Child Abuse and Academic Perfomance of Children
Abuse and/or neglect can have a damaging effect a child’s ability to develop adaptively in a broad range of areas – academic performance, family relationships, social interactions and psychological functioning. Abused and/or neglected children are vulnerable to developing mental health problems such as social skills deficits, posttraumatic stress disorder and other anxiety disorders, depression, or behavior problems. Understanding the nature and extent of abuse and neglect and their consequences for children is critical to the design of prevention and treatment programs.
In this issue of the NYU Child Study Center Letter, we discuss definitions and manifestations of the various types of child maltreatment, incidence, psychological effects, which children are vulnerable to being abused, available services, and mental health treatments that have been found to be effective for those who have been maltreated. AG/HSK Introduction Amber, a 6-year-old underweight, unkempt girl, was brought to a pediatric emergency room with a shoulder fracture and numerous old scars.
When questioned, she told a vague story of a fall occurring several days earlier, but she acknowledged that her dad often hit her with an electrical cord and had pushed her down a staircase. Jenny, aged 7, was described by her teacher as a withdrawn, quiet child who seemed somewhat distant from her peers. Although she had been an excellent student in the first grade, her second grade performance was below average. On several occasions, the teacher had observed her masturbating while she was working at her desk.
Jenny complained that she was tired, had trouble falling asleep at night and was often awakened by nightmares. When the psychologist spoke with Jenny, she learned that her mother had recently remarried and worked on the weekend, at which time Jenny was cared for by her step-father. Further exploration revealed that Jenny’s stepfather would often have a “funny smell on his breath” and then he would engage Jenny in mutual genital stimulation. Sean, 15 years old, is constantly berated by his parents. Neighbors report that Sean’s parents tell him they’re sorry he was ever born and call him stupid and ugly.
They threaten to send him to a “reform school” because they don’t like his friends. Sean attends school only when forced to and does not respond to overtures by his teacher, stating that he’s afraid she’ll tell his parents that he’s “bad. ” Situations like these are happening every day in the United States and around the world. The psychological, educational, and economic costs of child abuse and neglect are tremendous. In spite of the fact that 90% of Americans think child abuse is a serious problem, only 1 in 3 report abuse when confronted with an actual situation.
These children and the system that serves them are in need of attention. What are child abuse and neglect? How often do they occur? Definitions of child abuse and neglect vary across systems (e. g. , legal, medical, mental health, economic, child welfare, cultural). Even within one system, such as the legal system, definitions vary across states. New York State law specifies that “Child maltreatment involves any act of commission or omission which endangers or impairs a child’s physical or emotional health and development” (ChildhelpUSA. org).
Types of maltreatment include physical abuse, sexual abuse, emotional/psychological abuse, and neglect. Clearly, these forms of maltreatment are not mutually exclusive; for example, about 50% of physically abused children also experience neglect. The following is a summary of information from a chapter on child abuse and neglect. 1 education • clinical care • professional training • scientific research • school outreach • information update SCHOOL OF MEDICINE NEW YORK UNIVERSITY Kenneth G. Langone Chairman, Foundation Board of Trustees Robert M.
Glickman, M. D. Dean NYU School of Medicine Child physical abuse (CPA) has been defined as injury to a child or adolescent by a parent or other caregiver after intentional physical contact. It is defined not by the acts, but the results of the acts (e. g. , bruises, burns, broken bones). The physical injury may result from many different acts, including hitting, kicking, slapping, shaking, burning, choking, throwing, whipping, and/ or paddling. National surveys have been conducted to determine the incidence of CPA and other forms of abuse and neglect.
