substance abusers to treatment programs. Some states specifi cally note that pregnant women who use drugs qualify. For instance, Michigan law states that pregnant women who use certain drugs (cocaine, heroin, phencyclidine, methamphetamine, or amphetamine) habitually or excessively can be committed to treatment without their consent. Another example is seen in Flor- ida, where Hillsborough County has an Involuntary Drug Court
that can sentence a pregnant woman to jail for as long as 5 months and 29 days if she uses drugs or refuses treatment (Chasnoff & Lowder, 1999). Although putting preg- nant women who use drugs in prison may seem like an easy solution, this approach is contraindicated on two fronts. First, it means sentencing women to involuntary commitment who would not be likely to be committed if they were not pregnant. Second, the conditions in involuntary treatment centers and jails may pose a new set of threats to fetal health.
civil commitment
the confi nement of
a person who is ill,
incompetent, or addicted
to drugs.
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207FETAL ABUSE
Motivation for Responding to Alleged Fetal Abuse
While some argue that professionals must intervene in cases of fetal abuse to protect children and society, others feel that the motivation for punitive intervention may be more complex than that. Philosophy professors Sonya Charles and Tricha Shivas (2002) raise an interesting point regarding the reasons for punishing women who use drugs while pregnant. They point out that mothers who attempt to carry high- order multiple fetuses also put their fetuses at risk, and they are not punished. In fact, high-order multiple births, almost always the result of fertility treatments, may put fetuses at greater risk than would exposure to cocaine. The Centers for Disease Control says that the use of assisted reproductive technology increases the risk of serious health problems fourfold (Goodwin, 2011). Charles and Shivas compared the media’s response to the case of the McCaughey septuplets with its response to cases of women who used illegal drugs (generally cocaine) while pregnant. They speculated that if the main societal concern was for fetal health, the cases should have been handled in a similar manner. This, of course, was not what they found. McCaughey was praised for her decision, she was called brave, and she was even referred to as an “expert parent.” Of the articles about the McCaughey family, 42% mentioned the many gifts of products, time, and property that were showered on the family. None mentioned bringing criminal charges against Bobbi McCaughey for fetal abuse. In contrast, 40% of the articles about the mothers who used illegal drugs while pregnant made a direct analogy to abuse, 73% discussed punitive approaches, 31% made nega- tive comments about the character of the mother, and none mentioned gifts. With regard to life after birth, only 10% of the articles about the McCaughey’s septuplets mentioned concern with the children’s welfare (despite the fact that the children were born with serious medical problems), whereas 31% of the articles about moth- ers who used drugs addressed concerns about the subsequent development of the involved children. Jon and Kate Gosselin parlayed the birth of their sextuplets into a realty show and celebrity status for themselves (Goodwin, 2011).
Whereas mothers who use illicit drugs are prosecuted even if their children are born healthy, mothers who use assisted reproductive technology are not prosecuted even if their children suffer serious birth defects or die. When a couple, the Morri- sons, in Minnesota became pregnant with sextuplets, they were advised to selectively reduce their pregnancy. They refused this procedure, and Mrs. Morrison subse- quently gave birth 4.5 months early. Five of the six children died (Goodwin, 2011). No charges were brought against the Morrisons.
If prosecution is not exclusively about protecting the fetus, what is the motiva- tion behind this type of legal action? One possibility is that the character of the mother is being attacked. Whereas Bobbi McCaughey put her fetuses at risk because her religious convictions prevented selective reduction, drug-using mothers are seen as merely seeking self-gratifi cation. The fact that this is an oversimplifi ed and inac- curate view of addiction does not mean it is not a prevalent view. It may also be that some mothers are seen as deserving of support. In this comparison, a mother who has higher-order multiples deserves help to raise her at-risk children, but a drug- using mother does not. In both cases, the fetuses are harmed or at risk for harm, but only one set of mothers gets help to raise her child(ren) and prevent further harm (Charles & Shivas, 2002). So instead of treatment, drug-using mothers face criminal charges. Certainly, it does not escape notice that the mothers prosecuted for using
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208 TYPES OF ABUSE AND THEIR EFFECTS
drugs while pregnant are largely poor, minority women, whereas those using fertility treatments that can lead to higher-order multiples are mostly Caucasian and middle or upper class (Goodwin, 2011).
Prenatal Exposure and Risk for Harm After Birth It is possible that the concern for children who are exposed to drugs prenatally is that they will continue to be at risk for harm after they are born. Some states go so far as to state that a positive drug test at birth is de facto child abuse or neglect. In these states, the positive toxicology report is considered a substantiated charge of abuse or neglect. In other states, even without such laws, children have been removed from their mother’s care, temporarily or even permanently, based on positive drug screen- ings (Chasnoff & Lowder, 1999).
Some research exists that examines the relationship between prenatal drug expo- sure and later child maltreatment. In a study done in 1992, Kelly found that mothers who used cocaine while pregnant had a subsequent maltreatment rate of 23%. This was signifi cantly higher than the rate of 3% among matched controls. Another study, conducted in Illinois, followed 513 infants who had been exposed to cocaine pre- natally. The researchers found that 19.9% of the children had later been found to be maltreated. This was 3 times higher than the rate of matched peers. A link has also been established between mothers who use drugs while pregnant and previous charges of child maltreatment. After reviewing 3,436 cases in which children had been born with positive toxicology reports, it was found that 40% of the families had previous substantiated charges of child maltreatment against them. Even if one takes prenatal exposure out of the picture, parental substance abuse is a risk factor for child maltreatment. Living with a substance abuser increases a child’s risk of being abused 2.9 times and the risk of being neglected 3.24 times (Chasnoff & Lowder, 1999). Nephew and Febo (2012) reported that maternal cocaine use was associated with child neglect and disruptions in the bond between the mother and her infant. They also noted that women who use cocaine are more likely to suffer from depres- sion and anxiety, which can also interfere with parenting. Onigu-Otite and Belcher (2012) studied 91 high-risk children aged 4 to 7 years. They found that maternal drug abuse was associated with child neglect and child abandonment. Of the children being raised by mothers with a history of drug abuse, 81% were neglected compared to 47% of the children whose mothers did not have such a history. The mothers who had not abused drugs had an abandonment rate of 21% compared to a rate of 47% for the mothers who had abused drugs. Surprisingly, maternal drug abuse was also associated with a decreased risk of sexual abuse in this sample. This fi nding contra- dicts most research on maternal drug use and child sexual abuse.
Although the statistics presented earlier do document increased risk, they do not prove that all children prenatally exposed to drugs will suffer from later maltreat- ment. In fact, if 23% of the mothers are found guilty, that means that 77% were not. Assuming that many of these mothers are doing an adequate job of raising their children (and not simply that they have not been “caught” yet), would removing all children be a disservice? Perhaps offering services to all families who share this risk would be the best approach. Certainly, research indicates that mothers who use drugs may need additional support. Liles et al. (2012) found that women who used methamphetamines during their pregnancy were more likely to have symptoms of depression and that they reported more parenting stress than did the mothers in the
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209FETAL ABUSE
control group. Wouldes et al. (2012) noted that women in the United States who used methamphetamines during pregnancy had lower income than did non-drug-using mothers and that they were also signifi cantly more likely to suffer from a psychiatric disorder. Even if some mothers who used drugs during pregnancy are not maltreat- ing their children, the drug using mothers could likely benefi t from psychological services. For now, it seems clear that decisions should be made on a case-by-case basis as opposed to following a blanket approach.
CONCLUSION
Because the recognition of this type of maltreatment has a very short history, there are many unanswered questions. The law is still developing with regard to fetal abuse. As more cases are prosecuted, the role of the justice system in addressing cases of alleged fetal abuse will be clarifi ed. Issues of what punishment, if any, is appropri- ate need to be fi gured out, as do questions of custody for children who are prenatally exposed to drugs. In the meantime, child advocates are called on to fi nd ways to protect children by preventing fetuses from being exposed to toxins.
DISCUSSION QUESTIONS
1. Should the child maltreatment laws cover fetuses? Why or why not?
2. Which should be more important in assessing fetal abuse: the use of an illegal drug or how harmful the drug is known to be to fetal development?
3. If a mother ingests a substance that she does not know may harm her fetus, is she guilty of maltreatment? What if she does not know she is pregnant?
4. If you were given a $5 million grant to prevent fetal abuse in your community, how would you spend the money?
5. Does the criminal prosecution of alleged fetal abuse ultimately protect children?
6. Given that we do not know what level of drug exposure might be safe for fetal development, should there be a zero-tolerance policy for drug use during preg- nancy (e.g., even one glass of wine or one cigarette is abusive)?
7. Compared to the other types of maltreatment covered so far, would you be more or less comfortable reporting suspicions of fetal abuse?
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210
DEFINITION
Munchausen by proxy syndrome (MPS) is a rare form of child maltreatment in which the caretaker, usually the mother, fabricates, simulates, or induces symptoms of physical or psychological illness in a child. The Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ( DSM-IV ; American Psychiatric Association,
1994), which lists all psychological disorders and their symptoms, refers to this set of behaviors as factitious disorder by proxy. While the name in the DSM-IV is more self-explanatory, the more popular name of Munchausen syndrome has an interesting history. Baron Munchausen was an 18th-century German nobleman who joined the Russian military and who later entertained his guests with tales of his adventures in the Russo-Turkish War. The baron’s stories were essentially true; however, a man by the name of Rudolph Erich Raspe published Baron Munchausen ’ s Narratives of His Marvelous Travels and Campaigns in Russia in 1785. This book contained outlandish tales attributed to the Baron, including riding cannonballs, escaping from a swamp by pulling himself up by his own hair, and even of traveling to the moon! The baron sued Raspe, but his suit was unsuccessful. That the baron actually told these tales seems unlikely, but it became common to use the name Munchausen to mean someone who lies and/or exaggerates the truth (Lasher & Sheridan, 2004).
Based on this historical background, the label Munchausen syndrome was given to persons who sought medical attention for induced, faked, or greatly exaggerated symptoms. There are many in the fi eld who fi nd this name to be unfortunate, because the dis- order has little to nothing to do with the baron’s circumstances. However, despite the use of factitious disorder in the DSM-IV (American Psychiatric Association, 1994), the label of Munchausen syndrome persists in common usage. Dr. Richard Asher fi rst described Munchausen syndrome in 1951, but it was not until 1977 that Sir Roy Meadow, a pediatrician, coined the term Munchausen syndrome by proxy . Meadow used this new term in a short article to describe parents who exaggerate or induce illness in their children (a proxy) instead of themselves (D. Day & Moseley, 2010). In this fi rst MPS publication, Meadow (1977) described two cases of MPS in detail. He described the children’s alleged medical problems, the
procedures performed by the doctors, and the mothers’ behavior and attitudes. This article marked the beginning of the public discussion of MPS.
CHAPTER 9
Munchausen by Proxy Syndrome
Munchausen by proxy
syndrome (MPS)
a rare form of child
maltreatment in which
the caretaker, usually
the mother, fabricates,
exaggerates, or induces
symptoms of physical or
psychological illness in
a child.
factitious disorder by
proxy
the term used by the
Diagnostic and Statistical
Manual of Mental
Disorders to describe the
behaviors also referred to
as Munchausen by proxy
syndrome.
Munchausen syndrome
a psychiatric disorder
that involves
exaggerating or creating
symptoms of illness in
oneself, or acting as if
ill, in order to receive
attention and sympathy.
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211MUNCHAUSEN BY PROXY SYNDROME
Exaggeration, Fabrication, and Induction
Three categories of behavior are seen in MPS. Some caregivers may show all three, but others do not. First, a parent may exaggerate the child’s symptoms. In these cases, the parent is deliberately embel- lishing a genuine problem. This exaggeration must be beyond the normal use of hyperbole. Many mothers who are not perpetrators of MPS will say, “He always . . .” or “It has happened a million times.” The difference between a parent with MPS and a nonmaltreating parent is the motivation behind the exaggeration and the response to clarifying questions. Whereas the maltreating moth- ers are deliberately misleading in order to get more attention, the normal mothers are just using exaggerated speech without malicious intent. If a doctor questions a mother who is not guilty of MPS, she will focus on giving a more precise, accurate, and truthful answer; however, a mother with MPS will insist her exaggeration is accurate (Lasher & Sheridan, 2004). Second, a caregiver may fabricate symptoms by say- ing a child has a symptom he or she does not have. For instance, a mother may report that her child had a seizure when no such event had occurred. Third, a parent may actually induce an illness in a child. The myriad ways that parents have either made their children appear or actually become ill are almost impossible to believe. The
mixing of foreign blood with body fl uids and excretions, the addi- tion of, salt to urine or blood specimens, friction or chemicals to produce a rash, heating a thermometer with a match, laxatives for diarrhea, using drugs, suffocation or carotid sinus pressure to cause seizures, and injections of milk or other infectious materials are only some examples of what may be encountered.
(O’Shea, 2003, p. 37)
Although exaggerating or fabricating may not seem bad at fi rst glance, these behav- iors can lead to unpleasant and dangerous consequences for the child. If a parent insists that a child is ill, the child will be subjected to medical examinations and tests, some of which are invasive and painful (see Case Example 9.1 ).
exaggerate
to overstate; to increase
to an abnormal degree.
fabricate
to falsify; to report
something that is not
true.
induce
to cause or bring about
carotid
an artery in the neck that
supplies the brain with
oxygenated blood
CASE EXAMPLE 9.1
In the journal Pediatrics , Epstein, Markowitz, Gallo, Holmes, and Gryboski (1987) reported a case example of MPS that includes many of the classic traits of the disorder. Their report describes a male infant who was fi rst hospitalized at 3 months of age for diarrhea. The boy spent 2 months in the hospital undergoing a large number of costly and sometimes painful tests, all of which showed normal results. During this time, a central line was implanted surgically so that he could receive adequate nutrition. When the diarrhea stopped abruptly, he was discharged and remained healthy until he was 18 months old. At that time, he was readmitted to the hospital for intractable diarrhea that began after he had received multi- ple treatments of antibiotics to treat an unresponsive ear infection. Once again, a central line catheter was surgically implanted and extensive tests were done. Just as before, all of the test results were normal.
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212 TYPES OF ABUSE AND THEIR EFFECTS
At this point, several things began to arouse the doctors’ suspicions. First, despite extensive diarrhea, the boy was gaining weight and he stayed well hydrated. Second, the diarrhea generally occurred only when the boy was awake, and it ceased when he was away from his room for tests or procedures. The mother also displayed many of the traits seen in persons who perpetrate MPS: She was excessively complimentary to the medical staff, she developed extremely close relationships with the nurses, her relationship with her hus- band was estranged, she appeared to be overprotective of her child, and she had previous experience as a nurse’s aide.
When the mother was persuaded to spend some time away from the hospital, she remarked that her son was likely to improve in her absence. The boy’s diarrhea did cease when she was away and returned within days of her being back by his side. When the child was moved to a multibed room that was under constant observation by nurses, the diarrhea stopped again.
After discussion among the physicians, a social worker, the hospital administrators, and the hospital attorney, the decision to use covert video surveillance was made. The child was again placed in a private room, and within a day, the mother was observed injecting liquid into her son’s mouth with a syringe. A search of the room revealed “oily syringes, castor oil, milk of magnesia, phenobarbital, amitriptyline, oral hypoglycemics and other unidentifi ed pills” (Epstein et al., 1987, p. 221).
When the mother was confronted, she became extremely agitated and was admitted to a psychiatric hospital. Once separated from his mother, the boy’s diarrhea stopped, and he was returned to his father’s care.
CASE POINTS
This case illustrates many of the common features seen in MPS: a young victim, odd and/ or confl icting laboratory fi ndings, maternal behavior that can be indicative of MPS, and improvement when the mother is absent.
This case also highlights the use of covert video surveillance in order to prove allega- tions of MPS.
DISCUSSION QUESTIONS
1. If you were the pediatrician in this case, how long do you think it would have taken you to suspect MPS? What characteristics of the case might have delayed your recog- nition of the problem?
2. Without the information gathered from the covert video surveillance, would you have been confi dent in making a diagnosis of MPS?
If you are interested in reading more extensive case summaries of MPS written by the victims, consider the following sources:
For an article about being the victim of MPS, read “My Mother Caused My Illness: The Story of a Survivor of Munchausen by Proxy Syndrome,” by M. Bryk and P. T. Siegel (1997), Pediatrics, 100 (1), 1–7.
For a well-reviewed book about being the victim of MPS, read Sickened: The Memoir of a Munchausen by Proxy Childhood , by J. Gregory (2003), New York, NY: Bantam Dell.
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213MUNCHAUSEN BY PROXY SYNDROME
An interesting, modern twist on Munchausen Syndrome is to use the Internet to gain sympathy for symptoms that are exaggerated or completely made up. M. Feldman (2000) coined the term Munchausen by Internet in 2000 to describe people who seek sympathy for themselves on-line for made up illnesses. In 2011, McCulloch and Feldman documented a case of a women seeking attention online for her allegedly sick child. McCulloch and Feldman termed this use of the online community to provide support for false allegations of a child’s illness “Munchausen by Proxy by Internet” or MBPBI. In the case they reported, a woman who said she had fi ve children reported that one was very ill and even posted pictures of a sick infant. When her online sup- porters asked to send fl owers to the hospital, they were told the hospital ward did not allow this. At that point, a woman who actually had a child on the ward and knew this was not true became suspicious. It turned out there was no such child in the hos- pital. In fact, the woman did not even have children. Obviously, in this case, no child was harmed, but the case does highlight one other place that a parent might turn for sympathy and attention based on false claims of child illness.
Although most cases of MPS involve medical symptoms, a parent may also fab- ricate, exaggerate, or induce psychological or even educational problems (see Focus on Research 9.1 ). In educational settings, parents may request extensive assessments and treatments that their child does not actually need. For example, one mother asked that her son be assessed for special education when he was in fi rst grade even though his grades were in the average range. The mother was able to convince the school psychologist that her son suffered from attention defi cit hyperactivity disor- der (ADHD), and he was put on medication. The mother than became very involved in support groups for parents of children with ADHD. The mother continued to push for more testing for a range of cognitive problems. It became clear that there was a great discrepancy between the symptoms reported by the mother and the behavior seen by teachers. The child was eventually removed from his mother’s care and taken off all medication (Frye & Feldman, 2012).
FOCUS ON RESEARCH 9.1: MUNCHAUSEN BY PROXY IN SPECIAL EDUCATION
Most presentations of MPS involve medical symptoms, but it is also possible that a mother will fabricate, exaggerate, or create educational symptoms. Ayoub, Schreier, and Keller (2002) use the term educational condition or disability falsifi cation to describe this sort of case. They conducted a case review of fi ve families (nine children) in which this was strongly suspected or confi rmed. In all cases, the mothers insisted that their child (or children) had signifi cant educational problems, even though testing and teacher reports did not confi rm these maternal concerns.
After reviewing these cases, the Ayoub et al. (2002) presented the following results:
1. The victims: The average victim age at the time of diagnosis was 9.1 years, with a range of 7 to 13 years. The average time from the onset of symptoms until diagnosis was 5.3 years, with a range of 2 to 8 years. In three of the fi ve families, more than one of the children was presented as disabled. The children showed a host of symptoms while their mothers were engaging in educational condition or disability falsifi ca- tion, including aggressive behavior and depression as well as hypervigilance.
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214 TYPES OF ABUSE AND THEIR EFFECTS
Not only is MPS in an educational setting detrimental to the child involved; it is costly for the school district as well. The cost an Independent Educational Evaluation (IEE) ranges from $750 to $3,000 across the United States. Psychological evaluations range from $700 to $5,000, and independent medical evaluations cost between $500 and $5,000. If a parent disagrees with the schools Individual Education Plan, a due process hearing costs around $100,000. In addition, the school pays the costs for any treatments required to treat faked or exaggerated symptoms (Frye & Feldman, 2012).
In any type of MPS case, the parent’s behavior is not simply the result of igno- rance or misunderstanding of how to care for a child. The perpetrator shows clear evidence of planning, and the acts are calculated to avoid detection. Furthermore, these acts tend to be repeated over a long time. Children who are the victims of MPS end up with medical records that fi ll many fi les. When it can be determined, the average length of time between the onset of symptoms and the diagnosis of MPS is reported to be 21.8 months, nearly 2 years (Lasher & Sheridan, 2004).
VICTIMS
The victims of MPS are, most often, infants and toddlers. In a study of MPS in New Zealand, the median age at the time of diagnosis was 2.7 years, and 66% of the victims were under the age of 5 years (Denny, Grant, & Pinnock, 2001). Sheridan (2003) concluded, based on a review of the MPS literature, that most victims are
2. The perpetrators: All perpetrators were Caucasian mothers who were divorced. Two of the mothers had factitious disorder, two had previously attempted suicide, four either currently held positions in the educational system or were studying the fi eld, and three had been banned from their child’s school.
3. The outcome: Three of the families (representing six children) were referred to Child Protective Services (CPS). In all of these cases, the mothers were found to be guilty and the children were placed in out-of-home care with only supervised visits with their mothers. All the children showed marked improvement in their symptoms once they were removed from their mothers. All six children stopped receiving Rita- lin and were removed from special education classrooms. The mothers in these cases still deny the allegations of educational condition or disability falsifi cation and have resisted treatment. The two cases that were not referred to CPS involved three chil- dren. These children remained with their mothers and showed no improvement. In fact, all three were moved to more specialized and more restrictive educational set- tings.
Ayoub et al. (2002) concluded that educational condition or disability falsifi cation is harmful not only to the children but also to the schools. The mothers’ actions cost the schools fi nancially and the staff emotionally. For all of these reasons, it is important to identify educational condition or disability falsifi cation. Finally, the authors caution that their results are limited due to their small sample size.
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215MUNCHAUSEN BY PROXY SYNDROME
4 years of age or younger. Young children are particularly vulnerable to this type of maltreatment because they are not capable of speaking up for themselves and telling medical professionals what is actually occurring. It is not uncommon for a perpetra- tor to switch to a younger victim once the original victim begins to speak. One study revealed that 39% of children who were the victims of MPS had at least one sibling who had also suffered from a fabricated illness (O’Shea, 2003). Given this, special attention should be paid to children who have lost a sibling due to an unexplained illness (D. Day & Moseley, 2010).
Even though most victims are young, his does not mean, that older children are never victims. MPS has been diagnosed with victims ranging from 1 month to 21 years of age (Moldavsky & Stein, 2003), and approximately 25% of all victims of MPS are older than 6 years of age.
What might make an older child go along with his or her mother’s claims? One 14-year-old boy who had undergone 40 surgeries between the ages of 8 and 14 years reported that his mother promised him expensive rewards if he cooperated during a hospital stay. This same boy later revealed that his mother would frequently beat him with a belt. In this case, the mother used both reward and punishment to get her son to go along with her fabricated stories. In addition, many children are strongly motivated to maintain a relationship with their parents, even if the parents hurt them (Awadallah et al., 2005).
Male and female children are equally likely to be victimized in this way, and female perpetrators are as likely to have female victims as they are to have male vic- tims. Male perpetrators are more likely to have male victims, but it is rare to fi nd a male perpetrator (Parnell, 2002). The most common feature of these child victims is that they present as healthy in confl ict with the medical history provided by their caregiver.
PERPETRATORS
The majority (at least 76.5% and perhaps more than 90%) of perpetrators of MPS are mothers, whereas fathers make up less than 7% of perpetrators (Shaw, Dayal, Hartman, & DeMaso, 2008). The other perpetrators are female caregivers such as grandmothers, foster mothers, and babysitters (M. Feldman, 2004). One possible explanation for this sex discrepancy is that women are largely in charge of children’s health care, so they have more opportunities to fake illnesses (Parnell, 2002). Because most perpetrators of MPS are mothers, I use “mother” throughout this chapter to refer to the alleged perpetrator. Racial information on perpetrators of MPS has not been consistently recorded, so the data are incomplete in this area. In an analysis of 33 cases that documented race, 26 of the perpetrators (78.79%) were Caucasian (Sheridan, 2003). When compared to the perpetrators of other types of child mal- treatment, parents engaging in MPS tend to be older and better off fi nancially (i.e., one does not see the preponderance of young, low-class perpetrators as one does with neglect or physical abuse; Meadow, 1982).
Perpetrators of MPS generally appear to be normal and good mothers who are concerned with their child’s welfare (Meadow, 1977). Very few mothers charged with MPS have any previous involvement with CPS. However, on careful study, they may be found to be skilled liars and manipulators who are simply doing a good job of portray- ing themselves as doting mothers. One striking fi nding is that many of these women
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216 TYPES OF ABUSE AND THEIR EFFECTS
have a good deal of knowledge about health care and are more likely to have worked in a health-related fi eld than are other mothers. Between 14.16% and 30% of MPS perpetrators have been either employed or trained in a fi eld related to health, most commonly nursing (Rosenberg, 1996; Sheridan, 2003). This gives them the necessary background to induce or make up credible symptoms. Perpetrators of MPS tend to have a dramatic fl air, and they may seek attention from a wide variety of sources including professionals and nonprofessionals. Many of these mothers have a history of being abused themselves (M. Fraser, 2008), and they are more likely than are others to have dealt with a somatizing disorder, borderline personality disorder, or depression (Bools, Neale, & Meadow, 1994; Moldavsky & Stein, 2003). Bass and Jones (2011) examined
28 mothers who had subjected their children to MPS. They found that 16 (57%) of them suffered from a somatoform disorder and 18 (64%) were diagnosed with fi ctitious disorder (making or present- ing themselves as ill). However, it is not true that all perpetrators of MPS have a mental illness. In a good number of cases, the moth- ers have not received any diagnostic labels beyond MPS (Meadow, 1982). If the mother is challenged by the medical staff caring for her child, she is likely to deny the allegations but is not likely to stop the behavior. Instead, she will take her child to other doctors who have not questioned her motivations. This “doctor shopping” can result in the child being subjected to even more medical procedures.
INCIDENCE
It is not clear how common MPS is at this time, and data for the United States are particularly lacking. Some incidence studies indicate that it is quite rare in other coun- tries. For instance, Adshead and Bluglass (2001) report that the incidence of MPS in the United Kingdom is between 0.1 and 0.8 cases per 100,000. The reported incidence is a bit higher in New Zealand, 2 cases per 100,000, but still uncommon (Denny et al., 2001). Although a systematic study of incidence is lacking, there are more than 550 published case reports of MPS from more than 30 countries (Lasher & Sheridan, 2004), which means that professionals across the globe are starting to pay attention to this form of child maltreatment. One estimate is that there are approximately 1,200 new cases of MPS reported each year in the United States (M. Feldman, 2004). Some medi- cal doctors are beginning to express their belief that MPS may be more common than was generally thought but that it often goes unrecognized. Sir Roy Meadow (1982) cited Goethe, who wrote, “We see only what we know,” to indicate that as doctors learn to look for MPS, there may well be an increase in documented cases. As recently as 1988, a survey of pediatric nursing staff revealed that 55% had never even heard of MPS and 70% did not feel prepared to handle such a case (M. Feldman, 2004).
RISK FACTORS
An obvious question is, What would motivate a parent to fake or create illness in her own child? The motivation for MPS is complex, but it appears that the moth- ers are drawn to the attention they receive because their child is ill. Playing the role
somatoform disorders
disorders that involve
physical symptoms
in the absence of any
organic cause. The
symptoms must be severe
enough to interfere with
the person’s life and not
be under the person’s
voluntary control.
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217MUNCHAUSEN BY PROXY SYNDROME
of “mother to a seriously ill child” becomes their claim to fame. Mothers crave the gratifi cation that comes from being seen as a good, attentive mother. They like being seen as a woman willing to be a martyr for her child by giving up her own life to remain at her child’s side. It may be that an MPS mother fi rst had a child with a true illness or had a child who died, which resulted in attention and support. Denny, Grant, and Pinnock (2001) reported that more than half of the victims of MPS in their study (55%) had an underlying chronic illness. They speculated that early exposure to intense medical attention when caring for a newborn may make a mother who is oth- erwise isolated crave this sort of attention. Once the true crisis passed, they needed to create new situations that would elicit the same type of response. Some mothers seem particularly motivated to maintain a relationship with the medical community. They are comfortable in medical settings such as hospitals, and they want to feel a part of the unit. For some mothers, an additional benefi t is that being in the hospital with a child relieves them of all other parenting responsibilities. After all, a mother with a very ill child cannot be expected to cook, clean, or do laundry. Neglecting these tasks to care for a sick child is not frowned on. In fact, others are eager to cover the more mundane aspects of childcare while the mother attends to her ill child.
In some cases, this need for attention predates their maternal role. For about 10% of MPS perpetrators, their fi rst victim was themselves; before making their child ill, they suffered from Munchausen syndrome. The theory that MPS perpetrators are motivated by a need for attention is supported by the fi nding that many MPS moth- ers report that they have a poor relationship with the child’s father (Moldavsky & Stein, 2003). It may be that when their partner is not meeting their need for atten- tion, they use the child to force others to pay attention, or they use the sick child to force their spouse to engage with the family. Furthermore, spouses with very con- fl icted relationships may fi nd that their arguing ceases when they face a common adversity such as a child’s illness. However, the relationship between MPS and poor spousal relationship is only a correlational fi nding, so we cannot assume cause and effect. It is possible that some third factor causes women to have poor spousal rela- tionships and to commit MPS. It is also possible that a woman who had a good relationship with her spouse would not harm her child out of love for her spouse (i.e., she would not hurt him by hurting his child). If this is the case, a poor spousal relationship would fail to prevent MPS but would not cause it.
Some experts stress that the diagnosis of MPS should only apply to mothers who are motivated by the desire for medical attention, but others have noted that you may see the same behaviors for other reasons. A possible motivation for MPS behav- iors may be that the mother is desperate to keep the child at home with her. She does not want the child to start school or even to go to a friend’s house. The mother is so attached to the child that she cannot tolerate the idea of separation. It is socially unacceptable to keep a healthy child socially isolated; however, a mother who for- goes all outings to be with her ill child will receive only praise. Many researchers have noted that MPS mothers seem to be overly attached to their children. In one case report, a mother actually attended school with her daughter so that she could monitor her at all times. The mother did this despite the fact that there was already in-class nursing supervision (vonHahn et al., 2001).
Finally, a less selfi sh motivation for MPS behaviors may be that the mother is seeking help with parenting. In this scenario, the mother would be so overwhelmed by parenting and so worried that on her own she will fail that she would do whatever was necessary to ensure that others will help her.
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218 TYPES OF ABUSE AND THEIR EFFECTS
Regardless of the mother’s motivation, MPS is considered a form of child abuse and not only a psychological disorder. Most perpetrators of MPS do not have any symptoms of psychological problems beyond what they are doing to their children. To this end, mothers who attempt to use MPS as a legal defense when they are charged with making their children ill have not been successful (see Legal Example 9.1 ).
LEGAL EXAMPLE 9.1
Lorena Victorina Hernandez was charged with child abuse after she injected her 9-month- old, nondiabetic son, Isaiah, with insulin. The case was discovered when Isaiah was brought to the hospital, where he fell into a coma. The boy’s blood sugar levels were dangerously low, and manufactured insulin was detected in his blood. The injection could have been fatal, but Isaiah did survive. Investigation revealed that Hernandez had used her mother’s diabetes supplies to inject her son on at least two occasions.
At trial, Hernandez’s attorney claimed that Hernandez was not guilty because she suffered from MPS. Terry Bowman, the district attorney, argued that although MPS may explain what Hernandez did, it did not excuse the behavior. Hernandez’s defense was not successful, and she was convicted of two counts of child abuse (Romano, 2001).
CONSEQUENCES OF MPS
A review of the literature shows that all victims of MPS suffer at least in the short- term. In cases where symptoms are induced, the child will be subjected to the pain, suffering, and injury that are infl icted. Serious cases may result in perma- nent physical damage to the child. In approximately 7% of cases, long-term or permanent disability is documented (Sheridan, 2003). One common effect of MPS is the development of feeding disorders because so many cases involve negative interactions around feedings (e.g., when food is contaminated, when vomiting is induced, or when food is withheld). Other doctors have reported that victims of MPS suffer psychological as well as physical effects. These victims are immature,
they are overly dependent on their mothers, and they suffer from separation anxiety. The children may also be more irritable and more aggressive than their peers (McGuire & Feldman, 1989). Finally, some studies have noted attention defi cits, poor school performance, and symptoms of posttraumatic stress disorder in these children (Moldavsky & Stein, 2003).
In situations with fabricated, exaggerated, or induced symp- toms, children will face painful medical tests and procedures and may suffer from taking unnecessary medication or even hospitalization. In a review of 19 children, Meadow (1982) noted that the greatest physical harm to the children was infl icted by the doctors, not directly by the mothers. The time spent seeking medical treatment is also time taken from normal social and educational experiences, so the child suffers from missed opportunities as well. This is an indirect effect, but it can be a substan- tial one. If a mother is trying to convince the world that her child is gravely ill, she
separation anxiety
distress and/or anxiety a
child experiences when
separated from a primary
caregiver.
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219MUNCHAUSEN BY PROXY SYNDROME
cannot let the child out to play or even to attend school. For example, one 6-year- old male victim spent a full 13 months out of school, and he was hospitalized for 5 of those months (Meadow, 1982). Another indirect effect of MPS is that the child’s siblings may be injured. Research on MPS victims shows that 25% of their siblings are deceased, and 61.32% of their siblings have symptoms of illness with no known cause (Lasher & Sheridan, 2004; Sheridan, 2003). A third, indirect effect is tied to cases in which mental illness is faked. In these cases, the child is likely to suffer from embarrassment and shame because of the stigma that can be attached to hospitaliza- tion in a psychiatric ward (Lasher & Sheridan, 2004). In addition, children found to be the victims of MPS may be removed from their homes. Although this stops the abuse, it also means that the children may lose contact with many or all members of their family. Of course, the worst possible cases are those that are fatal. It is estimated that MPS has a mortality rate that is between 6% and 10% (Schreier & Libow, 1993; Sheridan, 2003). However, in cases that involve suffocation or poisoning, mortality rates may be as high as 33% (Shaw et al., 2008). The victims who die seem to repre- sent the lower age range of all MPS victims. In an examination of 21 MPS deaths, the average age at the time of death was 18.83 months (Sheridan, 2003). In keeping with the controversial nature of this diagnosis, it is not surprising that other authors argue that the data suggests a much lower mortality rate (Pankratz, 2010). Due to the secre- tive nature of child abuse and to the possibility of undiagnosed true medical illness in the child, it is likely that an accurate estimate will continue to elude us.
As the child ages, if the abuse does not stop, the child may begin to aid the par- ent in the deception, and the child may develop Munchausen syndrome as an adult (Epstein et al., 1987). It is not clear why the child would continue this painful cycle, but Libow (2002) suggested that if the child becomes the initiator, he or she may achieve a sense of control missing when the parent was creating the symptoms. An alternative theory, also proposed by Libow, is that the child may be angry with the doctors for failing to protect him or her and seeks revenge by tricking or deceiving the doctors. Finally, the child may truly believe that they are ill. Shapiro and Nguyen (2011) reported the case of a male adolescent who was removed from his parent’s care due to MPS. The boy continued to speak of his mother, the perpetrator, in loving terms and saw people who questioned his illnesses as “evil.” Furthermore, he continued to complain of symptoms that did not seem to be based in medical reality. Although some victims of MPS have been reported to develop Munchausen Syndrome as adults, this boy did not seem to be faking his symptoms. He seemed to fully believe that he was ill. Clearly, MPS is a complex problem that can lead to a myriad of outcomes.
Adult Survivors
Almost no research exists that examines which effects of MPS may persist into adulthood. One exception is the work of Libow (1995) that involved interviewing 10 self-identifi ed adult survivors of MPS and having them complete a questionnaire and a posttraumatic stress disorder checklist. Although this was a small, nonrandom sample and a retrospec- tive design, it provides a fi rst look at what MPS victims might be like as adults.
All of these adults reported that they were aware that something was wrong or unusual about their experiences as children, and all felt unloved and unsafe. Of the 10, 4 tried to tell an adult about the abuse, but none was believed. Although this may seem shocking, imagine that a child you believe to have serious medical problems tells you that his mother made him drink something that tasted funny and made
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220 TYPES OF ABUSE AND THEIR EFFECTS
him sick. Would you think MPS, or would you assume this child did not like to take medicine?
As adults, all victims placed the blame on the perpetrator (nine mothers and one father) and simply saw the other parent, who failed to protect them, as weak. At the time of the study, eight of the abusing parents were still alive, and four of the adult children had some contact with them, but none had a close relationship with the offending parent. No parent had admitted to abusing his or her child (Libow, 1995).
Furthermore, only two of the participants felt that their experience with MPS had not had a signifi cant impact on their adult life. The other eight reported lasting negative effects from the MPS. The commonly stated problems resulting from being the victim of MPS included “a struggle to avoid playing the victim role, diffi culty maintaining relationships, insecurity and ‘constantly doubting myself,’ a fruitless search for mother’s love, and diffi culty separating fantasy from reality—especially in relation to illness and the need for medical treatment” (Libow, 1995, p. 1137). Not only did the participants admit diffi culties to researchers, but seven of them had previously sought psychiatric/psychological services as well. On the checklist administered by the author, the participants’ responses indicated a signifi cant degree of posttraumatic stress disorder. On a positive note, it did not appear than any of the participants were repeating the MPS on their own children. Despite these preliminary fi ndings, much more research is needed on survivors of MPS across their life span.
INVESTIGATION OF MPS
If medical professionals suspect MPS, they should begin a careful review of the alleged victim’s chart. One indicator of MPS is a child who presents with multiple problems that do not respond to traditional treatment. In other words, the treatment that is prescribed based on the history given by the parent does not result in the expected alleviation of symptoms. A second indicator is odd or confl icting labora- tory fi ndings that do not support the symptoms reported by the parents. Medical staff should also check the signs of illness carefully. For instance, blood in the child’s stool or vomit may not even be the child’s blood. Some mothers add their own blood to their child’s feces or vomit to simulate illness. Although a hospital may not
be able to differentiate a mother’s blood from her child’s blood, a police forensic laboratory could assist (Meadow, 1982). To this end, specimens from children should be kept for detailed examina- tion in cases where there is suspicion. Doctors should also look for a discrepancy between the medical history of the child provided by
the mother and the clinical fi ndings and/or the general health of the child. Medical staff might also become suspicious if there is a previous, unexplained child death in the family. Another suspicious fi nding is that the child’s symptoms decrease when the alleged perpetrator is away and return or increase when contact is resumed (Mol- davsky & Stein, 2003).
With regard to the attitude of the caregiver, doctors look for parents who do not seem to be relieved by good news (or who go so far as to be angry about negative test results), who appear to enjoy the hospital environment, and/or who are unu- sually calm when confronted with medical problems. These mothers may appear excited about invasive procedures that most parents would be reluctant to allow before they were convinced that the tests were absolutely necessary (Meadow, 1982). Perpetrators of MPS also have a tendency to take over the child’s medical care to a
forensic
related to, or appropriate
for, use in legal settings
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221MUNCHAUSEN BY PROXY SYNDROME
degree that is far greater than normal. They are also described as overly attentive to their children when staff is present (Moldavsky & Stein, 2003). Finally, doctors assess how the caregiver interacts with them. Parents who are guilty of MPS tend to have extreme responses to doctors. On one hand, they may be particularly encouraging of the doctors, and on the other hand, they will express intense anger at the doctors and constantly switch doctors in search for one who will give them the attention they crave. Some parents also prohibit the dismissed doctors from sharing medical information with other physicians who become involved with the case.
Individually, none of these indicators proves that the case involves MPS, but a cluster of them should raise suspicion. Unfortunately, it is feared that many cases of MPS go undetected because medical personnel fail to consider the possibility that the parent is making the child ill. Given the rarity of MPS and the very real concern of most parents, this is understandable. Siegel (2009) points out the importance of the family physician or pediatrician when considering the possibility of MPS. Whereas specialists are focused on one narrow aspect of the presenting problem, the family doctor has a broader view and, often, a longer history with the family.
If doctors are suspicious, they are advised to put together a multidisciplinary team to investigate the case. Parnell (2002) suggests that the team should include the following personnel: “child protective services worker, law enforcement offi cer, psy- chologist or psychiatrist, prosecutor, hospital social worker, nurse, pediatrician, and other members of the child’s medical team” (p. 134). She further recommends that the team should include a physician who specializes in MPS and that the team should meet quickly. Although this certainly seems to be a sound plan, it may be a challenge to get so many professionals together to discuss an event that is statistically unlikely. Once gathered, the team should review all of the child’s medical records with MPS in mind. They should also conduct an “educated toxicology workup.” Instead of testing for conditions suggested by the history provided by the parents, the doctors should look specifi cally for signs of MPS.
Separation of Parent and Child
If this review is inconclusive, further investigation is necessary. Two courses of action, both controversial, may be pursued. One involves limiting the access that the suspected parent has to the child and not allowing that parent to participate in the child’s care. This approach will generally require a court order. If professionals are able to separate the parent and the child, they can determine whether the child improves in the absence of the caregiver. However, because it seems counterintuitive to separate an ill child from his or her parent, judges may be reluctant to grant such a request. Furthermore, if a child is to be separated from the caregiver, precise criteria for evaluating the child before and after separation must be established. It is impor- tant to have clearly identifi ed behaviors to assess and to have the data collected by objective observers (Pankratz, 2010).
Covert Video Surveillance
A second way to pursue suspicions of MPS is via covert video surveil- lance, generally in a hospital setting. This involves making audio and/ or video recordings of events in a child’s room without the knowledge or consent of the involved family. This approach raises issues concern- ing cost, legalities, and ethics (see Focus on Research 9.2 ).
covert video
surveillance
making a video recording
without making it clear
to the participants that
they are being taped
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222 TYPES OF ABUSE AND THEIR EFFECTS
FOCUS ON RESEARCH 9.2
D. Hall, Eubanks, Meyyazhagan, Kenney, and Johnson (2000) wanted to determine the value of covert video surveillance in diagnosing MPS. From 1993 until 1997, 41 patients were monitored via covert video surveillance at Children’s Healthcare of Atlanta at Scot- tish Rite when their doctors suspected MPS. The rooms were wired with multiple cameras that recorded audio and video information. All parts of the patients’ rooms, except the bathroom, were monitored. Before any patient was taped, a multidisciplinary team con- vened to discuss the case and whether covert video surveillance was appropriate. The team only elected to use covert video surveillance when they had agreed that a diagnosis of MPS was more than likely.
The hospital secured permission for covert recording in two ways. First, they posted a sign at the entrance to the hospital that said the facility was monitored and recorded via hidden cameras. Second, the hospital admission forms for consent to treatment contained the statement “Closed circuit monitoring of patient care may be used for educational or clinical purposes” (p. 2 of 20). No patients or parents were directly informed that they were being recorded.
Once covert video surveillance began, trained security guards monitored a live feed 24 hours a day. In order to keep the monitors alert, they watched for only an hour at a time. Logs were kept that detailed what happened in the room, and a fl oor nurse was paged immediately if the guard saw any suspicious behavior. When necessary, the nurse would intervene to protect the child. Finally, all instances of possible MPS were reviewed by hos- pital supervisors. The average length of observation was 3.57 days.
Evidence of MPS was found in 23 (56%) of the cases, but was not detected in 18 (44%) of the cases. Of these 18 cases, four of the mothers seemed to know that they were being observed. These mothers looked for cameras and made comments about being watched. In the 23 cases in which inappropriate parental behavior was seen, the recording was neces- sary for the diagnosis of MPS in 13 (56.5%) cases, supportive of the diagnosis in 5 (21.7%) cases, and not needed in 5 (21.7%) cases. In the fi ve cases in which the video was not needed, two were confi rmed by laboratory tests of drug levels, two by staff observation of abuse, and one by a maternal confession following confrontation.
The videos revealed the following behaviors:
• 4 suffocations • 1 injection of a bodily fl uid (urine) • 5 instances of oral medication administration • 1 gastrostomy tube medication administration • 1 burn • 10 instances of fabrication
In addition to these behaviors, mothers were heard coaching their children to fabri- cate symptoms. Mothers were also recorded telling lies to family and friends on the phone. One mother reported that her child was having constant seizures, when in fact no seizures were observed. Some of the mothers were also seen to be extremely attentive to their
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223MUNCHAUSEN BY PROXY SYNDROME
children while others were present, only to virtually ignore the children when they were alone. After confrontation with the video, 9 of 20 cases (45%) resulted in a maternal con- fession. The maternal response in 3 of the confi rmed cases was not known.
With regard to demographic variables, the authors reported that all perpetrators were mothers who were an average of 24.8 years old. Of these mothers, 55% had a history of health care work or study, and another 25% had worked in a day care. Of the guilty moth- ers, 35% reported a history of having been abuse victims themselves. Of the mothers, 93% were Caucasian, which is greater than the percentage of Caucasians in the general hospital population (68%). Although some of the mothers fi t the stereotype of MPS perpe- trators (great interest in and enthusiasm for medical tests, poor relationship with spouse, extremely close to medical staff), none of these factors was suffi cient to prove MPS.
The victims of MPS were as likely to be male (13) as female (10). The average age of the victims at the time of diagnosis was 26 months. Only one victim had a sibling who had died. When this mother was confronted with the current case of MPS, she also admitted to having smothered the sibling.
In four cases, the covert video surveillance resulted in the realization that the mothers were innocent despite strong suspicion of MPS. No instances of inducing or fabrication were seen on the videos, and in one case, the child’s true symptoms were recorded, which confi rmed the mother’s reports.
The authors conclude that covert video surveillance is a valuable tool for the diagnosis of MPS. In many cases, MPS would go unproven if the videos were not available, and the child would be exposed to further pain and danger. In addition to catching guilty parents, covert video surveillance can also show when parents are innocent. The authors believe that the effi cacy of covert video surveillance overrides the ethical concerns inherent in the procedure. They also argue that covert video surveillance is not likely to be overused because it is only begun when a team of professionals believes it is necessary. In addition, covert video surveil- lance is an expensive process that is not covered by insurance, so hospitals would be motivated to use it judiciously. Covert video surveillance is an important tool in protecting children.
The Fourth Amendment to the U.S. Constitution protects citizens from unreason- able search and seizure. This has been interpreted to mean that information cannot be collected from any place you can reasonably expect privacy unless there is prob- able cause that has been demonstrated to the court and a warrant has been obtained. If evidence is collected in violation of the Fourth Amendment, it is not admissible in court. However, the court has allowed exceptions to this rule in cases in which there is imminent threat to human life. What this means for covert video surveillance is that it would be clearly permissible in cases in which the hospital has obtained a warrant prior to recording. It is less certain that hospitals can record without a warrant based on the exception of imminent threat, because it generally does not take long to get a warrant and most MPS cases go on for months or even years before being diagnosed. If a doctor has had suspicions for months, it could be diffi cult to argue that waiting 1 day for a warrant would result in a threat to life. Another approach that has been argued by hospitals is that patients cannot reasonably expect privacy in the hospital. A patient is in the hospital specifi cally to be monitored by medical staff. Certainly, if you
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224 TYPES OF ABUSE AND THEIR EFFECTS
have ever been in a hospital, you know that you are not granted much privacy! Even Ron Madick, the director of the American Civil Liberties Union (ACLU) , has stated
that the use of covert video surveillance in hospitals is permissible because the expectation of privacy in such a setting is so low. Given that the goal of the ACLU is to protect our constitutional liberties, this is a strong statement in favor of covert video surveillance (Mor- rision, 1999).
A more practical concern about the use of covert video surveil- lance is the expense involved. Not only do hospitals have to pay for the equipment, but they must also pay staff to monitor the surveil- lance in real time. If a mother is taped while smothering her child and intervention is not begun immediately, the hospital may be considered negligent. The cost of constant monitoring can quickly deplete a budget.
Hospitals also face concerns of being considered negligent if they do not use cov- ert video surveillance in cases in which there is suspicion of MPS, or if they use covert video surveillance and the child is harmed. Some argue that it may be better to seek a court order to separate the child from the alleged perpetrator instead of perform- ing surveillance that still allows the child to be harmed (Foreman & Farsides, 1993). However, because courts are reluctant to separate ill children from their parents, this may not always be feasible. One fi nal concern about covert video surveillance is that it may interfere with the trust relationship between a family and its doctor. For now, each patient’s situation is assessed on a case-by-case basis by the medical staff along with legal consultation.
Use of Functional Magnetic Resonance Imaging to Interview Alleged Perpetrator A new approach to investigating allegations of MPS involves the use functional neu- roimaging. Spence, Kaylor-Hughes, Brook, Lankappa, and Wilkinson (2008) examined a 42-year-old woman who had been found guilty of poisoning a 4-year-old child in her care and who was then sentenced to prison. The woman continued to proclaim
her innocence and consented to a functional magnetic resonance imaging (fMRI) procedure (similar to a lie detector with the addition of neuroimaging). She was asked to both confi rm and deny sets of statements, some asserting her version of events and others echoing the beliefs of her accusers. On examination, this woman responded as an innocent person would—it took her longer to respond affi rma- tively to her accuser’s version of events than to hers, and she showed greater brain activation in areas associated with lying when answer- ing yes to her accuser’s version of events. Currently, there is not enough information on this use of fMRI for it to be used in a forensic setting, but it is a promising fi eld of research.
CONTROVERSIES RELATED TO MPS
Despite an increase in the interest in and attention to MPS, there are still many unanswered questions. Although there has been a signifi cant increase in the number of articles and books published about MPS in the last decade, these publications are
American Civil Liberties
Union (ACLU)
a national organization
that advocates for
individual rights
by preserving the
protections and
guarantees listed in the
Bill of Rights
fMRI
functional magnetic
resonance imaging that
measures blood fl ow
in the brain to provide
information about what
parts of the brain are
active during a particular
mental operation
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225MUNCHAUSEN BY PROXY SYNDROME
mostly the presentations of case studies or theoretical papers. There is still a defi nite lack of empirical research on this disorder (Mart, 2002). This lack of defi nitive data underlies the many controversial issues surrounding MPS.
Who Should Be Diagnosed With MPS?
One of the fi rst questions is about who is diagnosed with MPS. Is this a diagnosis given to the parent or to the child? If it is a diagnosis given to the parent, it is com- plicated because it is largely based on the parent’s motivation. If a parent is to meet the criteria for MPS, he or she must be making the child ill in order to receive atten- tion from others. What if the parent is making the child ill for some other type of gain? For instance, a parent may make the child ill in order to get money or earn an advantage in a custody battle. In these situations, the child would still be ill, but MPS does not fi t. The American Professional Society on the Abuse of Children suggests that children who are made ill or simply described as ill when they are not be diagnosed with pediatric condition falsifi cation (PCF) . This diagnosis would say nothing about the parent’s motivation, but it would simply describe what is happening to the child. In addition, the case could involve MPS if the parent’s motivation was attention, but this would not always be the motivation. If the medical professionals could not determine the parental motivation or if they thought the motive was to gain something other than attention, they would not diagnose MPS. So, you could have pedi- atric condition falsifi cation without MPS, but you could not have MPS without pediatric condition falsifi cation (Mart, 2004). Fur- thermore, if the parent is diagnosed with MPS, should it be usable as part of a criminal defense? If a person suffers from a documented mental disorder, it could be used as a way to mitigate criminal responsibility (Langer, 2009).
Focus on Motivation or Harm?
Some professionals argue that we should not try to determine something as sub- jective as motivation at all. Instead, we should simply focus on and describe the behaviors that are harming the child. However, parental motivation does become important if the case goes to court. A possible compromise is to have a two-tiered approach to diagnosis. First, the specifi c acts committed could be described without any prejudicial labels. Then, the second tier would involve an analysis of the perpe- trator’s behavior. What is the parent gaining by this behavior? Does the perpetrator suffer from some sort of psychopathology? How serious is the behavior? The answers to these questions would be important not only in determining guilt in a court case but also in devising treatment programs for the family if the child is to remain in their care (Mart, 2004).
The Placement of the Disorder in the Diagnostic and Statistical Manual
This lack of defi nitional clarity is highlighted by the position of the factitious dis- order by proxy in the Diagnostic and Statistical Manual , Fourth Edition ( DSM-IV ; American Psychiatric Association, 1994) . Factitious disorder by proxy is not listed
pediatric condition
falsifi cation (PCF)
a description suggested
by the American
Professional Society on
the Abuse of Children to
refer to any children who
are described as ill when
they are not, regardless of
parental motivation.
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226 TYPES OF ABUSE AND THEIR EFFECTS
among the offi cial diagnoses, but it is found in Appendix B, titled “Criteria Sets and Axes Provided for Further Study.” The DSM-IV ’s authors warn that the diagnoses in this section can only be considered tentative because the research supporting them is insuffi cient (Mart, 2002).
Malingering by Proxy
What if the parent coaches the child to fake symptoms in order to obtain some- thing external, such as money? In these cases, the term malingering by proxy
may be used. Consider the following case: A 13-year-old boy was injured in an accident at school. A concession stand window fell, cutting his hand, and he was pushed against a building. He was taken to the emergency room where he received sutures. The doctor who treated him noted that there was no injury to his tendons. Over the next year, the boy was taken repeatedly to the emergency room and to doctors’ offi ces, where he received many tests. The complaints were that the boy would frequently drop things, his hand would shake, he suffered from numbness, and he
had a limited range of motion. Two things were suspicious about the case. First, the mother did most of the talking for the boy even though he did not disagree with her, and he did hold his arm stiffl y. Second, none of the tests revealed any signs of damage. It should also be noted that the family was involved in litigations with the school where the accident had occurred. In this case, video surveillance revealed that the boy did have full range of motion, and the litigation was stopped. In other cases, mothers have falsely reported behavioral problems in their children in order to obtain disability benefi ts after the children received a psychiatric diagnosis (Stutts, Hickey, & Kasdan, 2003). Using the criteria recommended by the American Professional Society on the Abuse of Children, these children could all receive the diagnosis of pediatric condition falsifi cation with the additional note of parental malingering by proxy.
