*Methodological differences in samples, criteria and definitions
Looking at prevalence, May-Chahal and Cawson (2005) found that 16% of 2,869 18–24 year olds in the UK self-reported intra- or extra-familial maltreatment in childhood. However, as noted, prevalence rates are highly dependent on methodology, making comparisons between different studies difficult (Gilbert et al., 2009). Thus, gaining estimates from a variety of studies can be useful. A recent meta-analysis of worldwide prevalence of child maltreatment based on 244 studies and 551 prevalence rates, found that the overall estimated rates were 363 per 1,000 children for emotional abuse, 226 per 1,000 for physical abuse, 184/163 per 1,000 for emotional and physical neglect (respectively), and 127 per 1,000 for sexual abuse (Stoltenborgh, Bakersman-Kranenburg, Alink, & van IJzendoorn, 2015). The authors noted that, from the studies they reviewed, prevalence rates are similar across countries but cautioned that most research was conducted in developed countries, looked at child sexual abuse and used self-report methodologies.
In summary, rates of child abuse and neglect vary considerably depending on sample selection, methodology and definitions. Thus, caution needs to be taken in interpretation of findings and it can be useful to review trends. For example, in recent years, some research has indicated that sexual and physical abuse have declined in prevalence from 2003 to 2008 in the United States, whilst caregiver physical maltreatment and witnessed sibling victimisation have increased (Finkelhor, Turner, Ormrod, & Hamby, 2010). Given the difficulties inherent in this type of research, however, this assertion is still very much under debate.
5.2.3 Effects of Childhood Maltreatment
Negative effects of childhood maltreatment are found in both childhood (Table 5.4) and ongoing into adulthood (Table 5.5). These will be discussed further below, with particular focus on the possibility of the intergenerational cycle of maltreatment. However, it is also acknowledged that some children are able to emerge from maltreatment experiences showing functional, adaptive behaviour in their day-to-day life, known as resilience (Goldstein & Brooks, 2005; Masten & O’Dougherty Wright, 2010).
PHOTO 5.1 Whilst all forms of maltreatment have been found to have an effect, some studies suggest that psychological maltreatment or emotional abuse has the most negative impact.
Source: © Suzanne Tucker/Shutterstock
Table 5.4 Effects of maltreatment in childhood
Outcome
Death
Physical and mental disability
Mental health difficulties (e.g. post-traumatic stress, eating disorders, self-injurious behavior)
Physical health difficulties (e.g. sleep disorders, enuresis, encopresis, stress)
Emotional difficulties (e.g. low self-esteem, poor self-worth)
Behavioral difficulties (e.g.,antisocial behavioural, criminal acts, substance misuse)
Educational difficulties and failure
Impact on social and interpersonal functioning (e.g. relationships with others, attachment difficulties)
Risk of further victimisation
Table 5.5 Long-term effects in adulthood following childhood sexual abuse found in a review of 25 meta-analyses (adapted from Hillberg, Hamilton-Giachritsis, & Dixon, 2011)
Symptom Effect size range (Pearson’s correlations coefficient; r)
Alcohol problems .07
Anger .18
Anxiety .13–.20
Borderline personality disorder .28
Depression .12–.22
Dissociation .09–.19
Eating disorders .06–.10
Hostility .11
Interpersonal sensitivity .10
Interpersonal problems .19
Obsessive-compulsive symptomatology .10–.17
Paranoia .11
Phobia .12
Post-traumatic stress disorder .20
Psychological adjustment problems .10–.27
Psychotic symptoms .11
Self-esteem impairments .04–.17
Self-mutilation .20
Sexual adjustment .09–.18
Sexual promiscuity .14
Social adjustment .07
Somatisation .09–.17
Substance use .20
Suicidal ideation and behaviour .09–.22
Traumatic stress symptoms .25
5.2.3.1 In childhood
Unfortunately, death and/or disability are the most extreme forms of outcome following childhood maltreatment. In the US, France and the UK, most fatalities occur in children under the age of 5 years, with the greatest percentage of deaths in infants under 1 year old with head injury, physical battering and/or severe neglect the most common causes (Kleevens & Leeb, 2010; Makhlouf & Rambaud, 2014; Sidebotham, Bailey, Belderson, & Brandon, 2011). However, in Germany, it has been noted by some authors that issues with recording, investigation and decisions as to cause of death mean that data should be viewed as unreliable (Banaschak, Janβen, Schulte, & Rothschild, 2015) and, hence, should be treated with caution.