Based on these studies, cases of physical abuse were reported for 9 per 1,000 children per year. However, when children (instead of child protective services workers) are surveyed about their experiences, the rates are much higher. In fact, a national anonymous survey of adolescents found that abusive physical punishment occurred with 13% of the teens in a given year. Child sexual abuse (CSA) involves any form of sexual activity with a child or adolescent in which consent is not or cannot be provided (e. g. , if there is a significant disparity in age, development, or size). The sexual activity often includes physical contact (e. g. , penetration, touching) and may also reflect non-contact sexual acts (e. g. , exposure to pornography). Examples of sexual abuse include: fondling, penetration, pornography, exhibitionism, child prostitution, and forced observation of sexual acts. Incidence of CSA also depends on the group surveyed. In the aforementioned national surveys the national reporting rate by professionals was 4. 4 per 1,000 children. However, national surveys of the children themselves ndicate that the rates may be about ten-times higher than the reports made by professionals working with children. Retrospective reports from adults reveal even higher rates. Telephone and mail surveys of a national group of adults indicated that about 30% of women and 15% of men reported that they had experienced sexual assault before they were 18 years old. Editorial Board Harold S. Koplewicz, M. D. , Founding Editor Arnold and Debbie Simon Professor of Child and Adolescent Psychiatry Director of the Child Study Center New York University School of Medicine Anita Gurian, Ph.
D. , Editor Executive Editor, www. AboutOurKids. org Clinical Assistant Professor New York University School of Medicine Howard Abikoff, Ph. D. Pevaroff-Cohn Professor of Psychiatry Director of Research Child Study Center New York University School of Medicine Robert Cancro, M. D. Professor and Chairman Department of Psychiatry New York University School of Medicine Gabrielle A. Carlson, M. D. Professor of Psychiatry and Pediatrics New York State University at Stony Brook Stella Chess, M. D. Professor of Child Psychiatry New York University School of Medicine Gail Furman, Ph.
D. Women’s Commission on Refugee Women and Children, United Nations Glenn S. Hirsch, M. D. Assistant Professor of Clinical Psychiatry Deputy Director, Child Study Center Medical Director, Division of Child and Adolescent Psychiatry New York University School of Medicine Rachel Klein, Ph. D. Professor of Psychiatry New York University School of Medicine Maria Kovacs, Ph. D. Professor of Psychiatry University of Pittsburgh School of Medicine Wade P. Parks, M. D. , Ph. D. Professor and Chairman Department of Pediatrics New York University School of Medicine
Emotional or psychological abuse is hypothesized to be embedded in all other forms of abuse. It encompasses “any attitude or behavior which interferes with a child’s mental health or social development. ” Examples include: yelling, screaming, name calling, shaming, negative comparisons to others, and telling children they are “bad” or “no good. ” Another aspect of emotional abuse is the failure to provide the affection and support necessary for the development of a child’s emotional, social, physical and intellectual well-being.
Examples include: ignoring, withdrawal of attention, lack of praise, and lack of positive reinforcement. Although attention to other forms of abuse has increased in recent years, there is little understanding of the incidence of emotional or psychological abuse. Neglect, unlike abuse, is defined by the absence of specific events. There are currently five identified types of neglect. 1) Physical neglect is defined as a failure to provide for a child’s physical needs. This includes failure to provide adequate food, clothing, and shelter. ) Emotional neglect is defined as a failure to provide for a child’s emotional needs. In extreme cases, this can lead to nonorganic failure to thrive (stunted growth and physical illness/ abnormalities). 3) Medical neglect is defined as a failure to provide or comply with prescribed medical treatment for a child (e. g. , immunizations, surgery, medications). 4) Mental health neglect is defined as a failure to provide or comply with recommended corrective or therapeutic procedures in cases of serious emotional or behavioral disorders.
This is not widely accepted and investigated as a form of neglect. 5) Educational neglect is defined as a failure to comply with state requirements for school attendance. Incidence of neglect is unknown, partially due to the fact that there may be no visible sign to caregivers outside of the home (e. g. , teachers, pediatricians). education • clinical care • professional training • scientific research • school outreach • information update When the worst happens: Fatalities Every day in the United States, more than 3 children die as a result of child abuse and neglect.