Incorrect Diagnoses
A second concern is the possibility of a false diagnosis of MPS. Imagine how terrible it would be if you were separated from your seriously ill child because the medical professionals were suspicious of your behavior. As awareness of MPS increases, it is likely that the rate of false-positive diagnoses will also increase. (A false positive is a case in which a diagnosis of MPS is made when, in fact, the child is not being mal- treated.) There is some evidence of an increased rate of false positives in the United States and the United Kingdom, based on the fact that we have seen an increase in the number of cases in which parents have been convicted of MPS and later exon- erated after further examination of the case (Mart, 2004). The concern about false positives is tied to the fact that MPS is rare and, therefore, has a low base rate. For instance, one common manifestation of MPS is sleep apnea (the child stops breath- ing while asleep). In cases of MPS, this is either fabricated or induced by the parent. However, a doctor would not want to assume that a child with sleep apnea was the victim of MPS. In one study of 20,090 cases of sleep apnea, only 54 (0.27%) involved the suspicion of MPS. In another study of 340 infants with serious, episodic health
malingering by proxy
a parent’s coaching of a
child to fake symptoms
in order to gain
something external such
as money from a lawsuit
or an insurance claim
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227MUNCHAUSEN BY PROXY SYNDROME
problems, only 5 cases (1.5%) likely involved MPS (Mart, 1999). What these studies show is that because MPS is rare, the explanation for most child illnesses is not MPS, but a true medical condition.
Certainly, the stories of false-positive diagnoses of MPS can be heartbreaking. One mother was charged with MPS after her infant died. After she had served 5 years in prison, her conviction was overturned when it was discovered that her child had died of a rare medical condition (spontaneous methylmalonic acidemia) that had been unrecognized (Rand & Feldman, 1999). Here you have a case in which an inno- cent mother was sent to prison while she was grieving the loss of her infant. Other mothers have been kept away from their very ill children because medical doctors suspected MPS. Unfortunately, in some of these cases, the child died of an unrec- ognized, true illness while the mother was not present. Some of these mothers are fi ghting back by suing the doctors for this horrible mistake. A group of women who say they were falsely accused of MPS has gone so far as to form an organization they call MAMA (Mothers Against Munchausen by Proxy Allegations).
Suggestions to Prevent Misdiagnoses After reviewing 11 cases of misdiagnosed MPS, Rand and Feldman (1999) offered the following suggestions. First, they encouraged professionals not to rely on subjec- tive criteria. Although many parents who are guilty of MPS are unusually attached to their children, this is also true of many parents who are not maltreating their children. Using unhealthy attachment to diagnose MPS would result in a very high false-positive rate. The same can be true of other subjective criteria, such as having an unhealthy interest in the child’s medical situation or being resentful toward doctors who say the child is not ill. Many professionals note that MPS mothers are extremely demanding. Although this may be true, other mothers may be demanding because they sincerely believe their children are ill and/or because they have done a great deal of research on the condition, and they feel informed enough to be assertive. Doctors must be careful not to assume any aggressive mother is making her child ill. Even if these are warning signs of MPS, none of them is a confi rming sign.
Second, doctors are encouraged to do a complete review of all medical records and discuss those records with the parent. A mother who is engaging in MPS may take her child to many doctors and may have many tests done, and the same could be true of a parent who is not abusive. If a mother believes her child is ill and her current doctor cannot fi nd a problem, it would seem appropriate to seek a second and even a third opinion. Also, many doctors want to run their own tests instead of relying on forwarded tests from other offi ces. A thorough discussion with the mother could shed more light on the situation.
Rand and Feldman (1999) also caution that just because a child improves in his or her mother’s absence does not prove that the mother is making the child ill. It may sim- ply mean that the most recent treatment is working for the child, and the separation is a coincidence. In fact, many childhood illnesses do improve with time, so the illness may have simply run its course. Related to this point, an illness that has an unusual course does not necessarily mean MPS. It is also possible that the child has been misdiagnosed, especially if there is an underlying medical problem that is rare (Mart, 1999).
Certainly, exaggeration does not necessarily mean MPS. A parent may be using exaggeration to get the child’s case prioritized. If the mother feels that her child is not receiving adequate, needed attention, she may be motivated to exaggerate in
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228 TYPES OF ABUSE AND THEIR EFFECTS
order to get the child the care that she truly believes is needed. Doing what you deem necessary to ensure that the doctors pay attention to your sick child does not seem like child maltreatment. It is also possible that the mother sees every symptom in her child as a sign of a major problem. Although she may well be wrong, she is not trying to make the child appear ill to gain attention; she is genuinely concerned about her child’s health (Mart, 1999).
Another common pitfall in the diagnosis of MPS is the belief that parents who are guilty of MPS will deny the abuse when they are confronted. Although this is true in most cases, what about the parent who is not guilty of MPS? If a doctor asks an innocent person about making his or her child ill, this person will also say no. Because there are many more innocent parents than guilty parents, one cannot assume that a denial of abuse is proof of maltreatment. In some cases, parents have been told that they cannot see their child until they admit to making the child sick. Obviously, a “confession” based on this type of coercion is problematic. If your child is ill, it is possible that you would say or do anything in order to get to his or her side.
Expert Testimony Regarding MPS
Added to the inherent diffi culty in diagnosing cases of MPS is the controversy con- cerning expert testimony provided by Dr. Meadow, who fi rst identifi ed the disorder. Meadow became a frequent expert witness in cases of MPS in Britain, especially in cases where a family had experienced the loss of more than one child to cot death (known as sudden infant death syndrome in the United States). His now infamous dictum that one infant death was a tragedy, two were suspicious, and three were mur- der became known as Meadow’s Law. It should, however, be noted that Meadow was not the fi rst to say this, and he stated it as a working rule more than as a law (Reddan, 2008). Meadow did testify, as an expert, that the chance of two babies dying this way in one family was 1 in 73 million. He arrived at this number by starting with the chance that one child in a middle-class, nonsmoking home would die of cot death (1 in 8,500) and squaring it. The problem with this approach is that it works only if the event in question is totally random (like the roll of the dice). However, it is quite likely that cot death is a nonrandom event that has some unknown cause, possibly genetic (“The Probability of Injustice,” 2004). Members of the Royal Statistical Soci- ety responded that the fi gure was closer to 1 in 150 (Kaplan, 2008).
After several controversial cases were appealed in Great Britain, the appeals court ruled that a mother could not be convicted in a case of cot death based solely on the testimony of an expert witness. The court also ordered the review of 258 cases in which parents had been accused of murder, and 5,000 cases of children taken into care based on Meadow’s testimony (D. Cohen, 2004). Although this ruling found that Meadow’s statistical testimony was inaccurate, it did not fi nd that MPS is not possible. The courts merely urged prosecutors to rely more on the medical facts of the case and less on analysis of maternal behavior beyond the direct acts against the child.
CONCLUSION
The history of documented MPS is a short one, so as may be expected, there are still many diffi culties to iron out. As more professionals become educated about MPS, it is likely that more research will be conducted on this disorder. Having more
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229MUNCHAUSEN BY PROXY SYNDROME
information will hopefully mean that precise recommendations can be made in the future. It is also possible that medical advances will help to clarify many of the issues that relate to diagnosing MPS. Just as the invention of the X-ray machine dra- matically improved the diagnosis of child physical abuse, the development of more sensitive blood tests may eventually make it easier to detect MPS. The goal in dealing with MPS, as in all areas of child maltreatment, is to protect children who are being harmed without interfering with families who are not abusive.
DISCUSSION QUESTIONS
1. Which term do you think is the best description of the behaviors described in this chapter: Munchausen by proxy syndrome, factitious disorder by proxy, or pediatric condition falsifi cation? Why?
2. Some people argue that only medical doctors need to know about MPS. What arguments could you suggest to counter that claim?
3. Compared to the other types of maltreatment covered in this textbook, would you be more or less comfortable reporting suspicions of MPS to CPS?
4. Many people confuse hypochondria and Munchausen syndrome. How would you differentiate between these conditions?
5. Is there any way to prevent cases of MPS? If so, what type of prevention pro- gram do you think might be effective?
6. Is it ethical to use covert video surveillance in cases of suspected MPS?
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230
DEFINITION
As you have seen in the previous chapters, child maltreatment is a serious prob-lem with signifi cant negative consequences across a wide variety of domains including physical and mental functioning. However, there are also individual dif- ferences in how children respond to maltreatment. The purpose of this chapter is to
examine children who suffer maltreatment and seem to escape the negative consequences. We talk of these children as being resilient. Resiliency is the ability to come through negative life events rela- tively unscathed or even to thrive in the face of adversity (Tugade, 2011). Throughout this chapter, I use the broader defi nition of resiliency, which refl ects the absence of negative consequences instead of the more restrictive defi nition that requires higher than normal or superior functioning after adversity (Afi fi & MacMillan, 2011; see Case Example 10.1 ). However, there certainly are cases in which some individuals who suffer child maltreatment do manage
to have extraordinary lives (see Case Examples 10.2 ). If we knew what allowed some children to be resilient, it might give us insight into how to serve other maltreated children in more effective ways. The fact that some children are resilient does not, in any way, negate the very real negative consequences of maltreatment for so many children. In addition, talk of resiliency does not lessen the fact that all child maltreat- ment is wrong.
CHAPTER 10
Resilience
resilient
being able to recover
easily from diffi cult
circumstances; the ability
to bounce back and
persevere; being able to
adjust to misfortune;
adaptable.
CASE EXAMPLE 10.1
In my work as a guardian ad litem , I was frequently impressed by how well the children I worked with were functioning. Sometimes it was hard to reconcile the horrifi c case studies I read with the cheerful, well-functioning child in front of me. Despite a deck that seemed stacked against them, some of the children were succeeding.
Amber was 12 years old the fi rst time I met her, and her younger sister, Kelly was 8 years old. The girls were taken into custody when their father was arrested for driv- ing under the infl uence (DUI) while the girls were in the car. This was not the fi rst time that the children came to the attention of CPS. The girls were being raised by their father, who struggled with addictions to alcohol and drugs. There were several previ- ous charges of physical abuse that had been substantiated. The girls’ mother was very
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231RESILIENCE
low functioning. She was living in a trailer with a boyfriend, but did not feel capable of caring for the girls. She did not have access to either a car or a phone, and she was not employed.
There were no family members who could take custody of the girls, so they were placed in foster care. Our fi rst attempts were to keep the children together. However, four separate placements failed. In two cases, Amber adjusted well, but Kelly was in constant confl ict with the foster family. In the other two cases, the reverse pattern was true and only Kelly adjusted well. Although the girls had adjustment problems in foster care, Amber did discover religion. One of her foster families took her to church with them, and Amber dis- covered her own sense of spirituality. Even after that placement failed, Amber continued to explore her faith. She decided to be baptized, and she felt very well supported by her church family.
While the girls were moving about the foster care system, their father gave up his parental rights. We sadly agreed to separate the girls. Kelly opted to try another foster fam- ily. She did well on her own and was eventually adopted by her foster family. Amber asked to be placed in long-term residential care.
Amber did well in residential care. She struggled in school, but she was committed to graduating from high school. We met regularly with her teachers and the academic sup- port personnel at her school. Because Amber had been neglected for most of her life, she did not know many things . For instance, Amber never learned alphabetical order. Amber worked hard, and she was provided with tutors in school and after school. Not only did she graduate from high school; she also took several courses at a local community college after graduating.
As her guardian ad litem, I continued to meet with Amber at least once a month. We talked extensively about her goals. In addition to being the fi rst person in her family to graduate from high school, she wanted to avoid all drugs and to be married before she had children. She was committed to providing any future children with a better childhood than she had.
Interpersonally, Amber is delightful. She has a sunny, positive disposition. She has a tendency to look on the bright side. She is slow to anger and quick to forgive. Amber is close with her mother and accepts what her mother is able to give to her without judging her for her inability to raise her children. Although Amber has lost track of her father, she knows he has been in and out of prison. She realizes with sadness that he will never be a part of her life, but she does not dwell on this. She says she has forgiven him.
As a young woman, Amber is married to a man with a secure, full-time job. They own their own home, and they are raising two beautiful children. Amber is not wealthy or famous, but she is resilient. She survived an impoverished, abusive childhood and defi ed the odds. She has broken the cycles of poverty and abuse.
CASE POINTS
1. Sometimes resilience is not fl ashy, but simply a child doing better than expected. 2. The motto of the guardian ad litems is “one child at a time.” Each volunteer has to
realize that while they cannot eradicate child maltreatment, they can make a differ- ence for one child.
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232 TYPES OF ABUSE AND THEIR EFFECTS
DISCUSSION QUESTIONS
1. Would you argue that Amber is resilient? Why or why not? 2. What factors do you think contributed to Amber breaking the cycle of abuse?
NOTE
1. Names were changed to protect the privacy of the children.
CASE EXAMPLE 10.2
There are many examples of people who suffer from child maltreatment and go on to thrive by accomplishing great things. Many former victims not only succeed in their own lives, but they reach out to help other victims.
President Bill Clinton has talked and written about his experiences with domestic violence. President Clinton’s stepfather was an alcoholic and he beat Bill’s mother. In his memoir, My Life , Clinton writes of picking up a golf club and threatening to hit his step- father if he did not leave his mother alone. From this abusive background, Clinton went on to become president of the United States. As president, Clinton did not forget what he had witnessed as a child. Instead of being overwhelmed by his experiences, he was driven to protect women and children. While in offi ce, President Clinton signed into law the Vio- lence Against Women Act (September 13, 1994). This law provided 1.6 billion in funding to assist women who were the victims of violence in a variety of ways. The law increased funding for rape crisis centers and for battered women’s shelters. The law also provided funding for more police offi cers, more prosecutors, and more victim advocates. In addi- tion, this law funded a domestic violence hotline and provided training for judges who hear domestic violence cases (A. Drake, 2009a).
Tyler Perry is an actor, director, writer, and producer. Although he enjoys great fame and wealth now, his life began very differently. Tyler Perry was born Emmit Perry, Jr. He lived with his sibling and parents, Maxine and Emmit, in poverty, and he was emotion- ally and physically abused by his father. He father was so abusive that at one point, Tyler considered suicide. In an interview with Oprah Winfrey, Tyler described his childhood as “a living hell” (CBS News, 2010). He later changed his name to distance himself from his father. In addition to abuse suffered in his home, Tyler was molested by several men and by a friend’s mother. The fi rst instance of molestation took place when Tyler was only 5 years old. After hearing that writing about past trauma can aid in healing, Tyler wrote the musical I Know I’ve Been Changed that chronicled his experiences. Despite initial failure, Tyler reworked the show and eventually it was a success. Tyler is committed to charitable works and has donated a great deal of money to help people living in poverty and those hurt by natural disasters. Tyler Perry is also driven to protect civil rights. When he heard that 65 children in Philadelphia were denied access to a swim club because of their race,
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233RESILIENCE
he paid for all of them to travel to Disney World for a vacation. Despite a harsh childhood, Mr. Perry is a strongly Christian man who devotes time and energy to helping others who are struggling (see www.tylerperry.com for more details ).
Mary J. Blige is a popular singer. She is also the victim of child abuse. She was aban- doned by her abusive father when she was just 4 years old, and she was molested by a family acquaintance when she was only 5 years old. Not only has Ms. Blige succeeded as an entertainer; she has also given back to the community. She founded the Mary J. Blige Center for Women in Yonkers, New York, where she lived in poverty as a young girl. This center provides assistance to women who have been emotionally and/or physically abused. She also cofounded the Foundation for the Advancement of Women Now to help females of all ages gain the skills and self-confi dence they need to be successful. Not only has Mary J. Blige shown resilience; she has also dedicated considerable energy to helping others achieve their goals (A. Drake, 2009b).
The author Pat Conroy also has a history of child maltreatment. He was raised by an extremely violent, physically abusive father. He survived his childhood and became a very successful author. Mr. Conroy has used this platform to write about his own abuse and that of others. His very popular books including The Great Santini and The Prince of Tides have opened many discussions about child maltreatment (A. Drake, 2009c). Mr. Conroy has used his fame to shed light on a topic that is too often kept secret.
An NFL offensive guard for the Miami Dolphins, Victor Rivas Rivers was abused by his father. Victor suffered from physical abuse, neglect, and emotional abuse as a child. He chose to speak out about his experiences in the hope that he could use his story to help make changes that would benefi t others. Rivers wrote a memoir of his maltreatment titled A Private Family Matter . He also serves as the spokesman for the National Network to End Domestic Violence (A. Drake, 2010).
If you would like to read about more famous people and celebrities who have tri- umphed in spite of maltreatment, go to http://annecarolinedrake.com. Anne Drake, an attorney and child maltreatment survivor, writes extensively about famous people who are resilient in the face of child maltreatment.
CASE POINTS
1. Some victims of maltreatment do more than survive; they thrive and excel. 2. Victims of maltreatment who thrive often dedicate a great deal of time and money
to support other victims. 3. Domestic violence impacts many different types of people. It is important to note
that anyone from celebrities to politicians to professional athletes might have a per- sonal history that includes domestic violence.
DISCUSSION QUESTIONS
1. What characteristics of resilient people might be associated with both resilience and a desire to help others?
2. Do survivors of maltreatment who achieve fame have a moral obligation to share their story? Why or why not?
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234 TYPES OF ABUSE AND THEIR EFFECTS
People who are resilient have the ability to experience positive emotions even during diffi cult times. It is not that resilient people do not have to deal with negative emotions; they can bounce back from diffi cult times, and they can still experience positive emotions even when life events are challenging. The ability to feel positive emotions can help to control stress. Resilient people view stressors as challenges and face them with interest as well as anxiety. They react appropriately in stressful situ- ations; then they return to normal functioning once the threat has passed. This is important because negative emotions are associated with a great deal of physiologi- cal arousal. When threatened, our body naturally prepares to fi ght or fl ee. This type of arousal is exhausting. Positive emotions such as joy, interest, and love can decrease this physiological arousal. Positive emotions are associated with a range of health benefi ts including lower blood pressure, being less likely to have a stroke, and being less susceptible to the common cold. When you experience positive emotions, you also tend to feel safe. This feeling of safety allows you to confi dently explore your world or to simply relax (Tugade, 2011). If you never feel safe, it is unlikely that you will be able to learn and develop normally. Once again, we can refl ect on Maslow’s theory of development. He argued that before we can reach our full potential, we must satisfy our lower level needs including the need to feel safe (Maslow, 1962). Only when our physical needs are met and we feel safe are we able to turn our atten- tion to achieving long-term goals.
Measuring Resiliency
Resiliency can be a challenge to measure. For starters, it may vary across time. A child may seem resilient at one time only to show negative effects at a later developmen- tal period. Furthermore, a child may be resilient in one domain and not another (Afi fi & MacMillan, 2011). For example, a maltreated child may perform well in school but struggle with relationships. For this reason, it is suggested that research- ers assess functioning across a range of domains and at different points in time. It is also suggested that researchers get information from multiple sources. For instance, maltreated children have been known to report themselves as socially competent when their teachers rated them as socially defi cient (Heller, Larrieu, D’Imperio, & Boris, 1999).
In samples with young participants, researchers often compare the rates of inter- nalizing and externalizing symptoms found in maltreated youths to those seen in the general population. Research with adults has focused on assessing for psychologi- cal problems, measuring self-esteem, and examining the ability to form appropriate relationships (Afi fi & MacMillan, 2011).
Most researchers agree that it is best to use multiple indicators of functioning (see Focus on Research 10.1 ). A potential source of information is self-report data. One scale designed to measure resiliency, the Ego-Resiliency Scale, was devised in 1996 by J. Block and Kremen. This short, 14-item questionnaire assesses how well an individual can change his or her behavior to meet the demands of changing situ- ations. People taking this test are asked to respond to statements such as “I quickly get over and recover from being startled” and “I enjoy dealing with new and unu- sual situations” (J. Block & Kremen, 1996, p. 352). Another scale that was created to measure potential resiliency is the Child and Youth Resilience Measure (CYRM ) (Ungar & Liebenberg, 2009). This scale consists of 28 items and measures available
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235RESILIENCE
support in four areas: individual, relational, community, and culture. This test is appropriate for use with people from 12 to 23 years of age (Collin-Vezina, Coleman, Milne, Sell, & Daigneault, 2011). People who have more protective factors within themselves and in their environment are expected to be more resilient.
FOCUS ON RESEARCH 10.1
McGloin and Widom (2001) were interested in assessing how common resiliency was among adults with a history of substantiated child maltreatment. They interviewed 676 young adults who had been maltreated as children and 520 matched participants who had not been maltreated. During a 2-hour interview, participants were assessed on eight dimensions: employment, homelessness, educational level, social activity, psychiatric problems, substance abuse, criminal arrests and self-reported violence. First, in keeping with the research on the negative consequences of maltreatment, the maltreated group was less successful than the control group on 6 of the 8 dimensions. The researchers did not fi nd signifi cant differences on social activity or substance abuse. Both groups had relatively high levels of success on the social activity dimension (66.3% for the maltreated group and 65.9% for the control group). The rates of success with regard to substance abuse were below half for each group (38.2% for the maltreated group and 43.6% for the control group).
In order for a participant to be considered resilient, they had to have success on at least 6 of the 8 dimensions assessed. The rate of resiliency for the maltreated group was 22.1% overall. Maltreated females were signifi cantly more likely to be resilient (26.6%) than were maltreated males (17.6%). As expected, the control group had a signifi cantly higher rate of success across dimensions (41.2% were successful in at least 6 of 8 areas). As seen with the maltreated group, females in the control group were more likely to be successful (51.3%) than were males (32.5%).
With regard to the six dimensions in which the maltreated group was signifi cantly less successful than the control group, the lowest rate of success was seen with regard to employment. Only 19.3% of maltreated adults had a successful employment history (e.g., they had not been fi red or quit a job without having another one in place, and they had not had more than three jobs in 5 years). The control group had a signifi cantly higher success rate for employment (29.6%). Despite less than ideal employment, most participants were successful at avoiding homelessness (74.4% for the maltreated group, and 87.7% for the control group). High school graduation rates were signifi cantly lower for the maltreated group (48.5%) than for the control group (67.5%). Almost half of the mal- treated group (48.1%) was free of psychiatric problems assessed for (depression, dysthymia, generalized anxiety disorder, posttraumatic stress disorder, antisocial personality disorder) while 60.8% of the control group did not have these psychiatric problems. More control participants did not have an arrest record (57.5%) than was true for maltreated participants (43.5%). Finally, fewer maltreated participants self-reported no violence (67.8%) than did members of the control group (77.1%).
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236 TYPES OF ABUSE AND THEIR EFFECTS
In addition to using scales specifi cally designed to measure resilience, researchers have also used a myriad of tests and interview formats to assess functioning in many different domains. Information can be garnered from tests (psychological and intelli- gence) and interviews of the target person and others who know them (e.g., teachers, peers) as well as public records (e.g., for criminal behavior).
The most commonly used measure in research with children is the Child Behavior Checklist (CBCL). This requires the child as well as the child’s parents and teachers to answer questions about the child’s behavior and emotional func- tioning. Other researchers make use of tests designed to assess for a particular problem (e.g., Children’s Depression Inventory) or competence (e.g., Mini Battery of Achievement for Math; see Walsh, Dawson, & Mattingly, 2010). When assessing for trauma symptoms, researchers have made use of the Trauma Symptoms Check- list for Children (TSCC). The TSCC consists of 54 items that measure symptoms of anxiety, depression, anger, posttraumatic stress, dissociation, and sexual concerns (Collin-Vezina et al., 2011). An absence of these symptoms would be indicative of resilience.
Incidence
Not surprisingly, the incidence of resiliency is strongly infl uenced by how resilience is measured. For instance, in one study, the authors noted that if they considered a child to be resilient if they had scores in the normal range or above (one stand- ard deviation below the mean and above) on the Mini Battery of Achievement for reading than 75% ( n = 762) of the maltreated children they studied were resilient. However, if they defi ned resiliency as above average performance (more than one standard deviation above the mean), that number dropped to 22% (Walsh et al., 2010).
Even if you focus on the absence of negative effects and do not require the child to be above average, resiliency rates vary based on how many factors are assessed. Walsh et al. (2010) assessed the performance of children with substantiated cases of maltreatment. Among children aged 8 to 10 years, they examined nine measures of competence across three domains: behavioral, emotional, and educational. For any given measure, they found that 66% to 88% of the children were competent. How- ever, regarding the three domains, 27% were poor in all three, 19% were below normal in two, 27% were defi cient in one domain, and only 27% were competent across all three domains. Therefore, only 27% of the children were considered resilient.
The same pattern of results was seen with the adolescent sample that ranged in age from 11 to 15 years ( n = 1,041). In any given measure, the rates of competence ranged from 43% to 89%. In terms of the domains, 24% were functioning poorly in all three domains, 40% were below average in two domains, 20% were not competent in just one domain, and only 16% were competent in all three domains and, therefore, labeled as resilient (Walsh et al., 2010). Therefore, if resilience were defi ned as the score on a single measure, rates of resiliency could be as high as 89%, and if compe- tence in all three domains were required for resiliency, the rate would drop to 16%.
When reading research on resiliency, be sure to pay attention to exactly how resiliency was measured. With that warning in mind, when competence in sev- eral domains is required to achieve resiliency, rates among maltreated children tend to range between 16% and 35% with more females than males being resilient (McGloin & Widom, 2001; Walsh et al., 2010).
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237RESILIENCE
Factors Associated With Resiliency
What makes some people resilient in the face of adverse circumstances? Researchers in the last two decades have started to examine this question. The quest has been to fi nd factors that are associated with better outcomes in the face of child maltreat- ment. These factors have been referred to by various names including protective factors, compensatory factors, and even resilience factors (Masten & Wright, 2008).
Level of Trauma Suffered
Although it might seem obvious, it is the case the children are more resilient fol- lowing a low- to moderate-level trauma than a high-level trauma (Cloitre, Morin, & Linares, 2004). All else being equal, we would expect children who suffer severe abuse to have more diffi culty being resilient than children who suffer milder forms of maltreatment.
Herrenkohl, Herrenkohl, and Egolf (1994) studied a group of 23 adolescents who had a history of child maltreatment. Based on their teachers’ ratings and their school records, they were categorized as high, middle, or low functioning. In order to be high functioning, the teenagers had to be doing well (in the top 40%) in three domains: academic, social, and emotional functioning. Being in the bottom 40% in all three domains led to the label of low functioning. Of the 23 adolescents, 6 had a history of chronic physical abuse perpetrated by both parents or perpetrated by one parent with no protection from the other parent. All six of these adolescents had dropped out of school prior to graduating from high school. By contrast, of the 14 adolescents who were rated as high functioning, 9 had experienced only sporadic abuse at the hands of one parent while the other parent provided some degree of support. The teenagers with more abuse and less support in their past were less likely to be resilient than those with less abuse and more support.
Looking at survivors of child sexual abuse, Liem, James, O’Toole, and Boudewyn (1997) did not fi nd many differences between the sexually abusive experiences of their resilient group ( n = 40) and their nonresilient group ( n = 105). For both groups, the abuse started between the ages of 8 and 9 years, lasted for approximately the same length of time, and was perpetrated by a family member at the same rate (30%) as opposed to by someone outside of the family. There was, however, one difference in the quality of maltreatment suffered by each group. Participants in the nonresil- ient group were more likely to report that overt physical force had been used (54%) during their abuse than were participants in the resilient group (20%). Assuming that physical force is associated with more traumatic experiences, this fi nding supports the theory that higher levels of trauma are associated with lower levels of resiliency.
Family and Caregiver Support
One consistent fi nding in the literature is that people who are resilient report having had a supportive adult in their past. This person could be a parent, a foster parent, a teacher, or any alternative guardian. In some cases, a therapist fulfi lls this role. The important thing is that the child had a stable, consistent presence in their life. Having one person to trust seems to offset many of the negative consequences of maltreat- ment and other harmful life events. For victims of sexual abuse, having an adult who believes them and supports them when they disclose abuse has been shown to
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238 TYPES OF ABUSE AND THEIR EFFECTS
lead to a decrease in negative symptoms following abuse (Masten & Wright, 2008). Clancy (2009) quotes an adult survivor of child sexual abuse as saying,
After I told him he hugged me. He kept kissing me on the head and saying “I am sorry.” It was clear to me that it was not my fault and that I did the right thing by telling him. . . . He handled it, I think, very well. . . . I think it is one of the reasons today why I emerged undamaged. (pp. 173–174)
Although a reliable adult is clearly a protective factor, even having a peer who is prosocial and who obeys the rules is positively associated with resiliency (Masten & Powell, 2003). For adults, the role of a caring partner or spouse can increase resil- iency.
Having a supportive adult to turn to has been associated with a host of posi- tive outcomes in research on children. Those with a consistent caregiver had fewer posttraumatic stress symptoms, they were less likely to be depressed, they had fewer behavior problems, and they had better school achievement. As adults, those who had a stable, loving infl uence as they were growing up reported higher educational achievement, more housing stability, a better ability to support themselves, less violent behavior, a lower incidence of early parenthood, and better parenting skills (Houshyar & Kaufman, 2006).
A relationship with a reliable adult may lead to resilience in different ways. First, it may be that a positive, early relationship lets the child learn that other people can be counted on to provide support. Interacting with a caring adult allows the child to build confi dence in the belief that others will help when needed (Heller et al., 1999). This refl ects again the importance of early psychosocial development as described by developmental psychologist Erik Erikson. Erikson (1963) thought that the fi rst crisis a child had to resolve was deciding whether to trust others. If a child develops a sense of trust as an infant, they are better prepared to be resilient later in life. Second, it might also be the case that being cared for in a loving way increases the child’s sense of self-worth, which is what helps the child be resilient (Heller et al., 1999). Third, it may be that a caring adult is able to actually reverse the negative effects of a bad early experience. Animal research has shown that pre- and postnatal stress (e.g., separation from the mother) can lead to long-term neurobiological changes. These include neurochemical changes and changes in brain structure. However, these changes can be mediated by later good environ- ments (Houshyar & Kaufman, 2006).
A factor that is often closely related to having a consistent adult caregiver is having a stable family environment which is also associated with resiliency (Afi fi
& MacMillan, 2011). Coming from a family that experiences less stress and anger is associated with better outcomes in child victims (Masten & Wright, 2008). Furthermore, children are more likely to be resilient if they are raised by an authoritative parent (s). This parenting style involves a warm, loving response combined with clear expectations and boundaries. In addition to parenting style, parental involvement is important. Parents who spend time with their children and engage in shared activities with them have more resilient children (Oliver, 2007). Children who are resilient also tend to have adult role models who are able to resolve confl icts in
authoritative parent
a parenting style in
which parents are warm,
responsive, and loving
while also having high
expectations for their
child; they provide
reasons for discipline and
are appropriately fl exible.
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239RESILIENCE
positive ways (Cloitre et al., 2004). For adults, the role of a caring partner or spouse can increase resiliency.
Community Factors
In addition to having a caring adult or partner, social support more broadly defi ned has also been associated with resiliency. This support can come from extended family, friends, or the community (Masten & Wright, 2008). Community factors such as the presence of good schools and high-quality social services and health care services are associated with resilience. It is also good for children to grow up in communities that have prosocial clubs or religious organizations as well as libraries, recreation centers, and good public safety (Masten & Powell, 2003). These community centers provide both a positive supportive environment for the child and good role models for the child to emulate (Oliver, 2007). Not being able to draw support from a caring community is associated with more negative outcomes. For example, when a child lacks community support due to frequent relocations they are more likely to have academic problems (Heller et al., 1999).
Victim Characteristics
A good number of child characteristics are associated with resil- ience. Children with a positive self-esteem and those who have an easy temperament are more likely to be resilient than are other children. The personality traits of ego resilience and ego overcontrol have also been associated with resilience. People who are ego resilient are resourceful. They adapt well under conditions of stress. Ego overcontrol is defi ned as the ability to exert control over one’s impulses. People who have the trait of ego overcontrol are described as dependable and calm (Afi fi & MacMillan, 2011).
Unexpectedly, intelligence has not been consistently related to resilience. Many studies report weak links or no association between intelligence level and resiliency (Afi fi & MacMillan, 2011). Others, however, have noted positive relationships between cognitive factors (IQ scores, the ability to pay attention, and executive functioning skills) and later resiliency (Masten & Powell, 2003; Oliver, 2007). If intelligence promotes resiliency it might be that being intelligent allows the child to develop better coping skills and strategies to deal with their maltreatment. It might also be that intelligence leads to better school per- formance, which may then result in positive feedback and higher self-esteem, which is associated with resiliency (Heller et al., 1999).
Others have noted that resilience may be tied to how a child thinks about what happened to them. Resilient children may engage in cognitive strategies that allow them to cope more effi ciently with their maltreatment. Researchers have noted that resilient survivors of child sexual abuse disclose and discuss their abuse, mini- mize the abusive experience, attempt to reframe the experience in a more positive way, and refuse to dwell on the abuse (Himelein & McElrath, 1996) (See Focus on Research 10.2 ).
easy temperament
a temperament
characterized by the
ability to adapt quickly
to new experiences,
the tendency to have
a positive mood, and
normal patterns of eating
and sleeping
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240 TYPES OF ABUSE AND THEIR EFFECTS
Resilient children have also been found to be goal oriented and persistent. They are committed to completing tasks even in the face of early failure. Their goals are important to them and they enjoy the work involved in meeting those goals (Cloi- tre et al., 2004). Furthermore, resilient children have a tendency to be optimistic. They are hopeful and have faith that life is meaningful (Masten & Powell, 2003). Some researchers have noted a positive relationship between belief in a higher power and resiliency (Oliver, 2007). Spirituality might provide meaning for the victims and assure them of their worth despite what they have experienced. Participation in organized religion may also increase the amount of social support available (Heller et al., 1999). Others have noted that having a talent such as musical ability or being good at sports can increase resiliency. If children’s talents or gifts are valued by their peers or adults, it can increase their self-esteem (Oliver, 2007).
FOCUS ON RESEARCH 10.2
Himelein and McElrath (1996) conducted interviews with 20 female college students who were survivors of child sexual abuse. The average age of the participants was 18.2 years. Each participant was interviewed for 60 to 90 minutes. The goal of the trained interviewer was to gather information to answer fi ve questions: (a) How well adjusted was the woman presently? (b) What general coping strategies did she utilize? (c) What stressors had she experienced in the past? (d) What were the details of her sexual abuse experiences? and (e) What did she aspire to in the future?
The researchers found that 13 of the women were well adjusted and that 7 were not. The women who were in the high-adjustment group talked about their abuse experiences more easily. They volunteered more information and needed fewer prompts to talk about their past abuse. They were also able to provide information about the strategies they used to cope with the abuse. Conversely, 57% of the participants in the poorly adjusted group said they had not dealt with the abuse yet (Himelein & McElrath, 1996).
The positive coping strategies employed by the well-adjusted women included disclo- sure. Although only a few of the women had reported their experiences at the time they occurred, most said that talking about their experiences with friends and family had been benefi cial. The second strategy seen among the well-adjusted women was minimization. Either they claimed that the child sexual abuse had not been a major stressor in their lives, or they downplayed the impact that the abuse had on their lives. Members of the well- adjusted group went as far as to positively reframe the abusive experiences. They noted that they had grown and/or found meaning in adversity. Others noted that the abuse made them more cautious about men or taught them to engage in more self-protective behaviors. (Note that although these researchers found that minimization was associated with positive outcomes, many psychologists argue that this is a form of denial that is not, in the long run, benefi cial to survivors.) Finally, the well-adjusted women refused to dwell on the maltreatment. They had thought about the experiences in the past; they were not in denial. However, they made a conscious effort to move beyond the abuse experiences and not let them rule their present lives (Himelein & McElrath, 1996).
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241RESILIENCE
Another feature of resilient children is their ability to respond quickly to poten- tially dangerous situations. Not only do these children recognize danger; they are also able to adapt to the situation in order to avoid harm. This requires children to be vigilant, intellectually capable of devising a plan to keep safe, and able to keep their own emotions in check (Mrazek & Mrazek, 1987). In contrast, you may know children who seem oblivious of danger cues. These are the ones who will pester their mother even when it is clear that she is completely stressed and exhausted. They do not know how to assess the situation they are facing and to make a plan for a suc- cessful course of action.
When a professional is working with a maltreated child, he or she should try to identify and build on any protective factors that are present in the child’s environ- ment (Afi fi & MacMillan, 2011). Although it is not possible to make all children resilient, it may be possible to surround a child with more protective factors so they have the best chance to develop normally.
When looking at adults who are resilient, researchers have noted that they are more likely to have an internal locus of con- trol than are nonresilient adults. This means that they believe they can control the events that happen to them. People with an inter- nal locus of control believe that things occur because of their own actions and traits. It has been noted that having an internal locus of control for positive events is particularly important. People who attribute positive happenings to their internal characteristics tend to have higher self-esteem and lower levels of depression. As men- tioned earlier, both of these are associated with resiliency. On the other end of the spectrum, making external attributions for blame is associated with resilience in female sexual abuse victims (Heller et al., 1999). In other words, women who blamed their abuse on their abusers and not themselves were more likely to be resilient.
Resilient adults are also more optimistic than are their nonresilient peers. In addition, resilient adults have lower levels of self-destruction and self-blame than do nonresilient adults. Self-destruction includes a variety of negative behaviors includ- ing suicide, self-harm, eating disorders, and substance abuse. Self-blame involves holding oneself responsible for negative events and fi nding fault with one’s past behavior (Afi fi & MacMillan, 2011).
The Interaction of Genes and Environment
In 2003 Caspi et al. published an article in Science that addressed the question of why stressful experiences led to the development of depression in some people but not in others. They focused on a gene, 5-HTT, that regulates serotonin lev- els in the brain. Serotonin is a neurotransmitter that is important in the control of mood, as well as sleep and memory. The 5-HTT gene has two alleles, and each allele is either short or long. Among Caucasians, the most common allele combination is to have one short allele and one long one (51%). About one third (31%) of Caucasians have two long alleles, and about 17% have two short alleles. Afri- can Americans are more likely to have long alleles, and Asians are more likely to have short alleles. The combination of alleles is
internal locus of control
the tendency to
attribute the cause of
events to individual or
internal causes rather
than to external or
environmental factors
allele
one of two or more
alternative forms of a
gene found at the same
place on a chromosome
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242 TYPES OF ABUSE AND THEIR EFFECTS
important because researchers have found that people with short alleles are more likely to suffer from depression following a negative life event than are people with long alleles. One short allele is associated with moderate risk whereas two short alleles are related to a high risk. People with two long alleles are not likely to develop depression even if they face diffi cult circumstances. In the sample of 847 adults (26 years old) studied by Caspi et al. a history of child maltreatment was only associated with adult depression in adults who had at least one short allele.
Kaufman et al. (2006) studied a sample of 196 children (109 maltreated children and 87 children who were not maltreated). The children in the sample ranged in age from 5 years to 15 years. They assessed the children for psychiatric symptoms, they measured the social support the children received, and they tested the 5-HTT gene. They found the highest levels of depression in the children with two short 5-HTT alleles and a history of maltreatment. Nonabused children with two short alleles were not found to be depressed. When they assessed the role of social support, they found the highest levels of depression among maltreated children who had two short 5-HTT alleles and poor social support. This works illustrates the interaction between genetic predisposition and environment in creating children who are at risk or resil- ient (see Case Example 10.3 ).
CASE EXAMPLE 10.3
Emily Bazelon (2006) fi rst met two maltreated girls in 1993 when she was working as an intern for a local paper. Both of the girls, La’Tanya and Tichelle, were the victims of child sexual abuse that went on for years. The perpetrator was their mother’s boyfriend, Earl Osborn. When the girls told their mother, Jean, about the abuse, she made Earl leave the house, but he kept coming back. Jean put a lock on the girls’ bedroom door, but Earl simply broke it—three times. La’Tanya, the older child, was in sixth grade when she told a social worker what was occurring. Both girls testifi ed at Earl Osborn’s trial, and he was sentenced to 85-years in prison.
Bazelon was impressed with the girls, and she kept in touch with them long after she left the paper. She noted that despite the abuse and growing up in a poor, black neigh- borhood, they were functioning well. At the age of 26, La’Tanya was a certifi ed nursing assistant who was raising her two children and Tichelle was a computer operator with a son. Both had graduated from high school. In addition to being employed, each woman had her own apartment and owned a car. Bazelon attributed their resilience to several fac- tors. First, the girls looked after each other and leaned on each for support. They also had the support of their maternal grandmother, and La’Tanya developed a close relationship with an older half-sister (Bazelon, 2006).
Despite the fact that both girls were doing well, Bazelon (2006) noted that La’Tanya seemed to struggle more than her sister did. As an adult, Tichelle was able to forgive her mother and develop a positive relationship with her, but La’Tanya was not. La’Tanya also suffered crying spells and panic attacks. Because La’Tanya was older, she might have had to bear more responsibility than did Tichelle. However, Bazelon wondered if there was also a genetic factor at play. Both girls agreed to testing, and it was revealed that Tichelle
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243RESILIENCE
carries two long forms of the alleles for 5-HTT whereas La’Tanya carries one long form allele and one short form allele (Bazelon, 2006). Therefore, it is also possible that La’Tanya was genetically predisposed to struggle more in the face of adversity than was her sister.
CASE POINTS
1. Resilience can be seen as the lack of negative consequences. Resilience can also be defi ned as doing better than expected given one’s life experiences.
2. Having a supportive adult can help children overcome maltreatment. 3. Genes and environment can interact to predict resiliency.
DISCUSSION QUESTIONS
1. Would you argue that Tichelle is resilient? Why or why not? 2. Would you argue that La’Tanya is resilient? Why or why not? 3. Tichelle and La’Tanya’s mother failed to protect her daughters from sexual abuse? Do
you think she was guilty of child maltreatment? If so, what type of maltreatment is she guilty of committing?
4. Should we test victims for 5-HTT as a way to assess risk? Why or why not? 5. Would you like to know what 5-HTT alleles you carry? Why or why not?
NOTE
1. Middle names were used to protect the privacy of the family.
CONCLUSION
All children who are the victims of child maltreatment suffer at the hands of those who abuse or neglect them. Many of these children carry lifelong physical and emo- tional scars. Sadly, the pain of maltreatment, along with missed opportunities for healthy development, means that some victims are never able to achieve their full potential. However, as seen in this chapter, other victims are resilient; they succeed in spite of a deck stacked against them. This does not mean that what happened to them was all right or that it was not painful, but it does provide hope and a direction for future interventions. While working to eradicate all maltreatment, we can try to fi nd factors that increase resiliency so that we can best support all victims and that increase the chance that they lead happy and fulfi lling lives.
DISCUSSION QUESTIONS
1. Do you think the defi nition of resilience should be normal functioning follow- ing adversity (e.g., the lack of negative consequences) or superior functioning following adversity? Why?
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244 TYPES OF ABUSE AND THEIR EFFECTS
2. The research indicates several child factors that are associated with resiliency. Can any of them be changed to help children be more resistant?
3. If you were given a $5 million grant to increase the rate of resiliency for mal- treated children in your community, what would you do?
4. As seen in the Case Examples, some past victims of maltreatment dedicate large amounts of time and money to aid other victims. What do you think motivates this behavior?
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PART III
Legal Issues
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247
CHILDREN PROVIDING TESTIMONY
Forensic interviewing is the term used to describe attempts to elicit information from witnesses for use in a legal setting (Steele, 2012). Following the increase in attention given to the sexual abuse of children in the 1980s, states began to make changes in their laws that made it easier for children to provide testimony in court. Because children are frequently the only witnesses in cases of alleged abuse, it was imperative to have their testimony if prosecutors hoped for a conviction (Mart, 2010). In order to allow children to provide this type of evidence, two signifi cant changes were made. First, chil- dren were allowed to provide uncorroborated testimony in cases of alleged sexual abuse. This meant that children could testify to an event even if what they said was not supported or confi rmed by any other evidence or authority. Second, states eliminated the compe- tency requirement for child witnesses. Prior to the changes made in the 1980s, many states had age requirements related to competency, such as 10 or 14 years of age. However, the trend has been to move away from age requirements and to presume competence. In federal courts, the competency rules were abolished by Federal Rule of Evi- dence 601, which states that all witnesses are presumed competent, and it is up to the jury to assess the accuracy of testimony. This trend has been followed on the state level to varying degrees (Sagatun & Edwards, 1995). The result is that there has been a signifi cant increase in the number of children who are providing testimony in court.
THE ACCURACY OF CHILDREN’S TESTIMONY
The concern about these changes revolves around the question of how good children are at providing testimony. In the early 1980s when concern about sexual abuse was at a peak, little was known about how accurate children would be in a legal setting. The atten- tion given to some very high-profi le cases, such as the McMartin case in California, focused the media spotlight on children as wit- nesses and raised a plethora of questions (see Case Example 11.1 ).
CHAPTER 11
Forensic Interviewing of Child Victims
forensic interviewing
an interviewing
technique used to elicit
verbal information from
witnesses for use in a
legal setting
testimony
evidence given by a
witness who is under
oath at trial or in an
affi davit or a deposition
uncorroborated
a fact or statement that
is not supported or
confi rmed by additional
evidence or authority
Federal Rule of
Evidence 601
a rule governing the
admissibility of evidence
at trials in federal courts
that states that every
person is presumed
competent unless
otherwise noted in the
Federal Rules. Because
the rules do not list
age as a requirement,
children are presumed
competent.
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248 LEGAL ISSUES
The research that has taken place in the last two decades has demonstrated some strengths and some serious weaknesses in children’s ability to provide accurate tes- timony. The concerns are related specifi cally to information that is gathered from children for forensic purposes. In other words, the research presented here is focused on whether the statements given by children are appropriate for use in a court of law.
CASE EXAMPLE 11.1
The case that captured the nation’s attention with regard to child sexual abuse was the McMartin day care case in California. Virginia McMartin, 79 years old, had started a pre- school and hired family members to help her run the facility. Her daughter, Peggy Buckey, served as an administrator, and her grandchildren, Ray and Peggy Ann Buckey, were teach- ers. All was going well until 1983, when a mother, Judy Johnson, called the day care and was told that the center was at capacity and her son could not attend at that time. Ms. Johnson ignored this information and proceeded to drop off her 2-year-old son, Matthew, at the day care, where she left him in the yard. In a decision they would come to regret, the adults at the preschool began to provide day care for Matthew (Ramsland, 2007). Ms. Johnson was a psychologically unstable woman who was separated from her husband. She also seemed overly concerned with her son’s anus. Apparently, at some point Matthew had complained that it hurt when he had bowel movements. Ms. Johnson then specifi cally asked if Ray, the only male teacher at the day care, had hurt Matthew’s bottom. Matthew denied that Ray had hurt him, but Ms. Johnson persisted in her questioning. Finally, Mat- thew said that Ray had taken his temperature. Ms Johnson then took Matthew to the hospital for a rectal exam. At that time, she told the doctors that Matthew had been tied up and photographed naked at the school. She also added that other children had been simi- larly abused. Matthew was then taken to the Children’s Institute International (CII) at the University of California, Los Angeles (UCLA), where he was seen by an intern. This intern accepted Ms. Johnson’s story and diagnosed Matthew with penile penetration of the anus. Matthew was then sent to the Richstone Center for counseling for sexual abuse victims. Because Ms. Johnson said that Matthew had told her that other children were involved, police told parents who had children at the day care to question their children. All of the children denied having been abused. Ms. Johnson continued to tell stories of sexual abuse, and the media began to cover her allegations (Ramsland, 2007).
On September 7, 1983, Ray Buckey was arrested. However, because there was no physi- cal evidence and no confession, he was soon released. The police then sent a letter to parents who had, at any time, had a child at the day care. They told the parents what to look for in their children, and told them to question their children. The parents were told not to take no for an answer. Priests instructed parents on the techniques used by satanic cults and joined the police in telling the parents to question their children. At fi rst, the children continued to deny abuse, but as they were questioned repeatedly and counseled at CII, they began to make allegations. This intensifi ed the police’s search for evidence, especially pictures. Their search for physical evidence was not successful (Ramsland, 2007).
The interviews of the children continued. The interviewers used anatomically detailed dolls and puppets in attempts to help the children tell about what had happened. The
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249FORENSIC INTERVIEWING OF CHILD VICTIMS
children were pressured, even coerced, to tell. One young girl fi nally said that she was abused, but not by Ray. She pointed the fi nger at Peggy Buckey. Allegations later spread to the entire staff at the day care. Children who made allegations were promptly reinforced for their bravery. Children who continued to deny abuse were thought to be repressing memories, and the therapists set to work uncovering those memories. The children began to tell stories, not just of sexual abuse but of bizarre happenings. Children talked of under- ground tunnels, being taken to cemeteries to dig up and cut corpses, and torturing and killing animals. Matthew’s mother said her son reported being taken by plane to visit a goat-man, and once there, Matthew was forced to stick his fi nger in the goat’s anus. As the media hysteria grew, people began to attack the McMartins and the Buckeys. Their prop- erty was vandalized, and they were physically accosted (Ramsland, 2007).
The grand jury indicted all seven members of the staff at the day care on more than 150 counts. The district attorney added counts to bring the total to 208. In April of 1987, the defendants were imprisoned, and all but Virginia were denied bail. This denial of bail was based on an unsubstantiated claim by the prosecution that the defendants would intimidate witnesses if they were released. Following these events, paranoia seemed to run rampant. The children continued to make allegations against the seven who had already been arrested and against neighbors, babysitters, and coaches. Interestingly, these allega- tions were never pursued by the police. In the meantime, the behavior of Ms. Johnson continued to deteriorate. She claimed someone had raped her dog, she wrote a letter to the prosecuting attorney saying that she could not tell fantasy from reality, she accused her husband of sexually abusing their son, and she was drinking heavily. Ms. Johnson was eventually diagnosed with paranoid schizophrenia, and her son, Matthew, went to live with relatives (Ramsland, 2007).
At the preliminary hearing, much of the children’s testimony was bizarre. The result was that the charges against fi ve of the defendants were dropped. Only Ray and Peggy were to be tried. At this point Peggy was released on bail, but Ray remained in jail. Shortly after this, the original accuser, Ms. Johnson, died due to problems associated with alcohol use. Later, the defense learned of Ms. Johnson’s letter, which the prosecution had failed to share with them (Ramsland, 2007).
Despite these events, at the time of the trial, members of the community were con- vinced that the McMartin day-care staff was guilty. In one survey, 97.5% of respondents said that they thought the employees of the McMartin day care should be convicted. Even with this information, the judge denied a change of venue, and the trial began in April of 1987. The best 11 children from the preliminary hearing were called to testify. The medi- cal evidence presented by the prosecution was controversial in that the expert they used, Dr. William Gordon, was not a medical doctor, and he had no formal education in diag- nosis. Furthermore, he had been banned from testifying as an expert in other countries. The jurors also saw some videotaped interviews that contained very poor interviewing techniques. A defense expert, Dr. Michael Maloney, testifi ed about the problematic nature of the interviews. The trial lasted 28 months and cost the state more than $15 million. In January 1990, the jury was hung on 13 charges (all related to Ray, not Peggy) and acquitted on all others. Five months later, Ray was tried again on those 13 charges. When the jury deadlocked, the charges were dismissed. By then, Ray had spent 5 years in jail (Ramsland, 2007).
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250 LEGAL ISSUES
Conditions Related to Accurate Testimony
The good news is that under certain conditions, even young children can provide accurate testimony about events they have experienced. First, children who give spontaneous accounts of abuse are generally believed to be truthful and accurate. So, if a child comes up to you and tells you, without prompting, that he or she is being abused, you should make the assumption that the account is likely accu- rate and make the appropriate report to Child Protective Services (CPS). Because this untainted testimony is believed to be more accurate than what a child might say after repeated questioning, you should do your best to record exactly what the child said to you. Professionals are even more confi dent about the accuracy of a child’s memory if there is a minimal delay between the alleged incident occurring and the telling of it. Because memory decays with time, the more immediate the telling, the more confi dence we have in the details (see Case Example 11.2 ).
As a postscript to this story, in November of 2005, the Associated Press reported that Kyle Zirpolo, one of the children who had made accusations, admitted that he had lied. Zir- polo stated, “I’m not saying nothing happened to anyone else at the McMartin Preschool. I can’t say that—I can only speak for myself. But I never forgot I was lying” (Associated Press Worldstream, 2005, p. 1). Zirpolo was one of the older children in the case. He was 8 years old at the time he made allegations. Although he testifi ed before the grand jury, he did not testify at the trial. Zirpolo said he was coming forward now to provide an example for his children about doing the right thing (Associated Press Worldstream, 2005).
The media attention given to this case greatly increased public awareness of childhood sexual abuse. It also prompted researchers to explore how children respond to interviewing techniques.
DISCUSSION QUESTIONS
1. What mistakes were made in the investigation of the McMartin case? 2. Given the way that information was collected in this case, is it possible to know, for
certain, whether abuse occurred at the day care? 3. In what ways is the McMartin case similar to the Salem witch trials? 4. What role did the media play in this case?
CASE EXAMPLE 11.2
When Samantha Runnion was abducted, she was taken in the presence of her 5-year- old playmate, Sarah. When the police arrived, just 4 minutes after the abduction, Sarah explained that the man had asked the girls to help him fi nd his dog. She also described his appearance, his car, and his accent. The details Sarah provided were excellent and accu- rate. For instance, she reported that the car was green and that it had an H on the trunk. Sarah even worked with a sketch artist and created a picture that was a close match to the
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251FORENSIC INTERVIEWING OF CHILD VICTIMS
The problem is probably one that you have already recognized. Many children do not spontaneously tell others that they are being abused. It is common for abused children to delay disclosure (London, Bruck, Wright, & Ceci, 2008). Some children are afraid, others are ashamed, and still others do not realize that what is happen- ing is wrong or unusual. Therefore, it is frequently necessary for concerned adults to ask children questions about what is going on in their lives. Research has shown that children tend to be accurate when responding to open-ended, unbiased questions. Open-ended questions are those that can- not be answered with a single word. An interviewer should not ask a child, “Did Mr. Bob hurt you at day care?” A better question would be “What do you do at day care?” The fi rst question is not only closed; it is also biased. By associating Mr. Bob’s name with hurt , the child is being led to give the expected answer. Interview- ers should avoid providing the child with names or specifi c events in the context of their questions. If this sounds easy, try to come up with a series of questions that you could ask a 3-year-old that are open-ended and unbiased. Given that many young children do not provide much detail when they respond to open-ended ques- tions, getting information can be a real struggle. If an interviewer believes the child is being abused, there is an incentive to push the child with more pointed questions. The question for researchers is whether a child could be con- vinced that something bad had happened when it did not, simply by the way the child is questioned.
Suggestibility
Children seem to be especially prone to suggestibility. Early studies demonstrated that it was relatively easy to change a child’s mem- ory for story details. For instance, Ceci, Ross, and Toglia (1987) had researchers read a story to 182 children between 3 and 12 years of age. Part of the story included the information that the main charac- ter, Loren, had eaten eggs for breakfast and later got a stomachache.
perpetrator, Alejandro Avila, who was subsequently arrested and charged with Samantha’s abduction and murder (Lewin, 2002).
