Abuse affects all dimensions of human development and existence

Physical and neurobiological

In addition to such direct results of trauma as broken bones or ruptured internal organs, physically abused children often display retarded physical growth and poor coordination. Malnutrition may slow the development of the brain as well as produce such dietary deficiency diseases as rickets. In both children and adults, repeated trauma produces changes in the neurochemistry of the brain that affect memory formation. Instead of memories being formed in the normal way, which allows them to be modified by later experiences and integrated into the person’s ongoing life, traumatic memories are stored as chaotic fragments of emotion and sensation that are sealed off from ordinary consciousness. These traumatic memories may then erupt from time to time in the form of flashbacks.

Cognitive and emotional

Abused children develop distorted patterns of cognition (knowing) because they are stressed emotionally by abuse. As adults, they may suffer from cognitive distortions that make it hard for them to distinguish between normal occurrences and abnormal ones, or between important matters and relatively trivial ones. They often misinterpret other people’s behavior and refuse to trust them. Emotional distortions include such patterns as being unable to handle strong feelings, or being unusually tolerant of behavior from others that most people would protest.

Social and educational

The cognitive and emotional aftereffects of abuse have a powerful impact on adult educational, social, and occupational functioning. Children who are abused are often in physical and emotional pain at school; they cannot concentrate on schoolwork, and consequently fall behind in their grades. They often find it hard to make or keep friends, and may be victimized by bullies or become bullies themselves. In adult life, abuse survivors are at risk of repeating childhood patterns through forming relationships with abusive spouses, employers, or professionals. Even though a survivor may consciously want to avoid re-abuse, the individual is often unconsciously attracted to people who remind him or her of the family of origin. Abused adults are also likely to fail to complete their education, or they accept employment that is significantly below their actual level of abilit.

Adverse Childhood Experiences

The  adverse childhood experiences study population included 9,367 (54%) women and 7,970 (46%) men (total sample=17,337). Their mean age was 56 years. Seventy-five percent were white, 39% were college graduates, 36% had some college education, and 18% were high school graduates. Only 7% had not graduated from high school.1,13
The Study assessed 10 categories of stressful or traumatic childhood experiences (seen below). The experiences chosen for study were based upon prior research that has shown them to have significant adverse health or social implications, and for which efforts in the public and private sector exist to reduce the frequency and consequences of their occurrence.
Prior research into the effects of childhood maltreatment and related experiences (including witnessing domestic violence) has tended to focus on only one or two categories of experience, such as physical or sexual abuse or domestic violence, and has generally focused on a limited range of outcomes. The ACE Study is unique not only because of its size, but because it was also designed to assess the relationships of a broad range of adverse childhood experiences (ACEs) to a wide range of health and social consequences.

• Childhood abuse

-Emotional

-Physical

-Sexual

• Neglect

-Emotional

-Physical

• Growing up in a seriously dysfunctional household as evidenced by:

-Witnessing domestic violence

-Alcohol or other substance abuse in the home

- Mentally ill or suicidal household members

- Parental marital discord (as evidenced by separation or divorce)

- Crime in the home (as evidenced by having a household member imprisoned)

The first important conclusion to be drawn is that adverse childhood experiences are very common. Moreover, ACE Study estimates of the prevalence of childhood exposures to physical and sexual abuse are similar to population-based surveys. A national telephone survey of adults conducted by Finkelhor et al. used similar criteria for childhood sexual abuse and determined that 16% of men and 27% of women had been sexually abused; in the ACE Study cohort 16% of men and 25% of women in our sample had experienced contact childhood sexual abuse. In our study, 30% of the men had been physically abused as boys; this closely parallels the 31% prevalence recently found in a similarly structured population-based study of Canadian men. The similarity of the estimates from the ACE Study to those of population-based studies suggests that findings would be applicable in other settings.