Most of the children who die are younger than 6 years old. More preschoolers die from child abuse and neglect than any other cause of death (such as falls, choking on food, suffocation, drowning, residential fires, and motor vehicle collisions). • they were not functioning well prior to the abuse/neglect • they blame themselves for the abuse/ neglect and its consequences • they view the world as a dangerous place • they lack social support • they lack concrete coping skills What is known about the psychological functioning of abused and/or neglected children varies by type of maltreatment.
The following is a summary of extant research for each type of abuse and neglect. What must be highlighted is that there is no symptom cluster that we can use to identify a child as having been abused and/or neglected. Sexually abused children have been found to experience symptoms of posttraumatic stress disorder (PTSD), a combination of symptoms that involves reliving the trauma over and over, avoiding things that remind one of the trauma, anxiety responses in the body, behavior problems, and interpersonal deficits.
As many as 50% of sexually abused children meet criteria for PTSD, a higher rate than for any other form of abuse or neglect. Even if they do not meet full criteria, the majority of sexually abused children experience PTSD symptoms. Behavior problems of sexually abused children appear to differ by age. The caregivers of younger children report oppositional, aggressive, and defiant behavior. Adolescents tend to engage in risky behavior, such as drug use, eating disorders, and running away from home. Across childhood, sexual behavior problems are associated with having been sexually abused.
As with PTSD, children who have been sexually abused are more likely to exhibit sexual behavior problems than children who have been physically abused and neglected. Interpersonally, sexually abused children tend to be less socially skilled and more isolated. Feelings of shame and being different from other children exacerbate these interpersonal deficits. The symptoms experienced by physically abused children and sexually abused children overlap. Children who have been physically abused have been found to have symptoms of anxiety, depression, low selfesteem, behavior problems, and interpersonal problems.
Although these children have lower rates of PTSD, hypervigilance (a symptom defined as an extreme awareness of one’s surroundings and personal space) is a frequently reported symptom. Symptoms of separation anxiety and generalized anxiety disorders also are common among physically abused children. Behavior problems observed include aggression, juvenile delinquency, and oppositional behavior, occurring with parents, teachers, and peers, in both home and school settings. Physically abused children may have a variety of interpersonal deficits, including misreading of social cues, lower status among peers, and fewer social skills.
Their social networks tend to be more insular and negative. Our understanding of the impact of neglect on children’s psychological functioning is limited by the dearth of research in this area. Based on studies of children exposed to different types of neglect, preliminary findings indicate that these children may experience attachment problems, regressive behavior, learning problems, low self-esteem, and juvenile delinquency in later years. Compared to abused children, neglected children are less aggressive, less interactive with peers, more passive, and more depressed.
Neglected (versus abused) children tend toward helplessness under stress and have more severe developmental delays. Emotional abuse, as mentioned, may be a component of the other forms of abuse and neglect. Thus, emotionally abused children would be vulnerable to the symptoms described previously. Emerging research reveals that neglected children may experience insecure attachment relationships, aggression with peers and other behavioral problems, learning problems, low selfesteem, depression, failure to thrive, somatic symptoms and bed wetting.
Some psychologists have argued that emotional abuse may be the best predictor of maladaptive developmental outcomes. Which children are more vulnerable to abuse and neglect? Various characteristics of abused children have been examined by child protective services agencies for their association with physical abuse, sexual abuse, and neglect. Girls are 4 times more likely than boys to be sexually abused, whereas there are no gender differences for neglect and physical abuse. Older children are more likely than younger children to be abused or neglected.
There are no significant differences in maltreatment rates by race. Children living in single-parent homes may be more at risk for physical abuse and neglect than children living in two-parent homes. Families with limited financial resources are much more likely to maltreat children than families with annual incomes above $30,000. What are the effects of abuse and neglect? Abuse and neglect may interfere with a child’s development in various ways. Relationships with other people, self-esteem, physical activity, academic performance, and psychological functioning are impacted by child abuse and neglect.