In terms of rates, it was estimated that 0.56 per 100,000 children in France were fatally maltreated per annum in 1991–2008 (Makhlouf & Rambaud, 2014) with a similar UK rate of 0.63 cases per 100,000 children per year between 2005 and 2009 (Sidebotham et al., 2011). The most common causes of death were severe physical assaults and severe neglect (Makhlouf & Rambaud, 2014; Sidebotham et al., 2011). In the US, the rate in 2009 was higher at 2.34 deaths per 100,000 children (U.S. Department of Health and Human Services et al., 2010). In the UK study, the median age of the children was 16 months, with boys more likely to experience physical assaults, girls to be victims of severe neglect and older children to be victims of murder attempts, with just under a third of families known to child protection agencies. A national U.S. study similarly found that younger children living with both parents were more likely to be fatally maltreated, but there was also greater financial and housing difficulty in the family, when compared to children who were maltreated but survived (Douglas & Mohn, 2014).
PHOTO 5.2 Early studies showed that boys were more likely to develop externalising symptoms, such as aggressive behaviour and conduct disorders, while girls were more likely to develop internalising symptoms such as depression.
Source: © PhotoAlto/Getty Images
Looking beyond physical outcomes, one of the most identified effects of child maltreatment is the association with mental health and emotional/behavioural difficulties. Perhaps the most prominent of these are depression and other internalising disorders (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010; Kim & Cicchetti, 2006). These can include eating disorders (Nygaard Christoffersen & DePanfilis, 2009), psychological distress (Newcomb, Munoz, & Vargas Carmona, 2009), anxiety (Cougle, Timpano, Sachs-Ericsson, Keough, & Riccardi, 2010) and depression (Bennett, Wolan Sullivan, & Lewis, 2010), as well as self-injurious behaviour/suicidal behaviour, addiction and low self-esteem (see Gilbert et al., 2009 for a review). Whilst all forms of maltreatment have been found to have an effect, some studies suggest that psychological maltreatment/emotional abuse has the most negative impact (Nygaard Christoffersen & DePanfilis, 2009).
Behaviourally, early studies also tended to show that boys were more likely to develop externalising symptoms (such as aggressive behaviour, conduct disorders) and girls internalising symptoms (such as depression; Feiring, Taska, & Chen, 2002). More recently, all forms of child abuse and neglect have been associated with victims going on to experience at least eight out of ten adolescent health risks, including depression, regular alcohol use, binge drinking, 30-day marijuana or alcohol use in the past month, inhalant use and serious fights (Hussey, Chang, & Kotch, 2006).
However, one difficulty is understanding the distinction between the effect of the child maltreatment itself and other possible confounding factors, such as family environment, on outcome. Thus, research methodologies need to account for this. For example, one study showed that child maltreatment alone is predictive of internalising and/or externalising difficulties in adolescents, even after c
ontrolling for stressors (family conflict, parental personal difficulties, external constraints in home and community), socioeconomic status and child gender (Herrenkohl & Herrenkohl, 2007). Similarly, in a longitudinal study, children who experienced intentional harm (i.e. maltreatment by an adult or bullying by another child) were significantly more likely to show psychotic symptoms at age 12 years, even after controlling for confounding variables, such as socioeconomic deprivation, lower IQ and genetic vulnerabilities (Arseneault et al., 2011). Thus, maltreatment has a wide range of potential consequences for young people, which may go on into adulthood, and it is important to consider factors related to outcome.
Factors Related to Outcome
Age (stage of development), gender, type, relationship to perpetrator, frequency and severity of maltreatment have all been linked to outcome (Gilbert et al., 2009). Externalising behaviour has been associated with higher frequency of incidents and developmental timing, but impairments of social functioning are more associated with the distribution of incidents over time, suggesting that the child may have time to show resilience in maltreatment-free phases (English, Graham, Litrownik, Everson, & Bangdiwala, 2005). Furthermore, the presence of a supportive caregiver reduces the likelihood of long-term negative effects (Alexander & Lupfer, 1987), yet because the majority of child maltreatment is perpetrated by family members, friends or acquaintances, the likelihood of a supportive family environment is reduced.