CASE POINT
Despite Sarah’s young age, she was able to provide good information when questioned immediately after the event by an interviewer who had no preconceived notions about what had happened.
DISCUSSION QUESTIONS
1. Would you expect all 5-year-old witnesses to be as competent as Sarah? 2. What did the investigators do correctly in this case?
unbiased question
a question that is worded
in such a way that it
does not infl uence the
respondent’s answer.
open-ended question
a question with no set
of anticipated responses;
the respondent is free to
give any answer.
suggestibility
accepting or acting
on something that is
implied by another
person.
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252 LEGAL ISSUES
The story was accompanied by eight pictures. One day after hearing the story, half the children received misleading information. In the biased condition, children were asked, “Do you remember the story about Loren, who had a headache because she ate her cereal too fast? Then she felt better when she got to play with her friend Tricia’s Pac Man game?” (Ceci et al., 1987, p. 40). In the unbiased condition, the children were simply asked, “Do you remember the story of Loren, who was sick? Then she felt better when she got to play with her friend Tricia’s Pac Man game?” (Ceci et al., 1987, p. 40). Two days later, all children were asked to pick which two out of four pictures had been in the story. The pictures were of Loren eating eggs, Loren eating cereal, Loren with a stomachache, and Loren with a headache. Children in the biased condition made signifi cantly more errors than did children in the unbiased condition. Instead of choosing photos that represented the original story, they selected photos that depicted what the biased interviewer had suggested. There were no age differences in the unbi- ased condition, but in the biased condition, young children made signifi cantly more errors than did older children. This research showed that children, especially young children, were very sensitive to suggestion by adults.
Although a number of other studies replicated the fi nding by Ceci et al. (1987), some researchers argued that the errors made in those studies were about peripheral details that were not relevant to the child. The argument was that although a child may confuse eggs and cereal, it did not follow that a child would falsely recall or report being abused. To this end, researchers tried to create events that were ethical but more relevant to questions about child abuse. Empirical studies began to appear in the literature that provided evidence that even children as young as 3 or 4 years of age were able to provide good information about action-related, salient events (Lon- don, 2006). For instance, in 1991, Rudy and Goodman had pairs of children (both 4 years old or both 7 years old) enter a trailer and join an unfamiliar man there (Note that the man was a stranger to the child, but he was known by, and working with, the experimenter). One child was selected to be a participant while the other watched. When the children entered the trailer, the man used puppets to interact with the girls, and he spoke with them about general topics such as siblings, pets, and school. During this time, the man also put on a mask for a brief period. After drawing mar- bles, he assigned one child to watch and one to participate. The participating child played a series of games with the man, including playing Simon Says, putting on a clown costume (over the child’s clothes), posing the child for photographs, hav- ing the child tickle the man and touch his nose (acting like a clown who is trying to make someone laugh), and thumb wrestling. Finally, the man helped the child remove the costume. Both children were praised for doing a good job, and both were given a small toy. Between 10 and 12 days later, the children returned individually to be interviewed. The interview began with open-ended, unbiased questions concern- ing what happened in the trailer, what the man looked like, and what games were played. The experimenter then asked specifi c (e.g., Did he kiss you?) and misleading (e.g., What color was the hat he was wearing on his head?) questions.
Rudy and Goodman (1991) found that the older children gave more correct information in response to free-recall questions and specifi c questions. However, participants and observers did not differ. They did fi nd that participants were more resistant to suggestion than were observers and that older children were less suggest- ible regarding actions that had taken place. Most important, Rudy and Goodman found that regardless of age or role, children made very few errors that would be rele- vant in the assessment of abuse allegations. The conclusion from studies such as this was that children were not suggestible about events that were relevant to themselves.
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253FORENSIC INTERVIEWING OF CHILD VICTIMS
This research did not allay all concerns about children’s testimony. First, Ceci and Bruck (1993) pointed out that although most of the children in Rudy and Goodman’s study did not make false reports in response to abuse-relevant questions, some did. In response to misleading abuse questions, 12% of the 4-year-olds falsely assented, as did 6% of the 7-year olds. The rate of false reports was even higher in response to direct abuse questions (18% for 4-year-olds and 10% for 7-year-olds). If we are considering basing a prosecution for alleged child abuse based on testimony, a false- positive rate of 1 in 10 children is a bit scary. The second concern about Rudy and Goodman’s (1991) results was that they had only asked the leading questions once. In real abuse cases, children are questioned repeatedly by their parents, the police, therapists, and CPS workers. Would children be able to resist an erroneous suggestion about central experiences if they were questioned repeatedly?
Repeated Questions
On average, a child involved in an abuse investigation will be interviewed 11 times (London, 2006). It is imperative to know whether asking questions more than once has an impact on children’s reports. To explore this question, a series of experiments was conducted to assess the impact of repeated questioning on preschool children’s memories. Ceci, Crotteau-Huffman, Smith, and Loftus (1994) asked children to pick a card from a set held by an adult. Written on the cards were certain events, some of which the children had actually experienced and others that they had not. The adult then read the card to the child and asked the child to think hard about it and then tell the adult whether it had ever happened to them. False events included getting a fi nger caught in a mousetrap and having to go to the hospital and seeing alligators eating apples on an airplane. The children were given prompts to help them think about each event (e.g., Who was with you? What were you wearing? How did you feel?). This procedure was followed once a week for 10 weeks. Then, the children were interviewed by a new adult and simply asked if the various things had hap- pened to them. If the child said yes, he or she was asked to provide more details (e.g., What happened next?). The results were surprising. Of the children, 58% assented to at least one of the false events, and 25% assented to the majority of the false events. Not only did they say that the false events happened to them; they gave elaborate, rich details, and provided coherent, convincing stories. It seemed that the children were not lying or making up the stories; they seemed to believe them.
After the study was completed, John Stossel of 20/20 aired a story about the experiment. The parents of one boy, Bill, gave Stossel permission to interview their 4-year-old son, but they told Stossel that they had briefed Bill 2 days before. They had told Bill all about the experiment, and they told him that the mousetrap story was all in his imagination. The parents said that it took some time to convince Bill of the truth, but that he fi nally admitted that the mousetrap story never happened. However, when Stossel interviewed Bill, he was still able to tell the mousetrap story. Bill’s story was rich with detail, including which fi nger was injured, and who had gone to the hospital with him. When Stossel challenged the accuracy of Bill’s story, the 4-year-old insisted, “But it really happened! It wasn’t just in my imagination.” This study showed that children could be made to believe that something had hap- pened that was relevant to them simply by repeating a question. Keep in mind that this happened after weeks of simple questioning. In real abuse cases, not only are children questioned repeatedly; they are also questioned in ways that are leading and even coercive (see Case Examples 11.1 and 11.3 ).
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254 LEGAL ISSUES
CASE EXAMPLE 11.3
Kelly Michaels, a preschool teacher at Wee Care, was charged with the sexual molestation of the children under her care. The case started after Michaels had left Wee Care and went to work at another day care. She had been at Wee Care for 7 months, and during that time, there were no complaints about her, and nobody reported seeing or hearing anything odd. Then, a boy who Michaels used to look after during naptime was having his temperature taken rectally by a nurse, when he commented that his teacher at day care did this to him. He did not seem upset or scared when he made the comment, and when queried, he said, “Her takes my temperature” (Ceci & Bruck, 1995, p. 12). On further questioning, the boy said the teacher’s name was Kelly and that she also took the temperature of two other boys. At this point, his concerned mother called the police, and the investigation began (Manning, 2007). The two other boys denied that Michaels had taken their temperature, but when questioned by the assistant prosecutor, one said that Michaels had touched his penis. Two days later, this boy inserted his fi nger into the anal opening of an anatomically detailed doll (Ceci & Bruck, 1995).
After months of interviews, Michaels, 25 years old, was charged with 235 counts of sexual misconduct. The allegations were based solely on the testimony of young children, and they ranged from odd (e.g., playing the piano while naked, licking peanut butter off the children) to impossible (e.g., changing a child into a mouse). There was no physical evidence, even though many of the claims would have left such evidence (e.g., amputat- ing children’s penises). Despite every effort to fi nd physical evidence, the prosecution was not successful. For instance, after children claimed they had been forced to urinate on a piano bench, the bench was sent to the Federal Bureau of Investigation (FBI) for testing. The tests came back negative for urine. In addition, there were no adult witnesses to the alleged abuse (Manning, 2007).
Following a 9-month trial, the jury deliberated for 13 days before fi nding Michaels guilty. Michaels was convicted on 115 counts and sentenced to 47 years in prison. For the fi rst 18 months of her sentence, Michaels was in solitary confi nement for her own protec- tion. As Michaels sat in jail, her case was discovered by several journalists, including Debbie Nathan and Dorothy Rabinowitz, who raised public awareness about how her case was handled. Eventually, Morton J. Stavis, a well-respected attorney, decided to take Michaels’s case. An assistant to the defense team, Robert Rosenthal, asked researchers Bruck and Ceci (1995) to examine the interviews from the Wee Care case (Manning, 2007). After psycholo- gists reviewed transcripts of the interviews conducted with the children, they had serious concerns about the children’s testimony. Maggie Bruck and Steve Ceci fi led an amicus brief on Michaels’s behalf that highlighted problems with the interviews.
First, the children were asked the same question repeatedly. Consider the following exchange (Bruck & Ceci, 1995, p. 276) between an interviewer (Q) and a child (A):
Q: When Kelly kissed you, did she ever put her tongue in your mouth? A: No. Q: Did she ever make you put your tongue in her mouth? A: No.
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255FORENSIC INTERVIEWING OF CHILD VICTIMS
Q: Did you ever have to kiss her vagina? A: No. Q: Which of the kids had to kiss her vagina? A: What’s this? Q: No, that’s my toy, my radio box. Which kids had to kiss her vagina? A: No.
The children were also coerced. Specifi cally, the children were told repeatedly that their friends had already told the interviewers about bad things that Kelly Michaels had done to them (Bruck & Ceci, 1995, pp. 283–284).
Q: All the other friends I talked to told me everything that happened. 29C told me. 32C told me . . . And now it’s your turn to tell. You don’t want to be left out, do you?
Q: Boy, I’d hate having to tell your friends that you didn’t want to help them. The interviewers also suggested to the children that Kelly Michaels was bad (Bruck & Ceci, 1995, p. 276).
Q: Do you think that Kelly was not good when she was hurting you all? A: Wasn’t hurting me. I like her. Q: I can’t hear you. You got to look at me when you talk to me. Now when Kelly was
bothering kids in the music room— A: I got socks off. Q: Did she make anybody else take their clothes off in the music room? A: No. Q: Yes. A: No.
Other authors have highlighted different sections of questioning that also conveyed the idea that Michaels was bad (Manning, 2007, p. 5):
Q: You Wee Care kids seem so scared of her. A: I wasn’t. I’m not even. Q: But while you were there, were you real scared? A: I don’t know. Q: What was so frightening about her, what was so scary about her? A: I don’t know. Why don’t you ask her?
Finally, there were aspects of the interviewer’s questions that provided the children with explicit sexual information (Bruck & Ceci, 1995, pp. 276–278).
Q: Did you ever see Kelly have blood in her vagina? A: This is blood. Q: Kelly had blood in her vagina. A: Yeah. Q: She did? Did you ever get any of that blood on your penis?
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256 LEGAL ISSUES
A: No. Green blood. Q: Did you ever see any of your friends get blood on their penis from her vagina? A: Not green blood but red blood. Q: What did you put there? A: I put jelly right there. Q: Jelly. A: And I put jelly on her mouth and on the eyes. Q: You put jelly on her eyes and her vagina and her mouth. A: On her back, on her socks. Q: And did you have to put anything else down there? A: Right there, right here, and right here and there. Q: You put peanut butter all over? And where else did you put the peanut butter? A: And jelly. Q: And jelly? A: And we squeezed orange on her. Q: And you had to squeeze orange on her? A: Put orange juice on her. Q: And did anybody—how did everybody take it off? How did she make you take it
off? A: No. Lick her all up, eat her all up and lick her all up. Q: You had to lick her all up? A: And eat her all up. Q: Yeah? What did it taste like? A: Yucky. Q: So she made you eat the peanut butter and jelly and the orange juice off the vagina
too? A: Yeah. Q: Was that scary or funny? A: Funny, funny and scary.
In addition, the interviewers would not take no for an answer. If children admitted abuse, they were telling the truth. If they denied abuse, they were too scared to tell. A child could give to no response that would convince the interviewers that he or she had not been abused (Manning, 2007).
After reviewing all of the evidence, Ceci told a reporter, “The interviews with the children in the Michaels case are some of the worst I have ever heard. The children were undoubtedly abused, but probably not until they met the investigators” (Manning, 2007, p. 11).
Attorney Morton J. Stavis died before he could present his arguments to the appeals court, but his friend William Kunstler stepped in to take his place. The defense used research such as that covered in this chapter to raise concerns about the accuracy of the children’s testimony. Based on this evidence, the state appellate court overturned Michaels’s convic- tion. The judges were very critical of the way the children had been interviewed. This did not, of course, mean that Michaels was innocent, but only that her trial was fl awed. Prosecutors originally planned to retry her. However, in June of 1994, the Supreme Court
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257FORENSIC INTERVIEWING OF CHILD VICTIMS
of New Jersey ruled that there could not be a new trial without a taint hearing. This meant that it had to be determined whether the children’s testimony had been so tainted by the interviewers that it held no value or that truth could be discovered despite the poor tech- niques used. Knowing that there was no way to determine the truth after all that happened during the investigation, the charges were dropped in December 1994. At the age of 32, Kelly Michaels was free (Manning, 2007).
While this case may seem extreme, it is sadly not unique. If you are interested in read- ing about other cases, go to http://members.shaw.ca/imaginarycrimes/othercases.htm.
DISCUSSION QUESTIONS
1. What mistakes were made in the investigation of Michaels’s case? 2. Given the way that information was collected in this case, is it possible to know, for
certain, whether abuse occurred at the day care?
You may wonder why it is so problematic to ask a child a question more than once. One possible explanation is that adults know the answer to most of the questions they pose to young children. Think about the things we generally ask children: What color is my shirt? What is her name? What is this called? In all cases, the adult knows the correct answer. If the child provides the correct answer, the exchange ends, or the answer is rewarded. So, if I am wearing a red shirt and I ask a child what color my shirt is, and the answer is red, I either let it go or respond with something such as “You are so smart!” But what happens if a child says it is blue? A typical response from adults is to simply repeat the question, “What color is my shirt?” You will often hear an emphasis on the word what , which compounded with the second asking communicates to the child that the fi rst response was wrong. Most of the time children sense this and try another answer. Now, to put this in the context of an interview assessing allegations of abuse, consider the following question: “Did Mr. Bob hurt you at day care?” The child says, “No.” The adult says, “It’s OK; you can tell me. Did Mr. Bob hurt you at day care?” Well, there are only two answers to that question. No seems not to have worked, so the child tries yes. A concerned adult may then say, “You are so brave to tell me. You are a strong little boy. I am so proud of you!” This, of course, reinforces the yes answer. Although the adult knows that questions about shirt color and questions about abuse are very different, a young child would not necessarily know this.
Of course, it can be argued that thinking you had your fi nger caught in a mouse- trap is still a long way from thinking that someone molested you. In order to explore the question of children’s accuracy in an even more realistic scenario, researchers decided to question children following medical exams. After all, during a medical exam, a child is undressed and touched by an adult who is in a position of author- ity. Would a child say that a doctor touched his or her private parts when the doctor had not gone anywhere near the child’s private parts during an exam? Would the child continue to be accurate in reports of touching if asked leading questions or pre- sented with anatomically detailed dolls? Anatomically detailed dolls have vaginal, anal, and oral openings, and the adult dolls also have pubic and underarm hair. The theory behind using dolls is that a child may be able to show what he or she does not have the words to tell or about which he or she is too embarrassed to talk.
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258 LEGAL ISSUES
Although it is clear that repeating close-ended questions is problematic when interviewing young children, it might be a good thing to have repeated interviews in which open-ended questions are posed. Hershkowitz and Terner (2006) found that when children, aged 6 to 13 years, were interviewed twice with open-ended ques- tions, 25% of the information provided during the second interview was new and that much of this new information was forensically relevant.
Anatomically Detailed Dolls
Researchers have found that dolls are frequently used by professionals during the assessment of child sexual abuse allegations. Conte, Sorenson, Fogarty, and Dalla
Rosa (1991) surveyed 212 professionals (84 child protection work- ers, 98 mental health professionals, and 30 “others” including police offi cers and attorneys) who worked with sexually abused children. They found that 92% of professionals reported using anatomically detailed dolls in their interviews (see Figures 11.1 and 11.2). Kendall-Tackett and Watson (1992) conducted a similar study in Boston. They also found that police (62%) and mental health workers (80%) were likely to use anatomically detailed dolls.
FIGURE 11.1 Anatomically detailed dolls are generally presented to the children dressed as are the child dolls in this photograph. Photo credit: Monica L. McCoy.
anatomically detailed
doll
a doll with anatomical
details such as a penis or a
vaginal opening, an anal
opening, pubic hair, chest
hair, and underarm hair.
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259FORENSIC INTERVIEWING OF CHILD VICTIMS
Kendall-Tackett and Watson also reported that, contrary to what others had reported, almost all the professionals who used dolls (96.6%) were trained in using them, and many (77.8%) used a standard protocol. Furthermore, almost all of the professionals (98.6%) were careful to avoid the leading practices of presenting the dolls naked or undressing the dolls.
Given the high rate of doll use, researchers have attempted to evaluate the dolls’ strengths and weaknesses as interview tools. As mentioned earlier, researchers have examined the impact of using anatomically detailed dolls on young children’s reports about a medical exam (Bruck, Ceci, & Francoeur, 2000; Bruck, Ceci, Francoeur, & Renick, 1995). Bruck et al. (1995, 2000) interviewed children following a pediatric exam. Forty children age 3 (24 girls and 16 boys) and 44 children age 4 (24 girls and 20 boys) were randomly assigned to an exam with no genital touching or an exam with genital touching (Note that the researchers did not add the genital exam to the doctor’s visit; this study took place in a place where external genital exams were part of normal checkups.) After giving consent, the child’s parent accompanied the child to the examination room. The parent undressed the child, leaving underwear on, and dressed the child in a Mickey Mouse T-shirt and white socks that had been presented by the experimenter. The pediatrician, Dr. Francoeur, conducted a normal exam, with or without a genital exam, and added three odd steps. He measured the
FIGURE 11.2 Anatomically detailed dolls have anal and vaginal openings and genitalia as seen on these child dolls. Photo credit: Monica L. McCoy.
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260 LEGAL ISSUES
child’s wrist with a ribbon, he put a sticker on the child’s stomach, and he tickled the child’s foot with a stick.
Immediately after the exam, while still dressed in the T-shirt, socks, and under- wear, children were interviewed in the presence of their parents. The children were shown two anatomically detailed dolls. One was dressed like the doctor, and the other was dressed like the child (Mickey Mouse T-shirt, underwear, and socks). The “child doll” was the same sex as the child being interviewed. The children were fi rst asked to name 11 body parts on the child doll. The experimenter then undressed the child doll and showed the child that it was a special doll. The children were then asked to provide their name for the buttocks and the genitals and to describe the function of those parts. Next, the children were asked direct, doll-assisted questions. For instance, the experimenter would say, “Did Dr. F. touch you here?” (Bruck et al., 2000, p. 76). This was asked while pointing to the genitals and again while point- ing to the buttocks. After these questions, the experimenter redressed the doll and asked the child to demonstrate, using the doll, what the doctor had done with a stethoscope, a ribbon, a sticker, and a stick. Finally, children were asked to show the experimenter how things happened by using the dolls. These demonstration ques- tions required the children to “Show me on the doll how Dr. F. touched your . . . ” The blank was fi lled in with the child’s term for buttocks, and then their term for genitals. In the next phase of questioning, the children were given a spoon and asked what Dr. F. did with the spoon. If they reported, correctly, that there was no spoon involved, they were asked what he could have done with the spoon and to demon- strate that with the dolls. Although this may seem to be a bizarre series of questions, it was based on questions used in the Kelly Michaels case (see Case Example 11.3 ). Finally, children were asked to demonstrate what had occurred using their own bod- ies instead of the dolls.
Bruck et al. (2000) found that children were not more accurate in the doll con- dition than they were in the no-doll (using their own body) condition. The dolls did not seem to improve recall. There was, as expected, an age effect, with the 4-year-olds being more accurate than were the 3-years-olds. On the doll-assisted questions and the doll-demonstration questions, the children were more accurate if they had not had genital exams (64% correct for 3-year-olds and 86% correct for 4-year-olds) than if they had received a genital exam (38% correct for 3-year-olds and
45% correct for 4-year-olds). This means that children were mak- ing more omission errors (failing to admit to genital touch) than commission errors (saying that genital touching occurred when it did not). However, as you can see from the percentage of cor- rect answers, errors of both types were prevalent. Bruck et al. also noted that, on average, boys were more accurate than were girls. Looking at the spoon questions, 38 of the children (45%) said Dr. F. had used a spoon in some way. Another 35 (42%) were willing to demonstrate what Dr. F. might have done with a spoon. Although most of the 73 demonstrations involved nonsexual touching or feeding, 15% of the children either touched the genitals with the
spoon or inserted the spoon into the doll’s vaginal or anal opening. This was more common behavior from 3-year-olds (18%) than from 4-year-olds (9%). In addition to these sexualized acts, 12 of the children (14%) used the props (stickers, stick, stethoscope) in a sexual way, and 11 (13%) showed aggressive behavior toward the doll (e.g., hit the doll with their hands or with objects). The authors concluded that
omission errors
mistakes that involve
failure to report
something that did occur.
commission errors
mistakes that involve
saying something
occurred when it did not.
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261FORENSIC INTERVIEWING OF CHILD VICTIMS
58% of 3-year-olds and 43% of 4-year-olds showed some sort of suspicious behavior during the interviews, with girls being more likely to do so than the boys. Bruck et al. caution that in light of minimal evidence to suggest that anatomically detailed dolls help children’s memories, and a growing literature of evidence that they can mislead children, dolls should not be used when questioning children younger than 5 years of age.
There are a number of reasons why play with dolls should be interpreted care- fully. First, young children may not fully understand what they are being asked to do. Use of a doll in this manner requires children to be capable of dual representation, the understanding that one thing can be two things at once. The child needs to understand that the child doll is not only a doll, but it is also a symbol, or a representation, of the child. Likewise, the adult doll is both a doll and the repre- sentation of the alleged perpetrator. DeLoache and Marzolf (1995) explored whether young children were able to comprehend this sort of task. They had 72 children who were 2.5, 3, or 4 years old play games with a male experimenter. Before the games started, the children were asked to pick a pillow to sit on and a necklace to wear. They were also given the opportunity to wear a cape if they wanted to. After these selections were made, the children played three games in random order: a sticker activity, Simon Says, and a puppet activity. Immediately after playing, the children were interviewed by a female interviewer. She used a doll in the interview, with the prompt “Let’s pretend this doll is you. This can be the [child’s name] doll” (DeLoache & Marzolf, p. 161). If the child had worn a cape, the interviewer put a cape on the doll and pointed out the similarity. If the child had refused the cape, the interviewer noted that the doll would also not wear a cape. Then, the child was instructed to pick a necklace for the doll that was like the one the child had worn. If the child made an error, the interviewer corrected him or her. This same routine was followed for the pillow selection. All this was done to stress that the doll was representing the child. Following this, children were provided with miniature (doll-sized) props and asked to show what they had done with the male experimenter. None of the children spontaneously used the dolls to answer this ques- tion. Next, the interviewer asked the children to reenact the play session using the doll to represent themselves. The researchers wanted to see if the children could map on the doll what had happened to them.
DeLoache and Marzolf (1995) concluded that you cannot assume that young children can use dolls as representations of themselves. First, some children fl at-out refused to even pretend the doll was them. One child said, “No, that is not the Evan Doll. You think I’m a doll or what . . . Doll not me” (DeLoache & Marzolf, 1995, p. 168). The children who attempted the representation were not accurate with even a simple task prior to the age of 4 years. For example, the children were not able to show, using the doll, how the male experimenter had put stickers on them. Regard- ing the touch-related questions with the Simon Says game, no child spontaneously used the dolls to demonstrate touch, and most failed to show on the doll what they had reported verbally, even when prompted to do so. Finally, when asked to dem- onstrate touch with the doll, children tended to touch a different place on the doll than what they had reported verbally. The dolls did not help the children add any new, correct information.
A second reason to be cautious when interpreting doll play is that there is evi- dence that an expert cannot determine abuse status based solely on interviews using
dual representation
the ability to think of
one object as being or
representing two things
at once.
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262 LEGAL ISSUES
dolls. Realmuto, Jensen, and Wescoe (1990) had a child psychiatrist interview 15 children (6 abused, 5 nonclinical controls, and 4 clinical/psychiatric but nonabused controls). The psychiatrist did not know the children’s status prior to the interview. He followed a standardized protocol for the interview that included 10 minutes of free play, followed by presentation of the dolls for 10 additional minutes. Based on the interviews, the psychiatrist attempted to assess each child’s abuse status. He was correct 53% of the time (8 of the 15 cases). Because this success rate is not signifi - cantly different from chance, the authors concluded that interviews with dolls are not suffi cient for diagnosis of abuse. However, they did note that their study was lim- ited by a small sample size. Part of the diffi culty inherent in using dolls to diagnosis sexual abuse is that even nonabused children will sometimes play with doll in ways that appear to be quite sexual. Children may not realize that what they are doing is even sexual; they may simply be playing.
Despite these concerns, some researchers do advocate the use of anatomically correct dolls. Their argument is that although the dolls should not be used as a diag- nostic test for sexual abuse, they can be used in other ways that are productive. For instance, anatomically correct dolls can be used as an anatomical model. Using this detailed model, the children can demonstrate for the interviewer what they call vari- ous body parts. Because many parents do not teach their children the standard names for private parts, it is important that the interviewer is able to learn what words a child uses to refer to a bottom or a penis. The doll can also be used to question the child about the function of various body parts (Everson & Boat, 1994). The current state of knowledge seems to be that dolls can be used if the interviewer is well trained and aware of the necessity to avoid leading or aggressive questioning. However, other professionals still argue that props should not be used in forensic interviews because little research exists to show that they improve the information provided by child and evidence is available to show that they increase the rate of errors, especially false positives. When interviewers use props children are more likely to report that they were touched when, in fact, they were not (Poole, Bruck, & Pipe, 2011).
Interviewer Bias
You may be asking yourself why investigators would question children so aggressively. The answer is that the interviewers assume the abuse has taken place, and it is their job to get the conviction. They are motivated to get a dangerous perpetrator off the
streets. While this passion can be a good motivator, it can also be dangerous when it comes to uncovering the truth. There is a long list of research studies, dating as far back as 1929, that show how powerful interviewer bias can be in shaping reports. It seems that humans are very good at eliciting the responses they expect to hear. People tend to have a bias toward information that confi rms their beliefs and they frequently ignore or reject information that does not support their beliefs (Goodman & Melinder, 2007). Social psycholo- gists use the term self-fulfi lling prophecy to refer to the process by which one person’s expectations about another person will actually lead that other person to behave in the expected way. One of the classic studies in this fi eld was conducted by Robert Rosenthal and Lenore Jacobson in 1968. Rosenthal and Jacobson told elementary schoolteachers that certain students in their class were on the verge
interviewer bias
the attitudes or actions
of the interviewer
infl uencing the
respondent’s answers.
self-fulfi lling prophecy
the process by which
one’s expectations about
a person leads that
person to behave in
ways that confi rm those
expectations.
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263FORENSIC INTERVIEWING OF CHILD VICTIMS
of an intellectual growth spurt. The teachers were told that this prediction was based on an IQ test, but in fact, the children were selected at random. Eight months later, the children who had been selected actually showed greater increases in IQ scores than did a control group from the same class, and their teachers rated them more positively. This fi nding has since been replicated and is accepted as a true description of what can occur. The researchers chose, for ethical reasons, to increase teacher expectations, but this could also theoretically work in the opposite direction. For instance, a teacher may have preconceived negative ideas about a child who is poor or who has a diffi cult older sibling. What is unfortunate about this research is that the teachers were not even aware they were treating the children differently.
Research has also demonstrated that an interviewer’s bias can change what a child reports about an event. A 1990 study by Pettit, Fegan, and Howie (as cited in Ceci & Bruck, 1995) tested the impact of interviewer bias on children’s subsequent reports. The researchers had two actors, pretending to be park rangers, visit a pre- school classroom. The rangers’ task was to have the children help a bird fi nd a nest so that it could lay eggs. During the presentation, one of the rangers knocked a cake off the piano, and it was smashed all over the fl oor. The response to this event was shocked silence on the part of the rangers. Two weeks later, the children were inter- viewed about the event by one of three interviewers. The fi rst interviewer was given no information about the event ahead of time, the second interviewer was given an accurate description of the event, and the third interviewer was given inaccu- rate information about what had occurred. All of the interviewers were warned not to ask leading questions. Despite this advice, 30% of the interviewers did ask lead- ing questions, and half of the leading questions were actually misleading. Children agreed with 41% of the misleading questions. What was most telling, however, was that the interviewer who had been given inaccurate information was almost 5 times more likely to ask leading questions than were the other interviewers. Translated to abuse investigations, this could mean that an investigator who had a mistaken idea going into an interview would be more likely to ask misleading questions than would an investigator who had an open mind or one who was armed with accurate information.
One way to lower bias is to conduct allegation blind interviews. In this situa- tion, the interviewer does not have prior knowledge of the allegations. In addition to reducing bias, allegation blind interviews are associated with higher disclosure rates (Cronch, Viljoen, & Hansen, 2006).
Negative Stereotypes
Another thing that can alter children’s memories of events is the creation of nega- tive stereotypes. If adults convince a child that someone is bad, or clumsy, or mean, it is easier to lead that child to recall the maligned adult behaving inappropriately. Leichtman and Ceci (1995) tested this empirically with their Sam Stone study. Chil- dren from 3 to 6 years of age were told that Sam Stone was going to visit their classroom. Prior to the visit, some of the children were told that Sam Stone was very clumsy (stereotype group). They were told stories about Sam accidentally break- ing things and creating messes. Then, Sam Stone visited the room. While there, he did not do anything clumsy; he did not break anything, nor did he have any accidents. Following the visit, children were interviewed four times over a 10-week period. Some children were interviewed in a suggestive manner (suggestion group).
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264 LEGAL ISSUES
These interviews included misleading questions about events that had not occurred (tearing a book and getting a teddy bear dirty). After these interviews, the children were interviewed by another adult who asked general questions about the book and the teddy bear. Children in the control group (no stereotype induction, nonsugges- tive interviews) were the most accurate. None of these children made false claims in response to being asked to tell what happened the day Sam Stone came to visit. When asked specifi c questions about a book or a bear, only 10% of the children 3 or 4 years old erroneously said that Stone had caused the damage, and only 5% said they had seen Stone do the misdeed. When these children were gently challenged with the question, “You didn’t really see him do anything to the book/teddy bear?” only 2.5% maintained their false report. Among the children ages 5 and 6 in the control condition, only 3.7% made any false claims, and this disappeared when they were asked if they had seen the misdeeds themselves.
The children who had the preconceived negative stereotype of Sam Stone did not respond as accurately. In their free narrative, 21% of the younger children and 14% of the older children made false statements. When asked specifi cally about the bear and the book, 53% of the young children falsely blamed Sam Stone, as did 38% of the older children. When asked if they actually saw Sam hurt the book or the toy, 35% of the young children said yes, and 12% maintained this response when chal- lenged. For older children, these percentages were 11% and 5%, respectively. Finally, the third group was exposed to both the negative stereotype and the misleading questions. They were, not surprisingly, the most likely to give incorrect responses. Among the 3- and 4-year-old children, 72% said that Sam Stone was responsible for at least one misdeed. If the children were asked if they actually saw Sam Stone do the bad thing, the rate of allegations dropped to 44%, and when they were chal- lenged, 21% maintained that they had seen the events. Furthermore, the children provided many details about the events that never occurred. Their stories, illustrated with hand movements and appropriate facial expressions, were very convincing. Although older children (5 and 6 years old) were more resistant to suggestion, they still made false reports (39% said Stone was responsible, 14% said they actually saw Stone damage the toys, and 5% maintained their story when challenged). Not only does this study show the danger of creating negative stereotypes, but it also shows how this problem can be increased by the use of misleading questions, especially when dealing with very young children.
Immigrant Children
One must take special care when conducting a forensic interview with immigrant children or even children born in the United States who have immigrant parents. Given that 12.5% of the people living in the United States were born in a foreign country, it is likely that an interviewer may be faced with this situation at some point in his or her career. The fi rst major hurdle is language. Twenty percent of Americans do not speak English in their homes. It is imperative that forensic inter- views be conducted in the preferred language of the person being interviewed. In addition, all forms should be available in this language as well. If interviewers are not completely fl uent in the language the child knows best, they must hire a trained interpreter. In a forensic setting, it is not appropriate to have family mem- bers translate for each other even if they offer to provide this service. Not only does
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265FORENSIC INTERVIEWING OF CHILD VICTIMS
the interviewer need to respect language differences; they also need to appreciate cultural differences. For instance, if a child is from a culture that stresses keeping problems within the family, the interviewer needs to work hard to make them com- fortable and to refrain from becoming frustrated with them or their parents and labeling them as uncooperative. As another example, if children are raised not to make demands of others, they may be reluctant to ask for things they need. In these cases, the interviewer needs to make an extra effort to ensure that the child is not thirsty or does not need to use the restroom before the interview begins. Finally, children from different cultures may develop certain competencies at different ages due to parental caregiving styles. Children who are encouraged to be dependent, or who are allowed to use a bottle past infancy, may seem delayed to U.S. interview- ers. However, if these things are normative for their culture, the child’s cultural group may not provide good information for a developmental assessment. Another point to keep in mind is that children who have immigrated may have experienced trauma unrelated to child abuse in their country of origin, during their migration, or after arriving in the United States. An interviewer should take a full trauma his- tory of each child. If interviewers are going to work with immigrant families, they should devote time to learning as much as they can about the culture of the fami- lies (Fontes, 2010).
A Word of Caution
Thomas D. Lyon (2001), a law professor at the University of Southern California School of Law, wrote an article titled “Let’s Not Exaggerate the Suggestibility of Children.” Although he applauds the research that has been conducted about the possible suggestibility of young children, he cautions against overusing the “sug- gestibility defense” (2001, p. 12). Lyon points out that although the highly leading techniques reviewed in this chapter have occurred in some high-profi le cases, they are not the norm. He asserts that most real-life interviewers do not use techniques that are as problematic as those seen in Kelly Michaels’s case and that many cases do not involve testimony from very young children who seem especially suggestible in research settings. Lyon notes that particularly dangerous techniques such as stereo- type induction and coercive questioning are rare. Lyon further notes that in research studies children are generally being led to make false statements about events that involved relative strangers, not loved ones. His argument is that children may be more resistant to the suggestion that a person they are close to hurt them. Since the majority of child sexual abuse cases involve familiar adults, this is forensically relevant. Because of these concerns, Lyon suggests that it is not appropriate in all child abuse cases for experts to testify about the literature on suggestibility. Instead, this sort of testimony should be limited to cases in which the investigators did, in fact, use improper techniques. This decision, according to Lyon, should be left to the judge in the case. In addition, when experts do testify, they should be very specifi c about what the research shows and avoid over-generalized statements that indicate that all testimony from children is suspect. Lyon is not, however, naïve. Although Lyon maintains that investigators are not regularly making the most egregious errors, he acknowledges that real-world interviewers are not perfect. His own review of inter- views found that the questioners ask very few open-ended questions and too many yes/no or forced-choice questions.
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266 LEGAL ISSUES
Reviews of Forensic Interviews
A more negative review of real interviews was reported by Warren, Woodall, Hunt, and Perry (1996). Warren et al. examined the transcripts of 42 sexual abuse interviews that were conducted by CPS personnel. The goal of their research was to compare what was being done in “regular,” as opposed to high-profi le, cases and how the interviewers’ techniques compared to the best practices suggested by research. In the interviews they reviewed, the children being interviewed ranged in age from 2 to 13 years, with a mean age of 6 years.
The fi rst thing assessed by Warren et al. (1996) was whether the interviewer attempted to build rapport with the children. All of the interviewing guidelines the authors had reviewed stressed that it was important to establish a relationship with a child before asking ques- tions about the alleged abuse. This is necessary to help the child relax and be willing to share important information. The good news is that 71% of the interviews reviewed began with at least a minimal attempt
to build rapport. The bad news is that in some cases, the rapport-building section of the interview was very brief, and in 29% of the interviews, this important step was skipped entirely. Furthermore, Warren et al. noted that during the rapport-building stage, the interviewers did the majority of the talking. In fact, the interviewers spoke three times more than the children and asked specifi c rather than open-ended questions. Although this is not problematic in and of itself, it does set the stage for the rest of the interview. The expectation that is being created is that the interviewer will do most of the talking.
The next thing Warren et al. (1996) looked at was whether the interviewers estab- lished ground rules for the interview. Because a forensic interview is very different from discussions a child normally engages in, it is recommended that the children be told that there are “rules” for this talk. Before questioning begins, children should know that (a) they do not have to answer a question if they do not know the answer; “I don’t know” is an acceptable answer; (b) the interviewer does not know what happened and does not know the right answer; (c) the child may ask the interviewer to clarify a ques- tion that is unclear; and (d) the child may correct the interviewer if the interviewer is wrong. Not only is it important to tell the child about these rules; it is also necessary to practice them. If an investigator was interviewing a child, Chris, who was 4 years old, she might say to him, “You turned 3 on your last birthday. Isn’t that true?” If Chris agrees with her or is silent, the interviewer should remind him that he may correct her when she is wrong. She should also try a question such as “Is my blouse chartreuse?” If he answers, she would ask if he understood the question. Assuming he did not, she would remind him that it is all right to ask for clarifi cation or to say, “I don’t know.” By practicing the rules with neutral material, she is preparing Chris to give a better interview when they get to the abuse-specifi c questions. Of the interviews reviewed by Warren et al., only 29% (12 cases) made any reference to ground rules. All 12 of these included a reminder to tell the truth. In 6 cases, the children were informed that “I don’t know” was an acceptable answer, and in 3 cases, the child was told to tell the interviewer if he or she did not understand a question. Only one child was told that it was appropriate to say he or she did not remember, and none of the children was told that they could correct the interviewer. The fact that children do not spontaneously correct adults was illustrated by the following exchange (Warren et al., 1996, p. 235):
Interviewer: Is it good or bad to tell a lie? Child: G. A. touched me.
rapport
a feeling of connection
and trust that is
established between two
people.
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267FORENSIC INTERVIEWING OF CHILD VICTIMS
Interviewer: Jesus loves me? Is that what you said? Child: Yeah.
Researchers also recommend that interviewers do a practice interview with the children prior to asking about the abuse. These interviews should deal with neutral topics. In addition to allow- ing more time for rapport building, this allows the interviewer the opportunity to assess the child’s language ability and narra- tive style. It is also the chance to establish roles. The interviewer will ask a question and then listen to the child, who will do the majority of the talking. Research has shown that when children are given practice interviews, they give more information in the abuse- related part of the interview. Only 2 of the 42 interviews reviewed made use of this technique.
With regard to the types of questions asked, Warren et al. (1996) found that inter- viewers asked very few open-ended questions. The most frequent style of question used (62.8%) involved specifi c questions with yes/no answers. Furthermore, when asking about the abuse, only 10.5% of the questions were open-ended. Interviewers were also guilty of asking multiple questions. This is when the interviewer asks more than one question without allowing the child the chance to respond. For instance, consider the following exchange (Warren et al., 1996, p. 240):
Interviewer: He never kissed you? Did he ask you to kiss him? Have you touched him?
Child: No.
Clearly, it is diffi cult to interpret what the child’s response means. Looking at only a subset of 20 of the 42 interviews, Warren et al. noted 520 series of multiple questions. This common practice is one that interviewers need to learn to avoid.
Warren et al. (1996) were able to detect a number of interviewer oversights and errors, but it was impossible to determine whether the interviewers introduced any false information because there was no way to know what had actually occurred. However, Warren et al. did note that 93.9% of the interviewers introduced new infor- mation. In addition, the interviewers were introducing more than one piece of new information (the average across interviews was seven). It is probably not realistic to assume that all of this information was accurate.
Warren et al. (1996) concluded that because the interviews they reviewed were conducted during the late 1980s and the early 1990s, interviewers may not have been aware of the recent research on interviewing. It is possible that interviews have grad- ually become better since the study was conducted. As CPS workers have found out about the research on interviewing techniques, they may have improved their tech- niques. However, Warren et al.’s work does make clear that mistakes are not found only in high-profi le cases.
Unfortunately, when Mart reviewed forensic interviews in 2010, he noted that although some interviews were well conducted, too many interviewers were still making serious mistakes. Mart wrote, “the interviews I have reviewed have ranged from excellent to truly wretched” (2010, p. 327). Like Warren et al. (1996), Mart found a lack of rapport building. Mart reported that many practitioners were either inexperienced in establishing rapport or did not put enough value on making chil- dren comfortable. This lack of rapport was evident in child behavior that ranged
practice interview
a question-and-answer
session about a neutral
topic that allows the
person being interviewed
to become comfortable
with the process before
addressing the issue of
interest.
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268 LEGAL ISSUES
from minimal eye contact, to very limited response to even non-abuse related ques- tions, to full out crying and asking to leave. Obviously, a child who is uncomfortable is not going to provide the best information possible.
Furthermore, Mart (2010) said that professionals often failed to properly asses the child’s developmental level. Mart recommends that children’s understanding of number, time, position, and sexuality should be assessed before abuse specifi c ques- tions are addressed. Once the child’s developmental level is known, the interviewer is better prepared to ask questions and understand the child’s responses.
In addition, Mart (2010) wrote that interviewers do not always comprehend that their role should be one of hypothesis testing. The interviewer should not be trying to confi rm one hypothesis (e.g., the child was abused). Instead, they should be seek- ing evidence to support or rule out various hypotheses (e.g., the child was abused as alleged, the child was abused but not as alleged, the child was not abused but is mistaken, or the child was not abused and is lying). Mart said that too many inter- viewers reinforce answers they believe are correct and only repeat questions if the fi rst response is not consistent with their one hypothesis.
Mart (2010) also noted that interviewers frequently failed to establish contextual details, did not make use of a structured interview format, and neglected to assess external threats to interview reliability (e.g., repeated prior interviews by untrained adults). Although far more is known about the forensic interviewing children than was true just two decades ago, getting interviewers to learn and apply this knowledge is a process.
The good news is that interviewers can improve with training. Price and Rob- erts (2011) examined the impact of an 8-month training program, feedback, and refresher training on 12 interviewers. They found that after this extensive program, the interviewers conducted signifi cantly better forensic interviews. They asked more open-ended question and used more open-ended prompts. This approach yielded more details from children. No negative effects of training were seen.
Others have suggested that we should not think simply in terms of “good” or “bad” interviews. Wood and Garven (2000) suggest that it would be helpful to assess whether a poor interview was likely to elicit false information (improper) or to have
other negative consequences that did not lead to false allegations (clumsy). Improper interviews would be those that contained elements known to increase the risk for false allegations. Clumsy interviews were defi ned as those in which the interviewer failed to do at least one of the following things: make the child comfortable, convey interest in and warmth toward the child, use vocabulary that the child could easily comprehend, ask open-ended questions; introduce the topic of abuse in a nonsuggestive manner, encourage the child to tell the story in his own words from the beginning to the end, avoid interrupting the child, or fi nish by telling the child what would happen next. There can be overlap between improper and clumsy interviewing, but Wood and Garven assert that it is helpful to consider them as separate categories. Improper inter- views can lead to false allegations. Clumsy interviews are more likely to lead to a disclosure that is less coherent, less detailed, and less convincing than what would result from a good interview. As a result, these cases are less likely to be prosecuted, and if prosecuted, they are less likely to lead to a guilty verdict. The authors propose
improper interview
an interview that
contains elements known
to increase the risk for
eliciting false allegations.
clumsy interview
an interview that is
not likely to lead to
false allegations but
is conducted poorly.
Clumsy interviews lead
to statements that are less
coherent, less detailed,
and less convincing than
those garnered from
good interviews.
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269FORENSIC INTERVIEWING OF CHILD VICTIMS
that clumsy interviewing is much more common and more diffi cult to improve than improper interviewing. Training sessions that tell interviewers what not to do can greatly reduce the number of improper interviews. However, quick remedies do not seem to be available for improving clumsy interviewing. For example, after training, the interviews conducted by CPS workers in one agency were rarely improper (5%), but many were still clumsy (50%–70%). The authors suggest possible solutions that range from internships for interviewers, to using interviewing specialists, to relying on structured interviews. All of these methods may be promising, but they still lack empirical evidence to demonstrate that they are effective.
Although there is no way to determine how many false reports of abuse exist, estimates generally range between 5% and 8% of sexual abuse cases. Assuming there are approximately 200,000 cases of alleged sexual abuse each year, this would mean approximately 13,000 false allegations. There is also some evidence to suggest that the number of false allegations may be signifi cantly higher among children in fami- lies that are currently going through a divorce (London, 2006).
RECOMMENDATIONS FOR CONDUCTING GOOD FORENSIC INTERVIEWS
There are general and specifi c rules that have been recommended for interviewing that go beyond avoiding the pitfalls described in this chapter. In the book Investiga- tive Interviews of Children , Poole and Lamb (1998) provide the following fi ve general guidelines:
1. Interview the children as soon as possible. It is important to minimize the time delay between the alleged event and the interview.
2. Give the child the opportunity to get used to the interview setting before you ask about the alleged abuse. Take time to build rapport with the child, and take the time to do a practice interview about a neutral event before moving on to the abuse. Let the child know that it is OK to say that he or she does not under- stand a question or does not know an answer. It is even permissible to disagree with the interviewer.
3. Whenever possible, interviewers should ask open-ended questions.
4. The person conducting the interview should remain neutral and open. He or she should not convey that the child is correct or incorrect. The interviewer should be willing to consider multiple explanations for a child’s statements.
5. If the child is old enough, he or she should be given the opportunity to review and clarify the information that has been gathered.
London (2006) adds the following recommendations:
1. Use language that the child can fully comprehend. Interviewers must be aware that even some basic words such as touch and remember can be confusing for chil- dren. For instance, a child who says, “He put his fi nger inside me” (p. 39) may
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270 LEGAL ISSUES
say no in response to the question, “Did he touch you?” (p. 39). In other words, the child did not think that putting something inside and touching were the same thing. Children may also think that they can only remember something that they had previously forgotten. Therefore, if children have always recalled an event, they may indicate that they cannot remember it. Children also strug- gle with emotional words, time, passive voice, and negatively phrased questions. These defi cits persist until children are between 8 and 13 years of age.
2. The environment for the interviews should be carefully selected. Ideally, the child will be interviewed in a room with few distractions. A cheerful room that is not cluttered or threatening is ideal. Along with this, the interviewer should not be in a police uniform or wearing a gun. Finally, the setup of the room should allow for video- and audiotaping, as well as discreet observation via one-way mirrors.
Poole and Lamb (1998) use the next two sections of their book to cover interview protocols and how interviews can be customized. Their information moves beyond the scope of this book, but it is excellent reading for those interested in forensic interviewing and for those who may be considering a career in the fi eld. Well- conducted interviews are good for everyone. They lead to fewer false allegations and to better prosecution of true allegations. In cases in which so much rests on a child’s testimony, professionals must do whatever they can to ensure that the information obtained from witnesses is as accurate as it can possibly be.
Finally, interviewers can turn to the recommendations of the National Institute of Child Health and Human Development (NICHD). The NICHD research based interview protocol provides instructions on how to conduct forensic interviews. The NICHD recommends beginning with the establishment of rapport. Interviewers are reminded to be warm and friendly and to listen carefully to the children they are working with. The second step is to engage in narrative practice. During this phase, the child is asked to tell a story about a recent event (not abuse related). For exam- ple, a child may tell about a recent trip to the zoo or holiday celebration. After the child tells the story, the interviewer asks him or her to provide more detail. Next, the interviewer should establish rules about this discussion. The child should be informed that “I don’t know” and “I don’t understand” are acceptable answers. Chil- dren should also be given permission to tell the interviewer if the interviewer makes a mistake. In addition to telling the children about the rules, they should get to prac- tice them. For instance, an interviewer might say, “Elmo is a blue, isn’t he?” Children should be prompted to correct the interviewer if they do not do so on their own. Only after all of these steps are complete should the interviewer move on to asking questions about the abuse. Research has shown that when these conversational rules are talked about, young children provide more information during the substantive part of the forensic interview (Teoh & Lamb, 2010).
When the interviewer moves on to questioning about the alleged abuse, the questions should be open-ended and nonbiased. The questions should move from broad to more specifi c. Questioning should begin with general inquiries such as, “Tell me why you are here” or “Start at the beginning and tell me everything that happened” (Steele, 2012, p. 109). After questioning about the abuse is complete, the interviewer should move the interview to a neutral or positive topic before ending the interview (Steele, 2012).
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271FORENSIC INTERVIEWING OF CHILD VICTIMS
CONCLUSION
The research reviewed in this chapter has hopefully convinced you that children must be interviewed carefully in order to prevent the creation of false memo- ries. Perhaps the most important lesson is that forensic interviewing is outside the mandated reporter’s area of expertise and that it is not something you should attempt. Although it is appropriate to listen to a spontaneous report from a child, you should leave the interviewing to the experts. This area of investigation has become so specialized that most police offi cers and social workers do not do this sort of work. Instead, cities have established special centers, gen- erally called child advocacy centers (CACs) , where carefully trained forensic interviewers conduct all interviews, especially in cases of alleged sexual abuse (see Figure 11.3). Not only are these interviewers specially trained, but the facilities are also set up for this type of information gathering. For instance, the interview rooms are generally set up to allow for audio and video record- ing as well as observation through a one-way mirror (see Figures 11.4 and 11.5). All of these techniques are designed to reduce the number of interviews required and to provide an accurate record of not only what the child said but also what the interviewer said. CACs also allow for services for children to be centralized. In many cases, interviews, medical examinations, and therapy are all offered under one roof (see Figures 11.6 and 11.7 and Profi les 11.1 and 11.2 ). The interviewers at child advocacy centers are well trained in forensic interviewing, and they follow established guidelines for interviewing.
FIGURE 11.3 The Children’s Advocacy Center of Spartanburg, South Carolina. Photo credit: Monica L. McCoy.
Child Advocacy Center
(CAC)
a center designed to
assess allegations of
maltreatment and to
treat victims by enlisting
a multidisciplinary team
of law enforcement,
medical, social service,
legal, and clinical
professionals.
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272 LEGAL ISSUES
FIGURE 11.4 The interview room at the Children’s Advocacy Center of Spartan- burg, South Carolina. Photo credit: Monica L. McCoy.
FIGURE 11.5 Electronic recording devices are in a room adjacent to the interview room at the Children’s Advocacy Center of Spartanburg, South Carolina. This room also allows real-time observation of the interview via a one-way mirror. Photo credit: Monica L. McCoy.
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273FORENSIC INTERVIEWING OF CHILD VICTIMS
FIGURE 11.6 The child-friendly medical exam room at the Children’s Advocacy Center of Spartanburg, South Carolina. Photo credit: Monica L. McCoy.
FIGURE 11.7 One of the therapy rooms at the Children’s Advocacy Center of Spartanburg, South Carolina. Photo credit: Monica L. McCoy.
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274 LEGAL ISSUES
PROFILE 11.1
Nance Henderson, MD
Dr. Nancy Henderson is the medical director at the Child Advocacy Centers in Greenville and Spartanburg, South Carolina. She evaluates children for maltreatment, mainly sexual abuse. In addition to her work at advocacy centers, Dr. Henderson also assesses children for maltreatment in a hospital setting; most commonly physical abuse. After collecting evidence during exams, Dr. Henderson meets regularly with multidisciplinary teams to help devise the best plans to assist maltreated children. She also testifi es two or three times each month as an expert witness in child maltreatment cases.
Work such as this requires a great deal of training. Dr. Henderson earned her bachelor’s degree from Rutgers College of Pharmacy and her MD from Bowman Gray Wake Forest University. She then completed a residency in pediatrics at T. C. Thompson Children’s Hospital in Chattanooga, Tennessee. After devoting more than 50% of her time to working with child abuse victims for more than 5 years, Dr. Henderson took the board exams for child abuse making her a Board Certifi ed Child Abuse Specialist.
In addition to education, you need a passion for helping maltreated children and a great deal of empathy to do this sort of work. Dr. Henderson says she saw a need for a spe- cialist to assess child maltreatment and noticed that many professionals were reluctant to do this type of examination. As she gravitated toward work as a child abuse specialist, Dr. Henderson found that the work suited her. She fi nds helping children in this way to be a unique way to nurture children and to assist those who truly need an advocate. In most pediatric settings, parents serve as advocates for their children. However, if the parents are abusive, someone else needs to fi ll this role.
FIGURE 11.8 Dr. Nancy Henderson. Photo credit: Jud Stubbs.
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275FORENSIC INTERVIEWING OF CHILD VICTIMS
When asked about the thing she likes least about her work, Dr. Henderson says that there is frustration that things cannot be changed more quickly. Despite occasional frus- tration with the system or with families, Dr. Henderson notes that when she is having a rough day or week, one good thing will happen. That one positive outcome makes her realize that she just cannot give up on children. Dr. Henderson says the best thing about her work is that there is nothing better than being an advocate for children and no truer place to do it than in the context of maltreatment. She is fully committed to helping one child at a time.
PROFILE 11.2
Laurel Wanner
Laurel Wanner works as a Child Life Specialist. When maltreated children come in for their forensic medical exam, she makes sure they are prepared. She works hard to quickly establish a relationship with the child and their family; often, siblings also have fears and concerns about what is occurring in their families. She helps the young victims articulate what they are thinking about and what they are worried about. She can then give them the information they need and attempt to allay their fears. Ms. Wanner stays with the children during the medical exam, offering support and distraction. In addition to working directly with families, Ms. Wanner attends multidisciplinary team meetings to help develop plans for helping children.
In order to prepare for a career as a Child Life Specialist, Ms. Wanner earned her bach- elor’s degree in therapeutic recreation from the University of Florida and then earned her
FIGURE 11.9 Laurel Wanner. Photo credit: Jud Stubbs.
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276 LEGAL ISSUES
DISCUSSION QUESTIONS
1. After reading this chapter, would you be interested in pursuing a career in forensic interviewing? What would be the benefi ts and the drawbacks of this type of career?