The other findings from this study are detailed below:

The effects of ACEs are long-term, powerful, cumulative, and likely to be invisible to health care providers, educators, social service organizations, and policy makers because the linkage between cause and effect is concealed by time, the inability to “see” the process of neurodevelopment, and because effects of the original traumatic insults may not become manifest until much later in life. When a child is wounded, the pain and negative long-term effects reverberate as an echo of the lives of people they grew up with—and then they grow up, at risk for taking on the same characteristics and behaviors—thereby sustaining the cycle of abuse, neglect, violence and substance abuse, and mental illness.

References
Anda RF, Felitti VJ, Walker J, Whitfield, CL, Bremner JD, Perry BD, Dube SR, Giles WH. The Enduring Effects of Abuse and Related Adverse Experiences in Childhood: A Convergence of Evidence from Neurobiology and Epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 2006; 256(3):174-86
Dube SR, Miller JW, Brown DW, Giles WH, Felitti VJ, Dong M, Anda RF. Adverse Childhood Experiences and the Association with Ever Using Alcohol and Initiating Alcohol Use During Adolescence. . Journal of Adolescent Health, 2006;38(4):444.e1-444.e10.
Anda, RF, Felitti, VJ, Brown, DW, Chapman, D, Dong, M, Dube, SR, Edwards, VJ, Giles, WH. (2006) Insights Into Intimate Partner Violence From the Adverse Childhood Experiences (ACE) Study. In PR Salber and E Taliaferro, eds. The Physician’s Guide to Intimate Partner Violence and Abuse, Volcano, CA: Volcano Press; 2006.

Effects of childhood abuse

The effects as an adult can be severe and take years to work through. Often survivors spend years in therapy to overcome the effects of their childhood abuse that has crippled them from functioning normally as adults (Wiehe, 1997). Poor self esteem is a common effect. As children, victims of sibling sexual abuse tend to feel worthless, unwanted, inferior, unloved, and inadequate.

These feelings of worthlessness are often associated with guilt and shame which frequently leads to self-blame for the abuse. These kinds of symptoms can affect a person’s psychological development. Survivors can become overly sensitive to comments or criticism. Even looking for hidden negative meanings in positive messages.

Difficulty with interpersonal relationships and relationships with the gender of the offender are common problems of adult survivors of sibling sexual abuse. (Wiehe, 1997) Survivors tend to be suspicious and untrusting of others. They find it hard to become close to someone and trust them and often have problems controlling anger. Often survivors repeat the victim role in other relationships and enter into abusive relationships with both friends and romantic partners. Even as adults it can be difficult to view negative relationships as abusive because they tend to normalise

their abuse. Survivors can also have the opposite reaction and transfer their emotions about their experience of abuse to the offending gender in general. For example, they may feel fearful or hateful towards all men because the abuse was perpetrated by a brother who is also a man.

Self-blame and guilt are common emotions connected to sibling sexual abuse. The survivor feels that they had somehow allowed themselves to be abused and feel shameful and guilty for not being able to prevent the abuse from occurring. Often survivors blame themselves into adulthood.

These feelings can be made worse if during disclosure, a victim is blamed or not believed. (Wiehe)

Survivors often have extreme anger about the abuse which can be expressed in angry outbursts, anger at men, or anger provoked by various situations. Most survivors have to continually work towards controlling their anger especially when it is being directed inappropriately. Anger at their siblings or other family members can make it difficult to maintain relationships with the family of origin. (Wiehe, 1997) This can be very difficult for a survivor who may experience feelings of grief and loss due to the changes in the relationships in the family.