Not all children however, will show the same results. What predicts children’s psychological responses to abuse and/or neglect? Children are more vulnerable to the development of psychological problems if: • Abuse/neglect is more severe (longer duration of each incident, more chronic, more physical injury, more abusers) • they are younger when the abuse/ neglect begins • they have a closer relationship to the abuser education • clinical care • professional training • scientific research • school outreach • information update What if abuse or neglect is suspected?
If you are a child who is being abused and/or neglected, a caregiver who fears s/he may be at risk for abusing a child, or a concerned citizen who suspects that a child may be abused or neglected, you can contact your local state child maltreatment hotline. In New York State the number to call is: 1-800-3423720 (in state), 1-518-474-8740 (out of state). Child protective specialists will take the report or help decide if a report should be made. The investigation is initiated within 24 hours of the report and findings on the existence of abuse/ neglect are decided within 60 days of the report.
Mental health treatment of abused and neglected children: what the research tells us Over the past decade, there has been an exciting shift in the attention given to testing different forms of therapy for abused and neglected children. A number of rigorously conducted studies have found that cognitive behavioral therapy (CBT) is efficacious for children exposed to sexual and physical abuse. 4 Compared to other forms of therapy, CBT decreases symptoms of PTSD, general anxiety, depression, behavior problems, and social skills deficits.
The data suggest the importance of focusing directly on the traumatic event and including both children and their caregivers. To date, there has been no rigorous study comparing different interventions for neglect. According to Erikson and Egeland (2002),5 extant research indicates that interventions are successful with no more than 50% of participating families. Neglectful families may be difficult to engage in services because parents can be disorganized, distancing, or depressed. The most effective interventions are those that are comprehensive and relatively longterm.
One analysis of numerous prevention programs indicated that individualization may be critical for success. 6 Individualization means that different strategies are needed for different families dealing with different issues. Other factors to take into account include: child’s age, gender, and race, family composition, and characteristics of the parents (need for parent training, substance abuse treatment, etc. ) Cognitive Behavioral Therapy (CBT) This type of treatment involves both the abused child and caregiver.
The goals of therapy for the children are to provide a model for them to understand their reactions to abuse, normalize their experiences and symptoms, teach coping skills for upsetting thoughts, feelings, and behavior, and discuss the abusive events. The specific techniques can be tailored to take into account developmental differences (e. g. , age, cognitive development). Education is used to define child abuse, help children label and identify emotions, and teach the relationship between emotions, thoughts, and behaviors.
Coping Skills Training is designed to provide skills for children to cope with the diversity of abuse-related emotions. Relaxation Training provides training in diaphragmatic breathing and progressive muscle relaxation. A simple, two-step procedure (e. g. , acting like a “tin soldier,” then a “wet noodle”) is used with younger children, whereas progressive muscle relaxation is used with teenagers. These are portable techniques that children can implement in multiple settings in which symptoms arise (e. g. , classroom, home, car).
Cognitive Restructuring helps children systematically identify and challenge negative or distorted thoughts that may be precursors of emotional and behavioral problems. Anger Management Skills teach children to recognize anger-producing situations and implement problem solving through didactic exercises and role plays. Telling about the Abuse is designed to habituate children to cues of the abuse (e. g. , smells, sights, sounds) without the feared consequences, such that emotional distress and avoidance decrease.
Personal Safety Training involves communication skills training and developing a safety plan. Throughout therapy, techniques such as role plays and homework are used to practice the various skills and generalize in-session symptom reduction to real life situations. The therapist spends the end of each session in a joint meeting with the caregiver and child to review the content of the session and homework, such that the caregiver provides guidance to the child with skill acquisition and rehearsal.
The goals of therapy for the parents are to normalize their feelings and thoughts Services: Who gets what? Given the potential impact of abuse and neglect on children, there is an arguable need for services. The commonalities in symptoms across abuse types reveal that children experiencing physical or sexual abuse may benefit from similar mental health interventions. In contrast, service delivery studies indicate that physically and sexually abused children are receiving different types of services.