2. Should expert witnesses be called to provide testimony on interviewing in all cases of alleged child maltreatment? Why or why not?
3. Listen to the way adults talk to children, especially when they are trying to elicit information from them. Note whether their questions are appropriate. If you do not have any access to children, reality television shows such as Jon & Kate Plus 8 , 19 Kids and Counting , and Toddlers and Tiaras show a good deal of dialogue between adults and young children. Share your observations with your classmates.
4. For ethical reasons, we cannot deliberately try to make a child believe he or she was abused when he or she was not. Did the researchers go too far in the stud- ies you read in this chapter? (e.g., Is it right to make a child believe he had his hand caught in a mouse trap when this did not happen? Do the benefi ts of this research outweigh the potential costs to the children who participated?)
certifi cation as a Child Life Specialist after completing a 500-hour internship. (Beginning in 2015, a master’s degree will be required for those working as a Child Life Specialist.)
Ms. Wanner says the best part of her job is when a child gets through the medical exam successfully (the doctor is able to collect the necessary evidence, the child is not distraught by the experience, and/or the child is able to feel proud of what they were able to accomplish). Hugs from children and words of thanks from parents let her know that what she is doing makes a difference. The worst part of her job is when the child’s support system does not do its part to aid the child victim.
If you think you might be interested in a career as a Child Life Specialist, Ms. Wanner recommends that you get as much experience with children as possible. The best place to start is to work with normal, healthy children. Before you can understand abnormal child behavior, you need to know what normal development looks like. In addition, it is good to volunteer at a hospital to get an idea of what it is like to work in a medical setting.
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277
CHILDREN AND THE COURTROOM
For the most part, the U.S. court system is not set up to meet the needs of child witnesses. The court system in the United States is an adversarial system, or an accusatorial system. This means that each side presents its case to the court, and it is the job of the judge or the jury to decide which argument is more persuasive. The heart of the adversarial system is the use of cross-examination to challenge and discredit opposing witnesses. This can be contrasted with an inquisitorial system, in which the court’s role is to fi gure out the truth by gathering information and asking questions of lay witnesses and experts. Generally, an inquisitorial system is more child friendly (Myers, 1996).
The rules that govern testifying in an adversarial court system were designed with adult witnesses in mind. Being aggressively challenged by opposing counsel is frightening enough for adult witnesses, who have some understanding of the process. It can be overwhelming for children. It is obvious that children may struggle to communicate clearly in this adult context. One major drawback of being asked to perform in a developmentally inappropriate arena can be that children appear incompetent. Saywitz, Jaenicke, and Camparo (1990) suggest that some children may appear incompetent in a court setting, not because they are incapable of giving good testimony but because the adults who question them are not asking the questions appropriately. Specifi cally, adults may be using legal terms and/or advanced vocabulary that young children cannot comprehend. For instance, the authors provide the anecdote of a young child who surprised the adults in court when failing to perform when she was asked to “identify her assailant”—a task she had completed easily in the past. However, in previous questioning, the child had been asked to “point to” the person who had harmed her. The jury would have no way of knowing the child was suffering from a vocabulary problem. Instead, it looked like the child could not recognize the defend- ant. Stories like this prompted Saywitz et al. (1990) to study children’s understanding of legal terms from the ages of 5 to 11 years (see Focus on Research 12.1 ). Based on their research, they concluded that children need to be prepared to testify, attorneys must be trained in age-appropriate questioning, and judges should be encouraged to monitor the vocabulary used in cases involving children.
CHAPTER 12
The Legal System and Child Maltreatment
adversarial system
a court system that
involves active and
unhindered parties
contesting with each
other in the presence of
an independent decision
maker (judge or jury).
cross-examination
the questioning of a
witness by the opposing
party, especially for the
purpose of clarifying or
discrediting the witness’s
testimony.
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278 LEGAL ISSUES
FOCUS ON RESEARCH 12.1
Saywitz, Jaenicke, and Camparo published a paper titled “Children’s Knowledge of Legal Terminology” in Law and Human Behavior in 1990. They were interested in assessing chil- dren’s ability to defi ne legal terms and how their skills change with age. They used a sample of 60 participants: 20 kindergartners (average age of 5 years 10 months), 20 third graders (average age of 8 years 8 months), and 20 sixth graders (average age of 11 years 11 months). The sample came from primarily middle-class households in the Los Angeles area, and the majority were Caucasian (63%). All of the participants were of normal intel- ligence.
The researchers compiled a list of 35 terms that were used frequently in cases that involved child witnesses. College students then rated each word or phrase in terms of diffi - culty on a 3-point scale. The children were asked to defi ne the terms to someone who knew nothing about them (they were asked to think about explaining the words to a spaceman who was from another planet). Participants were prompted to give complete defi nitions by interviewers who asked, “Can you tell me more?” Responses were scored on a 5-point scale from 0 to 4. Zero represented I don’t know , whereas 4 was reserved for defi nitions that included the defi ning features of the term. Scores were then collapsed with 0, 1, and 2 con- sidered incorrect, and 3 and 4 rated as correct. Collapsed scores had an interrater reliability of 99% (this means that two raters agreed on the score 99% of the time).
The researchers found signifi cant differences among all three of the grade levels. Third graders were signifi cantly more accurate than were kindergartners, and sixth graders were signifi cantly more accurate than third graders. However, this difference was not evident for all terms, only terms of moderate diffi culty such as duty , identify , case , and oath . Terms that were easy or hard did not reveal a grade-related trend. Nearly all of the children could accurately defi ne easy terms such as lie , police , and remember , whereas almost none of the children could identify the diffi cult terms such as defendant , allegation , and minor .
The authors noted three types of errors. First, many children simply said they did not know what a term meant. This decreased signifi cantly with age (42%, 17%, and 5%). Second, children made auditory discrimination errors. In these cases, they defi ned a legal term as a similarly sounding, familiar term. For instance, children would defi ne jury as if it were jewelry or journey . Thirdly, children made homonym errors in which they gave only the nonlegal defi nition for a term and not the legal defi nition. In fact, they said that the term could not mean anything else in court. For example, a “charge” was something you did with a credit card, a “motion” was something like moving your arms, and “parties” were places you went to get presents. Errors of auditory discrimination and homonyms were both less common with the older children (sixth grade) than they were with the younger children.
The authors concluded that some terms should be avoided when dealing with child witnesses, and others should be used only with older children. They also noted that older children were less likely to say “I don’t know” and more likely to attempt to give a response even if they did not fully comprehend the question. Therefore, they proposed that chil- dren may move from a lack of understanding, to a mistaken understanding, and then to accurate knowledge of legal terms.
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279THE LEGAL SYSTEM AND CHILD MALTREATMENT
The Court Prep Group
As professionals recognize that court can be confusing and even traumatic for chil- dren, they are beginning to devise and implement programs to make the experience less stressful. The benefi ts of these programs are twofold. First, children are less likely to experience additional trauma if they are adequately prepared, and second, chil- dren will be able to provide better testimony if they are not anxious. Research has shown that children who know more about court are less distressed when it comes to attending hearings (Quas, Wallin, Horwitz, Davis, & Lyon, 2009). One such program is the court prep group devised by the National Children’s Advocacy Center. This program evolved in response to feedback that simply taking children on a single tour of the court- room prior to their giving testimony was not suffi cient (Keeney, Amacher, & Kastanakis, 1992).
The court prep group involves a series of six group sessions with children who are going to testify in court. Ideally, the children in the groups will be similar in age (ranges of 6–12 and 13–17 are recommended, with individual work for those who are younger or older). When possible, the sessions are held at a time that is close to the trial date. The groups are led by various types of profession- als including social workers, victim advocates, prosecutors, and therapists. During the fi rst session, which takes place in a natural setting, the leader explains the goals of the group and engages the children in ice-breaking activities, frequently engaging them in artwork. The children also assemble puzzles of court personnel and are given the opportunity to discuss their feelings. In the second ses- sion, also in a natural setting, the children engage in artwork and writing on what they have learned about court and about what they need to know, as well as their feelings about court. The leader also gives a good deal of concrete information about the court and the people who work there. Finally, the children engage in role-play with court props such as a judge’s robe and gavel. For example, children may be asked to role-play a court case in which the crime is an alleged robbery and the defendant is a friend of theirs. Sessions 3, 4, and 5 take place in the courthouse. During Session 3, the children get a tour of the entire courthouse. This part of the program was added once professionals learned that many children are intimidated by the courthouse itself, not just the courtroom. It gives the children the opportunity to see the courtroom, the jury room, the victim advocate’s offi ce, and the bathrooms. Then the children play a game during which they have to fi nd numbers that are placed around the courtroom and match them to the person who would be there during a trial. This gives the leader another chance to review the roles that various people play in the court system. Sessions 4 and 5 involve engaging the children in a mock court in the actual courtroom. The children get to take turns playing the dif- ferent roles—judge, witness, attorney, and so forth. The leader stresses appropriate witness behavior and helps the children focus on their feelings during the exercise. For very young children, the mock court would be replaced with watching a video of court proceedings. In the fi nal session, the group returns to a natural setting to draw about what they have learned and what they feel. They also review key concepts and discuss individual case plans. At the conclusion of this session, the children receive graduation certifi cates. In addition to learning about the court process, the children receive support from the other members of the group along with a sense that they are not alone (Keeney et al., 1992).
court prep group
a program devised by
the National Children’s
Advocacy Center to
prepare groups of
children for court
through education,
understanding of
emotional issues, role-
play, and touring of a
courthouse.
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280 LEGAL ISSUES
The Child Victim/Witness Program
A similar program, the Child Victim/Witness Program (CVWP) , is offered in Can- ada. However, there is no group work. The advocates work individually with each
family. There are also some unique aspects to the program. For instance, the victim advocate identifi es someone in the child’s life as the support person for the child (often this will be the nonof- fending parent). This person is then given the education necessary to allow him or her to fully support the child. The advantage of this tactic is that the person will have much more contact with the child than would an advocate with a large caseload. Another technique used by the CVWP is to allow the child to visit court while it is in session, although not for a sexual abuse case. This gives the child the opportunity to see a trial in action, which can be quite different from seeing an empty courtroom (Doueck, Weston, Filbert, Beekhuis, & Redlich, 1997). As more programs such as this emerge, it will be the job of social scientists to assess their effective-
ness so that the techniques used can be refi ned. The ultimate goal is to elicit accurate testimony while minimizing trauma to the child. See Focus on Research 12.2 .
Child Victim/Witness
Program (CVWP)
an individualized
Canadian program
that prepares children
for court by educating
them, by appointing
and educating a support
person to assist them,
and by visiting a court in
session.
FOCUS ON RESEARCH 12.2
McAuliff, Nicholson, Amarillo, and Ravanshenas (2012) surveyed 414 victim/witness assistants (VWAs). These professionals all worked with children in the legal system and represented 46 states. Each participant completed a 3-page survey that contained 16 mul- tipart questions. The fi rst thing the authors asked was who was most likely to serve as a support person for children in the court system. Most frequently the children were sup- ported by VWA staff (often or always) and/or a nonoffending parent (often). This was followed in frequency by other relatives, social workers, court-appointed special advocates (CASAs), and guardian ad litems (GALs). Although most children who entered court had a support person assigned to them, this was least often true for the youngest children (younger than 3 years old). Victims were most likely to have a support person, and child witnesses who were not victims were the least likely to have an advocate.
If the child was the alleged victim of sexual or physical abuse of the case involved adult domestic violence, the child was almost always assigned a support person (always/often). Neglected children were less likely to have a support person assigned to them (often/some) and children in divorce/custody cases were rarely assigned an assistant (McAuliff et al., 2012).
The support person was more likely to provide informational than emotional support to the child. Most often, the assistant referred the child to community resources, went to the courtroom with the child for a pretrial visit, and provided the child with procedural information about what was going to happen. The most common forms of emotional support were attending court with the child, comforting the child, and accompanying the child during pre-trial preparation (McAuliff et al., 2012).
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281THE LEGAL SYSTEM AND CHILD MALTREATMENT
TYPES OF COURTS
Not only can court be intimidating, but the entire court process can also be confus- ing for both adults and children. In addition to the fact that there are many different types of maltreatment, the cases are handled in different court systems, depend- ing upon the specifi c problem addressed (questions of who should raise the child versus questions of whether someone should be punished for maltreating behavior, for example). Not surprisingly, the legal handling of child maltreatment is almost as complex as the problem itself. Within the vast legal system are many places in which issues of child abuse and neglect are dealt. In the following section, I address, in detail, four legal contexts in which allegations of child maltreatment may be addressed: juvenile court, domestic relations court, criminal court, and civil court.
Juvenile Court
Juvenile court was designed to serve the interests of children and their families. These courts were fi rst established in Illinois in 1899. With the foundation of this court sys- tem, the government was saying that even though we generally rely on the family to provide for children, if that family fails, it is the responsibility of the court system to intervene for the sake of the child and society. The juvenile court was founded to meet two major goals. The fi rst was to rehabilitate youthful offenders, and the sec- ond was to protect children (Sagatun & Edwards, 1995). This second role of “state as parent” is referred to with the Latin phrase parens patriae. A literal translation of the phrase is “parent of the country” (Garner, 1996, p. 465).
Juvenile Delinquency Cases Juvenile court deals with three types of cases. First, judges in juve- nile court hear cases of juvenile delinquency. These cases involve acts committed by children that would have been criminally pros- ecuted if the defendants were legal adults at the time of the crime. The reason these cases were moved to juvenile court from criminal
juvenile delinquency
antisocial behavior by a
minor, especially if the
behavior is in violation
of the law and would be
punished criminally if
committed by an adult.
The victim assistances believed that their presence reduced stress in the children and increased the accuracy of the child’s testimony. The participants in the study said they believed that the VWA staff was most successful in aiding children followed by social work- ers and CASAs. They felt that older children (8 years and older) benefi ted more from their services than did the younger children. They also felt that their services were most needed for reducing stress in cases of alleged sexual abuse (McAuliff et al., 2012).
The VWAs reported some problems with interfering parents and noncooperative chil- dren. However, they noted that only rarely did the defense allege that the support person had an improper infl uence on the child victim. Further, the VWAs asserted that they did not think their presence was prejudicial to jurors (McAuliff et al., 2012). Of course, these fi ndings are related to the perception of the VWAs. Others in the courtroom may have a different perception.
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282 LEGAL ISSUES
court is that the founders believed that children who commit crimes should be dealt with differently from adults who commit crimes. In short, the focus of juvenile court was to be on treating and rehabilitating children more than on punishing them. To this end, the juvenile court was based on a clinical or medical model of intervention. Because the focus was on treatment, rather than on punishment, it was determined that child defendants would not need the same constitutional protections that were granted to adult defendants (e.g., the right to legal counsel, the right to avoid self- incrimination, the right to a jury trial). Although this policy sounded good, it did not work out exactly as planned. Over time, it seemed evident that child defendants were punished, not treated. Punishing child defendants, who were not protected by the constitutional guarantees enjoyed by adult defendants, was challenged in 1967 (Feller, Davidson, Hardin, & Horowitz, 1992).
The Supreme Court ruled In re Gault (1967) that the juvenile court system was not meeting the needs of child defendants. In this case, a 15-year-old boy, Gerald Francis Gault, was committed to a state industrial school in Arizona for 6 years for making lewd remarks over the phone. The trial court described the remarks as being offensive and sexual. If Gault had been tried as an adult in criminal court, the maxi- mum sentence he could have received was 2 months in jail and a fi ne of $50. Further, Gault had not been advised of his right to a lawyer or his right to remain silent. The Supreme Court ruled that, in order to ensure that child defendants were not pun- ished unfairly, they must have due process rights such as the right to a lawyer, the right to be notifi ed of the charges against them, the right to examine and cross- examine witnesses, and the right to avoid self-incrimination. Following this decision, the only signifi cant right still denied to defendants in juvenile court is the right to a jury trial (Bartol & Bartol, 2004).
Status Offenses In addition to cases of juvenile delinquency, juvenile courts also hear cases that involve status offenses. An act that is against the law only because the person who commits the act is a child is considered a status offense (Bartol & Bartol, 2004). For instance,
truancy is a status offense. A child who skips school can be punished legally. If you, as an adult, skip class, you only have to deal with your professor (and maybe your parents when they see your grade!), not the legal system. Underage drinking, underage smoking, and curfew violations are additional examples of status offenses. In most juris- dictions, attempts are made to keep children who are guilty of status offenses separated from children who are juvenile delinquents.
Dependency Cases The third type of case heard by juvenile court judges is the most relevant to child maltreatment. This court that hears dependency cases. The purpose of these cases
is to determine whether the child’s needs are met by the current guardians, generally the parents, or if the State needs to take tem- porary or permanent custody of the child. This court is charged with the mandates to protect children and to preserve families (Sagatun & Edwards, 1995). As you can imagine, in cases of child maltreatment, it can be diffi cult, if not impossible, to meet both of these goals.
status offense
an act that is against the
law only because the
person engaging in it is
a minor.
dependency case
a case to determine
whether a child’s needs
are being met by his
or her guardians or if
the state needs to take
temporary or permanent
custody of the child.
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283THE LEGAL SYSTEM AND CHILD MALTREATMENT
This court system follows a strict timetable. I provide general guidelines here, but note that there are variations from state to state. Once a child has been removed from his or her home based on allegations of maltreatment, a petition to declare the minor a dependent child must be fi led with the court within 48 hours. Dur- ing this time, the child has the right to make two phone calls, one to parents and one to a lawyer. Within an additional 24 hours, the case must be before a judge for a detention hearing. This hearing is often referred to as the 72-hour hearing (simply adding the original 48 hours and the next 24). The purpose of this court appearance is for the judge to decide whether there is suffi cient evidence to hold the child pending further investigation. Generally, the attorney for Child Protective Services (CPS) argues the case against the parents or guardians (Sagatun & Edwards, 1995).
If the judge fi nds suffi cient reason to keep the child in care, a second hearing, the jurisdictional hearing (called an adjudicatory or merits hearing in some states), is scheduled (between 15 and 30 days later). This gives CPS time to perform additional investigation. The parents may also use this time to prepare their own defense. At the jurisdictional hearing, the judge decides whether the child meets the description of a dependent child. The format of these hearings is more relaxed than what you would see in a criminal court. Many of the traditional evidentiary protections are not enforced at this hear- ing. For instance, hearsay evidence is generally allowed, and children are often allowed to testify outside of their parents’ presence. Finally, neither a husband nor a wife can claim spousal protection in this court. Because of these relaxed evidentiary standards, evidence gath- ered in these hearings cannot necessarily be used in other courts, such as criminal court (Feller et al., 1992; Sagatun & Edwards, 1995).
The judge then enters a decision at the dispositional hearing. This can take place immediately after the testimony is presented at the jurisdictional hearing, or up to 10 days later. At this time, the court decides what is to be done in the case. The major deci- sion revolves around the physical placement of the child: returned to parents, placed with a relative, placed in a foster home, and so forth. The standard for judgment in this court is clear and con- vincing evidence. If the judge determines that there is clear and convincing evidence that the child is in danger, the ruling will favor CPS. If the judge does not see danger, the ruling will favor the parents. In cases where the judges rule for CPS, in addition to deciding placement, they lay out mandatory treatment plans. For example, the court may order the parent, or parents, to attend parenting classes and/or drug and alcohol treatment. Other aspects of the treatment plan might involve contributing fi nancially to the child’s care, securing employment, and/or fi nding an appropriate place to raise the child. If appropriate, when a child is not returned home, a visitation schedule is devised and the details regarding how the visitation will occur are specifi ed. For instance, the court will determine where visitation will take place and whether it will be supervised (Feller et al., 1992; Sagatun & Edwards, 1995).
detention hearing
a hearing for the purpose
of determining whether
there is suffi cient
evidence for the State to
hold the child pending
further investigation; also
referred to as the 72-hour
hearing.
jurisdictional hearing
a hearing where evidence
is presented by Child
Protective Services
and parents and a
guardian ad litem so the
judge can determine
whether the child meets
the description of a
dependent child.
hearsay
testimony based not
on what one knows
personally but on what
someone else has said.
dispositional hearing
a hearing during which
the judge enters their
decision as to what is in
the best interest of the
child.
clear and convincing
evidence
a degree of evidence that
indicates that the issue
being proven is highly
probable. It is a higher
standard of proof than
the preponderance of
evidence, but a lower
standard than beyond a
reasonable doubt.
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284 LEGAL ISSUES
Six months later, a review hearing takes place. The purpose of this court appearance is to assess the progress that has been made on the treatment plan. The judge’s job is to decide if the parent, or parents, has made enough progress to ensure the safe return of the child to the home and the termination of court involvement with the family. If adequate progress has not been made, the treatment plan is reviewed and perhaps revised, and another review hear- ing is scheduled. By the time the child has been in out-of-home care for 12 to 18 months, the courts must hold a permanency planning hearing. Instead of allowing a child to languish in fos- ter care, professionals are required to prepare a long-term plan for each child. If the parents are not meeting the goals of the treat- ment plan, the permanency plan may involve steps to terminate the parents’ rights and make the child eligible for adoption (Feller et al., 1992; Sagatun & Edwards, 1995).
Termination of parental rights is a serious decision. Permanent breaking of parental–child bonds is done only when the court is convinced there is no way that the child can be safely reunited with his or her parents. Researchers have tried to determine whether one specifi c factor was likely to lead to termination of parental rights. What they found was that no single profi le led to termination of rights. Instead, termination of parental rights was best predicted by the number of risk factors a mother faced. As the number of risk factors present increases, so does the likelihood that parental rights will be terminated (Larrieu, Heller, Smyke, & Zeanah, 2008).
During this process, a guardian ad litem (GAL), or support person, may be appointed to the child so that there is always someone who is looking out for the child’s rights. In some states, this person is referred to as a court-appointed special advocate, or CASA. Although most people applaud the work of GALs/CASAs,
there is limited funding available for such programs. As a result, many people who serve in this capacity are trained and supervised volunteers (Poertner & Press, 1990; see Profi le 12.1 ).
review hearing
a hearing that takes place
approximately 6 months
after a care plan has been
enacted, for the purpose
of reviewing the progress
that has been made on
the treatment plan.
permanency planning
hearing
a review of the child’s
current placement and
progress with the goal
of establishing long-
range goals if the child
requires continued
care. Permanent plans
include the termination
of parental rights and
adoption.
guardian ad litem
an adult who is
appointed by the
court to represent the
best interests of the
child during court
proceedings.
PROFILE 12.1
Jean Bradley
Jean Bradley is the coordinator for the Guardian ad Litem Program for the 7th Judicial Circuit in South Carolina. Ms. Bradley has served in this capacity for 26 years. She and the volunteers she supervises serve as the spokespersons for children removed from their homes when there are allegations of child abuse or neglect. The Guardian ad Litems con- duct an investigation that is independent of those done by the police and the Department of Social Services. Ms. Bradley and her team then present their fi ndings and recommenda- tions to the court. Their goal is to work for reunifi cation of the family if it is in the best interest of the child. In addition to handling some cases personally, Ms. Bradley oversees
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285THE LEGAL SYSTEM AND CHILD MALTREATMENT
FIGURE 12.1 Jean Bradley. Photo credit: Jud Stubbs
120 volunteers, approximately 95 of whom have active cases at any given time. Although this is a large number of volunteers, it still fails to meet the needs of the community. In order to have enough volunteers to keep caseloads low, Ms. Bradley says she would need 150 volunteers. To this end, she also spends time recruiting and training volunteers. Vol- unteers goes through a 30-hour training before they are ready to take their fi rst case.
Ms. Bradley says that the best thing about her job is when she sees a child settled into a permanent home. In the ideal situation, this means the parents have completed necessary treatment and the child can be safely returned to their home. On the other hand, being forced to pursue termination of parental rights is what Ms. Bradley sees as the hardest part of her job. If parents cannot successfully complete their treatment plan in 12 months (pos- sibly extended to 18 months by a judge), they lose custody of their child.
In order to serve as a circuit coordinator for a Guardian ad Litem program, you need to have a bachelor’s degree in psychology or a related fi eld. The state provides ongoing training once you are in this position. It is also essential to have a true compassion for children and to be willing to open your eyes and notice how child maltreatment is having an impact on the children in your community. If you are think you might be interested in this type of career, consider volunteering now as a Guardian ad Litem to gain experience.
However, in some jurisdictions, GALS are attorneys, and in others, they work closely with attorneys. Some states are moving toward assigning a client-directed attorney to all children involved in maltreatment cases. These attorneys serve as both counselors and advocates for their young clients, and they present their client’s wishes to the court. These attorneys are advised to build a relationship with their cli- ent that is based on trust. In order to do this, they need to devote the time necessary to fully know the child’s circumstances and visit with them regularly. The attorney should also carefully explain the outcome of each hearing to his or her client. More
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286 LEGAL ISSUES
than half of all states require that children involved in maltreatment cases have an attorney/GAL and others regularly assign attorneys to children even though there is no state law that requires an attorney (Khoury, 2010).
Even as we move toward assigning legal representatives to children, there is ongoing debate about exactly how they should function. One potential problem is that the child may not be competent to direct counsel. Children differ from adults in that they do not generally seek or hire the attorney who represents them. For this reason, some suggest it is better for an attorney to work to represent the best inter- est of the child rather than being directed by the child, especially if the child is very young (Lehrmann, 2010).
Although there is not a great deal of research on the effectiveness of GAL/CASA programs, some studies have been conducted. Weisz and Thai (2003) compared 21 hearings in which there was a CASA to 20 hearings with no CASA and found that in cases with an advocate, the court received more and better information about the case. They did note, however, when there was a CASA, guardians tended to have less involvement. Litzelfelner (2008) analyzed 742 surveys that asked 24 questions about satisfaction with CASA volunteers. She found that whereas judges and attorneys were satisfi ed with the work done by the volunteers, social workers and parents were less pleased. These studies indicate that more work needs to be conducted to assess the effectiveness of GAL/CASA programs. What is truly lacking is research on the impact of having a GAL/CASA on the child victims.
Another area of disagreement centers on the fact that this court deals with issues of custody, not punishment. When parents are found guilty of child abuse or neglect in family court, the court does not have the authority to punish them. Judges can order that the child be removed from the home or that the abusive parent must leave the house. The only time judges in juvenile court can punish maltreating parents if when parents violate an order of the court. For instance, if a father is ordered not to have contact with his daughter and he sees her anyway, he can be found guilty of violating a court order and punished (Kelley, 1973). Shedlosky (2008) states that because of the inability to punish maltreating adults, the family court system does not adequately protect children. He argues that the best deterrent for maltreatment would be to use the criminal courts that are able to impose punishment following a fi nding of maltreatment.
For the most part, maltreated children do not attend dependency hearings. Their wishes are communicated to the court by professionals designated to advocate for them. However, this is not universal. In 2010, researchers interviewed 85 chil- dren between the ages of 7 and 10 years of age who had attended their dependency hearings. Overall, the children lacked a full understanding of the court process and younger children had the most confusion. Of these children, 54% did not even know the outcome of the hearing. Many of the children, especially the older ones, had neg- ative attitudes about the hearing. Of these children, 37% said that they did not feel they had been listened to or believed. More negative attitudes were positively corre- lated with anxiety. Because research has shown that the court preparation programs mentioned above can reduce anxiety, it is possible that they could also lower nega- tive attitudes. The experience of attending the hearings was not completely negative. Sixty-one percent of the children reported that they were glad to see their parents and only 25% said they had heard things they did not already know (Block, Oran, Oran, Baumrind, & Goodman, 2010). More research is needed to fully understand whether children are hurt by or benefi t from attending the hearings that pertain to
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287THE LEGAL SYSTEM AND CHILD MALTREATMENT
them. What is clear is that all children need to be informed, in a developmentally appropriate way, about what is going on with their case.
Another concern about the juvenile court system is that the professionals who work there often lack specialized training in dealing with young children. Programs are being designed and implemented to address this defi ciency. One such program is PREVENT (Prevention and Evaluation of Early Neglect and Trauma) in Miami, Florida. This program was devised because professionals noted that the current system was not adequately meeting the needs of young children. There are two main goals to PRE- VENT. First, a thorough, research-based evaluation is done on the child at the time he or she enters foster care. One evaluation is geared to children aged 12 to 30 months and another is designed for those from 31 to 60 months. Both protocols assess for social and emotional functioning as well as cognitive ability and language develop- ment. Assessments are conducted via interviews with the parents and the child as well as standardized tests. The second goal is to use the data gathered by the evalua- tion to make sure the family receives appropriate resources. The overarching goal is to move beyond responding only to the immediate crisis and, instead, prevent fur- ther negative consequences by providing court-ordered intervention services. These services can include therapy for the parents and children, case management, and matching families with necessary services (Malik, Lederman, Crowson, & Osofsky, 2002). Advocates for children must continually notice places where the system is failing and apply research-based evidence to address those concerns.
Within dependency court systems, many states have now developed Family Treatment Drug Courts (FTDC), also called Dependency Drug Court and Family Treatment Court. These courts came about due to the success of Adult Drug Courts and the recognition of how frequently child maltreatment cases involve substance abuse. The model for these programs combines the efforts of the judicial system and the child welfare system and employs many of the techniques used in Adult Drug Courts. The FTDC have frequent hearings, a high level of judicial monitoring, imme- diate drug treatment, regular drug testing, and rewards and sanctions for following or failing to follow treatment plans. The system is designed to be supportive rather than adversarial. Whereas the primary motivation those in Adult Drug Court is to stay out of jail, the primary motivation in those in FTDC is to be reunifi ed with children who have been removed from the home (Worcel, Furrer, Green, Burrus, & Finigan, 2008).
Research suggests that the FTDC model is superior to the traditional child welfare approach on several dimensions. Worcel et al. (2008) compared 301 families who went through FTDC to 1,220 matched families who went through the traditional child wel- fare court system. They found that FTDC mothers had more positive drug treatment outcomes: They started treatment more quickly, spent twice as long in treatment, and were twice as likely to complete treatment as compared to mothers who were seen in the traditional court setting. In addition, FTDC mothers were sig- nifi cantly more likely to be reunifi ed with their children, and their children spent less time in out-of-home-placement.
Domestic Relations Court
The function of the domestic relations court is the resolution of legal issues surrounding marriage and the rearing of children. In practical terms, this means the court deals mostly with issues
domestic relations
court
a court that is dedicated
to hearing cases related
to divorce, child custody
and support, paternity
and other family-law
issues; it is also called
family court.
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288 LEGAL ISSUES
of divorce, child custody, and child support. The presumption of this court is that parents are fi t and proper adults and that they know what is best for their own chil- dren. Therefore, the court is set up to make the parents’ decision legally binding. Only if parents cannot agree is a court hearing may occur. However, before schedul- ing a hearing, many jurisdictions require that the adults fi rst meet with a mediator
in an attempt to resolve these issues in a less adversarial way. If mediation fails, the court will move forward with a hearing. Stud- ies have shown that the vast majority of custody decisions are made by parents, not by the courts. Only a small percentage of cases, between 6% and 20%, are ultimately decided by the courts (Bartol & Bartol, 2004).
In domestic relations court, proceedings are initiated by par- ents. This differs from the juvenile courts, where proceedings are begun by CPS or by the police. This means that any allegations of child maltreatment also come from parents. Because this court
makes the presumption that the parents are “fi t and proper,” it is not set up to deal with child maltreatment. In fact, many recommend that any allegations of abuse that arise during divorce or custody proceedings should be referred to the juvenile court or CPS. Because the domestic relations court does not have the mechanisms in place to investigate charges of child maltreatment, it is up to the parent making the allegations to provide the evidence to support his or her claims. This can cause problems, because it means that the quality of the investigation and the evidence is tied to the abilities and resources of the parent who is alleging abuse.
The domestic relations court judge can have a psychologist brought in to eval- uate any children involved in custody disputes. The professional is then asked to report his or her fi ndings to the court with a focus on the best interest of the child (Bartol & Bartol, 2004). In addition to having children go through a court-ordered evaluation, parents may hire additional professionals to further assess the children involved. The court sets no limits on the number of times a child can be assessed. In hotly contested cases, a child may be subjected to many psychological evaluations, and this is only one of the common problems faced by children in domestic relations court. These children are rarely assigned a lawyer of their own. So, whereas both par- ents have representation, the most vulnerable parties, the children, are on their own. In addition, children may be asked to testify in the presence of both of their parents. During custody disputes, it is not uncommon for judges to ask a child about how their parents take care of them or even whom they would prefer to live with after the divorce. To make matters even more challenging, children are often asked to respond to these questions in the presence of their parents. A child who may have strong ties to both parents is put in an extremely diffi cult situation. The ability of judges to elicit information from children, in private chambers or in court, varies widely. Judges are not required to have any specialized training in child development, and they can be extremely intimidating.
After hearing the testimony, the judge makes a decision that is thought to be in the best interest of the child. Until about 30 years ago, in accordance with the tender years presumption, modern courts frequently ruled in the mother’s favor as a matter of routine. It was the overwhelming belief that young children needed their mothers more than their fathers. Today, other factors are considered by the court. For instance, a judge may consider
mediation
a neutral person’s
helping two disputing
parties arrive at a
solution that is mutually
acceptable; however, the
mediator’s decision is not
legally binding.
best interest of the child
the principle that drives
the judge’s decisions in
domestic relations courts
when deciding issues of
custody and support.
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289THE LEGAL SYSTEM AND CHILD MALTREATMENT
who has been serving as the primary caregiver for the child, which parent is the better parent, and which adult is more likely to encourage a healthy relationship between the child and the noncustodial parent, as well as parental problems such as mental illness, substance abuse, and even extramarital affairs if the affair(s) can be shown to have hurt the child. Courts will also consider violence within the home, including domestic violence and child abuse. Finally, especially with older children, the judge will weigh the stated preference of the child. Based on this evaluation, the judge not only determines custody but also sets up a visitation plan. Court-ordered visitation ranges from no visitation at all to supervised visits to unsupervised visits (Sagatun & Edwards, 1995).
After decisions have been made, the court has little enforcement power. The domestic relations court does not have the powers to investigate, prosecute, or super- vise the cases on which it rules. If one party fails to fulfi ll the court order, it is up to the injured party to bring a new complaint. If a parent does not pay court-ordered child support, it is up the parent who did not receive the money to bring a new complaint before the court. The custodial parent can also violate the court order by, for example, failing to produce the child for visitation. In this case, the noncustodial parent would have to bring the custodial parent back to court. With regard to child maltreatment allegations, the parent making the claims must report, prove, and then monitor the situation. If a parent is in clear violation of an order of the domestic relations court, he or she would be found to be in civil contempt. As such, the parent can be fi ned or jailed while he or she is violating the order. However, once the parent ends the violation (e.g., makes the payment or produces the child), he or she is no longer in contempt of court (Sagatun & Edwards, 1995). Clearly, this court is not the best response to allegations of child maltreatment.
Criminal Court
The most powerful response to child abuse and neglect is criminal prosecution. The criminal courts are the venues that can result in imprisonment for behavior. The vast majority of child maltreat- ment cases never make it to criminal court. This court is generally used only for the most severe cases of physical abuse (those caus- ing severe, permanent harm or death) and, more recently, cases of sexual abuse. Only cases of extreme physical neglect (that result in severe harm or death) are likely to be heard in criminal court. Criminal charges are rarely used to deal with maltreatment; however, they are the most intense charges. Addition- ally, the number of these cases that are brought to criminal court does appear to be increasing (see Focus on Research 12.3 ).
criminal court
the court charged with
the administration of
justice via penalty or
punishment.
FOCUS ON RESEARCH 12.3
In 2003, Cross, Walsh, Simone, and Jones published a meta-analysis of rates of criminal justice decisions in cases alleging child abuse. Although historically child abuse cases have not been heard in great numbers in criminal court, some surveys of prosecutors indicated that this was changing during the 1980s and 1990s. To determine rates of referral for
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290 LEGAL ISSUES
The decision to press criminal charges is usually decided by law enforcement and prosecuting attorneys. However, in some areas, there is increased contact between CPS and law enforcement. Their interaction is complex because, although they both strive to protect victims, they often have different goals. CPS and the dependency courts are designed as therapeutic models with hopes of reuniting families; the crimi- nal courts are focused on gathering evidence for the purpose of criminal prosecution, punishment, and the protection of potential future victims. It is not always clear which approach is the best in cases of maltreatment. Since the early 1970s, there have been calls for “interdisciplinary collaboration” between CPS and the police. When these interdisciplinary teams are created, they appear to be most successful when there are equal numbers of participants from each area, the participants from each area are perceived to be equal in power, there is mutual respect between team members, and there is regular and direct communication at meetings in neutral loca- tions (Sedlack et al., 2006). As you can imagine, it is diffi cult to meet these ideal
prosecution, charges, and guilty pleas, the authors reviewed 21 studies that had examined criminal prosecution in cases of child abuse. In order to be included in the meta-analysis, the study had to present quantitative data on at least one of the following aspects of case fl ow: referral to district attorneys, charging rate, the percentage of cases that were carried forward (they resulted in either a guilty plea or a trial), the rate of guilty pleas or verdicts, or the incarceration rate. With one exception (a study done in 1969), all studies were fairly recent (5 were conducted in the 1980s, 11 in the 1990s, and 4 in the 2000s).
The authors found that rates varied dramatically across studies. For instance, the refer- ral rate of child abuse claims to the district attorney ranged from a low of 40% to a high of 85%. Although the mean rate of referral was greater than 50%, the authors noted that the extreme variability makes the mean diffi cult to interpret. Once cases were referred to the district attorney, the rate of charging also varied signifi cantly (from a low of 28% to a high of 94%). However, once charges were fi led, a consistently high percentage (79%) of cases were carried forward and not dismissed or transferred. The majority of studies also showed high plea rates (82%) and low trial rates (18%). Although 14 of 19 studies reported trial rates that were equal to or less than 16%, the range across all studies was from 3% to 61%. The incarceration rate also varied greatly across studies, from a low of 24% to a high of 96%, with a mean rate of 54%.
The authors summarized the data by projecting the likely results of 100 hypothetical cases referred for prosecution of child abuse claims (Cross, Walsh, Simone, & Jones, 2003, p. 324):
• 66 would be charged • 43 would plead guilty • 12 would be dismissed or transferred • 2 would be diverted to treatment • 6 would be convicted at trial • 3 would be acquitted at trial • 26 would be incarcerated for that charge
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291THE LEGAL SYSTEM AND CHILD MALTREATMENT
standards among teams who come to the table with some fundamental differences in goals.
Charges and Pleas Unlike the other court systems covered so far, when a case is heard in criminal court, someone must be charged with an offense. Charges regarding child maltreatment can be felony or misdemeanor charges. Furthermore, once a per- son has been charged with a crime, the person has all of the rights for due process that are guaranteed by the Constitution: the right to an attorney, the right to be notifi ed of the charges, the right to confront and cross-examine witnesses, the right to remain silent, the right to a reasonable bail, the right to a jury trial, and the right to appeal the verdict of the court. The defendant is granted these rights in criminal court because the potential outcomes (prison, death penalty) are so severe. In addition to these rights, a further protection for defendants is the standard of proof used in criminal court. In order to fi nd a defendant guilty, the prosecution must prove guilt beyond a reasonable doubt. While there is much debate about exactly what this phrase means, all agree that it is the highest standard of proof used in the American courts (Brooks, 1996).
In criminal court, the case is called Name of State v. Name of Accused. If I were charged by South Carolina, the case would be called South Carolina v. McCoy. This helps to remind you that the party pressing charges is the State, not the victim. In fact, the State can press charges even if a victim would prefer that the defendant was not prosecuted (Brooks, 1996). The process begins when the charges are fi led and bail is set. In most jurisdictions, this is followed by a grand jury hearing. The purpose of these hearings is to make sure that the state has probable cause to try the case. Only the prosecution presents evidence at this time, and the jury decides by a majority vote. The purpose of this system is to prevent the state from harassing citizens whom it does not have suffi - cient evidence against and to control court costs by preventing trials that are highly unlikely to result in a guilty verdict (Shaw & Brenner, 2006).
If the state proceeds with its case, the next step is the arraign- ment. At this time, the defendant offi cially enters a plea. There are four possible pleas: guilty, not guilty, not guilty by reason of insan- ity, and no contest. A plea of no contest is not an admission of guilt; it simply means that the accused will not fi ght the charge(s). In this situation, the defendant then accepts whatever sentence is given. These sentences are frequently less than sentences imposed when a defendant is tried and found guilty. A defendant may choose this option if the case is likely to result in a subsequent civil action, because a plea of no contest may not be used against a defendant in later civil cases (Garner, 1996). In order to plead no contest, both parties and the judge need to agree that the verdict is acceptable.
After a plea of not guilty has been entered, plea bargaining begins. Most cases will end with this process. Generally, the defendant agrees to plead guilty to a lesser charge or to plead guilty to only some of the charges that have been fi led. In other cases, the defendant pleads guilty in return for a predetermined sentence. This type
felony
a serious crime that
is punishable with
imprisonment of greater
than 1 year or even
death.
beyond a reasonable
doubt
the burden of proof in
criminal court; the doubt
that prevents one from
being fi rmly convinced
of a defendant’s guilt; the
highest burden of proof.
arraignment
an initial step in criminal
prosecution during
which defendants hear
the charges against them
and enter a plea.
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292 LEGAL ISSUES
of plea bargaining, when permitted, is limited in many jurisdictions and generally requires the approval of a trial judge (Larson, 2000). This has some advantages and disadvantages for the child victims in maltreatment cases. On the positive side, the defendant is found guilty of some offense, and the child is not forced to testify at trial. On the negative side, the defendant often pleads guilty to a much less severe crime than that allegedly committed against the child. It is possible that this leaves the child feeling further victimized. To make matters worse, the victim has no offi cial say in what type of plea is offered.
Accommodations for Children Who Testify If the case does go to trial, the defendant has signifi cant rights, including the right to confront any witnesses who testify against them. As mentioned previously, this can be problematic for children who may be unable to testify in the presence of their alleged abusers. Attempts have been made to reduce the potential trauma of being a child witness. Instead of testifying in court, some children have been allowed to testify from a nearby location via closed-circuit television, and exceptions to hear- say laws have been granted to let adults testify about what a child said to them. Although these techniques may protect a child victim from further trauma, they can be problematic legally because they limit the defendant’s constitutional guarantee to confront and cross-examine witnesses against them (see Legal Example 12.1 ). Fur- thermore, Goodman et al. (2006) reported that jurors found children who testifi ed in person to be more credible and that the jurors felt more empathy for these alleged victims. In addition, jurors were more confi dent about the defendant’s guilt when the child’s testimony was presented in person and not via closed-circuit television.
LEGAL EXAMPLE 12.1
A major issue that professionals deal with when considering child witnesses is the confron- tation clause. According to the Sixth Amendment of the U.S. Constitution, a defendant is guaranteed the right “to be confronted with the witnesses against him.” This has been interpreted to mean that a witness must provide testimony in the presence of the accused, and the defendant has the right to cross-examine that witness. The basis of this guarantee is the belief that direct and cross-examinations are the best way to ensure truthful testi- mony. In opposition to this guarantee is research that fi nds that being forced to testify in the presence of the accused is a highly negative scenario for child witnesses (Bussey, Lee, & Grimbeek, 1993). Various attempts have been made to protect children without depriv- ing defendants of their constitutional rights. It has proven to be a tough ethical and legal dilemma. This issue has been heard twice by the U.S. Supreme Court in Coy v. Iowa (1988) and in Maryland v. Craig (1990).
Coy v. Iowa (1988)
In Coy v. Iowa the defendant was charged with the sexual molestation of two girls, both 13 years old. It was alleged that he entered the tent where they were camping in their
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293THE LEGAL SYSTEM AND CHILD MALTREATMENT
backyard and sexually assaulted them. At the time of his jury trial, the judge allowed a screen to be placed in the courtroom between the witnesses and the defendant. The screen was used based on a state statute that existed to protect child victims of sexual abuse. With the screen in place, and the lighting in the room adjusted, the defendant was able to see the witnesses dimly, and he could hear their testimony. The witnesses were not able to see the defendant. Coy was found guilty on two counts of lascivious acts with a child by the trial court. Coy appealed to the Iowa Supreme Court on the grounds that he had been denied the right to face his accusers. Coy’s team also argued that the use of the screen made him appear guilty and, therefore, interfered with the presumption of innocence. Coy’s conviction was upheld by the Iowa Supreme Court. The court ruled that because his attorney was able to cross-examine the witnesses, his right to confrontation had not been violated. The court further stated that the screen was not inherently prejudicial.
Coy’s case was then appealed to the U.S. Supreme Court on the grounds that his Sixth Amendment rights had been violated by use of the screen. The U.S. Supreme Court ruled in favor of Coy, stating, “That core guarantee serves the general perception that confrontation is essential to fairness, and helps to ensure the integrity of the fact-fi nding process by making it more diffi cult for witnesses to lie” (1988, p. 2). Although the court acknowledged that this could be traumatic for witnesses by writing that “it is a truism that constitutional protections have costs” (1988, p. 6) the court argued further that the use of the screen by the trial court violated this right. The U.S. Supreme Court justices wrote that there may be some exceptions to this guarantee, but they did not apply to this case. Although Iowa had a statute designed to protect child witnesses, it was not established that this protection was needed in this case. The justices noted that there was no evidence that these particular witnesses were in need of special protection. Therefore, the use of the screen was not acceptable.
This decision was a 6-to-2 ruling by the court (Justice Kennedy did not take part in either the consideration or the decision of the case; hence, only eight justices were involved). The dissenting justices (Blackmun and Rehnquist) felt that the screen had not violated Coy’s Sixth Amendment rights. They noted that the following conditions were met: The witnesses were under oath; they were subject to cross-examination; the jury, judge, and defendant could see and hear the witnesses; the jury and judge could see the defendant while the wit- nesses testifi ed; and the witnesses were aware that the defendant could see and hear them. Because all of these things were true, Coy’s Sixth Amendment rights were not violated. The dissenting justices went on to say that focusing narrowly on witnesses “seeing” the defend- ant while they testifi ed could obscure the more fundamental aspects of the confrontation clause—the right to cross-examine witnesses and the opportunity for the jury to observe the witnesses while they testify. The justices raised the following thought-provoking question: If seeing the defendant is an absolute requirement of the confrontation clause, how would the court handle a blind witness? The dissenting justices also argued that the use of the screen was not inherently prejudicial. Although wearing prison garb or being shackled does make a defendant look guilty, the same cannot be said of the screen because screens are not associated with convicts. Further, the trial court judge had instructed the jury not to draw any inference of guilt from the use of the screen.
Finally, the dissenting justices point out that face-to-face confrontation is preferred, but it is not an absolute. Because testifying may be traumatic for children, they should be
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294 LEGAL ISSUES
protected. If face-to-face testimony is overwhelming for children, procedures can be used to protect the children and possibly increase the accuracy of their testimony as a result of lowered anxiety. The justices wrote that it could be assumed that child witnesses would benefi t from the use of the screen without an individualized fi nding of trauma for each case.
DISCUSSION QUESTIONS
1. Which court decision do you agree with in Coy’s case? Why? 2. If you were a juror in this case, do you think that the use of the screen would have
made the defendant appear guilty? 3. Can you think of ways that children could testify that would protect them without
violating the rights of the defendant?
As you can see, this is not an easy issue to resolve. People have very strong feelings on both sides of this debate. Therefore, it is not overly surprising that the same issue was back before the U.S. Supreme Court only 2 years later in the case of Maryland v. Craig.
Maryland v. Craig (1990)
In 1986, Sandra Craig was charged with sexually abusing a 6-year-old who had attended the prekindergarten/kindergarten center that she operated. The child had attended the center for 2 years prior to the allegations of abuse. During her trial, the judge permitted the child witness to testify via one-way closed-circuit television. This was allowed after an expert had testifi ed that the child would suffer serious emotional distress if forced to testify in front of the defendant and that this distress would likely interfere with her ability to provide accurate testimony. During the trial, the child witness testifi ed in a separate room with only the prosecutor and defense counsel present. Her testimony was broadcast live to the courtroom, where the defendant, jury, and judge were able to see and hear the child. The defendant was also able to communicate with her counsel. Craig was found guilty by the trial court, but she appealed on the grounds that her Sixth Amendment rights had been violated. The Maryland Court of Special Appeals affi rmed the decision of the trial court, but the Maryland Court of Appeals reversed the decision of the trial court. The court of appeals did not agree with Craig that her right to face her accusers was absolute, but they said the current case did not meet the necessary standards to allow an exception. Specifi cally, the court wrote that it was not enough to have an expert say the child would be emotionally distressed if forced to testify in front of the accused. They suggested that this determination could only be made by attempting to question the child in front of the defendant and seeing if the child was too distressed to communicate. Further, they said the court should have explored an intermediate option like two-way television. The case was appealed to the U.S. Supreme Court.
In a 5-to-4 decision, the Supreme Court ruled to affi rm the trial court. The justices wrote that the confrontation clause does not guarantee defendants the right to be face-to- face with their accuser. Maryland’s desire to protect a child witness was a suffi cient reason to waive the right to face-to-face confrontation as long as the trial court established indi- vidual trauma. The ruling of an expert is suffi cient for this purpose. It is not necessary, as advocated by the Maryland Court of Appeals, to establish this by exposing the child to the
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295THE LEGAL SYSTEM AND CHILD MALTREATMENT
defendant. The justices did add that the expert must fi nd that the child would be trauma- tized specifi cally by facing the defendant and not by other aspects of testifying such as the courtroom itself.
The opinion of the four dissenting justices was written by Justice Scalia and begins with this very strong statement: “Seldom has this Court failed so conspicuously to sustain a categorical guarantee of the Constitution against the tide of prevailing current opinion” (1990, p. 14), and the introduction ends with “Because the text of the Sixth Amendment is clear, and because the Constitution is meant to protect against, rather than conform to, current ‘widespread belief,’ I respectfully dissent” (1990, p. 15). Scalia goes on to argue that face-to-face confrontation is a constitutional guarantee and not a mere preference. Although it may be nice to shield children, it is necessary to protect defendants by ensur- ing that they receive what they are guaranteed. Because research shows that children are, in fact, more vulnerable to suggestion and to confusing fantasy with reality, it is even more imperative to have them present their testimony live, in court, so it can be most fully assessed by the jurors. Scalia concluded by saying, “I have no need to defend the value of confrontation because the Court has no authority to question it” (1990, p. 18).
Given the intense debate on this issue, most prosecutors prefer to have children testify so that cases cannot be appealed on grounds such as these. Of course, this means that chil- dren are exposed to the emotional distress that this entails. For this reason, professionals continue to strive to fi nd ways to make this experience easier without violating the rights of the accused.
DISCUSSION QUESTIONS
1. Which court decision do you agree with in Craig’s case? Why? 2. If you were a juror in this case, do you think that the use of closed-circuit television
would have made the defendant appear guilty? 3. What do you think is necessary to establish that a witness would be traumatized by
facing a defendant in court? (e.g., is expert testimony suffi cient?) 4. Which technique do you think is better for the child: closed-circuit television or the
use of a screen? Which is better for the defendant?
Other minor changes can be made in the criminal court proceedings to make testifying easier on child victims while still having them testify in person. For exam- ple, a child’s testimony can be given in shorter segments with frequent recesses. In addition, if a child is going to testify, cases can be given priority to lessen the delay between the alleged crime and the child’s testimony. Simple changes may also be made to the physical setting of the courtroom. For example, a trial judge in Massa- chusetts allowed a child witness to testify while sitting at a child-sized table in front of the jury instead of from the witness stand. This decision was upheld by the Massa- chusetts Supreme Judicial Court. Not only does this relieve some of the child’s fears, but research has suggested that it also increases a child’s ability to provide answers during direct examination (Goodman et al., 1992). Other judges have required attor- neys to remain seated while questioning children, allowed the witness chair to be turned slightly away from the defendant, or forbidden people to enter or leave the
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296 LEGAL ISSUES
courtroom during a child’s testimony. Finally, the judge can restrict public access to the courtroom while a child is testifying. As mentioned previously, maltreated chil- dren may also be assigned a GAL/CASA or attorney to represent their wishes. Any of these things may make the experience easier for a young victim (Myers, 1996). See Search the Web 12.1 for other unique programs designed to provide comfort to child victims.
SEARCH THE WEB 12.1
There are a number of unique programs that have been established to help make testi- fying in court less traumatic for children. One approach is the use of dogs in court. To read more about these programs, go to www.courthousedogs.org. These dogs, trained via Assistance Dogs International programs, stay with children during forensic interviews and while they testify. To see video about the Ionia Canine Advocacy Program, go to www.mlive .com/news/grand-rapids/index.ssf/2013/05/dogs_in_court_see_how_canine_a.html. This 2-minute clip, explains the role that a courthouse dog, Patty, fi lls for children who are involved in court proceedings.
Another unique approach to making child victims feel safe is Bikers Against Child Abuse (BACA) International: Breaking the Cycle of Abuse. The mission of this group of bikers is to lend physical and emotional support to victims. This support can include a physical presence in the courtroom to show support for the victim and to let them know that they are not alone. To see more about their program, check out their web page at http://bacaworld.org/mission.
Although courts seem to be moving in the direction of accommodating child witnesses, these changes are not always upheld on appeal. In a number of cases, state supreme courts have ruled that some changes are not appropriate, especially in criminal courts. For instance, a trial judge was ruled to have gone too far by allowing a child witness to sit on his lap ( State v. Michaels , 1993), and another judge was faulted for promising to give a child ice cream if she told what was “real” ( State v. R. W. , 1986). In this case, the child refused to proceed with cross-examination before getting the promised treat. When the judge provided the reward in the courtroom, it appeared that the judge was agreeing that the child had, indeed, told what was real. While the reasoning behind these decisions may seem clear, other cases are less obvious. For instance, the Hawaii Court of Appeals ruled in State v. Palabay (1992) that a 12 year-old witness should not have been allowed to hold a teddy bear while testifying unless the state was able to provide a compelling reason for allowing this (Myers, 1996).