Sexual dysfunction is a common effect of sexual abuse. Survivors tend towards two paths; avoidance of all sexual contact or sexual compulsiveness or promiscuity. (Wiehe) Even though it is not as common, some victims of sexual abuse can act out and abuse others. This is called “repetition compulsion” and is an attempt for the victim to take him or herself out of the victim role and into a new role where he/she is no longer powerless. Boys who have been molested tend to repeat the abuse as girls tend to repeat the abuse as victims. Girls do not assume the role of sexual aggressor as often as boys but research shows that those who do usually have a background of lengthy and extreme abuse. The more common reaction of sexual compulsiveness or promiscuity could be viewed as an unconscious effort to overcome or deny their feelings of powerlessness, shame, and anger. Abuse contains elements of distrust, secrecy, danger, and physical or emotional abuse which is often recreated in the survivors’ promiscuous encounters in adulthood. It can also be seen as a confusion of boundaries between affection, sex, and abuse. It happens as a result of the developmentally inappropriate and personally dysfunctional ways a child’s sexuality was shaped. (Wiehe, 1997)

Some survivors also react by turning to drugs, alcohol, or eating disorders. These are used as coping mechanisms and eating disorders stem for a need to have control.

The emotional or psychological problems most commonly associated with sexual abuse are depression and post-traumatic stress disorder (PTSD). Depression can be evident in a child shortly after the initial incidence of abuse. The severity of the abuse is NOT correlated with the intensity of depression. Incidents of depression as adults are high. According a survey by Vernon Wiehe, 26% of survivors experienced depression that required hospitalization and 68% had attempted suicide, with 50% of those having more than one attempt. Anger and depression are often seen together. Depression can be defined as anger turned on oneself. PTSD is associated with symptoms of depression, general anxiety, anxiety attacks, and flashbacks. These symptoms can be triggered by events that remind them of abuse such as sexual activity or being alone at night or when in the presence of the perpetrator. Because survivors tend to push abuse out of their memory, repress, disassociate, or block-out memories, PTSD is an anxiety disorder which the survivor re-experiences the abuse. This can be a full flashback, or an emotional or physical memory or it may even be re-experienced in dreams (Wiehe, 1997).

Post-traumatic Stress Disorder can appear in children shortly after abuse or many years later as adults. PTSD is an anxiety disorder that can occur after someone has been through a traumatic event. SECASA defines PTSD as having the following criteria:

1. The person has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone.

2. The re-experiencing of the trauma in at least one of the following ways:

a. Recurrent and intrusive recollections of the event.

b. Recurrent distressing dreams of the event.

c. Sudden acting or feeling as if the event were recurring.

d. Intense psychological distress at exposure to events that symbolise or resemble an aspect of the traumatic event.

3. A numbing of responsiveness or reduced involvement in the external world some time after the trauma, indicated by;

a. Diminished interest in activities and/or

b.Feelings of detachment or estrangement from others and/or

c. Constricted affect; unable to have loving feelings or to feel anger

4. In addition, at least two of the following symptoms must be present

a. Hyper-alertness or being easily startled.

b. Sleep problems.

c. Guilt about surviving or behavior required to survive.

d. Problems with memory or concentration.

e. Avoidance of activities that arouse recollection.

f. Intensification of symptoms if events symbolize or resemble the traumatic event.

The national center of PTSD states that symptoms of PTSD can be terrifying and can disrupt one’s daily life. PTSD symptoms usually start soon after the traumatic event, but they may not happen until months or even years later. They may also come and go over a period of many years. Many people who develop PTSD get better over time but some (about 1 out of 3) may continue to have symptoms and need to seek treatment to better cope. There are four symptoms of PTSD; reliving

the event, avoidance, numbing, and feeling “keyed up” or hyperarousal. People  experiencing PTSD may also have problems with drinking or drugs, feelings of hopelessness, shame, or despair, employment and/or relationship problems (including violence and divorce), and physical symptoms. Treatment for PTSD is available including cognitive-behavioral therapy, EMDR (eye movement desensitization and repressing), medication such as SSRI (selective serotonin reuptake inhibitor)

Major depressive disorder, commonly known as depression, is another common psychological effect of sexual abuse. This can be in combination with PTSD or other emotional disorders.

Depression can severely disrupt one’s life, affecting your appetite, sleep, work, and relationships.