Investigations of families referred to child protective services found that victims of sexual abuse are more likely to receive any form of intervention than victims of physical abuse. When services are provided, sexually abused children tend to receive individual therapy, whereas physically abused children tend to receive inhome crisis services. 3 Neglected children (with or without exposure to abuse) have service needs that extend beyond mental health interventions. These children may benefit from improved housing, food stamps, clothing, medical care, and consistent school attendance.
There have been no studies of typical services provided to neglected children. education • clinical care • professional training • scientific research • school outreach • information update about their child’s experience, teach them the coping skills such that they can coach their children in the use of the skills, and provide behavior management training for externalizing symptoms. Using education, the parent is taught the relationship between emotions, thoughts, and behaviors, and relates this model to the treatment rationale.
Parent coping skills sessions include relaxation training and cognitive restructuring to help parents with their own symptoms and help them model coping skills for their children. A recommended model for parent training on behavioral management, particularly useful for families with abused children is Forehand and McMahon’s (2003)7 intervention program that has been shown to improve parenting practices with noncompliant children. The process is designed to encourage problemsolving skills through discussion, role playing, rehearsal, and live therapist feedback.
Program topics include: attending, rewards, ignoring, clear instructions, consequences for compliance and noncompliance, and standing rules. Training methods utilized are: instruction, modeling, rehearsal, practice with child while being observed and coached, utilization of behavioral criteria, and weekly homework. One benefit of cognitive behavioral therapy is its flexibility. The aforementioned treatment techniques can be used in individual, group, or family therapy, and in outpatient therapists’ offices, schools, and psychiatric units in hospitals.
The flexibility also allows the intervention to be adapted to the needs of the particular child. For example, if the child is going to court, education, anxiety management, and role plays should focus on that experience. If the child was abused by a caregiver, it is recommended that treatment begin with a non-offending caregiver while the offending caregiver receives separate treatment. The long-term goal would be to include the offending caregiver in the child’s treatment, building to clarification, a process in which the offender acknowledges the abuse, apologizes for his/her role, and discusses ways to prevent recurrence.
Medication may be relevant for particular symptom clusters, such as, insomnia and depression. Summary Child abuse and neglect is a commonly occurring phenomenon with tremendous psychological and economic costs to our society. Emerging research indicates that maltreated children may experience a variety of mental health problems, including PTSD and other anxiety disorders, depression, poor self-esteem, social skills deficits, and behavior problems. If not treated, these problems may persist through adolescence into adulthood.
In fact, abuse and neglect may have long term effects on a child’s selfesteem, relationships, professional success, and sense of wellbeing. Recent treatment studies inform us of the effectiveness of cognitive behavioral therapy. Next steps include making this type of therapy more available to patients through outreach, public education, and training of therapists in the techniques. References l. Runyon, M, Kelly, MC, Berry, EJ, Deblinger, E, & Brown, EJ (in press). Incidence and surveillance of child maltreatment, In J. Lutzer (Ed. ) Violence prevention. Kolko, DJ & Brown, EJ (2000) Child sexual abuse.
In RT Ammerman & M Hersen (Eds. ) Case studies in family violence. 2nd Ed. , pp. 177-207. New York: Plenum Publishing. Kolko, DJ, Selelyo, J, & Brown, EJ (1999) The treatment histories and service experiences of physically and sexually abuse families. Description, correspondence, and correlates. Child abuse and neglect, 23, 459- 476. Brown, EJ, Albrecht, A, MunozSilva, DM, McQuaid, J & Silva, R (in press) Treatment of children exposed to trauma: Research findings and therapy guidelines. In R. Silva (Ed. ) Handbook for posttraumatic stress disorder in children and adolescents.