As noted earlier, one accommodation to child witnesses has been to allow hear- say evidence under some conditions. Hearsay is defi ned by Black ’ s Law Dictionary as “testimony that is given by a witness who related not what he or she knows person- ally, but what others have said, and that is therefore dependent on the credibility of
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297THE LEGAL SYSTEM AND CHILD MALTREATMENT
someone other than the witness; such testimony is generally inadmissible under the rules of evidence” (Garner, 1996, p. 287). Because child abuse victims may disclose to adults (parents, teachers, professionals, etc.) and still be ineffective as witnesses them- selves, hearsay exceptions exist to get their statements admitted at trial. For instance, all U.S. courts recognize the excited utterance exception. This exception allows witnesses to testify about things a child said immediately after a startling event (Myers, 1996). The reasoning is that statements made by an upset or emotional child right after a traumatic event are likely to be true because such chil- dren are not in a state to make up plausible lies. A second hearsay exception is the medical diagnosis or treatment exception. This allows medical professionals to testify to statements made to them by children they were treating (Myers, 1996). The assumption is that a person would not lie to a person who was using the information to treat him or her. Some states have gone so far as to add more general exceptions for cases of child sexual abuse or for child witnesses in general (Myers, 1996).
Are Criminal Courts an Appropriate Venue for Allegations of Child Abuse? Given all of these controversial issues, there is still much debate about whether the criminal courts are the appropriate arena for addressing charges of child mal- treatment. Certainly, the criminal court is not geared toward helping a family stay together and work out their problems; this is not a therapeutic approach. If the per- petrator is jailed, the likelihood of family reunifi cation is low. Even when the child may not ever be safe with the perpetrator, criminal cases can tear apart the extended family as each person chooses a side. Second, criminal prosecution ignores the root of the problem. It does not attempt to address what caused the parent to behave inappropriately. If the root cause is not identifi ed, it will not be fi xed. Third, as men- tioned earlier, children often experience signifi cant stress if they have to testify in criminal court. In addition, a victim may feel guilty if his or her testimony sends a family member to jail. For all of these reasons, some argue that cases of child mal- treatment are best handled in the dependency courts.
On the other hand, there are some strong arguments in favor of prosecuting child maltreatment cases in criminal court. Perhaps the most striking reason is that criminal prosecution makes child maltreatment a real crime—one that has real penalties. Some argue that for too long, what goes on inside a family’s home has been too protected from legal intervention. A child who is victimized deserves to have the perpetrator prosecuted, even if that perpetrator is a family member. Also, because criminal courts can imprison guilty defendants, this court system is best set up to protect potential future victims from the perpetrator. Finally, because the standard of proof is so high in criminal court, it is less likely that a false allegation of abuse would be found to be true in this court. In this way, criminal prosecution offers extra protection to the wrongly accused. Given this controversy, it is not surprising that only a small number of child maltreatment cases are tried in criminal court.
Civil Court
Child maltreatment cases have not traditionally been heard in civil court. However, in recent years, there has been an increase
excited utterance
exception
an exception regarding
a statement that is
made while under stress
about an event, which
is admissible as hearsay
testimony.
civil court
a court that hears
noncriminal cases where
parties seek to settle
disputes and be awarded
damages.
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298 LEGAL ISSUES
in civil cases related to child abuse. The use of the civil court was often the only avenue available for people who allegedly recovered memories of child abuse after they were adults. Because they were no longer dependents, the cases could not be heard in juvenile courts or domestic relations courts. Criminal courts were not an option in any states that had a statute of limitations for criminal charges. If too much time (usually 7 years) had passed between the alleged event and the claim, the defendant could not be prosecuted criminally.
Tort Laws Child maltreatment cases heard in civil court have usually been related to tort laws. The tort laws allow people to sue others based on the claim that some con-
duct, product, or service has caused harm because it does not meet minimal, acceptable standards (Garner, 1996). You are probably familiar with cases using the term personal injury , and you have likely had the greatest exposure to cases dealing with product liability. If a person were injured by a product that was not well made, he or she could sue the manufacturer. In cases of child maltreatment, the plaintiff (person making the charges) is saying that the defendant did not meet society’s standard for child rearing. These cases can involve intentionally infl icted harm (what I have been referring to as abuse) or negligence and carelessness (which would be appropriate for cases of neglect). The goal of taking someone to civil court is to recover damages. If you are found guilty in civil court, you do not go to jail, but you must pay reparations to the alleged victim. Because this court can
only impose monetary punishment, as opposed to imprisonment, it does not offer as many protections to defendants. For instance, defendants still have the right to a trial by jury, but they do not have the right to have an attorney provided for them (Brooks, 1996).
It is easier to get a guilty verdict in civil court than in criminal court because the standard of proof is lower. In order to fi nd the defendant guilty in civil court, the jury or judge needs to fi nd that the preponderance of evidence favors the plaintiff (Loar, 1998). In other words, there is more evidence to support the plaintiff than there is to support the defendant. When a jury member believes that more than 50% of the evidence supports one party, he or she must rule for that party.
The plaintiff in a civil court case must be an adult. However, this does not mean that a child is forced to wait until age 18 in order to pursue a civil case. An adult can bring civil charges on a child’s behalf. Civil cases are labeled with the names of the parties involved (Carp, Stidham, & Manning, 2004). So, if I sued my neighbor, John Jones, the case would be McCoy v. Jones. Like criminal court cases, most civil court cases are settled prior to trial, but most courts require a review before an action brought on behalf of a child can be settled. If the case goes to trial, the procedure is similar to that used in criminal court, and once again, the child may be forced to testify.
statute of limitations
a law that sets a time
frame for the prosecution
of a crime or for suing
to ensure that cases
are resolved while
the evidence is still
reasonably available.
tort laws
laws that allow people to
sue others based on the
claim that some conduct,
product, or service that
does not meet minimal,
acceptable standards has
caused harm.
plaintiff
the party that brings the
suit in civil court.
preponderance of
evidence
the burden of proof in
a civil trial; the greater
weight of evidence,
however slight.
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299THE LEGAL SYSTEM AND CHILD MALTREATMENT
Class Action Suits C lass action suits are fi led in civil court. In these cases, an action is brought by a few people on behalf of a group. The goal is to seek relief for all members of the group. Often the purpose is to force a systemwide change so that an entire group is treated more fairly by an agency. With regard to child maltreatment, a group may sue the state under the general premise that children are not properly served because the agencies designed to protect them are under- staffed. They may also allege that maltreated children are at greater risk once in the care of the Department of Social Services than they were in their homes or that the agency is not following the federal regulations that address child maltreatment. In some cases, individual claims are made against the state. In general, the civil courts have found for the state if a child is injured at home. In other words, failure to protect the child is not something that the state is liable for. Furthermore, if a parent voluntarily places his or her child in the care of the state, the state is not liable if the child is harmed while in the state’s care. The only cases in which suits against the state on behalf of an individual child tend to be successful are when the child is harmed while in involuntary placement. In these cases, a child is removed from home against the wishes of parents and is maltreated or harmed while in the state’s care (Sagatun & Edwards, 1995).
Possible Defendants in Civil Suits Some civil cases against the State have been successful, as have cases against abusive parents. In addition, suits against nonabusive parents have been successful when it was shown that they allowed the abuse to occur. Although it is obvious that the most common defendants would be parents, there is a problem with this choice of defend- ant. Because civil courts can only issue fi nancial penalties, it is not very productive to sue parents who are poor. In response to this, some plaintiffs have attempted to sue insurance companies, usually under homeowner policies. In this scenario, the claim is that the child was harmed in the home, and therefore, the insurance company is liable. This approach has not proved to be successful because the policies insure against accidental injury, not injury that results from intentional or willful acts (Loar, 1998).
In other cases, civil charges have been fi led against professionals who came in contact with the child and failed to report suspected abuse. In fact, the courts have gone beyond failure to report suspected abuse and have found professionals respon- sible if they failed to notice signs of abuse that a trained professional should have noticed. (For an example, see the case of Landeros v. Flood in Chapter 3 .)
TESTIFYING IN COURT
If you work in the fi eld, there is a good chance that you will be called to testify in court. Although this can be frightening, it is your chance to provide the court with information so that the judge or the jury can make the best decision. In order to be an effective witness, you must look and act the part. When appearing in court, professional and conservative dress is expected. You are also expected to maintain
class action suit
a lawsuit in which one
person or a small group
sues as a representative of
a larger group of affected
people because the group
is so large that individual
suits would not be
practical.
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300 LEGAL ISSUES
a respectful, serious demeanor. While testifying, you should maintain good posture and speak clearly. Look at the person asking you questions and at the jury if one is present. Your testimony should be objective and sincere. Try to avoid both slang terms and professional jargon (Child Welfare Information Gateway, n.d.). Before going to court, you should prepare carefully for your testimony. You should know the details of the case involved (Child Welfare Information Gateway, n.d.).
This means that for all cases, you should keep careful, precise notes. Even events that seem dramatic or impossible to forget when they occur may be diffi cult to recall by the time you are called to testify. If you have good notes to review before testify- ing, you will be a better witness.
Prior to answering any question in court, make sure you know what is being asked. It is all right to pause and think before answering. If you do not understand a question, ask for clarifi cation before answering. You should limit your answer to the question asked; do not provide additional information. If you do not know the answer to a question, you should state this and not attempt to guess at the answer. When you know that answer to a question, focus on providing facts when you respond. Do not volunteer your opinion unless you are specifi cally asked to do so (Child Welfare Information Gateway, n.d.).
It is also a good idea to observe court cases before you are ever called as a witness. This gives you the opportunity to see how judges, attorneys, and witnesses conduct themselves in court. If you are more familiar with the process, you will be a more confi dent witness.
CONCLUSION
In conclusion, the law regarding child maltreatment is complex, as is the U.S. court system. Although nearly everyone agrees that the government needs to have a role in protecting the child, there is much less agreement about what that role should be. In addition, it is clear that even if protecting children is a goal of the courts, the courts were not set up with children in mind. Finally, some argue that little of this legal fi nagling actually helps to prevent child maltreatment. Still, given that this is the current state of the legal system, it is important for all of those who work with children to be aware of the basics of our court systems.
DISCUSSION QUESTIONS
1. What are the benefi ts and weaknesses of each court system when handling cases of alleged child maltreatment? Should maltreatment cases be heard in all four court systems?
2. Is it possible to protect child witnesses while preserving the rights of defendants in criminal court? If not, who should be protected fi rst?
3. If you were given a $1 million grant to protect child witnesses in your commu- nity, how would you spend the money?
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PART IV
What Happens Next
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303
Raising a family in the manner and style deemed personally appropriate and desirable is a fundamental parental right. With this right, however, comes obli- gation. Society presumes that parents will raise their children with the children’s best interests at heart. When this does not occur and parents do not protect their children from harm or do not meet their children’s basic needs, then society has the responsibility to intervene on behalf of the children (Goldman, Salus, Wolcott, & Kennedy, 2003).
In the United States, the governmental agency that receives and responds to reports of child maltreatment is broadly known as Child Protective Services (CPS). Each state is responsible for maintaining and operating its own child protective agency, which may vary in name from one state to another (Department of Children and Families, Department of Social Services, etc.). Although law enforcement may also be involved in the child protection process, the majority of child protection efforts fall on the shoulders of CPS agencies. See Profi le 13.1 for one CPS profes- sional’s outlook on working in the child protection fi eld.
CHAPTER 13
The Maltreated Child and Child Protective Services’ Response What Happens After a Report Is Made?
PROFILE 13.1
Angela Talley Robinson, Program Coordinator, Spartanburg County, South Carolina Department of Social Services
Mrs. Robinson began her career in human services in 1989 with the economic services branch of the Department of Social Services in Union County, South Carolina. She soon transferred to Child Protective Services as an investigative caseworker, later became a super- visory investigator, and is currently the program coordinator for Adult Protective Services and the program coordinator for intake and investigations of Child Protective Services. After earning her bachelor’s degree in marketing, Mrs. Robinson changed her focus noting that she was always interested in social work. Although Mrs. Robinson acknowledges that child
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304 WHAT HAPPENS NEXT
Although the primary responsibility for CPS jurisdiction lies at state and local levels, there are several federal laws that mandate and subsequently govern CPS agencies. The Child Abuse Prevention and Treatment Act (CAPTA) was passed in 1974 and authorizes the expenditure of federal dollars to individual states for their child protection efforts. To receive these funds, states must conform their child abuse reporting laws to federal standards and adhere to the minimum federal defi nitions of child abuse and neglect (Myers, 2002). CAPTA was amended and reauthorized in 2003 by the Keeping Chil- dren and Families Safe Act, and again in 2010 by the CAPTA Reauthorization Act.
Additional federal legislation includes the Indian Child Welfare Act (1978), which establishes jurisdiction for custody cases involving children of Native American descent. It states that tribal governments have sole authority to determine cus- tody when the child resides on tribal or reservation lands and have shared authority with state governments when the child does not reside on tribal or reservation lands. The Adoption Assistance and Child Welfare Act (1980) requires states to make reasonable efforts to prevent the removal of chil- dren from their parents (i.e., family preservation). If removal is unavoidable, this act further requires states to make rea- sonable efforts to reunify children with their parents (i.e., family reunifi cation). The Adoption and Safe Families Act (1997) was passed in an attempt to clarify the “reasonable efforts” requirement previously established by the Adoption Assistance and Child Welfare Act with respect to family pres- ervation and reunifi cation (“In making reasonable efforts, the child’s health and safety shall be the paramount concern”; Public Law 105–89) and to correct problems inherent in the foster care system that deterred the adoption of children with
protection is a diffi cult job, she also noted that she loves her work. Despite the challenges, she said that she focuses on the successes—the hugs that she receives from the children she has helped and the thank-yous she occasionally receives from parents. These small gestures help her work through the more challenging times. Mrs. Robinson mentioned that a sense of humor also helps! When asked about advice she might offer to people just beginning their careers in child protection, Mrs. Robinson noted that it is important to have a realistic eye. She has seen too many people burn out because they thought they would enter the fi eld and “save the world”; having more realistic expectations is crucial to lasting success. As an investigator, she mentioned that it is also important to be ready for the unexpected because “when you walk up to a house, you never know what is on the other side of the door.” Finally, Mrs. Robinson stated, “You have to care. It’s a calling, but it’s not for everyone.”
jurisdiction the authority to deal with legal matters and the limits within which that authority may be exercised. Child Abuse Prevention and Treatment Act (CAPTA) federal legislation passed in 1974 that sets forth a minimum defi nition of child abuse and neglect, establishes the Offi ce on Child Abuse and Neglect (OCAN), authorizes the expenditure of federal dollars to support state child protection efforts, and provides grants to public agencies to support child maltreatment research. Keeping Children and Families Safe Act federal legislation passed in 2003 to make improvements to and reauthorize programs under the Child Abuse Prevention and Treatment Act (CAPTA). CAPTA Reauthorization Act federal legislation passed in 2010 to amend and reauthorize programs under the Child Abuse Prevention and Treatment Act (CAPTA). Indian Child Welfare Act federal legislation passed in 1978 to establish jurisdiction in custody cases involving children of Native American descent. Adoption Assistance and Child Welfare Act federal legislation passed in 1980 to encourage caseworkers to work toward reunifying families and to avoid long-term and/or multiple foster care placements for children if possible.
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305THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
special needs (Myers, 2002). Finally, the Adam Walsh Child Protection and Safety Act (2006) is designed to protect children from sexual exploitation and child pornography. It further requires a national registry of substantiated cases of child maltreatment to be main- tained by the U.S. Department of Health and Human Services (Child Welfare Information Gateway, 2006).
The Offi ce on Child Abuse and Neglect (OCAN) , a division within the Children ’ s Bureau of the Administration for Children and Families (ACF) has developed a User Manual Series to provide state agen- cies with up-to-date knowledge and practice guidelines regarding child protection. As part of this series, Child Protective Services: A Guide for Caseworkers (2003) pro- vides guidance to state agencies regarding their specifi c child protection policies and regulations. According to this manual, the basic philosophical tenets of CPS are as follows:
A safe and permanent home and family is the best place for children to grow up.
Most parents want to be good parents, and when adequately supported, they have the strength and capacity to care for their children and keep them safe.
Families who need assistance from CPS agencies are diverse in terms of structure, culture, race, religion, economic status, beliefs, values, and lifestyles.
CPS agencies are held accountable for achieving outcomes of child safety, permanence, and fam- ily well-being.
CPS efforts are most likely to succeed when clients are involved and actively participate in the pro- cess.
When parents cannot or will not fulfi ll their responsibilities to protect their children, CPS has the right and obligation to intervene directly on the children’s behalf.
When children are placed in out-of-home care because their safety cannot be assured, CPS should develop a permanency plan as soon as possible.
To best protect a child’s overall well-being, agencies want to assure that children move to perma- nency as quickly as possible (DePanfi lis & Salus, 2003, emphasis added).
As should be clear from these tenets, the main role of any CPS agency is to help families function to the
reasonable efforts according to the Adoption Assistance and Child Welfare Act, the responsibility of state child welfare agencies to avoid foster care placement and/or to reunify a family whenever possible. This defi nition was amended in the Adoption and Safe Families Act, providing exceptions to the family preservation and reunifi cation requirements (especially in consideration of child safety issues).
Adoption and Safe Families Act federal legislation passed in 1997 to promote the adoption of children in foster care (in the event that reunifi cation with biological parents is not possible), especially children with special needs. It describes safety, permanency, and well-being as key principles in the implementation of child welfare legislation.
family preservation and reunifi cation an underlying principle of federal legislation (particularly the Adoption Assistance and Child Welfare Act) that encourages child protective agencies to maintain biological families whenever possible. Adherence to this principle has lessened since the passing of the Adoption and Safe Families Act, which focuses more on the child’s safety and well-being than maintaining a biological family.
U.S. Department of Health and Human Services established in 1979 with the goal of protecting the health of all Americans and providing essential human services.
Adam Walsh Child Protection and Safety Act federal legislation passed in 2006 to protect children from sexual exploitation and child pornography .
Offi ce on Child Abuse and Neglect (OCAN) established by the Child Abuse Prevention and Treatment Act (CAPTA) in 1974, this agency is part of the Children’s Bureau in the Department of Health and Human Services. It funds resources for improving state responses to child abuse and neglect.
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306 WHAT HAPPENS NEXT
best of their ability by providing services necessary to preserve the family structure. The ultimate goal of CPS is to help parents protect their children and to keep children with their families whenever possible. If the child’s home environment is not safe, then it is CPS’s obligation to intervene on the child’s behalf and establish a safe environment in which the child can live. Whenever possible, this entails allowing the child to remain at home and working with the fam- ily to improve the child’s living conditions and to remedy any safety concerns. Only if this is not pos- sible or cannot be readily accomplished should CPS remove children from their homes and place them in out-of-home care. Even under these circumstances, it is the agency’s responsibility to make every reason- able attempt to reunify a family before developing an alternate plan for residency. Regardless of the eventual outcome, it is understood that both conti- nuity and permanency with respect to a child’s living environment and overall developmental trajectory are paramount concerns and should be achieved as quickly and as smoothly as possible. To ensure that child welfare needs are being met at the state level, the Children’s Bureau monitors CPS agencies through the Child and Family Services Reviews. These periodic reviews of state child welfare services
help determine whether state agency guidelines and practices conform to federal requirements and assist state agencies to improve their effectiveness in achieving positive outcomes for children and families. See Search the Web 13.1 for a link to the Children’s Bureau website and a more thorough description of the Child and Family Services Reviews.
Children ’ s Bureau a division of the Administration for Children and Families that is primarily concerned with child protection, child abuse prevention, foster care, and adoption within the United States.
Administration for Children and Families (ACF) a division of the Department of Health and Human Services. It is responsible for federal programs that promote the economic and social well-being of children and families, and assists local agencies (both public and private) with relevant funding, policy direction, and educational services.
permanency the principle that a child’s ideal living environment is one that will be long lasting and stable.
continuity the principle that a child’s ideal living environment should be disrupted as little as possible.
Child and Family Services Reviews periodic reviews conducted by the Children’s Bureau to monitor state child welfare services.
SEARCH THE WEB 13.1
The Children’s Bureau, a division of the Administration for Children and Families, con- ducts periodic reviews of state child welfare services. To read more about these reviews, and for information regarding additional monitoring procedures conducted by the Children’s Bureau, go to www.acf.hhs.gov/programs/cb/monitoring.
In accordance with the previously mentioned tenets, the National Association of Public Child Welfare Administrators (NAPCWA) has outlined the mission of CPS agencies to include assessing the safety of children, intervening to protect children from harm, strengthening the ability of families to
National Association of Public Child
Welfare Administrators (NAPCWA)
founded in 1983, this organization
represents public child welfare agencies by
contributing to child welfare policy and
ensuring that children in the public child
welfare system have safe, permanent homes.
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307THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
protect their children, and providing either family reunifi cation or an alternative, safe family for the child. To fulfi ll its mission, CPS agencies should provide culturally responsive services to children and their families to achieve safety, well-being, and per- manency for children. In doing so, CPS agencies often facilitate collaborations with community agencies and enlist the help of these agencies to provide the necessary services and resources to support families and protect children from maltreatment (NAPCWA, 1999).
A large portion of CPS efforts is spent on activities centered on receiving and responding to allegations of child maltreat- ment. These allegations may reach CPS through a number of sources including law enforcement, legally mandated report- ers (e.g., physicians, mental health professionals, educators), concerned relatives or neighbors, or anonymous telephone calls to a 24-hour hotline. As part of this process, CPS agen- cies generally perform a variety of functions, including those listed next.
Intake and Screening. This process includes the receipt and evaluation of reports of suspected child maltreatment. During this process, it will be determined whether the reported infor- mation meets the statutory and agency guidelines for child maltreatment. Furthermore, based on the information reported, the urgency with which the agency must respond to the report will be determined.
Investigation and Initial Assessment. After receiving a report of child maltreatment, the agency will conduct an investigation to determine whether child maltreatment actu- ally occurred. In addition, the immediate safety of the child is assessed and appropriate action taken if that safety is in jeopardy. Furthermore, the assessment will likely include a determination of any future risk to the child, the level of that risk, and whether additional agency services are necessary to address any effects of child maltreatment and/or to reduce the risk of future maltreatment.
Family Assessment. Following the investigation and initial assessment, the CPS caseworker collaborates with family mem- bers toward identifying and understanding their strengths and any areas of need. Specifi cally, the caseworker may encourage the family’s use of available resources, identify potential risk fac- tors for future maltreatment, and help children cope with the effects of maltreatment.
Case Planning. In order to achieve CPS goals, three types of plans are developed: (a) a safety plan, which is developed when- ever a risk of immediate harm is determined; (b) a case plan, which includes the goals and desired outcomes determined by the family assessment; and (c) a concurrent permanency plan, which includes the steps by which family reunifi cation may be achieved while also outlining a plan to establish legal
culturally responsive
services
child welfare services
that include the
acknowledgement and
acceptance of other people’s
cultures and cultural values.
allegation
an unproven assertion that
child maltreatment has
occurred.
intake and screening
process by which reports
of suspected child
maltreatment are received
and initially evaluated by a
CPS agency.
investigation and initial
assessment
the process by which a
child protective agency
verifi es reports of child
maltreatment and
determines the immediate
safety of the alleged child
victim.
family assessment
following a child protective
services investigation
and initial assessment,
the process by which a
caseworker collaborates with
family members to identify
needed services.
caseworker
a professional employed
by child protective services
to investigate child
maltreatment, ensure
the safety of children in
their homes, and provide
necessary services to
families.
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308 WHAT HAPPENS NEXT
permanency with an alternate family in the event that reunifi ca- tion efforts are not achieved.
Service Provision. During this stage, the case plan is imple- mented. To some extent, it may be the responsibility of CPS to arrange, provide, and coordinate service delivery for children and their families. Ideally, these services are individually tailored to a particular child’s and/or family’s needs.
Family Progress. Ongoing assessment continues through- out the duration of an open CPS case. The caseworker will routinely evaluate safety issues, assess the presence of any risk factors for maltreatment, address any effects of maltreatment, and ensure that the family is achieving the goals established in the case plan.
Case Closure. Ideally, a case is closed when the family has achieved their goals and the risk of maltreatment has been sig- nifi cantly reduced or eliminated. In reality, a case may be closed for any one of several reasons, including situations in which at least some measure of risk reduction has been obtained, the family prematurely discontinues CPS services, or legal perma- nency with an alternate family is achieved (DePanfi lis & Salus, 2003).
It is important to note that not all families will experience all of the previously mentioned CPS activities. For example, a report may be screened out during the intake process and no further CPS involvement may be required, or a report may be unsubstantiated following an investigation or initial assess- ment and the case will be closed at this point in the process (although referrals to community agencies may be made). See Figure 13.1 for a fl ow chart outlining the various child protec- tive procedures and decision-making options. Factors such as the nature of a report, the available evidence for substantiation of a maltreatment allegation, the severity of the maltreatment, and individual family-based issues may determine which of these specifi c activities a particular family will receive. Many mandated reporters feel frustrated when they make calls to CPS and it looks like nothing was done. However, if the behavior in question does not meet legal defi nitions of maltreatment, or if CPS cannot fi nd evidence to support the allegations, legally nothing more can be done at that time. Reporters should continue to observe the child in question and call CPS again if they see further cause for concern. In addition, mak- ing the initial report (and any subsequent reports) is important because CPS agencies keep a computerized record of all the calls received. So, even if an initial allegation is not supported by evidence, a pattern of allegations may be enough to warrant further investigation.
case planning
the developing of three
types of plans by the
caseworker during a family’s
involvement with child
protective services;
a safety plan for the child, a
case plan aimed at allowing
the family to remain
together, and a concurrent
permanency plan that
establishes an alternate
living arrangement for the
child in the event that the
case plan is not successful.
safety plan
a plan that is developed
following a safety
assessment whenever a
risk of immediate harm
is discovered in order to
minimize and/or eliminate
that immediate risk.
service provision
the process by which a Child
Protective Services case plan
is implemented.
family progress
the ongoing assessment of
an open Child Protective
Services case by a
caseworker.
case closure
the process by which an
open Child Protective
Services (CPS) case is
resolved and the family no
longer receives CPS services.
unsubstantiated
(unfounded)
a report of child
maltreatment that has
been investigated, but not
confi rmed, by CPS.
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309THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
FIGURE 13.1 Flow chart outlining child protective procedures and decision- making options. Source: Courtesy of U.S. Department of Health and Human Services.
Note: CPS = Child Protective Services.
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310 WHAT HAPPENS NEXT
INTAKE AND SCREENING
Intake is generally the fi rst stage of the CPS process. It is a crucial decision-making point in the child protection system, as it is the point at which reports of suspected child maltreatment are received. During the intake process, certifi ed caseworkers gather information to determine safety concerns (i.e., whether the child is at risk of imminent harm), maltreatment risk (i.e., the likelihood that some form maltreat- ment will occur in the near future), and the type of CPS response that is required (whether the situation is an emergency that needs an immediate response, whether a call to law enforcement is necessary, whether further investigation by CPS is war- ranted, etc.). At intake, caseworkers should also perform a public relations function by responding to all reports in a professional and sensitive manner, and a public awareness function by clarifying the role of the agency to referral sources (Pecora, Whittaker, Maluccio, Barth, & Plotnick, 2000). Unfortunately, this goal is not always achieved due to time constraints that result from understaffi ng. This is just one more reason why it is helpful for mandated reporters to be knowledgeable about the sys- tem and what they can reasonably expect from CPS.
Although the specifi c nature of the intake process may vary somewhat from one jurisdiction to another, the basic process will be similar across jurisdictions. The primary tasks caseworkers should accomplish during the intake process include the following:
Gathering suffi cient information from the reporter to be able to identify and locate the child and parents/ primary caregiver, to assess whether the child is safe, to determine if the report meets the statutory and agency guidelines for child maltreatment, and to determine the credibility of the report/reporter.
Handling emergency situations including calming the reporter and determining how to best meet the immediate safety needs of the child and family (e.g., involving law enforcement).
Checking agency records and the state’s central registry (a centralized database containing information on all substantiated reports of child maltreatment) to determine whether the family and/or child are known to the agency (DePanfi lis & Salus, 2003).
The intake may be the only opportunity the agency has to obtain information from the reporter. The more comprehensive the information provided by the reporter, the better able the intake caseworker will be to determine the safety of the child, the urgency of the situation, and the appropriateness and type of CPS interven-
tion. Reports that are lacking in important or signifi cant amounts of information may prevent the caseworker from being able to adequately address the reporter’s concerns and/or to accept the case for further investigation. Additionally, the infor- mation obtained from the reporter may help to identify other potential sources of information about the family and the possibility of past, previously undocumented maltreatment. Finally, this information may assist the caseworker responsible for the investigation or initial assessment in locating all relevant parties (child, primary caregiver, and perpetrator) and in planning an effective investigation (DePanfi lis & Salus, 2003). It is helpful for mandated reporters to have a detailed list of information and concerns in hand before they call CPS. If you are worried about a child, make specifi c notes about your concerns. For instance, instead of saying, “She is bruised all the time,” a better report would note “Four times in the last 6 weeks, I noticed
primary caregiver
a person primarily
responsible for the health
and well-being of a child
(e.g., mother, father, legal
guardian).
central registry
a database maintained by
a state’s child protective
agency that contains
information on all
substantiated reports of
child maltreatment for
that state.
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311THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
signifi cant bruising on the back of her upper thighs.” The more detailed and specifi c information you can give, the easier it will be for a CPS caseworker to determine whether a report requires further investigation.
In addition to collecting as much information as possible from the reporter, the intake caseworker must also analyze that information and make decisions based on that analysis. This analysis will likely involve ensuring that the report meets crite- ria established by statutory and agency guidelines, evaluating the credibility of the reporter and the report, determining whether an investigation or initial assessment is warranted, establishing the urgency of CPS’s response to the report, and determining the appropriate agency response time based on that urgency (DePanfi lis & Salus, 2003).
Statutory and Agency Guidelines
Whether the report meets statutory and agency guidelines is generally determined by comparing the information obtained from the report to state law regarding the defi nition of various forms of child maltreatment and agency policies interpreting the law and practice standards. Additionally, the caseworker will likely determine the requirements for state or local county response, including the involvement of law enforcement and required response times. Finally, practical issues such as jurisdictional authority and caseload management may need to be considered (S. Wells, 1997).
Credibility of Reports
During the intake process, a crucial component is determining the consistency and accuracy of the information reported. Determining the full credibility of a report may not occur until the investigation or initial assessment phase, but some measure of determination will likely occur during the intake phase. The validity of a report may be called into question when it is infl uenced by a contentious divorce or by custody proceedings, general family dysfunction or confl ict, or poor neighborly relations. Ultimately, despite any suspicions a caseworker may have regarding the motives of the reporter, the case must be accepted for investigation if the allegations meet statu- tory and agency requirements for child maltreatment. However, documentation of these suspicions may assist the investigation or initial assessment caseworker in plan- ning an effective investigation (DePanfi lis & Salus, 2003).
Accepting a Report for Further Investigation
The decision whether or not to accept a report for CPS investigation is the primary responsibility of the intake caseworker. This decision is based on law, agency policy (and implementation of that policy), and specifi c information about the case that indicates harm or likely harm to the child (S. Wells, 2000a). This decision may also depend on a number of other factors including whether the child is at risk of harm due to noncaregiver maltreatment (e.g., physical abuse committed by a babysitter) or whether the risk is of a more indirect rather than direct nature (e.g., intimate part- ner violence, parental substance abuse, parental physical or mental health issues). In either case, the situation may be more appropriately addressed by an alternate agency, for example, law enforcement or a domestic violence shelter. Ultimately, if the caseworker determines that the child’s safety is more directly compromised
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312 WHAT HAPPENS NEXT
or that caregiver responsibility needs further investigation in any of the previously mentioned situations, then CPS involvement may also be warranted (DePanfi lis & Salus, 2003). In making these determinations, it is critical that the caseworker have all necessary information available and easily accessible, including any agency policy guidelines and screening tools, while responding to a report (S. Wells, 2000a).
Urgency and Response Time
Part of the intake process will include a safety assessment in which, pending face-to-face contact by the agency, establishing the child’s immediate risk of harm is the primary concern (Child Welfare League of America, 1999). Reports that likely require imme- diate CPS response (e.g., 2–3 hours) include situations in which the child’s injuries are severe enough to have caused serious physical harm; the child is particularly vulnerable due to age, illness, or dis- ability; the behavior of the caregiver is known to have previously caused harm to the child; there is no one able and/or willing to assure the child’s safety; the family is likely to fl ee the area with
(or abandon) the child; the report involves sexual abuse and the child continues to have contact with the alleged perpetrator; or the child has physical injuries that require immediate documentation (S. Wells, 2000b). Mandated reporters should keep in mind that only the most severe cases of maltreatment are addressed immediately. There will likely be a 1- to 3-day delay before most cases are investigated.
If the report does not require immediate response either by CPS and/or by law enforcement, the intake caseworker must determine the level of response (and the time frame for response) that is required. Many states have specifi c criteria for deter- mining the response time to a report, based on the nature of that report and the urgency of the situation. These criteria generally include the severity of the inci- dent or harm to the child, the person responsible for the alleged maltreatment, and specifi c information regarding the family’s situation (e.g., maternal mental health issues, parental employment status, family access to resources). For example, a case in which a day-care provider reports bruising on a child’s legs and buttocks may not require immediate action, especially if the day-care provider also notes that she has been caring for this child for more than a year, has never noticed bruises before, and there have been no previous reports of maltreatment fi led for this family. A case such as this would likely require a more standard CPS intervention time frame of 24 hours. Other reports may require CPS response but do not involve immediate or contin- uous danger of harm to the child. For example, a case in which a schoolteacher reports that a 10-year-old girl in his class routinely comes to school in dirty, smelly clothes and often falls asleep in class. Cases such as these may allow for a slight delay (48–72 hours or longer) in the standard CPS response time. Varying state and local agencies will establish their own criteria for determining standard response times based on the nature and particular details of each case (DePanfi lis & Salus, 2003).
INVESTIGATION AND INITIAL ASSESSMENT
The purpose of the investigation or initial assessment process is to gather informa- tion in response to reports fi led with CPS, to interpret the agency’s obligation to the children and their families, and to determine whether a family needs and will benefi t from further agency intervention. After gathering all of the relevant information, the
safety assessment
the process by which
a caseworker evaluates
a child’s living
environment and
determines whether there
is any immediate risk
of harm to that child’s
safety.
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313THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
caseworker must determine whether the report is substantiated or founded (i.e., credible evidence indicates that maltreatment has occurred) or whether the report is unsubstanti- ated or unfounded (i.e., there is a lack of credible evidence to indicate that maltreatment has occurred—this does not necessarily mean that the child was not maltreated, only that there is a lack of evidence to support the allegation). See Case Examples 13.1 and 13.2 for substantiated and unsubstantiated reports of child maltreatment. Depending on the particular state law, agencies may have 30, 60, or 90 days after receiving the report to complete the investigation or initial assessment and make a fi nal determina- tion (DePanfi lis & Salus, 2003). Again, this calls for patience on the part of the mandated reporter. Although a reporter is rightly concerned about the child, conducting a thor- ough and accurate investigation is important and, therefore, is a process that takes time.
CASE EXAMPLE 13.1
The following fi ctitious case is an example of a report that was substantiated following an investigation by CPS.
Mr. Jones is a third-grade teacher at Bennett Elementary School. Approximately a week into the new school year, he noticed that one of his students, Daniel, had a large bruise on his forearm. At the end of the day, he asked Daniel to talk with him for a few minutes. Mr. Jones learned that Daniel lives with his mother and her boyfriend of 5 years and that they recently moved to the area from out of state. Daniel told him that he got the bruise when he fell down some stairs the day before. Mr. Jones was suspicious of his story because the bruise looked very much like a handprint, and he decided to call CPS to fi le a report. During the investigation, the CPS caseworker learned from Daniel’s mother that money was tight because her boyfriend had been out of work for a while and that they had moved to town at the beginning of the summer because he got a job at the local factory. She also mentioned that her boyfriend has a drinking problem and a temper, but denied that he would ever hurt her son. Her boyfriend corroborated most of this information and denied ever hurting Dan- iel. The caseworker spoke with a few of Daniel’s neighbors, who mentioned that they often heard yelling coming from Daniel’s apartment and have considered calling CPS themselves because Daniel seems very “accident prone” and has had noticeable bruises on his arms and legs on several occasions since he moved in. The caseworker also spoke with Daniel’s mater- nal grandmother, who reported that Daniel’s mother begged her not to tell anyone when she confessed that her boyfriend had hit Daniel on at least one occasion. She feared his tem- per, Daniel’s maternal grandmother said. The caseworker obtained Daniel’s medical records, which revealed a history of “accidental” bruising and broken bones over the last 5 years. No reports of child abuse had ever been fi led, most likely because Daniel’s mother took him to a different clinic or hospital on almost every occasion. Finally, the caseworker had a physi- cian examine the current bruise on Daniel’s arm, and she confi rmed that it was likely made by someone grabbing his forearm. Through X-ray, the doctor also discovered several old rib fractures that had healed improperly because they did not appear to have ever been set. Based on all of the preceding information, the CPS caseworker determined that Mr. Jones’s report of physical abuse was substantiated and temporarily placed Daniel with his maternal aunt, who lived in the next town.
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314 WHAT HAPPENS NEXT
DISCUSSION QUESTIONS
1. Based on what you have learned so far, was the teacher obligated to fi le a report in this case?
2. Should the teacher have conducted any further investigation prior to fi ling his report?
3. What procedures and/or methods did the CPS caseworker employ during this inves- tigation?
4. Is there anything additional the caseworker could have done to make this investiga- tion more complete?
5. What element or elements of this case and/or the investigation clearly indicate that Daniel was physically abused?
CASE EXAMPLE 13.2
The following fi ctitious case is an example of a report that was unsubstantiated following an investigation by Child Protective Services (CPS).
During a “tickle fest” with her mother, 6-year-old Susie mentioned that that it was just like the “special time” she had with her uncle Steve. After talking with Susie about this further, she also learned about other concerning incidents including a lot of playtime in Uncle Steve’s bedroom and one particular game called “hide the snake.” Her mother became alarmed and questioned Steve about Susie’s comments, but he denied that they were true. Susie’s mother was still concerned, however, and contacted CPS. During the investigation, the CPS caseworker learned that Steve is Susie’s paternal uncle who has been living with the family for the last year. He takes care of Susie quite a bit because her mother works full-time outside the home, her father is often out of town on business, and Steve has been unable to work while he has been recovering from a serious car accident that occurred shortly before he moved in with Susie’s family. The caseworker interviewed Susie, her parents, and Uncle Steve. She also spoke with Susie’s teacher and a few neighbors. Susie’s report of her interactions with Uncle Steve remained fairly consistent, but the case- worker was unable to fi nd additional evidence of sexual abuse. Furthermore, the results of a physical examination were inconclusive. Based on the results of the investigation, the caseworker determined that the report of sexual abuse was unsubstantiated.
DISCUSSION QUESTIONS
1. What procedures and/or methods did the CPS caseworker employ during this inves- tigation?
2. Is there anything additional the caseworker could have done to make this investiga- tion more complete?
3. Based on what you have learned so far, how credible is the testimony of a 6-year-old? 4. Although the report was determined to be unsubstantiated, does this mean that Susie
defi nitely was not sexually abused?
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315THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
An effective investigation or initial assessment is cooperative in nature. The CPS worker should form an alliance with the child and family in order to gather relevant information and provide support to the family. This requires involving the child and family in exploring the nature of the allegations and obtaining their perceptions of the situation, focusing on the family’s strengths and resources, listening to the fam- ily’s concerns and expressing sensitivity and empathy regarding any anxiety or fears they may have, and involving the child and family in any decisions that affect them by providing choices and opportunities for input whenever possible (Goldman et al., 2003).
Effective decision making during this process requires competent interviewing skills; an ability to gather, organize, and analyze information; and the capacity to arrive at accurate conclusions. Methods typically employed in this process include the use of structured interview protocols with, and observations of, all relevant parties (identifi ed victims, siblings and any other children living in the home, all nonoffending adults living in the home, and the alleged maltreating caregiver), informa- tion gathered from collateral sources (e.g., relatives, babysitters, day-care providers, schoolteachers, physicians, clergy), and a care- ful analysis of all of the information obtained. One important note with regard to interviewing collateral sources is that special attention needs to be given to the family’s confi dentiality and any state regulations regarding contact with collateral sources. Ide- ally, interviews should be conducted both individually and with the family as a whole. Following the completion of data gather- ing, the caseworker should reconvene with the family to describe the fi ndings of the investigation or initial assessment, address any family concerns, and (if warranted) discuss options for further CPS, law enforcement, and/or court involvement (DePanfi lis, & Salus, 2003). If you feel that you would be good at conducting this type of investigation and that you would fi nd such work rewarding, you might want to consider a career in social work.
Decisions that must be achieved by the conclusion of the investigation and initial assessment process include determining whether the initial allegation of maltreatment is substantiated, assessing child/familial risk factors, evaluating child safety, deter- mining emergency needs for the family, and determining whether to offer additional services to the family (DePanfi lis & Salus, 2003).
Substantiation of Maltreatment
The decision to substantiate maltreatment depends on whether the harm (or threat of harm) to the child is severe enough to constitute maltreatment and whether there is suffi cient evidence to support the incident as a case of child maltreatment (B. Drake, 2000). Regardless of the fi nal decision, if possible, all information collected should be documented and retained, because unsubstantiated reports may eventually yield a pattern of incidents that warrants substantiation. An agency’s ability to maintain these records may vary based on statutory guidelines regarding the expungement of records. Following the completion of the initial assessment, the
structured interview
a face-to-face method of
collecting information
that follows a series of
pre-established questions.
collateral sources
individuals who
are interviewed by
caseworkers as part of a
CPS investigation (e.g.,
neighbors, teachers,
babysitters).
confi dentiality
an ethical principle
associated with people
in many human service
professions whereby
these professionals may
not divulge information
about their clients to
third parties.
expungement
the act of destroying or
sealing records following
a specifi ed period of time.
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316 WHAT HAPPENS NEXT
disposition of the report must be determined based on state laws, agency policies, and implementation of those policies. Each state has developed its own laws and policies that outline the guidelines for determining whether child abuse or neglect has occurred. Most states have a two-tiered system of substantiated–unsubstantiated
(or founded–unfounded), although a third tier ( indicated ) may be included. This third tier generally allows the caseworker to deter- mine that some evidence of maltreatment exists, but not enough to substantiate the case (DePanfi lis & Salus, 2003).
When evaluating a report of neglect, it is important to con- sider whether the conditions or circumstances indicate that a child’s basic needs are unmet and what harm or threat of harm has resulted (or may result) from these conditions or circum- stances (DePanfi lis, 2000). In deciding if a report of physical abuse should be substantiated, the caseworker will need to determine the plausibility of the caregiver’s and child’s accounts of the injury. This is generally accomplished by evaluating whether the injury could have occurred in a non-abusive manner and comparing the
explanation given for the injury to available physical evidence (Dubowitz, 2000). Substantiation of a sexual abuse report may be more challenging, as there is often lit- tle or no physical evidence to review. Important considerations include the nature of the allegation, any statements made by the child, and any behaviors exhibited by the child (Adams, 2000). Finally, substantiating a report of psychological maltreatment may prove even more challenging and requires information on caregiver behavior over time and indicators from the child (behavioral, cognitive, social, emotional and/or physical) with respect to any effects of this behavior (Brassard & Hart, 2000).
Risk Factors
Assessing risk factors entails identifying the factors in the family’s environment that increase the likelihood that a child will be maltreated, evaluating the family’s strengths and resources, and determining available agency and community services (Pecora et al., 2000). In evaluating the risk factors for maltreatment that may be present, caseworkers should organize the risk-relevant information by category (e.g.,
child factors, parental factors, family-functioning issues), estab- lish whether there are any interactions between risk factors and strengths, and determine the signifi cance of each of the risk fac- tors and strengths (W. Holder & Morton, 1999). Special cases of risk assessment include situations that involve parental substance abuse, situations that involve intimate partner violence, and any specifi c cultural factors (e.g., language barriers, parenting strate- gies, discipline techniques, cultural or religious practices) that may need to be considered as part of the investigation and initial assess- ment process (DePanfi lis & Salus, 2003).
Child Safety
The Adoption and Safe Families Act requires that states assess and assure a safe liv- ing environment for children. In part, this safety may be related to the risk factors and strengths present in the family, but risk assessment and safety assessment are
indicated
a designation utilized by
some child protective
agencies during the
course of an investigation
that allows the
caseworker to determine
that some evidence
of child maltreatment
exists, but not enough to
substantiate the case.
risk assessment
the process by which
a caseworker evaluates
a child’s living
environment and
determines whether any
factors are present that
increase the likelihood
for child maltreatment.
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317THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
separate decisions. Caseworkers must assess child safety during at least two points of the investigation and initial assessment process, the beginning and the end. During the fi rst contact, the caseworker must decide whether the child will be safe for the duration of the investigative process. On completing the assessment, the caseworker must determine whether the child will remain safe without ongo- ing CPS involvement and services. Additionally, safety should be assessed at any other point the caseworker deems necessary. Devel- oping a safety plan is a key component in safety assessment. The interventions in the safety plan are designed to control the risk factors that pose a safety threat to the child. These interventions should generally progress from least to most intrusive and include in-home services, partial out-of-home services (e.g., day-care/ respite services), removal of the abusive caregiver from the home, kinship care, or out-of-home placement. Ultimately, the safety plan should include interventions that strive to preserve or reunify families (DePanfi lis & Salus, 2003).
Emergency Needs
In addition to services aimed directly at child protection, CPS is often in a unique posi- tion to help families address other problems they may be facing. As child maltreatment is rarely an isolated issue, adopting an ecologically based approach may be more helpful to the family on a long-term basis. Exam- ples of emergency services may include health care (physical and/or mental), food, clothing, shelter, crisis counseling, and job placement services. Assisting a family with these additional emer- gency needs and arranging for emergency services for the child and family may be a crucial step in alleviating family dysfunc- tion and in reducing the risk for child maltreatment (DePanfi lis & Salus, 2003).
Additional Services
Upon completion of the investigation or initial assessment, the caseworker must decide if the family should receive ongoing child protective or additional agency services. This decision may be based on a variety of factors including whether a report is substantiated, the perceived level of risk for future maltreatment, the state or local guidelines, and the availability of services (DePanfi lis & Salus, 2003). Tradi- tionally, the role of CPS has been a primarily investigative one in which caseworkers are narrowly focused on obtaining evidence of maltreatment and then referring sub- stantiated cases to law enforcement. More recently, states are incorporating greater fl exibility in their response to allegations of child maltreatment by utilizing a “dual track” approach that provides a differential response system based on the child’s needs for safety, degree of maltreatment risk, and the family’s need for support or services. Typically, in cases where severe maltreatment has occurred, the more tra- ditional investigative route will be pursued. However, in less serious cases, a more thorough assessment that focuses on the family’s strengths and needs will be con- ducted. This type of assessment is designed to form a collaborative partnership with the family to determine the most benefi cial resources and services for the family.
out-of-home placement
often referred to as foster
care, the condition
by which children are
temporarily removed
from their home and
placed in an alternative
living environment (e.g.,
with a relative, in an
emergency shelter, in a
group home).
ecologically based
approach
a strategy in the delivery
of human services that
focuses on family and
community as a whole,
rather than focusing
solely on the individual.
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318 WHAT HAPPENS NEXT
However, at any point during the course of the assessment, a family may be trans- ferred to the investigative track if deemed necessary (Goldman et al., 2003). See Case Example 13.3 for a description of a state-based differential response system.
CASE EXAMPLE 13.3
Many states have recently initiated reform efforts with respect to traditional child pro- tective services. These efforts are often known by state-specifi c names, but the general movement in child welfare is to develop a differential (or alternative) response system when allegations of child maltreatment fall within a low to moderate range of risk for the child or children involved. The overall aim of these differential response systems is to pro- vide an alternative to the primarily investigative focus of more traditional child protection when child safety issues are minimal.
As a recent example of a state-based differential response system, South Carolina (SC) implemented their Appropriate Response system in January 2012. Initially piloted in a few select counties, the program was received with such success that statewide implementa- tion was complete within 1 year. The impetus to initiate programs such as SC’s Appropriate Response is often several-fold: to assist state agencies in meeting federal child welfare requirements, to alleviate the heavy caseloads burdening local agencies, and to better serve families who would benefi t more from assistance than an investigation. According to the Appropriate Response system, allegations of child maltreatment are screened according to a series of child safety standards. Cases that are determined to be of high risk (e.g., sexual assault, severe physical abuse, severe physical neglect, or a baby testing positive for illegal drugs at birth) remain with the Department of Social Services (DSS) for investigation. How- ever, cases that are determined to be of low risk (e.g., mild neglect involving a dirty house or an allegation involving an older child) are referred to Family Strengthening Services and cases determined to be of moderate risk (for example, inappropriate corporal punish- ment) are referred to Voluntary Case Management. Both these services are managed by an independent contractor (the Hope Center for Children in Spartanburg County, SC), and family involvement is strictly voluntary. Although DSS retains the fi le for these cases and is notifi ed when the case is closed, it is no longer involved with these cases unless the refer- ring agency discovers more substantive child safety issues and requests an investigation. According to Angela Talley Robinson, program coordinator for Child and Adult Protective Services in Spartanburg County, the Appropriate Response system is working very well, and she notes that the key is interagency communication.
Adult or Child Removal
One important consideration within the decision-making process during the investi- gation or initial assessment phase is the potential need to remove either the alleged perpetrator or child from the home. Removing the alleged perpetrator is generally the less intrusive (and, therefore, preferred) intervention. However, this intervention
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319THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
requires an agreement by the family (and a certainty on the part of the caseworker) that there will be no unsupervised contact between the alleged victim and perpetrator. Removing a child from the home is a more involved process requiring out-of-home placement needs that may have a more negative effect on the child. In addition to separating the child from the offending caregiver, removal also separates the child from the nonoffending caregiver and other potentially supportive relatives and friends. The effects of out-of-home placement are likely much greater than simply the loss associated with physical separation from the family. Unfortunately, in some situations, removing the child from the home may be the only viable option and the only way to assure separation between alleged victim and perpetrator (DePanfi lis & Salus, 2003).
FAMILY ASSESSMENT
The initial assessment focuses on identifying the risk factors and concerns present in a family, but the family assessment emphasizes the relationship between a family’s strengths and risks to a much greater extent. The family assessment is more thorough and in-depth. It focuses on the change that is necessary in a family to keep the child safe, reduce the risk of future maltreatment, and enhance overall family well-being. The family assessment promotes an understanding of the problems present in a fam- ily and becomes the basis for subsequent intervention (Goldman et al., 2003).
In order to be effective, family assessments should be culturally sensitive, strengths-based, and developed in collaboration with the family. Ideally, the goal is to allow children to reside safely in their homes by helping caregivers identify and resolve areas of concern (NAPCWA, 1999).
Culturally Sensitive and Strengths-Based Assessment
A culturally sensitive assessment acknowledges and respects the fact that diversity exists among families. It considers parenting practices within the context of eth- nic, racial, and religious differences and recognizes that a wide range of practices exist within the parameters of the law (Dunst, Trivette, & Deal, 1994, as cited in DePanfi lis & Salus, 2003). A strengths-based assessment recognizes that all people are capable of change, especially when the focus of change is on building their strengths. Although a standard protocol may assist the family assessment process, an individu- alized approach based on the particular strengths and needs of each family is likely to be most effective (Child Welfare League of America, 1999).
Interviews and Referrals
After reviewing all pertinent information regarding a particular family, the family assessment caseworker will conduct interviews with the child and family to deter- mine the family’s treatment needs. During these interviews, the caseworker should meet with the family as a whole and with family members individually. While meeting with the child, the caseworker will generally try to determine any and all effects of the maltreatment. While meeting with the caregivers, determining the causes of the maltreatment and the conditions under which it is likely to recur will
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320 WHAT HAPPENS NEXT
be the caseworker’s primary objective. During this phase of CPS intervention, the caseworker may also identify family issues that are in need of additional services (substance abuse, mental health concerns, or undiagnosed physical health con- ditions) and make the appropriate referrals to qualifi ed professionals (DePanfi lis & Salus, 2003).
Ultimately, the family assessment should be a comprehensive reporting of the family’s strengths, risk factors, and needs. It should include information such as the reason the family was referred for continuing CPS intervention, a description of the family system and all of its members, family background and history, the pre- senting problems as conceptualized by the family, the present status of the family, and a tentative disposition based on an analysis of all relevant information. The comprehensiveness of this assessment is crucial as it will likely form the basis for case planning and service provision (DePanfi lis & Salus, 2003).
CASE PLANNING
In addition to outlining the risks and problems present in a family, the case plan identifi es the strategies and interventions that will be employed to facilitate the changes necessary to assure child safety and for the family’s overall well-being. It also outlines the specifi c tasks, goals, and expected outcomes associated with these changes. Two crucial components of a case plan are fl exibility and creativity: fl ex- ibility because families and their needs and resources are constantly changing and creativity because this helps to generate new approaches to challenging, and often deeply entrenched, problems (DePanfi lis & Salus, 2003).
The purpose of case planning is to identify strategies that address the effects of maltreatment and change the behaviors and/or conditions that contribute to its risk, to provide clear and specifi c guidelines to implement these strategies, to estab- lish criteria to measure the family’s progress in achieving specifi ed outcomes, and to develop a framework with the family for case decision-making. Throughout case planning, it is important to involve the family in the decision-making process as much as possible. Families who feel as though their input was regarded during case planning are much more likely to be engaged in carrying out and adhering to the case plan (DePanfi lis & Salus, 2003).
Family Meetings
Since the early 1990s, CPS agencies have utilized a family group decision-making model to optimize family strengths in the case- planning process. This model includes the family and members of the family’s social support network in the decision- making pro- cess for ensuring the family’s safety and well-being. These family meetings have been effective in increasing the willingness of fam- ily members to accept the services outlined in the case plan, have improved relationships between the family and professionals, and have increased the support available to families through net- work connections (Merkel-Holguin, 2001, as cited in DePanfi lis & Salus, 2003).
family group decision-
making model
a strategy used by child
protective agencies to
optimize family strengths
in the case-planning
process. As part of this
strategy, the family and
members of the family’s
social support network
are included in the
decision-making process
during case planning.
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321THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
Outcomes
With the passage of the Adoption and Safe Families Act, child protection agencies have been federally mandated to design intervention programs around the achieve- ment of outcomes (DePanfi lis & Salus, 2003). The primary outcomes targeted through case planning comprise four broad domains and include child safety, child perma- nence, child well-being, and family well-being (Courtney, 2000). In order to achieve these broad-based outcomes, more specifi c outcomes must be outlined in each of four areas: child-level outcomes (e.g., peer relationships, behavioral control), car- egiver outcomes (e.g., mental health functioning, parenting skills), family outcomes (e.g., communication patterns, social support), and environmental outcomes (e.g., housing issues, neighborhood safety; DePanfi lis & Salus, 2003).