Symptoms of depression include;

• Constant feelings of sadness, irritability, or tension
• Decreased interest or pleasure in usual activities or hobbies
• Loss of energy, feeling tired despite lack of activity
• A change in appetite, with significant weight loss or gain
• A change in sleeping patterns, such as difficulty sleeping, early morning awakening, or sleeping too much.
• Restlessness or feeling slowed down
• Decreased ability to make decisions or concentrate
• Feelings of worthlessness, hopelessness, or guilt
• Thoughts of suicide

What causes Abuse?

The causes of interpersonal abuse are complex and overlapping. However, the following are widely regarded to be some of the most important factors:

• Early learning experiences: This factor is sometimes described as the “life cycle” of abuse. Many abusive parents were themselves abused as children and have learned to see hurtful behavior as normal childrearing. At the other end of the life cycle, some adults who abuse their elderly parent are paying back the parent for abusing them in their early years.
• Ignorance of developmental timetables: Some parents have unrealistic expectations of children in terms of the appropriate age for toilet training, feeding themselves, and similar milestones, and attack their children for not meeting these expectations.
• Economic stress: Many caregivers cannot afford part-time day care for children or dependent elderly parents, which would relieve some of their emotional strain. Even middle-class families can be financially stressed if they find themselves responsible for the costs of caring for elderly parents before their own children are financially independent.
• Lack of social support or social resources: Caregivers who have the support of an extended family, religious group, or close friends and neighbors are less likely to lose their self-control under stress.
• Substance abuse: Alcohol and mood-altering drugs do not cause abuse directly, but they weaken or remove a person’s inhibitions against violence toward others. In addition, the cost of a drug habit often gives a substance addict another reason for resenting the needs of the dependent person. A majority of workplace bullies are substance addicts.
• Mental disorders: Depression, personality disorders, dissociative disorders, and anxiety disorders can all affect parents’ ability to care for their children appropriately. A small percentage of abusive parents or spouses are psychotic.
• Belief systems: Many men still think that they have a “right” to a relationship with a woman; and many people regard parents’ rights over children as absolute.
• The role of bystanders: Research in the social sciences has shown that one factor that encourages abusers to continue their hurtful behavior is discovering that people who know about or suspect the abuse are reluctant to get involved. In most cases, bystanders are afraid of possible physical, social, or legal consequences for reporting abuse. The result, however, is that many abusers come to see themselves as invulnerable.

Child Neglect. What is it?

This is not an easy question. In general, neglect is an act of omission. It is the failure of a child’s primary caretaker to provide adequate food, clothing, shelter, supervision, and medical care. But what is adequate? And is it neglect if the primary caretaker is simply unable to provide for the child’s needs, or must the caretaker “wilfully” deprive the child? Is it neglect only if the child has suffered harm, or if the child is potentially at harm? There other types of deprivation not mentioned above-such as a failure to provide for a child’s educational or emotional needs-that also should be classified as neglect? Both legal and research professionals struggle with these questions.

Legal Definitions

The US

The Federal Child Abuse Prevention and Treatment Act (CAPTA) provide minimum standards for definitions. CAPTA states, “The term ‘child abuse and neglect’ means, at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm”

Using this minimum standard as a foundation, each State provides its own definitions for child abuse and neglect. There are three places in State statutes in which abuse and neglect are defined:

(1) Reporting laws for child maltreatment,

(2) Criminal codes, and

(3) Juvenile court statutes

(U.S. Department of Health and Human Services, 2000).

The UK

“ Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.”

‘Working Together to Safeguard Children’ (DoH, 2000).

Research Definitions
There is little agreement among researchers regarding a conceptual or operational definition of neglect. Researchers lament this situation because a lack of consensus makes it difficult to compare findings across studies and difficult to apply findings to child welfare professionals’ interventions (Black & Dubowitz, 1999; Zuravin, 1991). In addition to using various definitions, researchers also have used a variety of methods to measure neglect, including observations of the home, specific behavioral criteria, medical history, self-report measures, interviews, case record abstractions, and CPS case findings (Black & Dubowitz, 1999; Zuravin, 1999).