There is substantial evidence to suggest that one key outcome of maltreatment is the increased risk of subsequent maltreatment which, in turn, leads to more serious outcomes (Barnes, Noll, Putnam, & Trickett, 2009). Re-referral rates for a child range from 8–13% in four years (Fryer & Miyoshi, 1994) to 43.2% of maltreated infants followed up for 11–15 years (Thompson & Wiley, 2009). Family re-referral rates range from 1–2% (low risk) to over 50% (high risk families) in five years, and may go up to 85% over 10 years (DePanfilis & Zuravin, 1998). However, the risk is highest in the first 12 months following referral (Hindley, Ramchandani, & Jones, 2006), with the risk doubling once a child has been referred on two occasions (Hamilton & Browne, 1999). The presence of other risk factors can compound this. When interpersonal violence and child maltreatment co-occur, a higher number of prior referrals for both forms of family violence and greater severity of IPV have been found (Browne & Hamilton, 1999), and re-referrals occur quicker (Casanueva, Martin, & Runyan, 2009).
In terms of outcomes, in a cohort of 685 children, repeated maltreatment was shown to predict significantly more internalising and externalising behaviours (Li & Godinet, 2014). Furthermore, when the definition of victimisation is extended to include bullying and indirect victimisation, it is found that children who experience multiple victimisation types are more likely to show negative outcomes (Turner, Finkelhor, & Ormrod, 2009). Notably, however, young children who did not immediately show behavioural difficulties post-maltreatment sometimes began to as they progressed towards early adolescence (Li & Godinet, 2014). Thus, it is important to monitor children even significant periods of time after repeated maltreatment.
Mechanisms for negative outcomes
Research has begun to investigate the mechanisms through which child abuse and neglect lead to negative outcomes for young people. For example, familial trauma (compared to non-familial trauma or no trauma) is associated with poorer performance on executive functioning (e.g. working memory, processing speed) even after accounting for SES, anxiety and possible brain injury exposure, which may lead to difficulties academically, but also with social and interpersonal functioning (DePrince, Weinzierl, & Combs, 2009). In addition, those children who experienced physical and sexual abuse before the age of 5 years and showed internalising symptoms were found to have dysregulation of the emotion and stress pathways, via cortisol production (Cicchetti, Rogosch, Gunnar, & Toth, 2010). The authors postulated that genes may be one reason why some children with early sexual or physical abuse develop internalising symptoms and others do not, but note that this requires further investigation.
It has also been hypothesised that difficulties in recognising emotions in others is a by-product of depression, rather than an effect of child maltreatment per se. This hypothesis was investigated in a longitudinal study (Young & Widom, 2014), which found that childhood maltreatment did have an impact on emotion processing beyond childhood and even into middle adulthood. However, major depressive disorder, generalised anxiety disorder, post-traumatic stress, dysthymia and psychopathy did not mediate this relationship (i.e. child maltreatment and deficits in emotion processing), but IQ did. Thus, lower cognitive functioning (IQ) was associated with greater deficits. Limitations of this study include the fact that it was conducted with court-assessed families (hence, had low representation of higher socioeconomic groups) and that IQ was assessed in adulthood not childhood. Nevertheless, the methodology was as rigorous as perhaps can be achieved in the context of this subject and this is an important study.
In summary, associations between childhood maltreatment and negative long-term outcomes have been shown, but the pathways by which this occurs continue to require investigation.
5.2.3.2 Negative effects of child maltreatment in adulthood
In adulthood, long-term effects on mental and physical health, as well as social and emotional functioning from childhood maltreatment have been demonstrated (Table 5.5). Perhaps unsurprisingly, many of the presenting difficulties found in childhood remain in adulthood. The impact on enduring personality features is also more apparent (Kim et al., 2009). Long-term effects even extend as far as increasing risk of premature death in family members (i.e. under 65 years), possibly as a result of chaotic family environments, with the highest risks occurring in families characterised by physical neglect, substance misuse and criminality (Anda et al., 2009).