Goals and Tasks
The successful achievement of outcomes depends on the goals and tasks outlined in the case plan. If the goals are unrealistic or the tasks are overwhelming, the out- comes will never be realized. Goals should indicate the specifi c changes necessary to accomplish the outcomes. The objective is not to create a perfect family but one in which children will be safe and have their developmental needs met. Goals should be SMART, that is, Specifi c, Measurable, Achiev- able, Realistic, and Time-limited. In order to promote change, goals should also be framed within the context of positive behaviors or conditions that will result and should not highlight negative behav- iors or conditions. Furthermore, goals should be broken down into smaller tasks with specifi ed time frames for completion. These tasks incorporate the services and intervention necessary to achieve the goals and outcomes (DePanfi lis & Salus, 2003). For example, if a broad-based outcome for a particular family includes the development of effective parenting skills, then a goal for that family will likely include the consistent use of nonphysical discipline techniques for the violation of family rules, and a task for that family may include instruction in an effective time-out procedure that can be used for infractions surrounding chores and bedtime routines. As evidenced by this example, each step in the case-planning process becomes more specifi c and clearly defi ned so that the family is aware of the exact procedures necessary to achieve the overall target outcomes.
Concurrent Planning
As part of the case plan, concurrent planning works toward family preservation and/or reunifi cation while also establishing alternate permanency plans that can be implemented if preservation or reunifi cation becomes impossible. In accordance with this model, caseworkers need to develop two or more distinct case plans so that children can be transferred as quickly and smoothly as possible from one living environment to another if necessary. As some families may be unwilling or unable to change, and the risks associated with maltreatment are high, caseworkers need to make early decisions and plans regarding a permanent living environment for the child (Lutz, 2000, as cited in Goldman et al., 2003).
SMART
strategy used during the
case-planning process
whereby established goals
are Specifi c, Measurable,
Achievable, Realistic, and
Time-limited.
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322 WHAT HAPPENS NEXT
SERVICE PROVISION
The provision of services for families involved with CPS agencies will largely depend on the family’s level of maltreatment risk. Accordingly, a conceptual framework developed by the National Association of Public Child Welfare Administrators (1999) outlines the level of service appropriate to the level of risk present in a family. See Figure 13.2 for a diagrammatic representation of the service strategies and agencies appropriate for families at various levels of risk for child maltreatment.
High-Risk Families
Families that pose the highest risk of child abuse and neglect (serious physical injury, sexual abuse, and severe neglect) require service strategies related to court-ordered services, intensive family preservation, child removal, foster care, adoption, and criminal prosecution. The agencies involved with these families are CPS and law enforcement, and the primary concern is child safety.
Moderate-Risk Families
Families that pose moderate risk for child abuse and neglect (excessive or inappro- priate discipline, inadequate medical care, some supervisory neglect) require service
Services to Families at
High Risk for Child Maltreatment
Services to Families at Moderate Risk for Child Maltreatment
Services to Families at Low Risk for Child Maltreatment
Primary Agencies: CPS, law enforcement Primary Concern: child safety Service Strategy: intensive family preservation services, adoption, child removal, court-ordered services, foster care, criminal prosecution
Target: neglect, excessive or inappropriate discipline, inadequate medical care Primary Agencies: CPS, community partners Primary Concern: family functioning related to child safety Service Strategy: appropriate formal services coordinated through family support, safety plans, and community support agencies
Target: high family stress, emotional and economic stress, pre-incidence families Primary Agencies: community partners Primary Concern: child and family well-being Service Strategy: early intervention, family support center, formal and informal services, parent education, housing assistance, community or neighborhood advocacy
Target: serious injury, severe neglect, sexual abuse
FIGURE 13.2 Service strategies and service agencies appropriate for families at various levels of risk for child maltreatment. Source: Courtesy of U.S. Department of Health and Human Services.
Note: CPS = Child Protective Services.
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323THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
strategies related to safety plans, family support, and community support agencies. The agencies involved with these families are CPS and community service agencies, and the primary concern is family functioning relative to child safety.
Low-Risk Families
Families that pose the lowest risk for child abuse and neglect but may require CPS involvement (high level of family stress, emotional and economic stress, and pre- incidence risk factors) require service strategies related to early intervention, family support, parental education, housing assistance, and community and/or neighbor- hood advocacy. CPS may be involved with these families, although community service agencies are more likely to provide service delivery. The primary concern among these families is child and family well-being.
Intervention
CPS is responsible for identifying and providing access to all treatment and interven- tion services deemed necessary for ensuring child safety and reducing maltreatment risk. These services may be available directly through the CPS agency or may be offered through collaborations with community agencies. Services may range from supportive in nature to long-term psychological treatment. Some may be offered spe- cifi cally to children, others to caregivers, and others to the family as a whole. Specifi c services and programs may include art and/or play therapy for younger child vic- tims, trauma-focused therapies for older children and adolescents, parental training/ skills courses, parent–child interaction therapy, family preservation services, respite programs and support groups for caregivers or children, and anger management, bat- terer’s treatment, and sex offender treatment programs for perpetrators (DePanfi lis & Salus, 2003).
FAMILY PROGRESS
A key feature of CPS intervention is determining the extent and nature of family progress. Monitoring this type of change generally begins with the onset of program implementation and continues until case closure. Evaluation is a continual process that focuses on the family’s progress toward the attainment of outcomes, goals, and tasks established in the case plan. Additionally, the evaluation is an opportunity to reassess child safety. Although informal evaluations are more continual in nature, formal case evaluations generally occur at regular and predetermined intervals (e.g., every 3 to 6 months; DePanfi lis & Salus, 2003).
Evaluating Family Progress
The evaluation of family progress includes a review of the case plan, the collection of information from all service providers, the measurement of change, and the docu- mentation of progress attained. During this process, CPS caseworkers may consult with other professionals (therapists, guardians ad litem , etc.) who have been involved with case planning and/or service provision to assist them in evaluating a fam- ily’s progress. The issues addressed through the family progress evaluation include
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324 WHAT HAPPENS NEXT
determining whether changes to the safety plan are required, determining whether any changes in risk factors have occurred, evaluating the progress toward achieving case goals and outcomes, evaluating the services provided with respect to their ability to effect change, evaluating social support availability, and determining the poten- tial for continued family preservation or for initiating family reunifi cation. Routine monitoring of family progress allows both the caseworker and family to track family change and be aware of the status of case plan completion. Any decisions based on the family progress evaluation should be discussed with the family and documented for future case determination (DePanfi lis & Salus, 2003).
CASE CLOSURE
Case closure is the point at which CPS no longer maintains an active relationship with the family. The closing of a case may occur for several reasons. The best-case sce- nario is when case closure occurs as the result of the completion of the case plan in which all outcomes have been achieved. During this situation, both the caseworker and family may mutually agree that it is time to end the relationship between family and agency and that the family is ready to continue without agency involvement (DePanfi lis & Salus, 2003).
More realistically, case closure occurs when most of the goals and outcomes have been achieved and there is suffi cient reason to believe that the child is safe (although some risk may still be present). Cases may also be “closed” with respect to CPS inter- vention, but may still continue with services through community agencies. In some situations, cases may be closed due to premature discontinuation by the family. Under these circumstances, a family receiving voluntary services makes a unilateral decision to end its relationship with the agency. This decision may be communicated to the caseworker verbally or behaviorally (the family does not attend scheduled appointments and does not respond to the caseworker’s attempts at contact). A fam- ily that is receiving involuntary (i.e., court-mandated) services, however, cannot legally discontinue services in this manner. Finally, a case may be closed following the termination of parental rights and child adoption (DePanfi lis & Salus, 2003).
Clearly, the investigation of child maltreatment and the necessary follow-up for substantiated cases is an extremely time-consuming process. Although the steps out- lined in this chapter describe an ideal response, caseworkers are limited with regard to both time and resources.
DECISION MAKING
Although it may appear that the general CPS process is fairly straightforward, this is generally not the case. One major factor that signifi cantly affects the nature of this process for any particular family is decision making. Throughout the course of CPS involvement with a family, decisions are made. Whether the intake caseworker screens in or screens out a report, whether the investigation or initial assessment caseworker fi nds a report substantiated or unsubstantiated, the outcomes and goals outlined in a family’s case plan, and whether a case is to be closed are all decisions that must be made by individual and supervisory agency employees. This
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325THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
process can leave room for wide variations in consistency, both within and among CPS cases.
Unfortunately, expert consensus regarding decision-making criteria has been dif- fi cult to achieve. In a study of CPS decision-making (Rossi, Schuerman, & Budde, 1996, as cited in Wilson & Morton, 1997), the authors reported an overall level of agreement among experts that was below levels expected to provide clear standards for expert consensus. In this same study, the authors found that even when experts used the same factors in making decisions and combined these factors in a similar manner, they still arrived at differing decisions.
The very nature of the diffi cult decisions faced by CPS workers (e.g., whether a child should be removed from his or her home) contributes to the diffi culty in establishing consistent criteria for decision making. To some extent, decision mak- ers’ values and beliefs regarding the goals of child protection may infl uence this inconsistency, such that statutory and agency guidelines are applied differentially from one situation to another (D. Wilson & Morton, 1997). A caseworker’s beliefs concerning the importance of family, for example, may affect decisions regarding out-of-home placements. This may be more or less of an issue depending on who exactly is making the decisions (i.e., caseworker vs. supervisor vs. multidisciplinary team).
The National Study of Child Protective Services Systems and Reform Efforts, conducted by the U.S. Department of Health and Human Services (2003), reported that while most state poli- cies included a decision protocol for forwarding cases from intake to investigation, there were considerable differences with regard to who made those decisions. Of the 29 states indicating one approach to decision making across cases, 13 primarily relied on the caseworker’s decision with supervisory approval, 7 relied on supervisory decisions, 5 relied on joint decisions between case- worker and supervisor, 2 relied on the caseworker’s decision alone, and 2 reported other decision-making protocols. Of the remain- ing 21 states, different protocols were reported depending on case circumstances. Whether one, two, or more people are involved in the decision-making process (and their different levels/types of training) can have dramatic effects on decision-based outcomes.
This inconsistency may also be infl uenced by the ambiguity inherent in statutory guidelines and agency policies. Legal defi ni- tions of maltreatment are often vaguely worded; phrases such as “reasonable efforts” and “ reason to believe ” are common among legal statutes. Consequently, agency policies may lack clear opera- tional guidelines for decision makers to follow. In a study of the basis for ongoing CPS intervention (i.e., family assessment, case planning, service provision, and family progress evaluations), T. Holder (2000) noted that approximately 34% of survey respond- ents (CPS workers from 31 states) reported that their agency did not employ a specifi c assessment process to develop case/treatment plans. Unfortunately, nonspecifi c guidelines are likely to result in inconsistent decision making.
It is relatively clear that a lack of consistency in decision making exists, and that this inconsistency likely affects the CPS
National Study of Child
Protective Services
Systems and Reform
Efforts
a 2-year study (2000–
2001) conducted to assess
and evaluate the status
of the child protective
services system in the
United States.
reason to believe
a term often used in
child welfare legislation
with regard to mandatory
reporting guidelines.
Includes the notion of a
reasonable professional
standard for mandated
reporters, such that their
professional training
and experience informs
their ability to recognize
the presence of child
maltreatment.
6241-171-P4-013.indd 325 10/19/2013 10:17:00 AM
326 WHAT HAPPENS NEXT
process in signifi cant ways; however, the underlying causes of this inconsistency remain largely undetermined. More comprehensive training of agency employees and clearer guidelines with respect to statutory and agency policies are likely neces- sary to improve consistency in the decision-making process.
CONCLUSION
Although variations in the investigative and intervention processes may exist from one CPS agency to another, largely as a result of varying state laws and agency poli- cies, the child protection process generally follows the guidelines as described in this chapter, and this general process is fairly consistent nationwide. When differences do exist, they are most likely related to factors such as CPS response time frames, issues regarding the determination of jurisdiction, individually based decision-mak- ing issues, and variations with respect to statutory and agency defi nitional guidelines for maltreatment. In some cases, these differences may be substantial. Jurisdictional differences may result in cases that “fall through the cracks,” for example, if the agency policy for the state in which the maltreatment occurred dictates that the case be referred to the child’s home state, whereas the agency policy for the child’s home state dictates that the case remain in the jurisdiction of the agency where the maltreatment occurred (A. Robinson, personal communication, November 8, 2007). Situations such as these create a veritable “no-man’s land” and have the potential for dire consequences on an individual child’s safety and well-being. However, despite such individual cases, the overall impact of agency differences may remain largely unknown.
Child maltreatment is a problem with severe, and potentially fatal, conse- quences. Therefore, CPS intervention must function, fi rst and foremost, to protect children. However, the goal of CPS intervention is not, as many believe, to break families apart. Rather, CPS’s role in family intervention is to protect the safety of chil- dren by improving family functioning. In fact, a large factor in the mission of child protective agencies is family preservation and reunifi cation, that is, to keep families together. The hope is that this can be accomplished through the variety of services and resources provided by CPS and community agencies. Unfortunately, this hope is not always fulfi lled, and in these situations, child safety must take precedence.
DISCUSSION QUESTIONS
1. Should child protective agencies conform to a set of uniform regulations imposed at the federal level, or should they remain in operation on a state-by- state basis?
2. Does the child welfare principle of family preservation and reunifi cation mean that CPS caseworkers should make every effort to keep biological families together?
3. Does a caseworker’s ability to substantiate a report of child maltreatment vary depending on the type of maltreatment that is reported?
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327THE MALTREATED CHILD AND CHILD PROTECTIVE SERVICES’ RESPONSE
4. Should CPS caseworkers be allowed to interview collateral sources during a CPS investigation? Does doing so violate a family’s privacy and/or confi dentiality?
5. If an alleged case of child maltreatment is determined to be unsubstantiated by CPS, does this mean that no child maltreatment occurred in this case?
6. What are the advantages and disadvantages to including the family in case planning decisions?
7. Does the idea of concurrent planning run counter to that of family preserva- tion and reunifi cation?
8. Do you think that individual values and beliefs often affect the decisions made by CPS professionals? Should they?
9. The qualifi cations to become a CPS caseworker vary signifi cantly from state to state. For example, some states may require a bachelor’s degree only, while oth- ers require a master’s in social work. What level of education and/or training should be required to become a CPS caseworker? Should these requirements be established at the state level, or should they be set at the federal level?
10. How might the staff turnover/burnout rate for CPS caseworkers affect the qual- ity of service that CPS agencies are able to provide, and what might this mean with respect to the outcomes for children who need these services? What might CPS agencies do to help minimize staff turnover/burnout?
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328
Given the high prevalence of child maltreatment and the seriousness of its con-sequences, efforts to prevent child abuse and neglect are critical. In addition to the harmful short-term effects of child maltreatment, negative outcomes often
persist throughout the remainder of a victim’s life and may even be perpetuated in future generations. Additionally, once child maltreatment has begun, it tends to be a chronic condition that is fairly resistant to intervention efforts. This is often true regard- ing both the perpetrator’s behavior and the consequences to the
victim. Finally, it is expensive. Costs associated with social welfare services, medical care, and intervention are astronomical and must generally be subsidized through state and federal funding sources.
Most people, especially in the United States, are not accustomed to thinking preventively. Medical care is sought most often when we are sick; mental health professionals are contacted after psychological or adjustment problems have already begun; even cars are usually brought into maintenance garages only in response to repair needs—and not for routine “checkups.” As such, in the area of child mal- treatment, we have had a tendency to devote more time, money, and resources to
intervening once abuse or neglect has already occurred, and not on identifying and addressing the precursors of maltreatment risk. In part, this tendency is infl uenced by current laws and priorities such that child protection agencies have few resources for families who have not yet violated any statutory guidelines or agency policies. Unfortunately, the present system is primarily designed for protec- tion, which does not often permit offering assistance to parents
who could benefi t from an early intervention/prevention model (Wolfe, Reppucci, & Hart, 1995). Sadly, this means that children generally have to suffer before assis- tance is available. Recently, however, child welfare organizations have recognized the need for more prevention-focused efforts and are dedicating themselves toward these efforts. For example, in celebration of 100 years of service, the Children’s Bureau has outlined its vision for the future of child welfare. Among other initiatives, this vision includes increased attention to prevention programming within a universal frame- work of child protection; acknowledging that all families (not just those at high risk) need additional assistance and resources (L. Mitchell et al., 2012). This type of shift in mind-set is crucial to the success of child maltreatment prevention.
Working in the prevention arena poses unique challenges to mental health cli- nicians and researchers. First, because target families have not (yet) demonstrated
CHAPTER 14
Preventing Child Maltreatment
prevent
to reduce the likelihood
of an occurrence.
precursor
any factor that precedes
the onset of child
maltreatment and may
function as a risk factor.
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329PREVENTING CHILD MALTREATMENT
acts of maltreatment, they may not be aware or believe that they have a problem. Therefore, they are less likely to seek out services and may be more diffi cult for profes- sionals to identify. Second, families need to be motivated to participate in preventive services when they are offered. As their participation is largely voluntary, they may refuse or be unwilling to participate fully. Third, given constraints related to funding and available resources, it is important to identify potential participants who are at greatest risk and, therefore, most likely to benefi t from services (Leventhal, 1997).
OVERVIEW OF PREVENTION PROGRAMS
In general, prevention programs for physical abuse and neglect (unfortunately, psy- chological maltreatment is rarely targeted for prevention) attempt to reduce the likelihood of maltreatment by focusing on service delivery to parents. The underlying model of this approach is that maltreatment often stems from issues related to poor parenting and dysfunctional parental practices (e.g., excessive physical discipline, failure to provide children with basic needs, substance abuse, intimate partner violence), which are best resolved by improving parenting skills, increasing parental knowledge regarding child development and behavioral expectations, and offering supportive services to parents. The fundamental assumption of this approach is that physical abuse and neglect are less likely to occur if parents are armed with knowledge about appropriate child care, child development, and healthy family relationships. To this end, parent education and support programs (e.g., home visitation programs, family or community support centers, programs for new and/or teenage mothers, programs offering individual counseling and support groups) have been developed and implemented in an attempt to achieve these goals (Olsen & Widom, 1993).
Alternatively, child sexual abuse prevention programs typically target preschool through school-age children. Although these programs may include a parental education component, such as providing parents with information regarding the prevalence and nature of child sexual abuse and encouraging parent–child discus- sions of child sexual abuse–related issues, the focus is on educating children. These programs tend to be school or community based, and their emphasis is on empow- ering children and improving their ability to resist assault. They may be included as part of a larger child safety program that provides classroom-based instruction on how children can protect themselves from sexual assault and ways to cope with actual or potential sexual abuse. The fundamental assumption of these programs is that by arming children with information and skills associated with the prevention of child sexual abuse, they may be better able to protect themselves from victimiza- tion (Olsen & Widom, 1993).
The majority of prevention programs target and serve families who recognize their limitations with respect to caregiving and seek out services to address these limitations. However, fewer resources are available (and their effectiveness is limited) for families who do not even recognize they need assistance or are unable or unwilling to access resources. This is refl ected in the 30%–50% attrition rate observed throughout child abuse prevention programs (McCurdy, Hurvis, & Clark, 1996, as cited in Daro & Donnelly, n.d.). Further- more, many child abuse prevention programs fail to achieve their
attrition
the loss of participants
during a research study,
which may occur for a
variety of reasons (e.g.,
loss of interest in the
study, relocation, death).
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330 WHAT HAPPENS NEXT
desired outcomes. Despite our good intentions and best efforts, we continue to see high child abuse report rates, child abuse–related injuries, and child abuse fatalities among families receiving prevention services. It is estimated that as many as one third
of parents will abuse their children either during, or within 1 year of, their participation in a therapeutic program (Karski, Gilbert, & Frame, 1997, as cited in Daro & Donnelly, n.d.). Given these facts, efforts at prevention are clearly falling short of their goals. However, by continuing to develop prevention programs and evaluate their effectiveness, we will hopefully be able to improve our success rate and offer safety to children as a guarantee of childhood development.
A PUBLIC HEALTH ISSUE
Over the course of the last 20 to 30 years child maltreatment has come to be recognized as a serious public health issue—injury, acci- dental or intentional, is a leading cause of death for children in the United States. The Centers for Disease Control and Prevention, a public health agency, has been involved in child maltreatment prevention efforts since the 1980s, with an initial focus on child deaths that has since expanded to include the prevention of all cases of premature death and disability caused by injuries to chil- dren. More specifi cally, the Division of Violence Prevention has as part of its mission the prevention of injuries and deaths to children caused by violence. The range of health outcomes related to child maltreatment also poses a signifi cant public health burden, further ensuring its basis as a public health issue. For example, exposure to child maltreatment often increases risk factors for many of the leading causes of death among adults, including heart disease, can- cer, alcoholism, and suicide (Hammond, 2003).
Given the interpretation of child maltreatment as a public health issue, it seems appropriate that the remainder of this chap- ter should address child maltreatment prevention efforts within a public health context. That is, specifi c prevention efforts will be outlined and evaluated according to epidemiological terminol- ogy, which describes prevention efforts as primary (i.e., targeting the general population), secondary (i.e., targeting at-risk individu- als), or tertiary (i.e., targeting affected individuals).
Unfortunately, it is sometimes diffi cult to translate this catego- rization system into a psychological arena and categorization can lead to some confusion regarding the defi nitions of and distinctions between different types of prevention approaches. This confusion is especially true for primary versus secondary prevention approaches, as one person may consider a program primary in nature whereas another may consider it more of a secondary approach. For exam- ple, a home visitation program that targets at-risk families based on income level, educational level, single-parent status, maternal age, and so forth (but without any previous or current history of child maltreatment), may be considered a primary prevention
Centers for Disease
Control and Prevention
a division of the
Department of Health
and Human Services
whose mission is
to promote health
and quality of life
by preventing and
controlling disease,
injury, and disability.
Division of Violence
Prevention
a division of the Centers
for Disease Control
and Prevention that
is dedicated to the
prevention of all forms of
violence including child
maltreatment, intimate
partner violence, school
violence, and youth
violence.
epidemiological
that which pertains to
factors affecting the
health and illness of
populations (i.e., public
health).
at risk
individuals (or group
of individuals) who
are predisposed to
developing a maladaptive
behavior pattern (such as
child maltreatment).
primary prevention
targets the general
population to reduce the
incidence of all new cases
of a problem.
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331PREVENTING CHILD MALTREATMENT
program by some because there is no evidence of child maltreat- ment among the recipients of services. However, others may categorize this same approach as a secondary prevention program because it targets a specifi c, as opposed to the general, population. For the purposes of this review (and in an attempt to simplify this distinction), any program that targets a high-risk group or specifi c subgroup is considered a secondary prevention program, whereas the term primary prevention is reserved for programs that are more universally available.
Furthermore, discussions of tertiary (or indicated) prevention, which targets affected individuals in an attempt to prevent further incidents and reduce the pro- gression of an already existing problem, can create confusion because these programs are often considered to be synonymous with treatment/interven- tion (Harder, 2005). The goals of tertiary prevention programs are to minimize the negative effects of an existing problem, decrease the intensity and/or severity of a problem, reduce complications associated with the problem, and decrease recidivism. Examples of tertiary prevention programs related to child maltreatment include parent training classes and intensive family preservation services for families currently receiving child protective services, mental health services for children and families affected by maltreatment, and parent–mentor programs with nonmaltreating families. There- fore, because the intent of this chapter is to evaluate prevention programs, and not intervention programs, tertiary prevention is not a focus of subsequent discussion.
It is important to note that, when evaluating prevention programs, drawing comparisons among them can be diffi cult due to program diversity (even within a specifi c type of prevention program, e.g., home visitation). Variability includes (but is not limited to) the selection of participants, the duration of the program, the length of follow-up, the qualifi cations of program personnel, and outcome measure- ment (MacMillan, MacMillan, Offord, Griffi th, & MacMillan, 1994a). Additionally, many programs claim to target the primary and/or secondary prevention of child maltreatment, but then do not include outcome variables that can be directly con- nected to the measurement of child maltreatment such as reports to child protective agencies, medical records, or prospective information regarding sexual abuse victimi- zation (Peterson, Tremblay, Ewigman, & Saldana, 2003). These are just a few of the issues associated with evaluating child maltreatment prevention programs, and these should be kept in mind during the remainder of this review.
PRIMARY PREVENTION
Primary prevention programs universally target the general population (e.g., public service announcements) or individuals defi ned by geographical and/or chronologi- cal parameters (e.g., home visiting services for all women giving birth at a particular hospital during a specifi ed period of time) in order to reduce the incidence of all new cases of a problem (Harder, 2005). Sanders, Cann, and Markie-Dadds (2003) argue for a universal population-based approach to the prevention of child maltreatment, noting that an exclusive focus on intervention programs creates a developmental
secondary prevention
targets a specifi c group of
individuals to reduce the
incidence of new cases of
a problem among those
determined to be at some
identifi ed risk.
tertiary prevention
intended to minimize
the negative effects of an
already existing problem.
recidivism
the tendency for
something (such as a
disease or a maladaptive
behavioral pattern) to
recur.
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332 WHAT HAPPENS NEXT
disadvantage for children because they are usually only applied after maltreatment has already occurred. Further, they note that these interventions may only address part of a larger problem with family interactions, ignoring important factors such as parents’ negative attributions toward their children’s behavior and parents’ anger control issues. They propose that the enhancement of parental competence, preven- tion of dysfunctional parenting practices, changing parental attributions (for both their behavior and children’s behavior), and promotion of teamwork between par- ents are necessary in order to universally reduce family risk factors associated with child maltreatment. Critical aspects of such an endeavor include easy access to ser- vices, culturally appropriate family interventions, the use of effective parenting and family interventions, evidence demonstrating that decreases in dysfunctional par- enting and increases in parental competence are directly linked to child functioning, and knowledge of the prevalence/incidence of family risk factors and targeted child outcomes (Sanders, Cann, & Markie-Dadds, 2003).
Public Awareness Campaigns
Primary prevention programs that are geared toward public education and awareness campaigns have as their goal informing citizens about child maltreatment and how to report it if suspected. They include the ability to create awareness of a problem, improve knowledge of a problem, change attitudes regarding a problem, and either directly or indirectly change behavior (Daro & Donnelly, n.d.). They may include such media outlets as public service announcements on television and radio program- ming, billboards, advertisements in newspapers and magazines, internet sources, and distributed pamphlets or brochures. For an example of an awareness campaign advertisement, see Figure 14.1 . These types of media campaigns allow prevention programmers to target a large audience frequently and consistently. Unfortunately, they tend to be considered the least important approach to prevention.
Despite this mentality toward public awareness campaigns, they can be quite infl uential. In the mid-1970s, more than 90% of Americans were unaware of the extent of the child maltreatment problem in the United States. Following a media campaign in the 1970s and 1980s, studies showed that more than 90% of the public were aware of the problem and knew what to do in order to help resolve it (Daro & Gelles, 1992). During this same period, child protection reports increased from 100,000 in 1976 to over 1 million in the early 1980s, many of which were made by the general public (McCurdy & Daro, 1994).
Recently, the U.S. Department of Transportation’s National Highway Traffi c Safety Administration (NHTSA) announced a national campaign to prevent vehicle-
related heatstroke deaths in children (“Where’s the Baby? Look Before You Lock,” National Highway Traffi c Safety Administration, 2012). Reports from the NHTSA indicate that (for children under 14) the leading cause of non-crash, automobile-related deaths is heatstroke. Vehicle-related heatstroke may occur when a caregiver unintentionally leaves an infant in a rear-facing car seat in the back of a vehicle, when (unbeknownst to caregivers) older chil- dren obtain access to an unlocked car, or because caregivers leave children unattended in a vehicle without realizing the potential consequences of their actions. According to U.S. transportation sec- retary Ray LaHood, “This campaign is a call-to-action for parents
Where’s the Baby? Look
Before You Lock
a primary prevention
program sponsored
by the National
Highway Traffi c Safety
Administration to
reduce the incidence of
vehicle-related heatstroke
fatalities in children.
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333PREVENTING CHILD MALTREATMENT
and families, but also for everyone in every community that cares about the safety of children” (National Highway Traffi c Safety Administration, 2012, para. 2). This cam- paign includes radio and online advertisements, as well as a toolkit for parents and outreach organizations. As part of this campaign, the NHTSA urges caregivers to take precautions such as never leaving a child unattended in a vehicle, always looking in
FIGURE 14.1 Advertisement for a public awareness campaign sponsored by the Global Campaign for Violence Prevention. Photo credit: World Health Organization.
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334 WHAT HAPPENS NEXT
the front and back of the vehicle before walking away, storing car keys out of chil- dren’s reach, and teaching children that a vehicle is not a play area. The NHTSA also encourages community members to call 911 if they see a child alone in a vehicle. As this is a newly implemented program, effectiveness data are not yet available; however, the hope is that these measures will reduce the incidence of an entirely preventable source of child fatality.
The use of public awareness campaigns in an attempt to alter specifi c parental attitudes and behaviors has been viewed as more challenging and is often considered a less appropriate prevention strategy when compared to more targeted prevention efforts (e.g., home visitation). However, a campaign during the 1980s that targeted the use of physically and emotionally abusive discipline techniques demonstrated a reduction in the use of both corporal punishment and verbal aggression when disciplining children. These results, however, come strictly from parental report, so it is unclear whether they refl ect a true change in behavior or reluctance by par- ents to admit using discipline strategies they have been admonished against utilizing (Daro & Gelles, 1992).
Parental Education Campaigns
This type of primary prevention program is specifi cally targeted toward parents and is generally offered through certain venues (e.g., school system, medical facilities) but is available to all parents who choose to utilize these services. These programs have the advantage of being available to a large number and potentially wide range of parents. In addition, they provide a more universal level of support to parents, without the stigma associated with more targeted programs (Daro & Donnelly, n.d.). However, they do require that parents recognize that they need help raising their children and that parents be both willing and able to attend and learn from these programs. Unfortunately, many of the risk factors for child maltreatment (e.g., sub- stance abuse, high stress, low education levels, lack of support) may also prevent parents from taking advantage of programs like these.
Several of these programs have been developed for use in medical settings including the Detroit Family Project and Don ’ t Shake the Baby. In the Detroit Family Project, parent facilitators visit waiting rooms of health clinics with a mobile cart containing snacks, brochures, and toys for children. The facilitators initiate informal discussions with the parents about a variety of parenting- related topics and give parents brochures and suggestions for obtaining additional information. This program reaches approxi- mately 25,000 parents annually, and many report having learned information of which they were not previously aware (Whitelaw Downs & Walker, 1996, as cited in Daro & Donnelly, n.d.). Don’t Shake the Baby was developed to increase parental knowledge regarding the dangers of shaking infants and reduce the occur- rence of shaken baby syndrome. Over a 1-year period, information was distributed to parents on maternity wards. Parents reported that the information was helpful (Showers, 1992), but no attempts were made to determine whether this program affected the preva- lence of shaken baby syndrome. By taking the program to where the parents already are instead of waiting for parents to come to
Detroit Family Project
a primary prevention
program in which
facilitators engaged in
informal discussions on
parenting-related topics
with parents in the waiting
rooms of health clinics.
Don ’ t Shake the Baby
a primary prevention
program developed
to increase parental
knowledge regarding
the dangers of shaking
infants and reduce the
occurrence of shaken
baby syndrome.
6241-171-P4-014.indd 334 10/19/2013 10:17:22 AM
335PREVENTING CHILD MALTREATMENT
the program, more parents, including those who are less capable or motivated, may also be reached.
A more comprehensive parent education program for the prevention of shaken baby syndrome has been implemented throughout the state of North Carolina. The Period of PURPLE Crying: Keeping Babies Safe in North Carolina is based on research indicating that crying is the most common trigger for shaking, and it provides education to new parents regarding the developmental normalcy of infant crying (each letter in the acronym PURPLE represents a characteristic of crying in healthy infants that can be frustrating to caregivers; see Figure 14.2 ). The program is a 5-year statewide initiative that includes educating new parents in hospitals and birthing centers throughout the state, distributing information to expectant/new parents through health department and physicians’ offi ces, and a media campaign to educate the general community (Runyan et al., 2009). The cur- rent initiative will be complete at the end of 2012; therefore, effectiveness data are not yet available. However, similar programs conducted in Vancouver, British Columbia, and Seattle, Washington, have found that parents receiving the PURPLE information demonstrated increased knowledge regarding the normalcy of infant crying and a greater likelihood to share information with other caregivers about the dangers of shaking a baby and the possibility of walking away from an infant when frustrated. Furthermore, in the Vancouver study, parents receiving the PUR- PLE materials also reported an increased likelihood to walk away when frustrated (Barr et al., 2009a, 2009b). Although this level of program outreach is rare, positive fi ndings may underscore the need for such wide-scale efforts.
The Period of PURPLE
Crying: Keeping Babies
Safe in North Carolina
a primary prevention
program to reduce
the occurrence of
shaken baby syndrome
by educating new
parents regarding the
developmental normalcy
of infant crying.
FIGURE 14.2 The Period of PURPLE Crying, an acronym for developmentally normal infant crying. Photo credit: National Center for Shaken Baby Syndrome.
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336 WHAT HAPPENS NEXT
Child Sexual Abuse Programs
As previously mentioned, prevention efforts to reduce the rates of sexual abuse have taken a different approach from programs targeted at physical abuse and neglect in that child sexual abuse prevention programs generally target potential victims rather than perpetrators. The approach of these programs is primarily educational in nature. Children are provided with general information regarding sexual abuse and more specifi c information regarding how to protect themselves from and how to respond to sexual abuse. Programs also provide opportunities for children to discuss issues surrounding child sexual abuse with their parents and disclose past or current abuse to an adult. Child sexual abuse prevention programs may be provided directly through the school system and through community-based and national organiza- tions (Daro & Donnelly, n.d.).
Many people are concerned about the suitability of these programs, particularly with respect to potential negative effects on children, but research generally shows few negative side effects as a result of program participation (MacMillan, MacMillan, Offord, Griffi th, & MacMillan, 1994b; Wurtele & Miller-Perrin, 1987). Additionally, studies report that these programs yield a slight increase in children’s knowledge of sexual abuse and of how to respond (Carroll & Miltenberger, 1992; Rispens, Ale- man, & Goudena, 1997). As with any program, there appear to be some differences with respect to how this information is received. Children have more diffi culty accepting that this type of abuse can occur by someone they know than by strangers (Finkelhor & Strapko, 1992), and among younger children, the more complex con- cepts such as secrets and ambiguous feelings are often misunderstood (Berrick, 1989). Furthermore, programs that incorporate more active components (e.g., modeling, rehearsal, vignettes) tend to yield more positive results (Davis & Gidycz, 2000).
In an attempt to determine children’s exposure and response to child sexual abuse prevention programs, a national survey of children ages 10 through 16 years found that 67% had attended at least one program in their lifetime (Finkelhor
& Dziuba-Leatherman, 1995). Topics covered in these programs included information regarding intrafamilial and extrafamilial sexual abuse, appropriate versus inappropriate touch, strategies for stopping abuse attempts, the importance of disclosure, and reas- surance that abuse is not the child’s fault. Few of these programs included parents, although more than half of the children reported that they discussed the program with their parents. Most evalua- tions of the programs were positive; 95% of participants said they would recommend it to other children. With regard to potential
negative effects of program participation, younger children, minority children, and children from lower socioeconomic families reported more fear and anxiety. How- ever, these same children reported the most positive reactions to the program and the most use of program information and skills.
In a related study of the same group of participants, Finkelhor, Asdigian, and Dziuba-Leatherman (1995) reported results regarding the effectiveness of child sex- ual abuse prevention programs. Children who attended programs scored higher on a knowledge test related to child sexual abuse information and reported more dis- closures of current and past sexual abuse. Many of the children also reported that they had used the skills learned in the program during a variety of later real-life situ- ations (e.g., saying no to an adult, disclosure, helping a friend). Furthermore, they
extrafamilial
occurring outside of a
family.
intrafamilial
occurring within a
family.
6241-171-P4-014.indd 336 10/19/2013 10:17:23 AM
337PREVENTING CHILD MALTREATMENT
reported feeling better able to handle threats of victimization, although they were no more effective in thwarting actual assaults. That is, they did not have a lower level of completed victimizations. Unfortunately, these children were also more likely to be injured during sexual victimizations, probably resulting from a greater tendency to fi ght back. Accordingly, it is recommended that care be taken with respect to the strategies that children are taught to prevent abuse attempts, especially because these strategies may not reduce a child’s likelihood to actually prevent these attempts.
Although most child sexual abuse prevention programs are developed and mar- keted as efforts to prevent the occurrence of child sexual abuse, most evaluations of these programs focus on child knowledge (which is generally improved by interven- tion), but not actual ability to avoid sexual abuse in real life. In an attempt to discern whether these programs affect the incidence of child sexual abuse, Gibson and Leitenberg (2000) conducted a retrospective survey of female college students. They found that students who had not participated in a school-based child sexual abuse prevention program were twice as likely to experience subsequent child sexual abuse compared with the students who had participated in one of these programs. They did not fi nd any differences in rates of sexual abuse disclosure, although the students who had participated in a program tended to make earlier disclosures than did stu- dents who had not attended a program. Furthermore, any sexual abuse they had experienced was of shorter duration. In order to address public concerns regarding the potential negative impact of child sexual abuse programs on later sexual func- tioning, Gibson and Leitenberg evaluated sexual satisfaction and behavior among women who had not experienced child sexual abuse. The results of these analyses indicated that there were no differences in sexual satisfaction or behavior between students who had and had not previously participated in a prevention program. Overall, the results from this study suggest that attendance at prevention programs can have long-term positive effects on the incidence of child sexual abuse without negatively impacting sexual functioning. See Focus on Research 14.1 for further dis- cussion on the validity of results obtained through retrospective studies.
FOCUS ON RESEARCH 14.1
Several of the studies investigating the effectiveness of child sexual abuse prevention pro- grams mentioned in this chapter (Finkelhor & Dziuba-Leatherman, 1995; Finkelhor et al., 1995; Gibson & Leitenberg, 2000) required research participants to remember a program they had attended at some point in their lifetime (that is, the studies are retrospective in nature). A primary concern with retrospective studies is that they rely on the ability of people to remember the details of events that occurred sometime in the past. In the case of these child sexual abuse prevention studies, the participants were required to recall the details of an event that occurred many years in the past. In evaluating the results of these retrospective studies, we must consider whether people are able to remember adequately the details of a program they attended as many as 15 years ago. Additionally, we must consider the value of a prospective research design in evaluating the effectiveness of pre- vention programs—a design that is often underutilized because it tends to be more costly and time-consuming than a retrospective design.
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338 WHAT HAPPENS NEXT
Many feel that parents may be in a better position to protect their children from sexual abuse than are children to protect themselves and have suggested that child sexual abuse prevention programs should more regularly incorporate parental involvement (Reppucci, Jones, & Cook, 1994). Although some programs do include parental components, these are likely to be voluntary, and attendance may be poor. In fact, one study of parental involvement in a child sexual abuse prevention program for preschoolers reported that only 34% of parents attended the parent- focused meeting (Berrick, 1988). Furthermore, the results of this study indicated that the parents who did attend did not learn very much, because there were no differences in parental knowledge between those who attended and those who did not. Even those who did attend had diffi culty identifying the indicators of child sexual abuse, primarily noting an intuitive ability to recognize sexual abuse among their children (“I’d just know”). Despite these fi ndings, others have suggested strat- egies for encouraging parental attendance, including program involvement with parent–teacher associations (Brassard, Tyler, & Kehle, 1983), scheduling workshops on a Saturday with alternate activities (e.g., movies, games) for children, and form- ing smaller discussion groups rather than the typical larger lecture format (Reppucci et al., 1994).
Darkness to Light, an organization based out of Charleston, South Carolina, has developed a unique approach to the prevention of child sexual abuse. Their mission is to “educat[e] adults about the steps they can take to prevent, recog- nize, and react responsibly to the reality of child sexual abuse” (Darkness to Light, n.d.), which is accomplished by encouraging adults to be responsible for the safety and protection of children. This organization offers practical recommendations for individuals who interact with, and organizations that serve, children with respect to sexual abuse prevention. For example, it provides parents with guidelines for selecting youth-based organizations for their children and encourages youth- based organizations to conduct more extensive staff/volunteer screenings than can be offered through criminal background checks alone. Their Stewards of Chil- dren workshop provides adults with detailed information about sexual abuse and concrete strategies for protecting children. In two independent empirical investiga- tions, researchers found that individuals who participated in Stewards of Children
reported greater sexual abuse–related knowledge, an increased attitudinal shift with respect to the role of adults in child pro- tection, and positive changes in prevention behaviors when compared to waitlist control conditions. Remarkably, many of these effects continued to be observed during follow-up testing (Derrick, Flynn, & Rodi, 2007; Rheingold et al., 2011). It would seem that this alternative approach to the prevention of child sexual abuse (i.e., focusing on adult responsibility for the safety of children) positively infl uences adults’ knowledge, attitudes, and behaviors with respect to child protection. Whether it can support Darkness to Light’s ultimate mission, to end childhood sexual abuse, remains to be seen. See Profi le 14.1 for a closer look at one of the individuals responsible for the development of Stew- ards of Children.
waitlist control
an experimental
condition in which
participants are assigned
to a waiting list to receive
an intervention after
the active treatment
group completes
the intervention.
The purpose of this
condition is to provide
a comparison for the
intervention group.
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339PREVENTING CHILD MALTREATMENT
SECONDARY PREVENTION
Due to monetary and resource costs associated with primary prevention efforts, many programs targeting child maltreatment adopt a more selective approach. In order to effectively reach those most in need of services, and to be able to offer them more comprehensive services from a limited pool of resources, preven- tion programs tend to target individuals at risk for maltreatment rather than offering services to the general population.
This more selective approach to prevention efforts is called secondary prevention, which targets at-risk individuals in order to reduce the incidence of new cases of a problem among those deter- mined to be at some identifi ed risk. These individuals may include single parents, young parents, parents with a psychiatric history, parents with a history of having been abused themselves, and low-income families, among others (Harder, 2005). Helfer (1976, as cited in McMurtry, 1985) proposed that a “ disease model ” be
PROFILE 14.1
Martha Tumblin, MEd, LISW-CP
Martha Tumblin (a Licensed Independent Social Worker-Clinical Practice) earned both her bachelor’s degree in psychology and her master’s degree in secondary guidance and coun- seling from the University of South Carolina. She has worked for more than 30 years in the fi eld of addictions counseling and, through that work, came to understand the direct con- nection between addiction and trauma. Her passion for child advocacy stems from her work with addictions clients and their families, helping them through their recovery from addic- tive illnesses, codependency, and healing processes from childhood trauma. She became more directly involved in the prevention movement following a community crisis related to child sexual abuse in the late 1990s. Since that time, she has avidly supported community engage- ment and grassroots prevention efforts. She initially became involved as a supporter and contributor to these efforts, and is currently a consultant and trainer for child sexual abuse pre- vention through Darkness to Light. This organization was founded in 2000, with the ultimate mission to end child sexual abuse. To accomplish this mission, Darkness to Light (n.d.) strives to empower adults to “prevent, recognize, and react responsibly” to child sexual abuse. Martha contributed to the development of (and is now an authorized facilitator and certifying instruc- tor for) Darkness to Light’s Stewards of Children training, an adult-focused prevention program aimed at increasing awareness of child sexual abuse and teaching adults the skills needed for child protection. She travels all over the country to promote this message and to encourage others to do so as well. As a therapist, Martha saw the pain and continued loss that can follow a history of trauma and hopes her work will keep people from having to go through that pain.
disease model
a term borrowed from
medical science to refer
to maladaptive behavior
patterns (e.g., addiction,
child maltreatment) as
lifelong illnesses that
involve both biological
and environmental
sources of origin.
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340 WHAT HAPPENS NEXT
applied to our understanding of secondary prevention efforts for child maltreatment, in which the goal is to inoculate susceptible parents against abusing/neglecting their children. The general approach is governed by the principle that, although everyone can presumably benefi t from services aimed at the prevention of child maltreatment, not everyone needs them. Therefore, secondary prevention approaches may offer advantages in service effi ciency. Unlike the more conventional disease model, how- ever, the prevention of child maltreatment is faced with some formidable diffi culties. First, there is no clear defi nition of child maltreatment, and therefore, its existence (to some extent) is a matter of subjective interpretation. Furthermore, it is not a discrete
phenomenon that a parent clearly does or does not demonstrate, but it may actually lie on a continuum that also includes good parenting characteristics. Third, a clear and useful etiology of the problem is unknown (McMurtry, 1985). The problem, therefore, is deciding who exactly should be targeted for prevention programs.
Findings From Specifi c Prevention Programs
Most secondary prevention programs for child maltreatment focus their efforts pri- marily on reducing the likelihood for physical abuse, although they may indirectly address factors related to neglect as well. Few attempt to investigate any effects on psychological maltreatment, either directly or indirectly (Baker, Brassard, Schnei- derman, Donnelly, & Bahl, 2011). Additionally, recognizing the many challenges associated with the prevention of physical abuse and neglect, especially once risk
factors are present and have been identifi ed, most secondary prevention programs tend to be fairly comprehensive in nature. They incorporate components from models of parental education/ training, peer support (available primarily through group- or center-based programs), family support, crisis intervention, thera- peutic intervention, and home visitation.
Several secondary prevention programs, in particular, have had a large impact on the overall child maltreatment preven- tion fi eld. One such program is Hawaii ’ s Healthy Start Program, which began in the mid-1980s and focused on home visitation for families identifi ed as being at risk for maltreating their new- born children. Families participating in this program were enrolled during the mother’s pregnancy, and they began receiving home visits shortly after childbirth. Families received services for the fi rst 3 years of the child’s life. Home visits were conducted by trained paraprofessionals and initially occurred on a weekly basis. Over the course of the program, visits gradually decreased to quarterly appointments. Although this initial program did not include a con- trol group comparison, results indicated that there were no child protection reports of physical abuse and only 4 reports of neglect (out of 234 participating families) among program enrollees (Dug- gan et al., 1999).
The success of Hawaii’s Healthy Start Program spearheaded home visitation efforts across the United States, particularly Healthy Families America (HFA), is a program that was initiated
etiology
the study of causation;
why things occur and/or
the reasons for behavior.
Hawaii ’ s Healthy Start
Program
a secondary prevention
program that provides
home visitation for
families identifi ed
as being at risk for
maltreating their
newborn children.
paraprofessional
a job title given to people
in occupations for which
they have received some
specialized training but
are not professionally
licensed.
Healthy Families
America
a home visitation
program that was
modeled after Hawaii’s
Healthy Start Program.
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341PREVENTING CHILD MALTREATMENT
by Prevent Child Abuse America in 1992 and, by 1997, had been implemented in approximately 38 states and in the District of Columbia. Healthy Families America programs include weekly home visits that begin shortly after childbirth, with visit frequency tapering over time. Home visits are conducted by paraprofession- als, and services are available to families for the fi rst 5 years of a child’s life. Daro and Harding (1999) reviewed Healthy Families America data related to CPS reports of child physical abuse and neglect and found a 6% child maltreatment rate among program participants. This percentage is higher than the national average at the time (4.7% in the late 1990s), but is 2 to 3 times lower than the estimated rate for families with at-risk characteristics (e.g., low income, single mothers) similar to those of the pro- gram participants. However, studies conducted with control group comparisons have not demonstrated different child maltreatment rates between treatment and control group families.
Hawaii’s Healthy Start Program and Healthy Families America have more recently come under fi re, especially given their apparent inability to produce results similar to those obtained by the initial project in Hawaii. Duggan et al. (2004) reviewed the results from 12 of Hawaii’s Healthy Start Programs. In general, the authors found no program impact on preventing child physical abuse or promoting nonviolent discipline techniques and only modest effects related to child neglect. Given these negative fi ndings, researchers have generally concluded that the use of paraprofes- sionals to deliver prevention services may not be appropriate for high-risk families who often have complex and multiple psychosocial risk factors (e.g., parental sub- stance abuse, poor maternal mental health, domestic violence). Interestingly, in a survey of Healthy Families America home visitors, LeCroy and Whitaker (2005) noted that the biggest challenges faced by home visitors in conducting visitations included limited resources, family mental illness (e.g., threatening suicide), substance abuse in the home, domestic violence, families in constant crisis, safety issues, and unmo- tivated families.
Another secondary prevention program that has had a signifi - cant impact on child maltreatment prevention efforts is the Nurse Home Visitation Program. Participants in this program included pregnant women whose fetuses were at risk for later health and developmental problems due to factors such as maternal age, single parenthood, and low socioeconomic status. The program consisted of weekly home visits conducted by nurses. Home visits generally began during the second trimester of pregnancy and gradually decreased in frequency until program termination at the child’s sec- ond birthday. Results of this program revealed a signifi cant reduction in substantiated CPS reports among home-visited families (compared to control-group participants) by the child’s second birthday. This effect was especially dramatic among a subsample of poor, unmarried teenage mothers. During a 15-year follow-up, results indicated half as many substantiated CPS reports among home- visited families compared to control group participants. Again, this effect was strongest among poor and unmarried women (Olds et al., 1999). The Nurse Home Visitation Program (now known as the Nurse-Family Partnership ) is currently available in 400 counties
Prevent Child Abuse
America
an organization that
began in 1972 with the
mission of preventing
all forms of child abuse
and neglect in the United
States.
Nurse Home Visitation
Program
a secondary prevention
program that targets
pregnant women
whose fetuses are at
risk for later health and
developmental problems.
Nurse-Family
Partnership
see Nurse Home
Visitation Program.
6241-171-P4-014.indd 341 10/19/2013 10:17:23 AM
342 WHAT HAPPENS NEXT
across 40 states in the United States, as well as in the United King- dom (Olds, 2012). It is generally regarded as the gold standard for child maltreatment prevention programs, and its results are cer- tainly more positive than those from Hawaii’s Healthy Start Program and Healthy Families America. Many have credited the difference in program effectiveness to the utilization of more qualifi ed and highly trained home visitors in the Nurse Home Visitation Program (i.e., nurses vs. paraprofessionals). Whether this difference in professional qualifi cations explains the resulting difference in fi ndings remains unknown. However, it is encouraging to know that positive reports from a well-executed home visitation program are attainable.
A meta-analysis of reports on secondary prevention programs revealed an overall positive effect. Positive outcomes were spe- cifi cally connected to decreases in abusive and neglectful acts; a reduction in risk factors related to child, parent, and family func- tioning; and improvements in parent–child interaction. Although this meta-analysis did not reveal any benefi cial program effects based on actual indicators of maltreatment (i.e., CPS reports), the fact that positive effects were found on several other measures of child maltreatment is noteworthy. This suggests that the use of proxy measures (e.g., risk factors) may be preferable to direct out- come measures that may not accurately refl ect the true prevalence of abuse and neglect and that are diffi cult to detect given their rarity (Geeraert, Van den Noortgate, Grietens, & Onghena, 2004).
Given the potential diffi culties and methodological issues in using CPS reports as an indicator of child maltreatment, one alter- native outcome measure in the study of child abuse is parental
discipline styles. Prevention programs may examine factors associated with one increased risk for child abuse, such as harsh physical discipline. One such program assessed seven components related to successful parenting: parenting skills, awareness of developmentally appropriate behaviors, parental beliefs, parental affect, parental role, maternal role, and parental effi cacy. Participants included low-income mothers with children from 18 months to 4 years of age. Intervention included weekly group therapy sessions and weekly home visits for 16 weeks. Compared to control groups, measures of harsh discipline revealed a signifi cant treatment effect—such that harsh discipline among the treatment group decreased, while it remained the same among control groups. This study did not directly measure child maltreatment, as there was no inclusion of reports to CPS, emergency room visits, injuries, hospitalizations, and the like. It did, however, examine “harsh discipline” (e.g., shouting, threatening, shoving, slapping) within the context of parenting skills, which is a potential risk factor for child maltreatment. As such, this study is of interest because it demon- strates the range of variability with regard to methodological considerations that
is apparent among prevention efforts (Peterson, Tremblay, Ewig- man, & Saldana, 2003).
Finally, Barth (1991) reported results for the Child Parent Enrichment Project. This program included 6 months of home visitation that began during pregnancy. Participants were primarily high-risk mothers (e.g., low IQ, mental illness, history of maternal abuse). The program received high consumer satisfaction scores but
gold standard
the best available
program and the
benchmark against
which all other programs
are measured.
proxy measures
variables that are used
instead of the actual
variable of interest
because it cannot be
measured or is diffi cult to
measure.
meta-analysis
a statistical technique
that allows researchers
to combine the results of
several different studies.
Child Parent
Enrichment Project
a secondary prevention
program involving home
visitation for high-risk
mothers.
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343PREVENTING CHILD MALTREATMENT
did not show any evidence of child abuse and neglect prevention. These results high- light the need to include objective (rather than relying solely on subjective) outcome measures. Although it is helpful to know that the mothers liked the program, it is not the same as knowing that the program was effective at reducing child maltreatment.
Prevention Targeting Child Neglect
Although neglect is the most often reported form of child maltreatment, little is known regarding effective methods for prevention. Given the complex, and likely chronic, nature of neglect, a simple prevention program is unlikely to have much impact. Consequently, prevention programs do not often target neglect directly or explicitly. In a study conducted by DePanfi lis and Dubowitz (2005), residents of an impoverished urban neighborhood with several additional risk factors for neglect (e.g., nonreportable neglectful characteristics, parental mental health issues, child behavior problems) and a child between the ages of 5 and 11 years old were recruited as participants. Participants were assigned to either a 3- or 9-month Family Connections Program. Components of the program included home-based interventions (e.g., social support, behav- ior management), referrals to community services (e.g., substance abuse treatment), supportive recreational activities (e.g., trips to museums, baseball games, holiday celebrations), and emergency (e.g., eviction notice, lack of food, intimate partner violence) assis- tance. Although some improvements in risk and protective factors were seen (and maintained at 6-month follow-up), issues related to child safety and maltreatment reports were still present following the program’s termination. Fur- thermore, there were no observed differences between the treatment groups based on duration of program participation.
One explanation for the lack of positive fi ndings relevant to child maltreatment in this study is the possibility that the program was not long enough to evidence any subsequent effects. That is, 3 or 9 months is likely not enough time to resolve issues related to a problem as pervasive as child neglect. Furthermore, a methodo- logical issue present in this study is that without a control group comparison, it is impossible to determine whether the effects observed resulted from program imple- mentation, the passage of time, or issues associated with participant and researcher expectations. Despite the limited positive fi ndings from this study, the fact that it directly addressed the prevention of child neglect makes it a unique contribution to the prevention fi eld. This is an issue that is worthy of continued consideration. Hopefully, more researchers will begin focusing on child neglect as an area worthy of more targeted prevention efforts.