One important element of a child neglect definition or classification system is the identification of behaviors or conditions that are considered “neglectful.” Some behaviors seem universally classified as neglect by researchers. These include:

• Inadequate nutrition, clothing, or hygiene
• Inadequate medical, dental, or mental health care
• Unsafe environments
• Inadequate supervision, including use of inadequate caretakers
• Abandonment or expulsion from the home (Barnett, Manly & Cicchetti, 1993; Sedlack & Broadhurst, 1996).

However, many behaviours may be categorized differently by different classification systems. Table 1 illustrates this using examples from two widely known classification systems: the Third National Incidence Study of Child Abuse and Neglect (NIS-3) (Sedlack & Broadhurst, 1996) and the Maltreatment Classification System (MCS) developed by Barnett, Manly and Cicchetti (1993).

Behavior	Sedlack & Broadhurst, 1996 NIS-3 Classification	Barnett, Manly & Cicchetti, 1993 MCS Classification
Inadequate education	Educational Neglect	Moral-Legal/Educational Maltreatment
Exposure to domestic violence	Emotional Neglect	Emotional Maltreatment
Exposure to drugs in utero	Other Maltreatment	Physical Neglect-Failure to Provide
Exposure to or allowing child to engage in illegal activities	Emotional Neglect	Moral-Legal/Educational Maltreatment
Shelter-related neglect such as homelessness or inadequate sanitation or utilities in the child’s home	Not addressed	Physical Neglect-Failure to Provide
Inadequate nurturance/affection	Emotional Neglect	Emotional Maltreatment

In addition to identifying behaviours that are considered neglectful, there are other considerations regarding a definition of neglect. These include:

• Should there be evidence of harm, or does neglect include endangerment of a child’s health or welfare?
• Should the caretaker’s intent to harm be a consideration?

Many researchers, including Zuravin (1991), propose that endangering a child’s health or welfare should be included in any definition of neglect, and that a caretaker’s intent to harm or culpability should not be a consideration.

These differences highlight the challenges posed in comparing findings across studies that have used varying definitions of neglect. For example, when examining the rates of child neglect over time, a change in the numbers may not solely represent an actual increase or decrease in the number of children affected, but may partially be accounted for by a change in the definition.

Recognising these difficulties, Federal agencies have been leading efforts to develop clear research definitions and a measurement tool to collect data on child maltreatment.

Throughout the 1990s, Congress mandated a number of Federal agencies to increase their focus on the problem of child abuse and neglect. The National Institutes of Health (NIH) created the Federal Child Abuse and Neglect Working Group (co-chaired by the National Institute on Mental Health and the National Institute for Child Health and Human Development [NICHD]). The Working Group began work in 1998 to develop clear classification systems and operational definitions for all types of child maltreatment, including child neglect, which can be used by researchers and also overlap with existing legal and clinical definitions. The Working Group is continuing to pursue this effort.

In 1994, the Federal Interagency Task Force on Child Abuse and Neglect challenged its Research Committee to address definitional issues confronting the child abuse and neglect research community nationally. The committee had representatives from several DHHS agencies (e.g., NIH, Centres for Disease Control, Substance Abuse and Mental Health Services Administration) and from other departments (e.g., Defence, Education, Interior, and Justice). The efforts of this group focused on developing a data collection system that could be used by researchers to define and identify all types of child abuse and neglect. By 1999, these efforts resulted in an instrument entitled the Child Maltreatment Log. This instrument is being field tested in two 17-month pilot projects that were initiated in September 2000. Once the results of the pilots are analyzed, the instrument will be revised and disseminated for use by the research community.

The goals of these projects are to offer researchers a common definition and measurement tool so that the findings of various studies can be compared and the studies can be replicated, both of which contribute to a stronger knowledge base. In the field of child neglect, many researchers and policy makers consider this to be an important step in building our knowledge about the problem, the factors associated with it, and how to address it.