Individuals who have been maltreated in childhood may also have an increased risk of further victimisation in adulthood through sexual victimisation and/or intimate partner violence (Gilbert et al., 2009) or engagement in criminal behaviour (known as the victim to offender cycle; Farrington et al., 2001). Over 25 years ago, Widom (1989) noted that there was an increased risk of involvement in criminal activity following child maltreatment, which was then supported by other studies (see Falshaw, Browne & Hollin, 1996, for a review). Even then, however, it was also acknowledged that most do not go on to commit crimes (Widom, 1991), with those experiencing recurrent forms of maltreatment most at risk of committing violent crimes (Hamilton, Falshaw, & Browne, 2002).
Another widely debated effect is the risk of maltreated children becoming familial abusers themselves – the so called “intergenerational cycle of maltreatment” (ICM); see Case Study 5.1 for an example). Some argue the rate is as high as 30% +/−5% (Kaufman & Zigler, 1987), but other evidence suggests that in a 13-month follow-up the rate is as low as 6.7% (Dixon, Browne, & Hamilton-Giachritsis, 2005). Given the potential impact of over-emphasising the ICM, it is important to be very clear about outcomes. A 30-year follow-up study of abused children who later became parents has shown that when all types of maltreatment were considered, these parents were twice as likely to be referred to children’s services compared to parents who were not abused as a child (21.4% versus 11.7% respectively; Widom, Czaja, & Du Mont, 2015). However, that is still only one in five of abused children who go onto abuse their own child(ren). The picture is complex, though, and may depend, in part, on the method of data collection; for example, official records may show up some forms of abuse more than others. For example, by utilising data from a variety of sources and three generations, Widom et al. (2015) noted that children of abused parents were more likely to be reported to child protection services for neglect, but that those children were more likely to self-report both neglect and sexual abuse.
CASE STUDY 5.1 RECURRENT VICTIMISATION AND THE INTERGENERATIONAL CYCLE OF MALTREATMENT
Sharon is a single mother in her early thirties. She has four children (two girls and two boys). Her early experiences wer
e both abusive and neglectful, with the maltreatment covering many aspects of her life. Sharon’s mother was an alcoholic and was emotionally abusive towards her; her father was physically violent to Sharon and her mother, as well as some other siblings who all left home as quickly as they could. As a result, Sharon and one sister were taken in and out of care. When Sharon disclosed sexual abuse by a family member, nobody protected her. At school, Sharon was also bullied by other children because of her physically neglected appearance. Thus, there were many negative experiences with few protective factors. From adolescence, Sharon began to show both internalising (i.e. depression) and externalising (i.e. aggressive behaviour, risk-taking behaviour, drinking) consequences. In turn, this made Sharon vulnerable to further victimisation and she was subject to sexual assaults in her teens and early adulthood. As an adult, Sharon has difficulties with substance misuse, self-harming behaviour, depression and aggressive behaviour. She has also been victimised by her partners. Sadly, her relationship with all four of her children appears to be quite emotionally neglectful and physically abusive. They have been exposed to repeated episodes of Sharon’s self-harming and subsequent attendance of medical professionals and/or the police at the house. She admits she does not show them much love but gives them material belongings. Notably, the children are beginning to show similar behaviour and the pattern is being repeated again.
Some have argued that it is the accumulation of risk factors that is most important in the intergenerational cycle of maltreatment (Thornberry et al., 2014). For example, parents abused as a child who also have other risk factors (being a young parent, a history of mental illness or depression, the presence of a violent adult in the household) combined with poor parenting styles (i.e. unrealistic expectations, poor quality of interaction and negative attributions) were more likely to continue the cycle of maltreatment (Dixon, Hamilton-Giachritsis, & Browne, 2005). Notably, the presence or absence of social support and financial security distinguished Cycle Breakers from Maintainers (i.e. who continued the ICM) and Initiators (i.e. non-abused parents who maltreated; see Figure 5.1; Dixon, Hamilton-Giachritsis, & Browne, 2009). This confirms previous studies that have identified the importance of emotional and social support as protective factors for adults with a background of abuse and the absence of support as a risk factor for all parents (Cerezo et al., 1996; Egeland, 1988; Ertem et al., 2000).
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