CONCLUSION
Unfortunately, we are faced with the reality that that we do not yet know how to effectively prevent child maltreatment. With con- tinued development and evaluation of prevention programs, we stand a better chance of achieving success. Additional research that is empirically tested is necessary to attain this goal. In conducting
Family Connections
Program
a secondary prevention
program specifi cally
targeting the prevention
of child neglect.
empirically
obtained through
experimental and/or
experimental observation
methods; derived from
science and the scientifi c
method of gathering
evidence.
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344 WHAT HAPPENS NEXT
these evaluations, several methodological issues should be taken into consideration. First, the lack of clear statutory defi nitions and guidelines for identifying maltreatment
complicate our ability to conduct effective outcome research. Sec- ond, incorporating follow-up protocols is necessary to determine any long-term programmatic gains and/or “ sleeper ” effects (i.e., those that emerge sometime after program completion). Third, the role of potential mediators of maltreatment risk, such as parental attitudes, should be considered in research designs. Finally, researchers need to develop ways to make program participation more appealing so that families are willing to take part in these programs before it becomes too late to help them reverse dysfunctional patterns of behavior (Wolfe, Reppucci, & Hart, 1995). This is by no means intended as an exhaustive list of methodological issues associated with prevention research but certainly are some of the important factors to consider.
Finally, some have argued for an overhaul in our thinking about child maltreatment and its prevention. Rather than viewing poor parental practices and lack of support as indicators of dysfunction and, therefore, adopting a stigmatizing intervention approach, a truly prevention-focused model encourages us to recognize the need for varying levels of services among all families (Wolfe et al., 1995). In other words, who would not benefi t from a little extra support, a few more resources, or a bit of education? These services are important for the healthy functioning of all families, and this model encourages us to view family functioning from a developmental perspective in which the goal is to promote positive behaviors from the beginning rather than eliminate negatives ones after they have occurred.
DISCUSSION QUESTIONS
1. Provide an additional example of how U.S. society is more intervention, than prevention, focused. Why do you think this is the case?
2. How can primary and secondary prevention efforts be distinguished from each other?
3. Should agencies devote the bulk of their resources to primary or secondary pre- vention methods?
4. Do you consider tertiary prevention to be a form of prevention or intervention?
5. What are the advantages and disadvantages of public awareness campaigns?
6. In the prevention of child sexual abuse, do you think it makes sense to target potential child victims (the focus of most current prevention programs) rather than parents and/or potential perpetrators?
7. Does the disease model for secondary prevention efforts seem appropriate?
8. What are the primary methodological issues in researching the prevention of child maltreatment? How might we overcome these methodological issues?
9. Working in small groups of students, design either a primary or secondary prevention program from beginning to end. What are your program’s strengths and weaknesses? What challenges did you face in designing your program?
sleeper effect
an outcome that emerges
sometime after a program
has been completed.
mediator
a factor that may
explain the relationship
between two other
variables. For example,
the relationship between
race and parenting
style may be explained
by socioeconomic
status (SES). That is,
SES may mediate the
relationship between race
and parenting style so
that when you remove
the effect of SES, the
relationship between race
and parenting style is no
longer apparent.
6241-171-P4-014.indd 344 10/19/2013 10:17:23 AM
345
APPENDIX OF ABBREVIATIONS
ACF Administration for Children and Families ACLU American Civil Liberties Union ADHD Attention Defi cit Hyperactivity Disorder APSAC American Professional Society on the Abuse of Children ASPCA American Society for the Prevention of Cruelty to Animals BDI Beck Depression Inventory CAC Child Advocacy Center CAPTA Child Abuse Prevention and Treatment Act CBCL Child Behavior Checklist CHILD Children’s Healthcare is a Legal Duty CPA Child Physical Abuse CPS Child Protective Services CSA Child Sexual Abuse CSEC Commercial Sexual Exploitation of Children CTS Confl ict Tactics Scale CVS Covert Video Surveillance CVWP Child Victim Witness Protection Program CYRM Child and Youth Resilience Measure DCS Department of Children’s Services DID Dissociative Identity Disorder DSM Diagnostic and Statistical Manual of Mental Disorders DSS Department of Social Services DUI Driving Under the Infl uence ECF Educational Condition or Disability Falsifi cation EHS Early Head Start FAE Fetal Alcohol Effects FAP Family Advocacy Program FAS Fetal Alcohol Syndrome FDBP Factitious Disorder by Proxy FE Family Environments HFA Healthy Families America IRB Institutional Review Board MA Methamphetamine MAMA Mothers Against Munchausen by Proxy Allegations MHP Mental Health Professionals MMPI Minnesota Multiphasic Personality Inventory MPD Multiple Personality Disorder MPS Munchausen by Proxy Syndrome
6241-171-BM1.indd 345 10/19/2013 10:06:01 AM
346 APPENDIX OF ABBREVIATIONS
NAPCWA National Association of Public Child Welfare Administrators NAMBLA North American Man/Boy Love Association NCAND National Child Abuse and Neglect Data System NCCAN National Clearinghouse on Child Abuse and Neglect NFTT Nonorganic Failure to Thrive NICHD National Institute of Child Health and Human Development NIDA National Institute on Drug Abuse NIS National Incidence Studies NIS-3 Third National Incidence Study NIS-4 Fourth National Incidence Study NPSP New Parent Support Group OCAN Offi ce on Child Abuse and Neglect OI Osteogenesis Imperfecta PA Physical Abuse PCF Pediatric Condition Falsifi cation PLS Preschool Language Scale PURPLE Peak of crying, Unexpected, Resists soothing, Pain-like face, Long lasting,
Evening PTSD Post-Traumatic Stress Disorder RBPC Revised Behavior Problem Checklist SBS Shaken Baby Syndrome SD Standard Deviation SES Socioeconomic Status SIS Shaken Impact Syndrome SMART Specifi c, Measurable, Achievable, Realistic, and Time-limited SPCA Society for the Prevention of Cruelty to Animals SPCC Society for the Prevention of Cruelty to Children STD Sexually Transmitted Disease STI Sexually Transmitted Infection TSCC Trauma Symptoms Checklist for Children VD Venereal Disease WISC Wechsler Intelligence Scale for Children
6241-171-BM1.indd 346 10/19/2013 10:06:02 AM
347
GLOSSARY
abandonment : desertion; severing ties with and failing to support one’s own child.
abrogated : cancelled or annulled by offi cial means or authority.
Adam Walsh Child Protection and Safety Act : federal legislation passed in 2006 to protect children from sexual exploitation and child pornography.
Administration for Children and Families (ACF) : a division of the Department of Health and Human Services. It is responsible for federal programs that promote the economic and social well-being of children and families, and assists local agencies (both public and private) with rel- evant funding, policy direction, and educational services.
Adoption Assistance and Child Welfare Act : federal legislation passed in 1980 to encourage caseworkers to work toward reunifying families and to avoid long-term and/or multiple foster care placements for children if possible.
Adoption and Safe Families Act : federal legisla- tion passed in 1997 to promote the adoption of children in foster care (in the event that reuni- fi cation with biological parents is not possible), especially children with special needs. It describes safety, permanency, and well-being as key prin- ciples in the implementation of child welfare legislation.
adversarial system : a court system that involves active and unhindered parties contesting with each other in the presence of an independent decision maker (judge or jury).
aggression : behavior that is intended to cause harm or pain; a disposition to behave in a violent way even when not provoked.
alcohol : an intoxicating beverage containing a chemical produced by yeast fermentation or hydration of ethylene.
allegation : an unproven assertion that child mal- treatment has occurred.
allele : one of two or more alternative forms of a gene found at the same place on a chromosome
American Academy of Pediatrics : an organi- zation of approximately 60,000 pediatricians dedicated to the health of all children.
American Civil Liberties Union (ACLU) : a national organization that advocates for indi- vidual rights by preserving the protections and guarantees listed in the Bill of Rights.
American Professional Society on the Abuse of Children (APSAC) : a national nonprofi t organi- zation that is committed to preventing child maltreatment, promoting research, informing U.S. public policy, and educating the public about maltreatment.
anatomically detailed doll : a doll with ana- tomical details such as a penis or a vaginal opening, an anal opening, pubic hair, chest hair, and underarm hair.
anorexia : an eating disorder characterized by the relentless pursuit of thinness through starvation.
arraignment : an initial step in criminal prosecu- tion during which defendants hear the charges against them and enter a plea.
at risk : individuals (or group of individuals) who are predisposed to developing a maladaptive behavior pattern (such as child maltreatment).
attachment : a strong, affectionate bond between two people. Infants typically form an attach- ment to their primary caregiver between 6 and 12 months.
attention defi cit hyperactivity disorder (ADHD) : a mental disorder characterized by a limited attention span, overactivity, restlessness, and impulsiveness.
6241-171-BM2.indd 347 10/19/2013 10:52:53 AM
348 GLOSSARY
attributions : determinations about what caused an event or a condition; explanations for one’s own behavior or the behavior of others.
attrition : the loss of participants during a research study, which may occur for a variety of reasons (e.g., loss of interest in the study, relocation, death).
authoritative parent : a parenting style in which parents are warm, responsive, and loving while also having high expectations for their child; they provide reasons for discipline and are appro- priately fl exible
avoidant attachment : an insecure attachment style in which the infants tend to avoid or ignore their caregivers.
Beck Anxiety Inventory : a 21-item scale designed to measure anxiety and to discriminate between anxiety and depression.
Beck Depression Inventory: a 21-item, multiple choice, self-report measure that assesses the sever- ity of depression.
best interest of the child : the principle that drives the judge’s decisions in domestic relations courts when deciding issues of custody and support.
beyond a reasonable doubt : the burden of proof in criminal court; the doubt that prevents one from being fi rmly convinced of a defendant’s guilt; the highest burden of proof.
borderline personality disorder : a mental dis- order marked by signifi cant impairment in inter personal relationships, problems with self- esteem and self-image, and impulsivity.
bulimia : an eating disorder characterized by cycles of bingeing and purging.
buprenorphine : a medication used during the treatment of heroin addiction that prevents the experience of withdrawal symptoms.
burns : injuries caused by fi re, heat, or acid; fi rst- degree burns cause red skin, second-degree burns result in blisters, and third-degree burns cause deep skin destruction.
bruising : injury in which capillaries are damaged, allowing blood to seep into the surrounding tis- sue; generally caused by striking or pressing that does not break the skin.
Caida de Mollera : a sunken anterior fontanel (space between the bones in an infant’s skull) that can be the result of severe illness, signifi cant weight loss, or dehydration.
cannabinoids : the chemical compounds that are the active components of marijuana.
Cao Gio: a Southeast Asian practice in which a practitioner massages a heated ointment or oil on an ill child’s neck, spine, and ribs, and then runs a coin or a spoon along the child’s skin with fi rm, downward strokes.
CAPTA Reauthorization Act : federal legislation passed in 2010 to amend and reauthorize pro- grams under the Child Abuse Prevention and Treatment Act (CAPTA).
carotid : an artery in the neck that supplies the brain with oxygenated blood.
case closure : the process by which an open child protective services (CPS) case is resolved and the family no longer receives CPS services.
case planning : the developing of three types of plans by the caseworker during a family’s involve- ment with child protective services: a safety plan for the child, a case plan aimed at allowing the family to remain together, and a concurrent per- manency plan that establishes an alternate living arrangement for the child in the event that the case plan is not successful.
case study : an in-depth analysis of one person or event. This research method provides signifi cant detail about one case, but the fi ndings cannot be generalized to other persons or events.
caseworker : a professional employed by child protective services to investigate child maltreat- ment, ensure the safety of children in their homes, and provide necessary services to families.
Centers for Disease Control and Prevention : a division of the Department of Health and Human Services whose mission is to promote health and quality of life by preventing and controlling dis- ease, injury, and disability.
central registry : a database maintained by a state’s child protective agency that contains information on all substantiated reports of child maltreatment for that state.
child abuse : an act, generally deliberate, by a parent or a caregiver that results in harm or death to a child.
Child Abuse Prevention and Treatment Act (CAPTA) : federal legislation passed in 1974 that sets forth a minimum defi nition of child abuse and neglect, establishes the Offi ce on Child Abuse and Neglect (OCAN), authorizes the expenditure of
6241-171-BM2.indd 348 10/19/2013 10:52:53 AM
349GLOSSARY
federal dollars to support state child protection efforts, and provides grants to public agencies to support child maltreatment research.
Child Advocacy Center (CAC) : a center designed to assess allegations of maltreatment and to treat victims by enlisting a multidisciplinary team of law enforcement, medical, social service, legal, and clinical professionals.
Child and Family Services Reviews: periodic reviews conducted by the Children’s Bureau to monitor state child welfare services.
Child Behavior Checklist (CBCL) : a 118-item scale designed to measure a child’s behavio- ral problems and social competencies based on parental report.
child endangerment : placing a child in a situa- tion that is potentially harmful.
child maltreatment : the abuse and/or neglect of children. Specifi c defi nitions vary by state and purpose (legal, research, etc.).
child neglect : the failure of a parent or a caregiver to meet the minimal physical and psychological needs of a child.
Child Parent Enrichment Project : a secondary prevention program involving home visitation for high-risk mothers.
child physical abuse : an act by a caregiver that results in a nonaccidental injury to a child.
Child Protective Services (CPS) : a government agency charged with protecting children and pre- serving families. This is the agency that responds to charges of child maltreatment. Not all states use the title CPS; variations include Department of Family Services (DFS) and Department of Social Services (DSS).
child sexual abuse (CSA) : the involvement of a child in any sexual activity in which consent is not or cannot be given.
Child Victim/Witness Program (CVWP) : an individualized Canadian program that prepares children for court by educating them, by appoint- ing and educating a support person to assist them, and by visiting a court in session.
Children’s Bureau : a division of the Administra- tion for Children and Families that is primarily concerned with child protection, child abuse prevention, foster care, and adoption within the United States.
civil commitment : the confi nement of a person who is ill, incompetent, or addicted to drugs.
civil court : a court that hears noncriminal cases where parties seek to settle disputes and be awarded damages.
class action suit : a lawsuit in which one person or a small group sues as representative of a larger group of affected people because the group is so large that individual suits would not be practical.
clear and convincing evidence : a degree of evidence that indicates that the issue being proved is highly probable. It is a higher standard of proof than the preponderance of evidence, but a lower standard than beyond a reasonable doubt.
cleft palate : a congenital condition that results in a crack in the roof of the mouth.
clinical population : a group of people defi ned by their association as patients within a treat- ment facility.
clumsy interview : an interview that is not likely to lead to false allegations but is conducted poorly. Clumsy interviews lead to statements that are less coherent, less detailed, and less convinc- ing than those garnered from good interviews.
cocaine : a crystalline alkaloid that comes from coca leaves. It is used illicitly as a stimulant and to induce euphoria.
collateral sources : individuals who are inter - viewed by caseworkers as part of a CPS investigation (e.g., neighbors, teachers, babysitters).
commission errors : mistakes that involve saying something occurred when it did not.
conduct disorder : a personality disorder of child- hood marked by persistent disruptive behavior and repeated violation of the rights of others and of societal norms.
confi dentiality : an ethical principle associated with people in many human service professions whereby these professionals may not divulge information about their clients to third parties.
Confl ict Tactics Scale (CTS) : a scale that meas- ures psychological and physical maltreatment as well as nonviolent discipline. The parent/child version was designed to gather information about how parents have disciplined their children over the last year. The child fi lls out one form, and a parent fi lls out another.
6241-171-BM2.indd 349 10/19/2013 10:52:53 AM
350 GLOSSARY
congenital : a condition that is present at birth.
continuity : the principle that a child’s ideal liv- ing environment should be disrupted as little as possible.
control group : participants in a study who are not exposed to the variable being explored.
corporal punishment : physical punishment such as spanking or slapping.
correlational research : a study in which two or more variables are measured so that the degree of relationship between them can be measured.
court prep group : a program devised by the National Children’s Advocacy Center to prepare groups of children for court through education, understanding of emotional issues, role-play, and touring of a courthouse.
covert video surveillance : making a video recording without making it clear to the partici- pants that they are being taped.
criminal court : the court charged with the administration of justice via penalty or punish- ment
cross-examination : the questioning of a witness by the opposing party, especially for the purpose of clarifying or discrediting the witness’s testi- mony.
culturally responsive services : child welfare services that include the acknowledgement and acceptance of other people’s cultures and cultural values.
culture : the socially transmitted behaviors, arts, beliefs, and institutions that characterize a group of people.
denying emotional responsiveness : a care- giver’s ignoring his or her child or showing no emotional reactions while interacting with the child.
dependency case : a case to determine whether a child’s needs are being met by his or her guard- ians or if the state needs to take temporary or permanent custody of the child.
detention hearing : a hearing for the purpose of determining whether there is suffi cient evidence for the State to hold the child pending further investi- gation; also referred to as the 72-hour hearing.
Detroit Family Project : a primary prevention program in which facilitators engaged in informal
discussions on parenting-related topics with par- ents in the waiting rooms of health clinics.
Diagnostic And Statistical Manual Of Mental Disorders ( DSM ) : a manual published by the American Psychiatric Association that lists the criteria for diagnosing mental disorders as well as provides information on causes, age of onset, gender differences, and prognosis.
disclosure : the act of revealing; telling someone else or making known what has previously been hidden.
disease model : a term borrowed from medical science to refer to maladaptive behavior patterns (e.g., addiction, child maltreatment) as lifelong illnesses that involve both biological and envi- ronmental sources of origin.
disinhibition : a loss of the ability to restrain from or to suppress behaviors or impulses.
dispositional hearing : a hearing during which the judge enters their decision as to what is in the best interest of the child.
dissociation : the separation of some mental pro- cesses from conscious awareness.
Dissociative Experience Survey : a 28-item self- report measure designed to be a screening test for dissociative identity disorder (DID), formerly called multiple personality disorder (MPD).
Division of Violence Prevention : a division of the Centers for Disease Control and Prevention that is dedicated to the prevention of all forms of violence including child maltreatment, intimate partner violence, school violence, and youth vio- lence.
domestic relations court: a court that is dedi- cated to hearing cases related to divorce, child custody and support, paternity and other family- law issues; it is also called family court.
domestic violence : violence, abuse, or intimida- tion that takes place in the context of an intimate relationship.
Don’t Shake the Baby : a primary prevention pro- gram developed to increase parental knowledge regarding the dangers of shaking infants and reduce the occurrence of shaken baby syndrome.
Down syndrome : a chromosomal abnormal- ity (an extra copy of the 21st chromosome) that results in mental retardation, abnormal facial
6241-171-BM2.indd 350 10/19/2013 10:52:53 AM
351GLOSSARY
features (fl attened nasal bridge, widely spaced and slanted eyes), slowed growth, and other physical problems.
dual representation : the ability to think of one object as being or representing two things at once.
dysmorphic : an abnormality of the structure of part of the body that results from a developmen- tal defect.
dysthymia : a chronic, mild depression that per- sists for more than 2 years.
easy temperament : a temperament characterized by the ability to adapt quickly to new experiences, the tendency to have a positive mood, and normal patterns of eating and sleeping.
ecologically based approach : a strategy in the delivery of human services that focuses on family and community as a whole, rather than focusing solely on the individual.
educational neglect : the failure to meet legal requirements for school enrollment or attendance, or the lack of attention to special educational needs.
emotional neglect : the failure to meet a child’s emotional needs.
empirically : obtained through experimental and/ or experimental observation methods; derived from science and the scientifi c method of gather- ing evidence.
epidemiological : that which pertains to factors affecting the health and illness of populations (i.e., public health).
Erikson : a psychologist who proposed a theory of psychosocial development in which people develop across their entire life span by confront- ing various social issues.
etiology : the study of causation; why things occur and/or the reasons for behavior.
exaggerate : to overstate; to increase to an abnor- mal degree.
excited utterance exception : an exception regarding a statement that is made while under stress about an event, which is admissible as hear- say testimony.
experiment : a form of scientifi c research in which a researcher manipulates one or more variables in
order to see the effects on another variable or vari- ables.
exploiting/corrupting : encouraging children to develop and engage in inappropriate behaviors.
expungement : the act of destroying or sealing records following a specifi ed period of time.
extrafamilial : occurring outside of a family.
fabricate : to falsify; to report something that is not true.
factitious disorder by proxy : the term used by the Diagnostic and Statistical Manual of Mental Dis- orders to describe the behaviors also referred to as Munchausen by proxy syndrome.
family assessment : following a child protective services investigation and initial assessment, the process by which a caseworker collaborates with family members to identify needed services.
Family Connections Program : a secondary pre vention program specifi cally targeting the prevention of child neglect.
family group decision-making model : a strat- egy used by child protective agencies to optimize family strengths in the case-planning process. As part of this strategy, the family and members of the family’s social support network are included in the decision-making process during case planning.
family preservation and reunifi cation : an underlying principle of federal legislation (partic- ularly the Adoption Assistance and Child Welfare Act) that encourages child protective agencies to maintain biological families whenever possible. Adherence to this principle has lessened since the passing of the Adoption and Safe Families Act, which focuses more on the child’s safety and well-being than maintaining a biological family.
family progress : the ongoing assessment of an open Child Protective Services case by a case- worker.
Federal Rule of Evidence 601 : a rule governing the admissibility of evidence at trials in federal courts that states that every person is presumed competent unless otherwise noted in the Fed- eral Rules. Because the rules do not list age as a requirement, children are presumed competent.
felony : a serious crime that is punishable with imprisonment of greater than 1 year or even death.
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352 GLOSSARY
fetal abuse : behaviors that put the fetus at risk for harm.
fetal alcohol effects: symptoms present in a child that are associated with maternal alcohol consumption during pregnancy but which do not meet the diagnostic criteria for fetal alcohol syndrome.
fetal alcohol syndrome (FAS) : a series of birth defects resulting from a mother’s consumption of alcohol during pregnancy. Symptoms include mental retardation, low birth weight, head and face abnormalities, and growth defi ciencies.
fMRI : functional magnetic resonance imaging that measures blood fl ow in the brain to provide information about what parts of the brain are active during a particular mental operation.
folk medicine : health practices that come from cultural traditions; native remedies.
forensic : related to, or appropriate for, use in legal settings.
forensic interviewing : an interviewing technique used to elicit verbal information from witnesses for use in a legal setting.
fractures : the partial or complete breaking of bone or cartilage.
Freud : a Viennese physician who developed the psychoanalytic theory that stresses the impor- tance of the unconscious mind and the constant confl ict within each person’s personality.
gold standard : the best available program and the benchmark against which all other programs are measured.
guardian ad litem : an adult who is appointed by the court to represent the best interests of the child during court proceedings.
Hawaii’s Healthy Start Program : a secondary prevention program that provides home visita- tion for families identifi ed as being at risk for maltreating their newborn children.
Healthy Families America : a home visitation program that was modeled after Hawaii’s Healthy Start Program.
hearsay : testimony based not on what one knows personally but on what someone else has said.
heroin : a highly addictive narcotic derived from morphine; it decreases the ability to perceive pain.
hypersexual : excessively or unusually interested in sexual matters.
hypervigilance : excessive watchfulness or wari- ness; constant scanning of the environment for signs of danger
immunity (legal) : exception from civil or crimi- nal liability or prosecution.
impetigo : a contagious skin infection that is marked by blisters that erupt and form crusts.
improper interview : an interview that contains elements known to increase the risk for eliciting false allegations.
incidence : the number of new cases occurring or being diagnosed in a year.
Indian Child Welfare Act : federal legislation passed in 1978 to establish jurisdiction in cus- tody cases involving children of Native American descent.
indicated : a designation utilized by some child protective agencies during the course of an investigation that allows the caseworker to deter- mine that some evidence of child maltreatment exists, but not enough to substantiate the case.
induce : to cause or bring about.
infanticide : the killing of an infant, particularly a newborn.
infantile amnesia : the inability of adults to remember much, if anything, about the fi rst 3 years of their life.
informed consent : the ethical requirement that participants voluntarily agree to take part in an experiment only after they have been told what their participation will entail.
institutional review board (IRB) : a group of pro- fessionals charged with determining whether the benefi ts of a proposed research project outweigh the potential costs to participants.
intake and screening : process by which reports of suspected child maltreatment are received and initially evaluated by a CPS agency.
intergenerational transmission : the passing down of a trait or behavior from one generation to the next.
internal locus of control : the tendency to attribute the cause of events to individual or
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353GLOSSARY
internal causes rather than to external or envi- ronmental factors.
interpersonal relationship: social association, connection, and involvement between two people.
interviewer bias : the attitudes or actions of the interviewer infl uencing the respondent’s answers.
intrafamilial : occurring within a family.
investigation and initial assessment : the pro- cess by which a child protective agency verifi es reports of child maltreatment and determines the immediate safety of the alleged child victim.
isolating : confi ning a child or not allowing a child to have the opportunity to socialize with others.
jurisdiction : the authority to deal with legal mat- ters and the limits within which that authority may be exercised.
jurisdictional hearing : a hearing where evidence is presented by child protective services and par- ents and a guardian ad litem so the judge can determine whether the child meets the descrip- tion of a dependent child.
juvenile court : a court established in 1899 to hear cases of dependency and juvenile delinquency.
juvenile delinquency : antisocial behavior by a minor, especially if the behavior is in violation of the law and would be punished criminally if committed by an adult.
Keeping Children and Families Safe Act : federal legislation passed in 2003 to make improvements to and reauthorize programs under the Child Abuse Prevention and Treatment Act (CAPTA).
language delays : the failure to develop language skills according to the usual timetable resulting in development that is signifi cantly below the norm for a child of a given age.
legend drug : a drug that is approved by the Federal Drug Administration and that requires a prescription
longitudinal research : a research design that involves repeated observations of a group of par- ticipants at regular intervals over a relatively long time.
malingering by proxy : a parent’s coaching of a child to fake symptoms in order to gain some- thing external such as money from a lawsuit or an insurance claim.
malnourished : having a medical condition caused by an improper or insuffi cient diet.
malpractice : professional negligence; failure to exercise the minimum degree of care expected by professional standards.
mandated reporters : people required by law because of their occupation to report suspected cases of child maltreatment to the proper authorities.
marijuana : the dried leaves and female fl owers of the hemp plant that are used as an intoxicant. It can be smoked or eaten and it produces mild euphoria and possibly distorted perceptions.
Maslow : considered the father of humanistic psychology, Maslow studied healthy people and classifi ed human needs into a hierarchy.
meconium : dark greenish-brown material that builds up in the digestive tract before birth; excreted as fecal matter shortly after birth.
mediation : a neutral person’s helping two dis- puting parties arrive at a solution that is mutually acceptable; however, the mediator’s decision is not legally binding.
mediator : a factor that may explain the relation- ship between two other variables. For example, the relationship between race and parenting style may be explained by socioeconomic status (SES). That is, SES may mediate the relationship between race and parenting style so that when you remove the effect of SES, the relationship between race and parenting style is no longer apparent.
medical neglect : the failure to seek medical treatment or to provide treatment that has been prescribed.
mental health, medical, and educational neglect : caregivers’ failing to meet their chil- dren’s psychological, medical, or educational needs.
mental health neglect : the failure to seek help for a child’s severe psychological problems or to com- ply with recommended therapeutic procedures.
meta-analysis : a statistical technique that allows researchers to combine the results of several dif- ferent studies.
metabolite : a product of metabolism.
methadone : a synthetic narcotic that is used to relieve pain and as a heroin substitute during treatment for heroin addiction.
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354 GLOSSARY
methamphetamine (MA) : a potent, highly addic- tive central nervous system stimulant that causes an increase in energy and a decrease in appetite.
Minnesota Mother/Child Interaction Project : a longitudinal study of 267 children who were born to high-risk mothers.
Minnesota Multiphasic Personality Inventory (MMPI) : a 576-item, true/false questionnaire that provides scores on 10 clinical scales and 1 scale designed to assess whether the participant was truthful.
misdemeanor : a crime that is less serious than a felony and is usually punished with a lesser penalty (a fi ne, forfeiture, or less than 1 year in prison).
molestation : the act of subjecting someone to unwanted or improper sexual activity.
Mongolian spot : a birthmark that is a smooth, fl at, bluish-gray spot that looks like a bruise.
Munchausen by proxy syndrome (MPS) : a rare form of child maltreatment in which the care- taker, usually the mother, fabricates, exaggerates, or induces symptoms of physical or psychological illness in a child.
Munchausen syndrome : a psychiatric disorder that involves exaggerating or creating symptoms of illness in oneself, or acting as if ill, in order to receive attention and sympathy.
National Association of Public Child Welfare Administrators (NAPCWA) : founded in 1983, this organization represents public child wel- fare agencies by contributing to child welfare policy and ensuring that children in the public child welfare system have safe, permanent homes.
National Child Abuse and Neglect Data System (NCANDS): a voluntary, national data collection and analysis system that gathers and maintains data relevant to child maltreatment.
National Child Abuse Hotline : 1-800-4-A-CHILD; a phone line that is staffed 24 hours a day, 7 days a week, by professional counselors who can answer questions about child maltreatment. The counselors have access to a very large database of resources including emergency, social services, and support services.
National Clearinghouse on Child Abuse and Neglect (NCCAN) : a national resource for
professionals that provides information regard- ing child maltreatment including prevalence, incidence, treatment, statistics, and statutes.
National Institute on Drug Abuse (NIDA) : an organization dedicated to bringing the power of science to bear on issues of drug abuse and addiction by supporting research and disseminat- ing research fi ndings related to drug prevention, treatment, and policy.
National Study of Child Protective Services Sys tems and Reform Effort : a 2-year study (2000– 2001) conducted to assess and evaluate the sta- tus of the child protective services system in the United States.
neonatal asphyxia : a signifi cant decrease in oxy- gen and an increase in carbon dioxide that can lead to loss of consciousness and death.
neurobehavioral : the study of the way the brain affects emotion, behavior, and learning; the assessment of a person’s neurological status by observing his or her behavior.
nicotine : a toxic, addictive substance derived from tobacco that acts as a stimulant.
nonorganic failure to thrive : a child’s failing to reach normal milestones for physical growth (falling below the third percentile) when the child has no known organic disease.
Nurse-Family Partnership : see Nurse Home Visi- tation Program.
Nurse Home Visitation Program : a second- ary prevention program that targets pregnant women whose fetuses are at risk for later health and developmental problems.
obsessive compulsions : the persistent intrusion of unwanted thoughts accompanied by ritualistic actions.
Offi ce on Child Abuse and Neglect (OCAN) : established by the Child Abuse Prevention and Treatment Act (CAPTA) in 1974, this agency is part of the Children’s Bureau in the Department of Health and Human Services. It funds resources for improving state responses to child abuse and neglect.
omission errors : mistakes that involve failure to report something that did occur.
open-ended question : a question with no set of anticipated responses; the respondent is free to give any answer.
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355GLOSSARY
operational defi nition : a precise defi nition of a variable in terms of observable procedures or measurements.
oppositional defi ant disorder : a disruptive pattern of behavior in childhood that is charac- terized by defi ance and disobedience as well as hostile behavior. These behaviors persist for at least 6 months and interfere with everyday func- tioning.
osteogenesis imperfecta : a genetic disorder in which bones fracture easily.
out-of-home placement : often referred to as foster care, the condition by which children are temporarily removed from their home and placed in an alternative living environment (e.g., with a relative, in an emergency shelter, in a group home).
paranoid ideation : abnormal suspicion that is not based on fact.
paraprofessional : a job title given to people in occupations for which they have received some specialized training but are not professionally licensed.
parens patriae : a Latin term meaning that the State acts on behalf of a child or mentally ill person. The State is the guardian of those who cannot protect themselves.
parent–child relational problem : a mental dis- order marked by clinically signifi cant impairment in the interaction between parent and child that has an impact on family functioning or leads to the development of negative psychological symp- toms in the parent or the child.
pediatric condition falsifi cation (PCF) : a des- cription suggested by the American Professional Society on the Abuse of Children to refer to any children who are described as ill when they are not, regardless of parental motivation.
perinatal : occurring shortly before or shortly after birth.
The Period of PURPLE Crying: Keeping Babies Safe in North Carolina : a primary prevention pro- gram to reduce the occurrence of shaken baby syndrome by educating new parents regarding the developmental normalcy of infant crying.
permanency : the principle that a child’s ideal liv- ing environment is one that will be long lasting and stable.
permanency planning hearing : a review of the child’s current placement and progress with the goal of establishing long-range goals if the child requires continued care. Permanent plans include the termination of parental rights and adoption.
permissive reporter : a person who is allowed, but not required, to report suspected child mal- treatment.
perpetrator : a person who commits an offense or crime.
phobic anxiety: worry about irrational fears.
physical neglect : the failure to meet the minimal physical needs of the child.
placenta abruption : the condition in which the placenta separates from the uterine wall prior to birth; this can result in severe bleeding .
plaintiff: the party that brings the suit in civil court.
platelet aggregation disorder : a medical condi- tion that occurs when platelets do not form plugs at injury sites.
polydrug : multiple, different drugs.
postpartum depression : prolonged sadness, cry- ing spells, impatience, or mood swings following the birth of a child; may include mixed feelings about motherhood and/or an inability to care for the newborn.
postnatal : occurring after birth.
posttraumatic stress disorder (PTSD) : an anxiety disorder that occurs in response to experienc- ing extreme stress (generally involving actual or threatened death or serious injury). The person experiences symptoms including re-experienc- ing the event, avoiding stimuli reminiscent of the event, and increased arousal for at least 1 month.
poverty : a situation in which income and resources are inadequate to obtain and maintain an acceptable standard of living. Offi cial poverty levels are set by the Social Security Administration.
practice interview : a question-and-answer session about a neutral topic that allows the per- son being interviewed to become comfortable with the process before addressing the issue of interest.
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356 GLOSSARY
precursor : any factor that precedes the onset of child maltreatment and may function as a risk factor.
preponderance of evidence : the burden of proof in a civil trial; the greater weight of evidence, however slight.
prevalence : the number of cases that exist in a specifi ed population at a given point in time.
prevent : to reduce the likelihood of an occurrence.
Prevent Child Abuse America : an organization that began in 1972 with the mission of prevent- ing all forms of child abuse and neglect in the United States.
primary caregiver : a person primarily responsi- ble for the health and well-being of a child (e.g., mother, father, legal guardian).
primary prevention : targets the general popula- tion to reduce the incidence of all new cases of a problem.
proxy measures : variables that are used instead of the actual variable of interest because it cannot be measured or is diffi cult to measure.
psychological abuse : parental behaviors that actively harm their child’s mental health.
psychological neglect : a parent’s failing to meet the emotional needs of his or her child.
psychomotor : pertaining to the function of vol- untary muscles.
psychotic : mental disorders marked by the loss of contact with reality; generally marked by delusions, hallucinations, or serious thought dis- turbance.
psychoticism : impaired contact with reality.
PsycINFO : an electronic database produced by the American Psychological Association that indexes the psychology literature.
racial bias : a negative opinion, attitude, or response toward a group of people who share a common physical attribute such as skin color.
rapport : a feeling of connection and trust that is established between two people.
reason to believe : a term often used in child welfare legislation with regard to mandatory reporting guidelines. Includes the notion of a reasonable professional standard for mandated reporters, such that their professional training
and experience informs their ability to recognize the presence of child maltreatment.
reasonable efforts : according to the Adoption Assistance and Child Welfare Act, the responsibil- ity of state child welfare agencies to avoid foster care placement and/or to reunify a family when- ever possible. This defi nition was amended in the Adoption and Safe Families Act, providing excep- tions to the family preservation and reunifi cation requirements (especially in consideration of child safety issues).
recidivism : the tendency for something (such as a disease or maladaptive behavioral pattern) to recur.
repression : a defense mechanism in which pain- ful or unacceptable memories or fears are rejected by the conscious mind and are buried in the unconscious.
resilient : being able to recover easily from dif- fi cult circumstances; the ability to bounce back and persevere; being able to adjust to misfortune; adaptable.
resistant attachment : an insecure attachment style in which infants cling to their caregivers at times and resist closeness at other times.
retrospective design : a research design that uses data based on recollections of past events. This type of design is limited because of concerns about memory degradation over time.
review hearing : a hearing that takes place approx- imately 6 months after a care plan has been enacted, for the purpose of reviewing the progress that has been made on the treatment plan
risk assessment : the process by which a case- worker evaluates a child’s living environment and determines whether any factors are present that increase the likelihood for child maltreatment.
safety assessment : the process by which a case- worker evaluates a child’s living environment and determines whether there is any immediate risk of harm to that child’s safety.
safety plan : a plan that is developed following a safety assessment whenever a risk of immediate harm is discovered in order to minimize and/or eliminate that immediate risk.
secondary prevention : targets a specifi c group of individuals to reduce the incidence of new cases
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357GLOSSARY
of a problem among those determined to be at some identifi ed risk.
secure attachment : an infant’s using a caregiver as a secure base from which to explore his or her surroundings.
self-actualization : according to Maslow, the high- est level of psychological development; a person’s reaching his or her full potential.
self-effi cacy : a person’s belief that he or she is capable of doing what is necessary to produce the desired result in a given situation.
self-fulfi lling prophecy : the process by which one’s expectations about a person leads that person to behave in ways that confi rm those expectations.
separation anxiety : distress and/or anxiety a child experiences when separated from a primary caregiver.
service provision : the process by which a Child Protective Services case plan is implemented.
sexual dysfunction : any problem during the sexual response cycle from desire to arousal to orgasm that prevents the achievement of sexual satisfaction.
sexual exploitation : use of a child (younger than age of 18 years) for the purpose of prostitution or pornography.
sexually transmitted diseases (STDs) : diseases that are most commonly spread via sexual con- tact; also called venereal disease (VD) or sexually transmitted infections (STIs).
shaken baby syndrome (SBS) : a condition of severe internal bleeding, particularly around the brain or eyes, that is caused by violently shaking an infant or a young child.
“sleeper” effect : an outcome that emerges some- time after a program has been completed.
SMART : strategy used during the case-planning process whereby established goals are Specifi c, Measurable, Achievable, Realistic, and Time- limited.
socially isolated : lacking suffi cient social ties or support.
social referencing : reading another person’s facial expressions in order to decide on an appro- priate response.
Society for the Prevention of Cruelty to Chil- dren (SPCC) : a nonprofi t organization that was founded in 1875 to protect children and strengthen families. The SPCC offers mental health, legal, and educational services.
socioeconomic status (SES) : a measure of a per- son’s standing within a social group based on factors such as income and education.
somatization : the expression of psychological distress as physical symptoms.
somatoform disorders : disorders that involve physical symptoms in the absence of any organic cause. The symptoms must be severe enough to interfere with the person’s life and not be under the person’s voluntary control
spina bifi da : a congenital abnormality in which the fetus’s spinal cord does not form properly, leaving part of the spinal cord unprotected.
spurning : caregiver behaviors that are hostile and rejecting toward a child.
status offense : an act that is against the law only because the person engaging in it is a minor.
statute : a law passed by a legislative body.
statute of limitations : a law that sets a time frame for the prosecution of a crime or for suing to ensure that cases are resolved while the evi- dence is still reasonably available.
strange situation task : a laboratory task designed to measure an infant’s attachment to a caregiver.
structured interview : a face-to-face method of collecting information that follows a series of pre- established questions.
substantiated : a report of child maltreatment that has been confi rmed by child protective services.
sudden infant death syndrome : the unexplained and unexpected death of an infant (younger than 1 year old) who was apparently healthy; generally occurs during sleep.
suggestibility : accepting or acting on something that is implied by another person.
suicidal ideation : thoughts about suicide; plans to end one’s life; may include suicide attempts.
tabula rasa : a blank slate; a mind that has not yet been affected by experiences or impressions.
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358 GLOSSARY
terrorizing : a caregiver’s threatening his or her child or the child’s loved ones or possessions with violence or abandonment, or placing the child in a dangerous situation.
tertiary prevention : intended to minimize the negative effects of an already existing problem.
testimony : evidence given by a witness who is under oath at trial or in an affi davit or deposition.
therapeutic relationship : the working alliance between a counselor and a patient.
tort laws : laws that allow people to sue others based on the claim that some conduct, product, or service that does not meet minimal, accept- able standards has caused harm.
toxicology : the study of poisons and drugs and their effects.
unbiased question : a question that is worded in such a way that it does not infl uence the respond- ent’s answer.
uncorroborated : a fact or statement that is not supported or confi rmed by additional evidence or authority.
unsubstantiated (unfounded) : a report of child maltreatment that has been investigated, but not confi rmed, by Child Protective Services.
U.S. Department of Health and Human Services : established in 1979 with the goal of pro- tecting the health of all Americans and providing essential human services.
waitlist control : an experimental condition in which participants are assigned to a waiting list to receive an intervention after the active treatment group completes the intervention. The purpose of this condition is to provide a comparison for the intervention group.
Where’s the baby? Look before you lock : a primary prevention program sponsored by the National Highway Traffi c Safety Administration to reduce the incidence of vehicle-related heat- stroke fatalities in children.
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359
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SUBJECT INDEX
abandonment 112–13 abrogated communication 43 academic problems 84–5, 117–19, 120–21, 171 Ad Hoc Committee on Sexual Abuse 165 Adam Walsh Child Protection and Safety Act 305 Administration for Children and Families (ACF)
306 adolescence, consequences of neglect in 120–21 adolescent sexual abuse 183;
see also child sexual abuse Adoption and Safe Families Act 305, 316, 321 Adoption Assistance and Child Welfare Act 15,
304 adult-adolescent sex 183 adult-child sex 183 adversarial system 277 aggression 85–6, 143, 196, 218 alcohol abuse, and pregnancy 191–3, 198; see
also substance abuse allegations 307 alleles 241–2 American Academy of Pediatrics 107 American Civil Liberties Union (ACLU) 224 American Humane Association 46 American Medical Association 42 American Professional Society on the Abuse of
Children (APSAC) 128, 225, 226 American Society for the
Prevention of Cruelty to Animals (ASPCA) 9–11
amphetamine 206 anatomically detailed dolls 257–62 anorexia 176 antisocial functioning 143; see also social and
antisocial functioning anxiety 121, 141–2, 174, 182 arraignment 291 Assistance Dogs International 296 at risk, defined 330 attachment issues 17, 115–16, 140 attachment theory 140 attention deficit hyperactivity disorder (ADHD)
88, 196, 213
attorneys: and children 285–6; as mandated reporters 43–4
attorney-client privilege 43 attributions 179–80 attrition 19, 329 authoritative parents 239 avoidant attachment 116
“Baby Haley” case 66–7 battered-child syndrome 49 “The Battered Child Syndrome” (Kempe et al.)
13–14, 42 Beagley, Jessica 70 Beck Anxiety Inventory 173, 174 Beck Depression Inventory (BDI) 173 best interest of the child 288 beyond a reasonable doubt 291 Bikers Against Child Abuse (BACA) International
296 bipolar disorder 88 birth defects, and substance abuse 193–4 Blige, Mary J. 233 borderline personality disorder (BPD) 142,
175–6 Bradley, Jean 284–5 bruising 71–4 bulimia nervosa 142, 176; see also eating
disorders buprenorphine 197 burns 79–81
Caida de Mollera 84 cannabinoids 198 Cao Gio 83 CAPTA Reauthorization Act 304 Caring for Patients from Different Cultures:
Case Studies from American Hospitals (Galanti) 83
carotid artery 211 case closure 308 case planning 307–8 case studies 146 caseworkers 307, 311
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392 SUBJECT INDEX
Catholic Church, and child sexual abuse 163–5
Centers for Disease Control and Prevention 330 central registry 310 chicken pox 82 Child Abuse Potential Inventory (CAP) 142 Child Abuse Prevention and Treatment Act of
1984 (CAPTA) 15, 107, 304 child abuse: defined 3; see also child
maltreatment; child physical abuse; child sexual abuse; emotional abuse; psychological abuse
child advocacy centers (CACs) 271 Child Advocacy Studies (CAST) programs 54 Child and Family Services Reviews 306 Child and Youth Resilience Measure (CYRM)
234–5 Child Behavior Checklist (CBC) 145, 236 child endangerment 102 child labor laws 6–7, 12 Child Life Specialists 275–6 child maltreatment: defined 3, 43; effects of
18–19; failure to report 49–52; forms of 17–18; history of 4–8; how to report 47; incidence of 68; parental factors in 23–9; prevalence of 68–9; professional publications 13–14; research on 3, 16–21, 45; secrecy surrounding 21; substantiated reports of 68, 315; when to report 45–7; see also child abuse; child neglect; child physical abuse; child sexual abuse; prevention of maltreatment; risk factors
child neglect 17; abandonment 112–13; consequences of 114, 117–20; definitions of 3, 90–92; in infancy 114–17; incidence of 113; intergenerational transmission of 28–29, 121–2; physical 92–105; prevention targeting 343; see also child maltreatment; educational neglect; emotional neglect; medical neglect; mental health neglect; physical neglect
Child Parent Enrichment Project 342–3 child physical abuse: aggression resulting from
85–6; bites 73–4; bruising 71–4; burns 79–81; changes in cognitive processing resulting from 85; defined 63, 65–6; fatal 76, 81–2; fractures 74–6; head injuries 76; identifying 17; injuries from falls 77–8; intellectual problems resulting from 84–5; internalizing of symptoms 86–7; interpersonal relationship issues resulting from 85; marks resembling 82–4; nonphysical consequences of 84–8; physical consequences of 71–82; psychological abuse compared with 141; paired with psychological maltreatment 132; prevalence
and incidence 68–9; PTSD resulting from 87; shaken baby syndrome 77; substance abuse resulting from 86
child pornography 169 child prostitution 169 Child Protective Services (CPS) 18; additional
services of 317–18; addressing emergency needs 317; adult or child removal by 318–19; and achievement of outcomes 321; case closure by 324; case planning by 320–21; and child safety 316; credibility of reports to 311; decision making by 324–6; and dependency cases 283; evaluation of families by 54, 99, 319–20, 322–3; and family progress 323–4; intake and screening by 307, 310–12; intervention by 323; investigation and initial assessment by 307, 312–13, 315; jurisdiction of 303–9, 311; and law enforcement 290; options and procedures 303–9; reports accepted by 311–12; reports to 43, 45–50, 55–6, 81, 88, 155, 161, 250; risk assessment by 316; role of 23, 54; service provision by 322–3; statutory and agency guidelines 311; substantiation of maltreatment by 315; urgency and response time 312
Child Protective Services: A Guide for Caseworkers (DePanfilis/Salus) 305
child sexual abuse (CSA) 3, 14, 124, 146; on boys vs. girls 186–7; in daycare centers and preschools 166–7; defined 148–53; extrafamilial 163–8, 186, 336; grooming of victims 159–61; incidence of 17, 153–5; intrafamilial 169, 172, 185–6, 336; perpetrators of 156–9; prevalence of 155; programs addressing 336–8; in religious and church settings 163–5; research on 146–7, 170–72, 181–5; in school and sports teams 167–8; secrecy surrounding 153; by teachers 158–9, 167–8; victims of 161–3, 187; see also sexual abuse consequences; sexual exploitation
child support 288 Child Victim/Witness Program (CVWP) 280 Child Welfare Information Gateway 44, 65, 81–2 Child Welfare Services 15 childhood, in history 4–7 Children’s Advocacy Center (Spartanburg, South
Carolina) 271–3 Children’s Bureau of the U.S. Department of
Health 13–14, 42, 113, 306, 328 “Children’s Knowledge of Legal Terminology”
(Saywitz et al.) 278 civil commitment 206
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393SUBJECT INDEX
class action suits 298 clear and convincing evidence 283 cleft palate 195 clergy, as mandated reporters 44 clinical populations 155–6 Clinton, Bill 232 cocaine 193–4, 198, 206 cognitive processing: changes in 85; cognitive
distortions 179–80 collateral sources 315 commission errors 260 compliance 70, 149, 163, 166 computed tomography (CAT scan) 76 conduct disorder 88 confidentiality 315 confinement 135 Conflict Tactics Scale (CTS) 145 congenital abnormalities 193–4 Conroy, Pat 233 continuity 306 control groups 146 corporal punishment 5, 37–8, 69–71 correlational research 19 corrupting/exploiting 129 court prep group 279 court-appointed special advocates (CASAs)
280–81, 284, 296 courts, types of 281: civil 297–9; criminal
289–91, 295–7; domestic relations 287–9; juvenile 281–7
covert video surveillance 212, 221–4 criminal domestic violence (CDV) 99; see also
domestic violence cross-examination 277 cultural factors 37–9: and corporal punishment
69–71; and CPS agencies 307; and family assessment 319; folk medicine 82–4; in forensic interviews 264–5; Native American children 304; and psychological abuse 123
culturally responsive services 307 custody issues 286, 288–9
Darkness to Light 338–9 death: and medical neglect 109; resulting from
abuse 76, 81–2 “Deaths From Falls in Children: How Far Is
Fatal?” (Chadwick et al.) 78 delinquency: see juvenile delinquency Department of Health and Human Services 330 dependency cases 282–4 Dependency Drug Court 287 dependency hearings 283, 286
depression 26–7, 81, 88, 141–2, 171–3, 182, 185, 241–2
detention hearings 283 Detroit Family Project 334 Diagnostic and Statistical Manual of Mental
Disorders , Fourth Edition ( DSM-IV ) 27, 87, 125, 165, 173, 175, 210, 225–6
Diagnostic and Statistical Manual of Disorders , Fifth Edition ( DSM-V ) 99
disclosure 186–7 disease model 339 disinhibition 25 dispositional hearings 15, 283 dissociation 177, 182 Dissociative Experience Survey 177 Division of Violence Prevention 330 divorce 288 dogs, in courtrooms 296 dolls, anatomically detailed 257–62 domestic violence 31, 99, 103–4, 136, 144, 232 Don’t Shake the Baby 334 Down syndrome 193 drugs: parental permission for use of 136;
postnatal exposure to 91; prenatal exposure to 208–9; see also substance abuse
dual representation 261 dysmorphic features 193 dysthymia 88
Early Head Start (EHS) 35 easy temperament 239 eating disorders 142, 176–7, 182 ecologically based approach 317 educational condition or disability falsification
213 educational neglect 111–12, 129 Ego-Resiliency Scale 234 emotional abuse 17, 125; codes for 135–6;
incidence of 136–8; by teachers 144; see also psychological abuse
emotional neglect 105, 125, 129; codes for 136; incidence of 137–8; see also psychological neglect
emotional problems 142 emotional responsiveness, denying 129 empirically tested research 343 epidemiological terminology 330 exaggeration 211 excited utterance exception 297 experimentation 20 exploiting/corrupting 129 expungement 315 extrafamilial abuse 163–8, 186, 336
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394 SUBJECT INDEX
extrafamilial factors: lack of support 33–4; military families 36–7; poverty 34–6
fabrication 211 factitious disorder by proxy 210 Fair Labor Standards Act 6 falls, injuries from 77–9 families: assessment of 307, 319–20; high-risk
322; identification and assessment of 328–30; low-risk 54, 323; moderate-risk 54, 322–3; planning for outcomes 321; progress of 323–4; see also family structure and functioning
Family Advocacy Program (FAP) 36, 37 family assessment 307 Family Connections Program 343 family group decision-making model 320 family meetings 320 family preservation and reunification 305 family progress 308 family structure and functioning 29–30;
domestic violence 31; large family size 31–2; poor family functioning 32; single parents 30; see also families
Family Treatment Court 287 Family Treatment Drug Courts (FTDC) 287 federal legislation, and child welfare 14–15,
304–5 Federal Rule of Evidence 601 247 felonies 291 fetal abuse: causes of 190–91; criminal
prosecution of, for and against 199–206; defined 189–90; incidence of 190; mandated reporting of 198; responding to 197, 207–8; treatment for 197–8
fetal alcohol effects (FAE) 193 fetal alcohol syndrome (FAS) 192–3 fetal neglect 91; see also child neglect; fetal abuse flashbacks 175 folk medicine 82–3 forensic interviewing 220, 247; accuracy of
testimony 247–51, 265; cautions concerning 265; guidelines for 269–70; of immigrant children 264–5; interviewer bias 262–3; negative stereotypes 263–4, 265; repeated questions 253–8, 265; reviews of interviews 266–9; suggestibility of children 251–3, 265
forensic investigations 220; see also forensic interviewing
foster care 15 fractures 74–6 Freud, Sigmund 177
functional magnetic resonance imaging (fMRI) 224
Global Severity Index 121 gold standard 342 guardian ad litems (GALs) 230–31, 280, 284–6,
296, 323
head injuries 76 Healthy Families America (HFA) 340–41 Healthy Start Program (Hawaii) 340, 341 hearsay 283, 296–7 Henderson, Nancy 274–5 heroin 197, 206 The History of Childhood (DeMause) 4 hoarding 99 homeschooling 112 hostility 182 hypersexual behavior 180–81 hypervigilance 174
I Know I’ve Been Changed (Perry) 232 immigrant children, interviewing 264–5 immunity (legal) 42 impaired socialization 119–20; see also social and
antisocial functioning impetigo 82 incidence, defined 68 Indian Child Welfare Act 304 indicated (alleged abuse designation) 316 induction 211 infancy: see infants infanticide 4, 14, 27 infantile amnesia 179 infants 4; nonorganic failure to thrive in 114;
poor attachment in 114–16; signs of neglect in 116–17
informed consent 45 Institutional Review Board (IRB) 45 intake 307, 310–12 intellectual problems 84–5, 117–19, 120–21, 171 intergenerational transmission (of abuse and
neglect) 28–9, 121–2 internalizing symptoms 234 Internet Crimes Against Children (ICAC) 160 interpersonal relationships 85, 182, 185 interviewer bias 262–3 interviewing techniques: see forensic
interviewing; interviews interviews: clumsy 268–9; and family assessment
319–20; guidelines for 269–70; improper 268–9; practice 267; structured 315; see also forensic interviewing
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395SUBJECT INDEX
intrafamilial abuse 169, 172, 185–6, 336 intrapersonal thoughts, feelings, and behavior
141–2 investigation and initial assessment 307 IQ scores 118, 121 isolating 129
Jenny, Carole 75 John Jay College 163–4 jurisdiction 304, 311 jurisdictional hearings 283 juvenile court 11–12, 281–7 juvenile delinquency 12, 121, 143, 281–2
Keeping Children and Families Safe Act 304
language delays 117 learning problems 143 legal cases xviii; Coy v. Iowa 292–4; Ferguson v.