New York, NY: Norton Medical Publications. Erickson, MF & Egeland, B (2002) Child neglect. In JB Myers, L Berliner, J Briere, CT Hendrix, C Jenny, TA Reid (Eds. ) APSAC handbook on child maltreatment, 2nd Ed. (pp 3-20) Thousand Oaks, CA: Sage Publications. Wekerle, C, & Wolfe, DA (1993) Prevention of child abuse and neglect: Promising new directions. Clinical psychology review, 13(6), 501-540. Forehand, R & McMahon, RJ (2003) Helping the noncompliant child: A clinician’s guide to parent training, 2nd Ed. New York: Guilford Press. 2. 3. 4. About the Authors
Elissa J. Brown, Ph. D. , is Assistant Professor of Psychiatry, Child Study Center, NYU School of Medicine. Dr. Brown’s primary clinical and research interests include the prevention and treatment of child trauma and posttraumatic stress disorder. She has participated in research on the psychosocial sequelae and treatment of sexual assault, child physical abuse, and children with sexual behavior problems. Dr. Brown is the principal investigator of a 5-year grant from the National Institute of Mental Health to study the treatment of child physical abuse .
She is one of the investigators for a center grant from the Substance Abuse and Mental Health Services Administration to join the National Child Trauma Center. Shamir A. Khan is a doctoral candidate in Clinical Psychology at Teachers College, Columbia University. He is also a Research Assistant at the Child Study Center on a study of traumatically bereaved children. His primary research interests include the interactions between child trauma and family functioning. 5. 6. 7. education • clinical care • professional training • scientific research • school outreach • information update
Helpful Links from ChildhelpUSA. org Arizona Child Abuse InfoCenter Child Welfare League of America Child Welfare League of America National Data Analysis System CWLA, in cooperation with the nation’s state child welfare agencies, provides a comprehensive, interactive child welfare database. Internet users can create customized tables and graphs, as well as access information and links to additional information. Child Trends Data Bank Children’s Action Alliance Children’s Defense Fund Children Now KIDS COUNT Data Book (Annie E.
Casey Foundation) MEDLINEplus® (A service of the U. S. National Library of Medicine and the National Institutes of Health) MEDLINEplus® Informacion de Salud (Un servicio de la Biblioteca Nacional de Medicina EE. UU. y los Institutos Nacionales de la Salud) National Clearinghouse on Child Abuse and Neglect Information: The nation’s largest database of child maltreatment and related child welfare materials. Includes publications, fact sheets, searchable databases, child abuse reporting telephone numbers, statistics, and summaries and analyses of state laws.
Parents Anonymous Prevent Child Abuse America Search Engine for Children: This site contains over 20,000 child-safe sites, and over 4,000 categories including the arts, computers, directories, entertainment, games, health, news, people, pre-school, school time, sports, hobbies, and family. Stand for Children State Sex Offender Registries U. S. Department of Health and Human Services, Children’s Bureau: Produces two primary sources of national statistics on child abuse and neglect, which are Child Maltreatment: Reports from the States to the National Child Abuse and Neglect Data System (NCANDS) and the National Incidence Study (NIS), vailable from the National Clearinghouse on Child Abuse and Neglect. AboutOurKids Related Articles About Posttraumatic Stress Disorder (PTSD) http://www. aboutourkids. org/articles/about _ptsd. html About Reactive Attachment Disorder of Infancy or Early Childhood http://www. aboutourkids. org/articles/about _attachment. html Helping Children Develop Healthy Sexual Behavior and Attitudes http://www. aboutourkids. org/articles/ sexual_development_part2. html Institute for Trauma and Stress http://www. boutourkids. org/programs/ trauma_stress. html Resources for Helping Children Cope with Trauma and Loss http://www. aboutourkids. org/articles/crisis _index. html Towards a Better Understanding of Children’s Sexual Behavior http://www. aboutourkids. org/articles/ sexual. html Child Study Center 5 5 0 F i r s t A v e n u e N e w Yo r k , N Y 1 0 0 1 6 (212)263-6622 NEW YORK UNIVERSITY The NYU Child Study Center Letter is published five times annually. Letter SCHOOL OF MEDICINE