City of Charleston 205; In re E. G. 107–8; In re Gault 12, 282; Landeros v. Flood 49, 299; Maryland v. Craig 294–5; People v. Stewart 200; Prince v. the Commonwealth of Massachusetts 12–13, 106; Stallman v. Youngquist 199; State v. D.R.H. 162; State v. Horne 201; State v. Johnson 199–200; State v. McKnight 201–2; State v. Michaels 296; State v. Palaby 296; State v. Pfannenstiel 200; State v. R.W. 296; State of Tennessee v. Jones 98; Whitner v. State 201; see also legal issues
legal issues: attorneys and children 285–6; charges and pleas 291–2; and child sexual abuse 150–53; children and the courtroom 277–80; civil court 297–9; and corporal punishment 71; custody issues 286; federal regulations 14–15, 304–5; and fetal abuse 199–206; legal terminology 277–8; in medical neglect cases 106–7; and psychological abuse and neglect 124; state laws 65–6, 91–2, 90–91, 91–2; testifying in court 299–300; testimony by children 247, 292, 295–7; see also courts, types of; legal cases
legend drugs 203 LeTourneau/Fualaau affair 158–9 “Let’s Not Exaggerate the Suggestibility of
Children” (Lyon) 265 Locke, John 5 locus of control, internal 182, 241 longitudinal research 19
McMartin daycare case 147, 166, 247–50 magnetic resonance imaging (MRI) 76 maladaptive behavior 136
malingering by proxy 226 malnourishment 92–8 malpractice 49 mandated reporters 42–4, 48; calls to CPS by
310–11; see also mandated reporting mandated reporting: of child abuse xvii,
xviii, 14; confidentiality and 47–8, 55–6; confrontation resulting from 48; education regarding 52–5; evaluation of 56–7; failure to report 49–52; of fetal abuse 198; history of 42; racially biased 56; see also mandated reporters
Mandated Reporting of Suspected Child Abuse: Ethics, Law, and Policy (Kalichman) 46
marijuana 195–6, 198 Mary Ellen case 8–11 Maslow’s hierarchy of needs 139 mature minors 107–9 meconium 91, 195 mediation/mediators 288, 344 Medical, Legal and Social Science Aspects of Child
Sexual Exploitation – A Comprehensive Review of Pornography, Prostitution and Internet Crime (ed. Cooper et al.) 170
medical neglect 105–6, 129; and the age of the child 107–9; delay in seeking treatment 110–11; disagreement with doctors 106; legal precedents for 106–7; religion-motivated 105, 109
memory impairment 177–9 mental health neglect 111, 129 mental health professionals, as mandated
reporters 55–6 mental illness, parental 26–7 mental retardation 193 meta-analysis 170–72, 181–2, 342 “A Meta-Analytic Examination of Assumed
Properties of Child Sexual Abuse Using College Samples” (Rind et al.) 182
metabolite 91 methadone 197 methamphetamine (MA) 195, 206 Michaels, Kelly 254–7 military families, risk of child maltreatment in
36–7 Minnesota Mother/Child Interaction Project 140 Minnesota Multiphasic Personality Inventory
(MMPI) 172, 174 misdemeanors 49 molestation 154; see also child sexual abuse Mongolian Spot 82 mood disorders, maternal 26–7 Moore, Thomas 7 morbid obesity 95–7
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396 SUBJECT INDEX
Munchausen by Internet 213 Munchausen by proxy syndrome (MPS) 210;
adult survivors of 219–20; consequences of 218–19; controversies related to 224–8; in educational settings 213–14; exaggeration, fabrication and induction 211–14; expert testimony regarding 228; incidence of 216; incorrect diagnoses 226–8; investigation of 220–24; perpetrators of 215–16; risk factors for 216–18; victims of 214–15
Munchausen syndrome 210 My Life (Clinton) 232 “My Mother Caused My Illness: The Story of a
Survivor of Munchausen by Proxy Syndrome” (Bryk/Siegel) 212
The Myth of Repressed Memory: False Memories and Allegations of Sexual Abuse (Loftus/Ketcham) 177–8
National Association of Public Child Welfare Administrators (NAPCWA) 306
National Child Abuse and Neglect Data System (NCANDS) 137
National Child Abuse hotline 47 National Clearinghouse on Child Abuse and
Neglect (NCCAN) 15, 44, 65, 92 National Highway Traffic Safety Administration
(NHTSA) 332–4 National Incidence Study-1 (NIS–1) 30 National Incidence Study-2 (NIS-2) 30, 113 National Incidence Study-3 (NIS-3) 30, 105,
113 National Incidence Study-4 (NIS-4) 30–31, 35,
65, 68, 111, 112, 113, 135–7, 154, 156, 161 National Institute of Child Health and Human
Development (NICHD) 270 National Society for the Prevention of Cruelty to
Children 138 National Study of Child Protective Services
Systems and Reform Efforts 325 National Violence Death Reporting System 81 The Nature and Scope of Sexual Abuse of Minors by
Catholic Priests and Deacons in the United States 1950–2002 163
negative stereotypes 263–4, 265; see also racial bias
neonatal asphyxia 192 neurobehavioral abnormalities 194 New Parents Support Program (NPSP) 36 nicotine 196 nonorganic failure to thrive (NFTT) 114–15 nonsuicidal self-injurious (NSSI) behavior
144, 174
North American Man/Boy Love Association (NAMBLA) 183
Nurse Home Visitation Program 341 Nurse-Family Partnership 341–2
obesity 95–7 obsessive compulsions 121, 182 Office on Child Abuse and Neglect (OCAN) 305 omission errors 125, 260 operational definition 20 opiates 193–4, 198, 206 oppositional defiance disorder (ODD) 88, 180,
197 osteogenesis imperfecta (OI) 82 out-of-home placement 317 overpressuring 130 overprotectiveness 136
paranoid ideation 121, 182 paraprofessionals 340 parens patriae 13, 281 Parent Opinion Questionnaire 142 parent-child relational problem 125 parents: authoritative 239; campaigns to educate
334–5; factors in child maltreatment 23–9; lack of preparation in 27–8; mental illness of 26–7; parental behavior and psychological abuse 126–7, 133; parental intent 127, 133, 225; problematic personality traits of 26–7; relationships with children 142–5; substance abuse by 24–5
Paterno, Joe 51 pediatric condition falsification (PCF) 225 pedophilia 165, 168 perinatal mortality 193 The Period of PURPLE Crying: Keeping Babies
Safe in North Carolina 335 permanency 305–6; permanency planning
hearings 284 permissive reporters 44 perpetrators 47; relation to victim 172, 174, 185;
removal of 187, 286, 318–19 Perry, Tyler 232–3 personality disorders 175–6 phencyclidine 206 phobic anxiety 121, 182 physical abuse: see child maltreatment; child
physical abuse (CPA) physical health, and psychological maltreatment
143–4 physical neglect: abandonment 112–13;
adequate supervision 99–102; appropriate shelter 99; car seats/seat belts 97–8; chronic
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397SUBJECT INDEX
nature of 94–5; consequences of 117–20; dietary 92–3, 95–7; indicators of 104–5; intergenerational transmission of 121–2; see also child neglect
physicians, as mandated reporters 43 placenta abruption 192 plaintiffs 298 platelet aggregation disorder 82 postpartum depression 26–7, 191 posttraumatic stress disorder (PTDS) 87, 120,
171, 174–5, 185, 220 poverty 19, 34–6, 81, 104 precursor, defined 328 prenatal development, effects of drugs on 191–2 preponderance of evidence 298 Preschool Language Scale (PLS) 117 prevalence, defined 68 Prevent Child Abuse America 341 prevent, defined 328 Prevention and Evaluation of Early Neglect and
Trauma (PREVENT) 287 prevention of maltreatment 328–9; prevention
programs 239–30; as public health issue 320 primary caregivers 310 primary prevention 330–32; child sexual
abuse programs 336–8; parental education campaigns 334–5; public awareness campaigns 332–4
privacy, in hospitals 224 proxy measures 342 psychiatric disorders 121, 182; see also psychotic
disorders psychological abuse 123, 124; and attachment
theory 140; definitions of 128–30; emotional problems resulting from 142; and Erikson’s theory 139; and intrapersonal thoughts, feelings, and behavior 141–2; and learning problems 143; and Maslow’s theory 138; and Minnesota Mother/Child Interaction Project 140; overlap with other maltreatment 132; and physical health 143–4; and social/ antisocial functioning 143; see also emotional abuse
psychological development, theories of 138–40 psychological maltreatment: consequences
of 138–45; defining 123–30; incidence of 135; measuring 135; paired with physical abuse 132; and parental intent 127, 133; and physical health 143; see also child maltreatment; psychological abuse
psychological neglect 123, 124, 129; see also emotional neglect
psychomotor delays 115 psychotic disorders 26–7; see also psychiatric
disorders psychoticism 121: see also psychiatric disorders;
psychotic disorders PsycINFO 13, 147 public awareness campaigns 332–4
questions: open-ended 251, 265, 269–70; unbiased 251, 265; see also forensic interviewing; interviews
racial bias 198; see also negative stereotypes rapport 266, 269–70 reason to believe 325 reasonable efforts 305 recidivism 331 relationships, appropriate 234 religion: and child maltreatment 12–13; and
child sexual abuse 163–5; and medical neglect 107–9
repressed memory 177–9 resiliency 114, 144–5; community factors 239;
defined 230; examples of 230–34; factors associated with 237–43; and family support 237–9; genes/environment and 241–3; incidence of 236; and level of trauma 237; measuring 234–6; victim characteristics 239–41
resistant attachment 116 retrospective design 16 review hearings 284 Revised Behavior Problems Checklist (RBPC) 121 risk assessment 316 risk factors: child factors 32–3; cultural 37–9;
evaluation and identification of 316; extrafamilial 33–7; family structure and functioning 29–30, 31–2; parental factors 23–9, 30; prenatal exposure to drugs 208–9
Rivers, Victor Rivas 233 Robinson, Angela Talley 303–4 Rousseau, Jean-Jacques 5–6 runaways 120
safe haven laws 112–13 safety plan 307–8 Sandusky, Jerry 51–2 scapegoating 128 secondary prevention 331, 339–40; specific
programs 340–43 secure attachment 115 self-actualization 138 self-destructive thinking and behavior 173–4
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398 SUBJECT INDEX
self-efficacy 179 self-esteem 86, 140, 141–2, 182, 185, 234 self-fulfilling prophecy 262 self-mutilation 144, 174 separation anxiety 218 serotonin 241 service provision 308 72-hour hearings 283 sex trafficking 169–170 sexting 151–3 sexual abuse: see child sexual abuse (CSA); sexual
abuse consequences sexual abuse consequences: anxiety 174;
boys vs. girls 186–7; cognitive distortions 179–80; depression 172–3; dissociation and memory impairment 177–9; eating disorders 176–7; over time 187; personality disorders 175–6; posttraumatic stress disorder 174–5; professional disagreement concerning 181–6; self-destructive thinking and behavior 173–4; sexualized behavior 180–81; social functioning 180; substance abuse 175; victims with no symptoms 187
sexual dysfunction/maladjustment 143, 181, 182, 185
sexual exploitation 124, 168–70 sexual promiscuity 171 sexualized behavior 180–81 sexually transmitted diseases (STDs) 153, 181,
184 Shaken Baby Syndrome (SBS) 77, 334–5 shelter, appropriate 99 Sickened: The Memoir of a Munchausen by Proxy
Childhood (Gregory) 212 sleeper effect 344 SMART goals 321 social and antisocial functioning 143, 180, 182,
196, 234 social isolation 33, 120 social referencing 115 Social Security Act (1935) 15 Society for the Prevention of Cruelty to Children
(SPCC) 11 socioeconomic status (SES) 19, 86, 161, 171; see
also poverty somatization/somatoform disorders 121, 182,
216 spina bifida 193 spurning 128 status offences 282 statute of limitations 298 statutes: defined 65; federal 14–15, 304–5; state
65–6, 90–91, 91–2
stereotypes, negative 263–4, 265 Stewards of Children workshop 338–9 strange situation task 115 structured interviews 315 substance abuse: addressing 287; alcohol
191–3, 198; and child maltreatment 24–5; civil commitment for 206; cocaine 193–4, 198, 206; and drug courts 287; as fetal abuse 190–91; heroin 197, 206; marijuana 195–6, 198; methamphetamine (MA) 195; nicotine 196; parental 24–5; during pregnancy 190–97; polydrug users 192; and risk of child abuse 208–9; in adult victims of child abuse 86, 182, 185, 241; see also drugs
substantiated reports 68 sudden infant death syndrome 194 suggestibility 251–3, 265 suicidal ideation 86, 173–4, 182 suicide 171–4; attempts 87, 141 supervision, adequate 99, 113, 161 Symptom Checklist-90-Revised 121
tabula rasa 5–6 teachers: emotional abuse by 144; sexual abuse
by 167–8 terrorizing 128–9, 136, 141 tertiary prevention 331 testimony 247; accuracy of 247–51, 265 therapeutic relationship 49 threats: see terrorizing tort laws 298 toxicology 91 Trauma and Recovery: The Aftermath of Violence
from Domestic Abuse to Political Terror (Herman) 178
The Trauma Myth: The Truth About the Sexual Abuse of Children and its Aftermath (Clancy) 185
Trauma Symptoms Checklist for Children (TSCC) 236
trauma-related symptoms 120; see also posttraumatic stress disorder (PTSD)
truancy 111–12 Tumblin, Martha 339
U.S. Constitution: Fourth Amendment to 205, 223; Sixth Amendment to 293, 295; Eighth Amendment to 205
U.S. Department of Health and Human Services 305–6
U.S. Department of Transportation 332–4 U.S. Trafficking Victim Protection Act (TVPA)
169–70
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399SUBJECT INDEX
uncorroborated testimony 247 unsubstantiated reports 308, 313, 316 “Unto the Third Generation” (Vieth) 54
verbal assaults 135–6 victim-perpetrator cycle 171 victim/witness assistants (VWAs) 280–81 Vieth, Victor I. 53–4 Violence Against Women Act 232
waitlist control 338 Wanner, Laurel 275–6 Wechsler Intelligence Scale for Children
(WISC) 118 Wheeler, Etta 9–11 Where’s the Baby? Look Before You Lock 332–4 Wilson, Mary Ellen, case of 8–11
X-rays 76
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401
AUTHOR INDEX
Abdul-Ghani, K. 82 Abel, G. 164 Aber, J. L. 36 Accornero, V. H. 194 Ackerman, J. P. 194 Adams, J. 180, 316 Adshead, G. 216 Afifi, T. O. 230, 234, 238, 239,
241 Alati, R. 84 Aleman, A. 336 Alink, L. R. A. 17–18 Alio, A. P. 192 Aliyu, M. H. 192 Allen, B. 141 Allen, D. B. 95, 96 Allen, D. M. 45, 86 Allen, R. E. 117 Alpert, J. L. 165 Amacher, E. 279 Amarillo, D. 280–81 Ammerman, R. T. 24 Amrung, S. A. 118, 119 Anda, R. F. 69 Anderson, C. 51 Anderson, J. C. 141 Arani, S. 95, 96, 97 Armas, G. C. 52 Arnsberger, P. 28 Arria, A. M. 195 Asdigian, N. 336, 337 Ashton, V. 46 Asmundson, G. J. G. 88 Asser, S. M. 109 Åstedt-Kurki 28, 29, 31,
32 Astor, R. A. 36 Augustyn, M. 194 Aviram, S. 87 Awadallah, N. 215 Ayoub, C. C. 213–14 Azar, S. T. 142
Bachli, E. B. 83 Bahl, A. 340 Bailey, B. A. 192 Baker, A. J. L. 124, 340 Baker, T. M. 86 Balloch, J. 66, 67 Bandstra, E. S. 194 Barker, L. H. 37 Barlow, B. 78 Barnett, D. 145, 183–4 Barr, M. 335 Barr, R. G. 335 Barra, M. 335 Barrett, M. E. 190, 198, 205 Bart, R. P. 56 Bartell, P. A. 50 Barth, R. P. 310, 316, 342 Bartol, A. M. 282, 288 Bartol, C. R. 282, 288 Basena, M. 24, 30, 32, 34, 35,
65, 68, 111, 113, 135–7, 154, 156, 290
Bass, C. 216 Bath, H. I. 114 Baumrind, N. 286 Bauserman, R. 181–4 Bazelon, Emily 242–3 Beam, C. 87 Beekhuis, R. 280 Belden, M. 195, 196 Bell, R. 86 Belsky, J. 28, 32, 33, 38 Benbenishty, R. 36 Bendel, R. 57 Ben-Yehuda, A. 87 Beresford, T. P. 176 Berger, L. M. 28 Berliner, L. 149, 153, 156, 161,
174, 175, 177, 179, 181, 183–4
Bernet, W. 126, 130, 133 Bernstein, D. P. 135
Bernstein, E. M. 177 Bernstein, N. 113 Berrick, J. D. 336 Berry, K. D. 37 Bhargava, S. 200, 202 Bhargavaraman, R. P. 27 Bilaniuk, L. T. 76 Binggeli, N. J. 140–41, 142, 143 Bishop, S. J. 33 Black, I. B. 107, 115 Black, M. 27, 28, 31, 32, 77,
79, 194 Blackson, T. C. 24 Blanco, C. 88 Bliss, D. L. 26 Bloch, Y. 87 Block, J. 234 Block, S. D. 286 Bluglass 216 Boat, B. W. 262 Bolger, K. 27 Bolton, R. G. 28 Bools, C. 216 Bor, W. 84 Borduin, C. M. 33, 121 Borger, S. C. 88 Boris, N. W. 234, 238, 239, 240,
241 Boudewyn, A. C. 237 Bou-Saada, I. E. 30 Bousha, D. M. 119 Bower, C. 193 Bowlby, J. 115 Boyle, M. H. 88 Brady, M. 190 Bramen, J. 195 Brant, R. 335 Brassard, M. R. 111, 128,
140–41, 142, 143, 316, 338, 340
Breitbart, V. 198 Brennenstuhl, S. 86
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402 AUTHOR INDEX
Brenner, S. W. 291 Brestan, E. V. 194, 203, 204 Brick, J. 196, 197 Briere, J. 141, 156, 172, 173,
174, 175, 176, 177, 179 Broadhurst, D. D. 34 Brockington, I. F. 191 Brodeur, A. E. 74, 83, 84 Brodowski, M. 169 Bronfenbrenner, U. 23 Brook, M. L. 224 Brooks, C. M. 291, 298 Bross, D. C. 57 Brown, J. 26, 28, 30, 32, 34,
38, 39 Brown, R. 50 Brown, S. 159, 160–61 Browne, K. 29 Bruck, M. 251, 253, 254, 255,
259, 260, 261, 262, 263 Brunner, R. 27 Bryk, M. 212 Burd, S. A. 145 Burgess, A. W. 160 Burke, J. 27 Burkhart, B. R. 173 Burnett, B. B. 133–4 Burns, N. 167 Burrell, L. 341 Burrus, S. W. M. 287 Bussey, K. 292 Butcher, J. 172
Callans, L. 76 Camparo, L. 277–8 Cankaya, B. 174 Cann, W. 331–2 Cantwell, H. B. 105, 114, 116,
120 Carey, M. P. 181 Carlson, R. S. 167 Carlson, V. 36 Carp, R. A. 298 Carr, A. L. 95, 96 Carroll, L. A. 336 Caspi, A. 241, 242 Castelli, P. 292, 295 Catellier, D. J. 30 Catherine, N. 335 Ceci, S. J. 251–2, 253, 254, 255,
259, 260, 261, 263 Cepeda-Benito, A. 184 Chadwick, D. L. 78
Chaffin, M. 153, 183–4 Chamberlain, H. 37 Chance, T. 50, 55 Chandra, P. S. 27 Chandy, J. 27 Chang, G. 191 Charles, Sonya 207 Chasnoff, I. J. 190, 196, 198,
205, 206, 208 Chavkin, W. 198 Chen, I. 53 Chen, W. A. 192 Chin, S. 78 Chiodo, L. M. 192 Christian, C. W. 76 Cicchetti, D. 17–18, 36, 125 Clancy, Susan 185–6 Clark, L. A. 99 Claussen, A. 132 Clinton-Sherrod, M. 36, 37 Cloitre, M. 237, 239, 240 Cohen, D. 228 Cohen, J. 171 Cohen, P. 26, 28, 30, 32, 34,
38, 39 Cohen-Callow, A. 26 Colangelo, J. J. 181 Colbus, D. 86 Cole, R. E. 341 Coleman, K. 235, 236 Collin-Vezina, D. 235, 236 Condon, J. T. 189–90, 191 Connell-Carrick, K. 24, 25 Connor, K. R. 173 Conrad, J. 197 Conte, J. R. 258 Conway, J. 335 Cook, S. L. 338 Cooper, Sharon W. 169, 170 Cordon, I. 183–4 Courtney, M. 321 Coury-Doniger, P. 181 Cox, B. J. 88 Craig, I. W. 241, 242 Craig, M. E. 49 Crain, J. 135 Craven, S. 159, 160–61 Crawford, E. 141 Crenshaw, W. B. 50, 55, 56 Crittenden, P. 132 Cronch, L. E. 263 Cross, T. P. 289–90 Crosson-Tower, C. 116, 117
Crotteau-Huffman, M. 253 Crouch, J. L. 119 Crowson, M. M. 287 Cummings, P. 335 Currie, J. 88 Cutajar, M. C. 175
D’Imperio, R. 234, 238, 239, 240, 241
Daeppen, J. 192 Daigneault, I. 235, 236 Dale, K. A. 165 Dalla Rosa, J. 258 Dallam, S. J. 184 Dammeyer, M. D. 178 Dannerbeck, A. 27 Daro, D. 329, 330, 332, 334,
336, 341 Darwin, A. 95 Davidson, H. A. 140, 282, 283,
284 Davis, E. 279 Davis, M. K. 336 Davis, R. 83 Dawes, M. A. 243 Dawson, J. 236 Day, D. 210, 215 Day, S. 193 Dayal, S. 215, 219 de Arellano, M. A. 338 Del Castillo, D. 141 Delaney-Black, V. 192 Delaronde, S. 57 Deliberto, T. L. 144 DeLoache, J. S. 261 DeMaso, D. R. 215, 219 DeMattei, R. 53 deMause, Lloyd 4, 146 Denniston, J. 169 Denny, S. J. 214, 216, 217 DePanfilis, D. 308, 310, 311,
312, 313, 315, 316, 317, 319, 320, 321, 323, 324, 343
De Pedro, K. M. T. 36 Derauf, C. 195, 209 Deriaz, O. 192 DeRobertis, Eugene M. 127 Derogatis, L. R. 121 DeRosa, R. R. 86, 88 Derrick, C. M. 338 Desch, L. W. 32 Diekema, D. S. 97
6241-171-BM4.indd 402 10/19/2013 10:07:15 AM
403AUTHOR INDEX
DiLillo 29 Dixon, L. 29 Dodge, D. 142 Donald, T. 71 Donnelly, L. J. 329, 330, 332,
334, 336, 340 Donohue, B. 105 Dorahy, M. J. 142 Doris, J. 114 Dorne, C. K. 27 Doueck, H. J. 280 Douglas-Palumberi, H. 242 Douglass, D. 180 Doward, J. 138 Doyle, C. 143 Draca, J. 135 Drake, Anne 232–3 Drake, B. 56, 315, 318, 319,
321 Driessnack, M. 53 Droegemueller, W. 13–14, 42 Duberstein, P. R. 174 Dubes, R. 172 Dubowitz, H. 27, 28, 31, 32, 35,
107, 316, 343 Duggan, A. K. 340, 341 Duku, E. K. 88 Dunne, M. 53 Durbin, D. R. 76 Duthie, S. 142 Dziuba-Leatherman, J. 336, 337
Eckenrode, J. J. 114, 341 Edwards, L. P. 12, 49, 104, 200,
247, 281, 282, 283, 284, 289, 299
Egeland, B. 118, 119, 121, 122, 140
Egolf, B. 237 Eisbach, S. S. 53 Elliott, D. M. 149, 153, 156,
161, 174, 175, 177, 179, 181 Elliott, K. 38 Elman, D. 198 Emery, R. E. 56, 57 Epstein, M. A. 211, 212, 219 Erickson, M. F. 118, 119, 121,
122, 140 Erikson, Erik H. 139, 143,
238 Esqueda, M. C. 36 Estes, Richard 170 Estrada, J. 36
Etheir, L. S. 120 Eubanks, L. 222 Everson, M. D. 51, 262 Ewigman, B. 331, 342
Faller, K. C. 166 Fan, Z. 36, 37 Farberman, H. A. 45 Farsides, C. 224 Febo, M. 208 Fegan, M. 263 Feldman, K. 79, 80, 81, 218 Feldman, M. D. 213, 214, 215,
216, 217, 227 Felitti, V. J. 69 Feller, J. N. 282, 283, 284 Fenfang, L. 28 Fergusson, D. M. 157, 161, 175,
187 Filbert, L. 280 Finch, S. J. 45 Finigan, M. W. 287 Fink, L. 135 Finkelhor, D. 152, 154–5, 156,
157, 161, 166, 167, 169, 170, 180, 186–7, 336, 337
Finnegan, M. 195, 196 Fisher, C. 118, 119 Fluke, J. 56 Flynn, C. 338 Fogarty, L. 258 Follette, V. M. 172, 173, 174,
175 Follingstad, D. R. 49 Fong, R. 24 Fontes, L. A. 38, 39, 265 Foote, J. 135 Foreman, D. M. 224 Fost, N. 95, 96 Fox, L. 117 Francoeur, E. 259, 260, 261 Frank, D. A. 194 Fraser, J. A. 53 Fraser, M. 216 Frawley-O’Dea, M. G. 165 Freeman, J. 53 Fromuth, M. E. 173 Frost, R. O. 99 Frye, E. M. 213, 214 Fuddy, I. 340, 341 Fujiwara, T. 335 Fuller-Thomson, E. 86 Furrer, C. J. 287
Galanti, G. 83 Gallo, D. M. 211, 219 Gallup, G. H. 154 Gandhi, R. D. 78 Garbarino, James 132 Garner, B. A. 281, 291, 297, 298 Garrity, S. E. 169 Garven, S. 268 Gaudin, J. M. 118 Gause, S. 190 Gavin, H. 142, 144 Geeraert, L. 342 Geffner, R. 51 Gelemter, J. 242 Gelles, R. 38, 332, 334 Genuis, M. L. 171 Georgiades, K. 88 Gerber, S. 192 Germain, R. 128 Gershoff, E. T. 69, 70, 71 Gerson, A. 195, 196 Giardino, Angelo P. 112, 170 Giardino, E. R. 112 Gibbs, D. A. 36, 37 Gibson, L. E. 337 Gidycz, C. 336 Gilchrist, E. 159, 160–61 Glaser, D. 127, 129–30 Glasser’s delta 171 Glassman, L. H. 144 Gleaves, D. H. 184 Godinet, M. T. 28 Goerge, R. M. 28, 34 Goldman, J. 303, 315, 318, 319,
321 Good, J. B. 94 Goodman, G. 183–4, 252, 253,
262, 286, 292, 295 Goodwin, M. 207, 208 Goudena, P. P. 336 Govenzensky, J. 87 Gowan, J. 117 Graham-Bermann, S. A. 31 Grant, B. F. 88 Grant, C. C. 214, 216, 217 Grant, P. 195 Grasso, D. 242 Green, Arthur H. 146, 170 Green, B. L. 287 Greene, A. 24, 30, 32, 34, 35,
65, 68, 111, 113, 135–7, 154, 156, 290
Greene, S. 202
6241-171-BM4.indd 403 10/19/2013 10:07:15 AM
404 AUTHOR INDEX
Greenfield, T. K. 86 Gregory, J. 212 Grietens, H. 342 Griffith, L. 331, 336 Grimbeek, E. 292 Gromoske, A. N. 28 Gryboski, J. D. 211, 219 Gudjonsson, G. H. 163 Gushwa, M. 50, 55 Gutowski, C. 99 Guy, L. S. 42, 49
Haapala, D. A. 114 Hall, A. K. 176 Hall, D. E. 222 Hall, R. C. W. 176 Hamarman, S. 126, 130, 133 Hamby, S. L. 154–5 Hamilton-Giachritsis, C. 29 Hammond, W. R. 330 Handelsman, L. 135 Hannigan, J. H. 192 Hansen, D. J. 86, 263 Hansen, K. K. 84 Harder, J. 331, 339 Hardin, M. 282, 283, 284 Harding, K. A. 341 Harlow, N. 164 Harper, G. 217 Harrington, H. 241, 242 Harris, W. R. 118, 119 Hart, S. 111, 128, 140–41, 142,
143, 316, 328, 344 Hartman, J. K. 215, 219 Harvey, S. M. 142 Hasin, D. S. 88 Hathaway, S. 172 Haugaard, J. J. 148, 150 He, H. 173 Hekmatpanah, J. 76 Helfer, M. E. 4 Helfer, R. E. 77, 79 Heller, S. S. 234, 238, 239, 240,
241, 284 Henderson, C. R. Jr. 341 Hennink-Kaminski, H. J. 335 Herbert, B. 202 Herbison, G. P. 141 Herman, Judith 178 Heron, J. 28 Herrenkohl, E. C. 237 Herrenkohl, R. C. 237 Hershkowitz, I. 258
Hibbard, R. A. 32 Hickey, S. E. 226 Higman, S. J. 341 Himelein, M. J. 239–40 Hindman, H. D. 6 Hobfoll, S. E. 87 Hodes, D. 38 Holder, T. 325 Holder, W. 316 Holl, J. L. 27 Holmes, J. W. 211, 219 Hooley, J. M. 144 Hopkins, K. 70 Horowitz, B. 279 Horowitz, R. M. 282, 283, 284 Houshyar, S. 238, 242 Howie, P. 263 Howing, P. T. 118 Hudson, J. I. 176–7 Hughes, T. 38 Huizink, A. C. 196 Humphrey, J. 93, 94 Hunt, J. S. 266–7 Hunt, S. 106 Hunter, W. M. 30 Hyde, B. 106
Jacobson, Lenore 262 Jadhav, A. 110 Jaenicke, C. 277–8 James, J. B. 237 Jamieson, E. 88 Janisse, J. 192 Jaworski, J. 99 Jensen, J. 262 Johnson, B. 71 Johnson, C. F. 71, 83, 84 Johnson, R. E. 36, 37 Johnson, S. C. 222 Johnston, J. G. 26, 28, 30, 32,
34, 38, 39 Jolley, J. M. 56 Jones, C. 216 Jones, H. 196, 197 Jones, J. 7–8 Jones, L. 152, 156, 169, 289–90,
338 Jones, T. 145 Jonson-Reid, M. 56 Jungmeen, K. 17–18
Kahr, B. 4 Kalichman, Seth 42, 46, 48, 49
Kane, S. P. 28 Kaplan, S. J. 86, 88 Karageorge, K. 48 Kasdan, M. L. 226 Kastanakis, J. A. 279 Kaufman, J. 238, 242 Kaylor-Hughes, C. J. 224 Kazdin, A. E. 86 Kearney, M. H. 25 Keefe-Cooperman, K. 181 Keegan, J. 195, 196 Keeney, K. S. 279 Kehle, T. J. 338 Keller, C. 213–14 Kelley, F. M. 286 Kelley, S. J. 24, 25, 29, 208 Kellog, Nancy 170 Kempe, C. H. 13–14, 42 Kempe, R. S. 4 Kendal, R. 48 Kendall-Tackett, K. 166, 172,
180, 258–9 Kennedy, K. Y. 303, 315, 318,
319, 321 Kenney, R. D. 222 Kenny, M. C. 52 Kent, L. 191 Keogh, N. J. 87 Ketcham, Katherine 178, 179 Khoury, A. 286 Kiefer, E. 197 Kilpatrick, D. G. 175, 338 Kim, K. 113 King, G. 57 Kirchner, H. L. 194 Kirisci, L. 24 Kirk, A. B. 51 Kitchen, L. 78 Kitzman, H. J. 341 Klevens, J. 82 Knight, B. 14 Knight, W. G. 194 Kolko, D. J. 24, 68, 85, 86 Korcha, R. A. 86 Kotch, J. B. 30 Kraemer, H. C. 184 Kremen, A. M. 234 Krugman, M. K. 144 Krugman, R. D. 4, 144 Krystal, J. H. 242 Kuczkowski, K. M. 195, 196 Kuehnle, K. 180 Kurtz, P. D. 118
6241-171-BM4.indd 404 10/19/2013 10:07:15 AM
405AUTHOR INDEX
Labbe, J. 14 LaGasse, L. L. 195, 209 Laidlaw, J. D. D. 191 Laippala, P. 28, 29, 31, 32 Laird, M. 114 Lamb, M. E. 269, 270 Landress, H. J. 190, 198, 205 Landsverk, J. 78 Laner, R. H. 28 Langer, R. 225 Langlois, A. 117 Lanier, P. 56 Lankappa, S. T. 224 Larrieu, J. A. 234, 238, 239,
240, 241, 284 Larson, A. 292 Larzelere, R. E. 71 Lasher, L. J. 210, 211, 214, 216,
219 Last, A. 292, 295, 340, 341 Laumann-Billing, L. 56, 57 Lawson, L. 153 Lazoritz, S. 8, 11 Leadbeater, B. J. 33 Leblanc, W. 78 LeBuffe, P. A. 145 Leckman, J. F. 99 LeCroy, C. W. 341 Lederman, C. S. 287 Lee, B. J. 28, 34 Lee, K. 292 Leeb, R. T. 82 Lehrmann, D. H. 286 Leichtman, M. D. 263 Leitenberg, H. 337 Lemola, S. 192 Lengua, L. J. 335 Leshner, Alan I. 194 Lester, B. 195, 209 Levenon, M. 110 Leventhal, J. 329 Levkovitz, Y. 87 Lewis, B. 194 Li, S. 24, 30, 32, 34, 35, 65, 68,
111, 113, 135–7, 154, 156, 290
Libow, J. A. 217, 219, 220 Lichtenberg, J. W. 55, 56 Liem, J. H. 237 Liles, B. D. 208 Lin, K. H. 88 Linares, L. O. 237, 239, 240 Lindsey, D. 43, 56
Lipovsky, J. A. 175 Lipschitz, D. 242 Little, R. 193 Litzenfelner, P. 286 Loar, L. 298, 299 Loeber, R. 143 Loftus, Elizabeth 178, 179, 253 Logli, P. A. 203 London, K. 251, 252, 253, 269 Long, S. H. 117 Lovejoy, M. 135 Lowder, L. A. 190, 196, 206,
208 Lown, E. A. 86 Ludwig, D. S. 95 Lyncy, O. 192 Lyon, Thomas D. 265, 279 Lyons, P. M. 42, 49
Mabrey, V. 152, 153 McAuliff, B. E. 280–81 McCarroll, J. E. 36, 37 McChesney, K. L. 165 McClain, N. M. 169 McClellan, J. 180 McCord, J. 121, 166 McCoy, M. L. 146–7, 178, 206 McCulloch, V. 213 McCurdy, K. 329, 332 McCurry, C. 180 McDaniel, M. 27 McDaniel, S. P. 217 Macedo, C. A. 118, 119 McElrath, J. A. V. 239–40 McFarlane, E. C. 340, 341 McGee, R. A. 126–7 McGloin, J. M. 235, 236 McGraw, S. 159 McGuire, T. L. 218 McIntosh, H. 169 McIntosh, L. C. 197 McIsaac, C. 133 McKinley, J. 172 McLaughlin, M. 70 Macmann, G. M. 145 MacMillan, A. 331, 336 MacMillan, H. L. 88, 135, 230,
234, 238, 239, 241, 331, 336 MacMillan, J. H. 331, 336 McMurtry, S. L. 339–40 McPherson, K. 24, 30, 32, 34,
35, 65, 68, 111, 113, 135–7, 154, 156, 290
Madison, P. 177 Mahoney, M. 160 Maier, S. E. 192 Malik, N. M. 287 Malinosky-Rummell, R. 86 Maluccio, A. N. 310, 316 Mandel, F. S. 86, 88 Maniglio, R. 173, 175 Manning, K. L. 298 Manning, L. 254, 255, 256, 257 Mansoor, E. 194 Mara, B. A. 24, 110, 120 Margolin, G. 87 Margolin, L. 166 Markie-Dadds, C. 331–2 Markowitz, R. L. 211, 219 Marshall, N. A. 125 Mart, E. G. 219, 225, 226, 227,
228, 247, 267–8 Martin, J. L. 141 Martin, S. L. 36, 37 Marty, P. J. 192 Marzolf, D. P. 261 Maslow, A. H. 138–9, 234 Masson, J. M. 177 Masten, A. S. 237, 238, 239 Mataix-Cols, D. 99 Mathews, B. 53, 57 Mattingly, M. J. 236 Meadow, Roy 210, 215, 216,
218, 219, 220, 228 Melinder, A. 262 Mennen, F. E. 113 Mercado, C. C. 164 Meredith-Benitz, E. 335 Merrick, J. C. 191, 192, 193,
194, 199, 200, 204, 205 Merrill, L. L. 37 Merriman, G. 181 Mersky, J. P. 28 Mettenburg, J. 24, 30, 32, 34,
35, 65, 68, 111, 113, 135–7, 154, 156, 290
Meyer-Leu, Y. 192 Meyyazhagan, S. 222 Miller, D. P. 86 Miller-Perrin, C. L. 84, 85, 86,
158, 336 Mills, R. 84 Milne, L. 235, 236 Milner, J. S. 119, 142 Milot, T. 120 Miltenberger, R. G. 336
6241-171-BM4.indd 405 10/19/2013 10:07:15 AM
406 AUTHOR INDEX
Minnes, S. 194 Mitchell, K. 152, 169 Mitchell, L. 169, 328 Mitgang, M. 95, 96 Moehler, E. 27 Moffitt, T. E. 241, 242 Moldavsky, M. 215, 216, 217,
218, 220, 221 Montaldo, C. 158 Monteleone, J. A. 74, 83, 84 Moore, D. W. 154 Moore, J. K. 76 Moore, T. E.145 Moran, G. F. 5 Morelen, D. 53 Morelli, K. 93, 94 Morgenbesser, L. 160 Morin, N. A. 237, 239, 240 Morrison, C. A. 224 Morrow, C. E. 194 Morton, T. D. 316, 325 Moseley, R. L. 210, 215 Moser, J. 86 Mrazek, D. A. 241 Mrazek, P. J. 241 Mulder, E. J. H. 196 Mulford, Robert 125 Mullen, P. E. 141, 157, 161,
175, 187 Murphy, N. 32 Murphy, R. A. 335 Murphy, S. 25 Murtagh, L. 95 Myers, J. E. 8, 11, 14, 15, 42,
46, 49, 277, 292, 295, 296, 297, 304, 305
Nack, W. 168 Najman, J. M. 84 Nana, P. N. 192 Nayak, M. B. 86 Neale, B. A. 216 Nephew, B. C. 208 Newby, J. H. 36, 37 Newman, E. 209 Newman, T. 202 Ney, P. G. 28, 29 Nguyen, M. 219 Niccols, G. A. 192, 193 Nicholson, E. 280–81 Nichtern, S. 197 Niemirska, M. 78 Nightingale, N. N. 178
Nilsen, P. 191 Nitzan, U. 87 Nobus, D. 164 Nocera, M. 335 Nock, M. K. 144 Norton-Hawk, M. A. 205 Nunez, S. C. 195
O’Brien, P. L. 191 O’Callaghan, M. 84 O’Connor, M. J. 195 O’Hagan, K. 126 O’Leary, C. M. 193 O’Malley, D. 145 O’Shea, B. 211 O’Toole, J. G. 237 Offord, D. R. 331, 336 Ogloff, J. R. P. 175 Okado, Y. 142 Olds, D. 341, 342 Olfson, M. 88 Oliver, D. A. H. 238, 239, 240 Oliver, J. M. 117 Olsen, G. 158 Olsen, J. L. 329 Omar, H. A. 151–2 Ondersma, S. J. 183–4, 194,
203, 204 Onghen, P. 342 Oran, D. 286 Oran, H. 286 Ormrod, R. 154–5 Osofsky, J. D. 287 Ostrager, B. 152, 153 Ostrea, E. M. 190
Paavilainen, E. 28, 29, 31, 32 Paltrow, L. M. 202, 204, 205 Palusci, V. J. 34 Pankratz, L. 219, 221 Pannaraj, P. 76 Paolucci, E. O. 171 Parks, A. 64 Parnell, T. F. 215, 221 Parva, M. 195, 196 Patton, M. 338 Paunonen-Ilmonen, M. 28, 29,
31, 32 Paxson, C. 30 Pearl, P. S. 141, 143 Pecora, P. J. 310, 316 Pelcovitz, D. 86, 88 Pell, T. 194
Pelton, L. H. 35 Pepler, D. J. 145 Perez, C. M. 120, 121 Perozzi, D. 152, 153 Perrin, R. D. 84, 85, 86, 158 Perry, N. W. 266–7 Pertusa, A. 99 Peterson, D. R. 121 Peterson, L. 29, 331, 342 Petta, I. 24, 30, 32, 34, 35, 65,
68, 111, 113, 135–7, 154, 156, 290
Pettit, F. 263 Pianta, R. 118, 121, 140 Pierce, A. 170 Pilkington, E. 206 Pinnock, R. 214, 216, 217 Pipe, M. E. 262 Plante, T. G. 165 Plotnick, R. D. 310, 316 Pltokin, R. 142 Poertner, J. 284 Pollitt, K. 199, 200 Polusny, M. A. 172, 173, 174,
175 Pond, R. E. 117 Poole, D. A. 262, 269, 270 Pope, H. G. 176–7 Poulton, R. 241, 242 Powell, J. L. 238, 239 Press, A. 284 Price, H. L. 268 Provost, M. A. 120 Putnam, F. W. 177
Qin, J. 292, 295 Quandt, L. 195 Quas, J. A. 279, 292, 295 Quay, H. C. 121 Queh, D. 194
Radbill, S. X. 4, 7, 9 Radharkrishna, A. 30 Raghunandan, V. N. G. P. 27 Raman, S. 38 Rampini, S. K. 83 Ramsland, K. 248–9 Rand, D. C. 227 Ravanshenas, D. 280–81 Raymundo, A. L. 190 Realmuto, G. 262 Reck, C. 27 Reddan, J. 228
6241-171-BM4.indd 406 10/19/2013 10:07:15 AM
407AUTHOR INDEX
Redlich, A. D. 292, 295 Redlich, H. F. 280 Reece, R. 57 Renick, A. 259 Rentsch, K. 83 Reppucci, N. D. 328, 338,
344 Resch, F. 27 Reutter, M. 190 Reynolds, A. J. 28 Rheinberger, M. M. 4, 7, 9 Rheingold, A. A. 338 Riggins, T. 194 Rind, B. 181–4 Rispens, J. 336 Rivara, F. P. 335 Roberts, K. P. 268 Robinson, John 5, 158 Rodi, M. 338 Rogeness, G. A. 118, 119 Rogers, J. 53 Rogosch, F. A. 17–18 Rohde, C. A. 340 Rohner, R. P. 114 Rohrbeck, C. A. 142 Roland, B. 172 Romano, B. 218 Romans, S. E. 141 Rorty, M. 142 Rosenbaum, M. 25 Rosenberg, J. 216 Rosenthal, Robert 262 Ross, D. F. 251–2 Rossotto, E. 142 Roussotte, F. F. 195 Rubin, D. M. 76 Rudy, L. 252, 253 Ruggiero, J. 135 Runtz, M. 141, 172, 173, 174,
175, 176, 177, 179 Runyan, D. K. 335
Sadovi, C. 99 Safranek, L. 101 Sagatun, I. J. 12, 49, 104, 200,
247, 281, 282, 283, 284, 289, 299
St.-Laurent, D. 120 Saldana, L. 331, 342 Salerno, C. 78 Salihu, H. M. 192 Salkever, D. S. 340 Salter, A. 51
Salus, M. K. 303, 308, 310, 311, 312, 313, 315, 316, 317, 318, 319, 320, 321, 323, 324
Salzinger, S. 26, 28, 30, 32, 34, 38, 39, 86, 88
San, J. 113 Sanders, M. R. 331–2 Santrock, J. W. 195, 196, 197 Saradjian, A. 164 Satayathum, S. 194 Saunders, B. 175, 338 Saxena, S. 99 Saywitz, K. 277–8 Scannapieco, M. 24, 25 Schaefer, C. 133 Schneemann, M. 83 Schneiderman, M. S. 340 Schreier, H. A. 213–14, 219 Schulte, G. 153 Schumacher, R. B. 167 Schumm, J. A. 87 Schussel, R. 154 Scolforo, M. 52 Sedlak, A. J. 24, 30, 32, 34, 35,
65, 68, 111, 113, 135–7, 154, 156, 290
Sell, J. 235, 236 Senn, T. E. 181 Shafer, A. 53 Shah, R. 195, 209 Shaligram, D. 27 Shannon, D. 159, 160 Shapiro, M. 219 Shaw, L. E. 291 Shaw, R. J. 215, 219 Shedlosky, E. C. 286 Shelman, E. A. 8, 11 Sheridan, M. S. 210, 211, 214,
215, 216, 218, 219 Sherry, J. 53 Shin, S. H. 86 Shivas, Tricha 207 Shoop, R. J. 167–8 Short, E. 194 Showers, J. 334 Sidebotham, P. 28 Siegel, D. M. 217, 221 Siegel, P. T. 212 Sigurdsson, J. F. 163 Silberg, J. L. 184 Silver, H. K. 13–14, 42 Silverman, F. N. 13–14, 42 Silvern, L. 172
Simone, M. 289–90 Simpson, S. M. 194, 203,
204 Singer, L. T. 194 Sirotnak, A. P. 140 Skagerstrom, J. 191 Skellern, C. 71 Slack, D. 27, 110 Slovis, T. L. 77, 79 Small, M. A. 42, 49 Smalley, S. 110 Smith, E. 253 Smith, J. C. 76 Smith, L. 195, 209 Smith, M. C. 52 Smith, M. G. 24 Smithe, G. R. D. 36 Smyke, A. T. 284 Sokol, R. J. 192 Sorenson, E. 258 Sowell, E. R. 195 Sparta, S. N. 180 Spataro, J. 175 Speckhardt, R. 165 Spence, S. A. 224 Spiegel, D. 184 Spitz, Rene 143–4 Srinivas, A. 151–2 Sroufe, A. 118 Stander, V. 37 Starr, R. H. 27, 28, 31, 32,
107 Steele, B. F. 13–14, 42 Steele, L. C. 247, 270 Stein, D. 215, 216, 217, 218,
220, 221 Steiner, V. G. 117 Stevens, M. 190 Stidham, R. 298 Stone, L. 5, 7 Stone-Manisa, K. 200 Storck, M. 180 Stowman, S. A. 105 Strapko, N. 336 Strathearn, L. 84 Straus, M. 38, 104, 145 Streissguth, A. 193 Strouthamer-Loeber, M. 143 Strozier, M. 50 Stutts, T. 226 Sugaya, L. 88 Sugden, K. 241, 242 Swan, R. 109
6241-171-BM4.indd 407 10/19/2013 10:07:15 AM
408 AUTHOR INDEX
Talbot, N. L. 173, 174 Tallon, J. A. 164 Tanaka, M. 88 Tannous, Z. 82 Tardieu, Ambroise 14 Tarnowski, K. J. 86 Tatelbaum, R. C. 341 Taylor, A. 241, 242 Taylor, J. 335 Teicher, M. H. 86 TenBensel, R. W. 4, 7, 9 Teoh, Y. 270 Terner, A. 258 Terplan, M. 194, 195 Terry, K. J. 164 Thai, N. 286 Thomas, M. L. 14, 169 Thomas, S. D. 175 Tice, L. 176 Toglia, M. P. 251–2 Tonmyr, L. 135 Tremblay, G. 29, 331, 342 Trickett, P. K. 36, 113 Tromovitch, P. 181–4 Tugade, M. M. 230, 234 Turner, H. 154–5 Twentyman, C. T. 119,
142 Tyler, A. H. 338 Tyler, K. A. 181 Tyrggvadottir, H. B. 16
Urban, M. A. 181 Urquiza, A. 38 Ursano, R. J. 36, 37
Vanable, P. A. 181 VanBergeijk, E. O. 47 Van Dang, V. 83 Van den Noortgate, W. 342 van Harmelen, A. L. 142 Varness, T. V. 95, 96 Vaughan, C. 99 Veronen, L. J. 175 Vertue, F. M. 142
Vickerman, K. A. 87 Vieth, Victor I. 51, 164, 165,
170 Viljoen, J. L. 263 Villeponteaux, L. A. 175 Vinovskis, M. A. 5 Violato, C. 171 Visk, J. 160 vonHahn, L. 217
Waldfogel, J. 30 Wallace, H. 114 Wallin, A. R. 279 Walsh, K. 53 Walsh, W. A. 236, 289–90 Walters, J. L. H. 36, 37 Walters, R. 169 Walton-Moss, B. J. 197 Ward, E. A. 174 Ward, M. 194, 203, 204 Warren, A. R. 266–7 Watkins, S. A. 9, 11 Watson, M. W. 258–9 Watt, J. W. 27 Weierich, M. R. 144 Weiss, K. J. 99 Weisz, V. 286 Wells, D. L. 175 Wells, K. 77 Wells, S. 311, 312 Wengrovius, E. 15 Wenzel, K. 135 Wescoe, S. 262 West, Samuel 14 Weston, E. A. 280 Whitaker, K. 341 White, J. W. 51 White, M. 151–2 Whittaker, J. K. 310, 316 Widom, C. S. 85, 88, 120, 121,
235, 236, 329 Wiebel, A. 27 Wilhelm, S. 99 Wilkinson, I. D. 224 Williams, G. M. 84
Williams, L. 155, 167, 178 Williamson, J. M. 33, 131 Wilson, D. 325 Wilson, M. 170 Wilson, R. E. 192 Wind, T. W. 172 Windham, A. M. 340, 341 Winton, M. A. 24, 110, 120 Wise, P. H. 198 Wodarski, J. S. 118 Wolak, J. 152, 169 Wolcott, D. 303, 315, 318, 319,
321 Wolfe, D. A. 126–7, 133, 328,
344 Wood, J. M. 268 Woodall, C. E. 266–7 Wooley, B. 176 Worcel, S. D. 287 Wouldes, T. A. 209 Wright, A. 145 Wright, D. B. 251 Wright, M. O. 141, 237, 238,
239 Wright, T. 194, 195 Wurtele, S. K. 336
Yaeger, D. 168 Yager, J. 142 Yang, B. 242 Yeatman, G. W. 83 Yoo, J. 27 You, S. 173
Zaidi, L. Y. 156, 173, 174 Zajac, K. 338 Zazyczyny, K. A. 76 Zeanah, C. H. 284 Zelhart, P. 172 Zimmerman, I. L. 117 Zolotor, A. J. 335 Zuckerman, B. 194 Zuravin, S. J. 26, 27, 28, 31, 32,
107 Zwickl, S. 181
6241-171-BM4.indd 408 10/19/2013 10:07:15 AM
- Cover
- Title
- Copyright
- CONTENTS
- Dedication
- Preface
- Acknowledgments
- Author Biographies
- PART I Introduction/Purpose
- CHAPTER 1 Introduction
- A Brief History of Child Maltreatment
- Responding to Children in Crises
- Research on Maltreatment
- Conclusion
- Discussion Questions
- CHAPTER 2 Risk Factors for Child Maltreatment
- Family Factors
- Child Factors
- Extrafamilial Factors
- Cultural Factors
- Conclusion
- Discussion Questions
- CHAPTER 3 Mandated Reporting
- The History of Mandated Reporting
- Persons Required to Report
- When to Report
- How to Report
- Failure to Report
- Education Regarding Mandated Reporting
- Confidentiality and Mandated Reporting
- Is Mandated Reporting a Good Thing?
- Conclusion
- Discussion Questions
- PART II Types of Abuse and Their Effects
- CHAPTER 4 Physical Abuse
- Definition
- Prevalence and Incidence
- Corporal Punishment
- Consequences of Physical Abuse
- Caution: Not All Marks Are Signs of Abuse
- Marks From Folk Medicine Practices
- Nonphysical Consequences of Physical Abuse
- Conclusion
- Discussion Questions
- CHAPTER 5 Child Neglect
- Definition
- Subtypes of Neglect
- Incidence
- Consequences of Neglect
- Intergenerational Transmission of Neglect
- Conclusion
- Discussion Questions
- CHAPTER 6 Psychological Maltreatment
- Definition
- Defining a Line on a Continuum of Behavior
- Incidence
- Consequences of Psychological Maltreatment
- Conclusion
- Discussion Questions
- CHAPTER 7 Sexual Abuse
- Definition
- Incidence and Prevalence
- Perpetrators
- Victims
- Extrafamilial Child Sexual Abuse
- Child Sexual Exploitation
- Consequences of Sexual Abuse
- Conclusion
- Discussion Questions
- CHAPTER 8 Fetal Abuse
- Definition
- Incidence
- Causes of Fetal Abuse
- Effects of Drugs on Prenatal Development
- Responding to Fetal Abuse
- Conclusion
- Discussion Questions
- CHAPTER 9 Munchausen by Proxy Syndrome
- Definition
- Victims
- Perpetrators
- Incidence
- Risk Factors
- Consequences of MPS
- Investigation of MPS
- Controversies Related to MPS
- Conclusion
- Discussion Questions
- CHAPTER 10 Resilience
- Definition
- Conclusion
- Discussion Questions
- PART III Legal Issues
- CHAPTER 11 Forensic Interviewing of Child Victims
- Children Providing Testimony
- The Accuracy of Children’s Testimony
- Recommendations for Conducing Good Forensic Interviews
- Conclusion
- Discussion Questions
- CHAPTER 12 The Legal System and Child Maltreatment
- Children and the Courtroom
- Types of Courts
- Testifying in Court
- Conclusion
- Discussion Questions
- PART IV What Happens Next
- CHAPTER 13 The Maltreated Child and Child Protective Services’ Response: What Happens After a Report Is Made?
- Intake and Screening
- Investigation and Initial Assessment
- Family Assessment
- Case Planning
- Service Provision
- Family Progress
- Case Closure
- Decision Making
- Conclusion
- Discussion Questions
- CHAPTER 14 Preventing Child Maltreatment
- Overview of Prevention Programs
- A Public Health Issue
- Primary Prevention
- Secondary Prevention
- Conclusion
- Discussion Questions
- Appendix of Abbreviations
- Glossary
- References
- Subject Index
- Author Index
