Child abuse

Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention (CDC) define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. There are four major categories of child abuse: neglect, physical abuse, psychological/emotional abuse, and child sexual abuse.

Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. According to the Journal of Child Abuse and Neglect, child abuse is "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, an act or failure to act which presents an imminent risk of serious harm". A person who feels the need to abuse or neglect a child may be described as a "pedopath".

Types
Child abuse can take several forms: The four main types are physical, sexual, psychological, and neglect.

Neglect
Child neglect is where the responsible adult does not provide adequately for various needs, including physical (not providing adequate food, clothing, or hygiene), emotional (not providing nurturing or affection), educational (not enrolling a child in school), or medical (not medicating the child or taking him or her to the doctor). There are many effects of child neglect, such as children not being able to interact with other children around them. The continuous refusal of a childs basic needs is considered chronic neglect.

Physical abuse
Physical abuse is physical aggression directed at a child by an adult. It can involve punching, striking, kicking, shoving, slapping, burning, bruising, pulling ears or hair, stabbing, choking, belting or shaking a child. Shaking a child can cause shaken baby syndrome, which can lead to intracranial pressure, swelling of the brain, diffuse axonal injury, and oxygen deprivation; which leads to patterns such as failure to thrive, vomiting, lethargy, seizures, bulging or tense fontanels, altered breathing, and dilated pupils. The transmission of toxins to a child through its mother (such as with fetal alcohol syndrome) can also be considered physical abuse in some jurisdictions.

Most nations with child-abuse laws consider the infliction of physical injuries or actions that place the child in obvious risk of serious injury or death to be illegal. Beyond this, there is considerable variation. The distinction between child discipline and abuse is often poorly defined. Cultural norms about what constitutes abuse vary widely: among professionals as well as the wider public, people do not agree on what behaviors constitute abuse.

Some human-service professionals claim that cultural norms that sanction physical punishment are one of the causes of child abuse, and have undertaken campaigns to redefine such norms.

Child sexual abuse
Child sexual abuse (CSA) is a form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation. Forms of CSA include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact against a child, physical contact with the child's genitals, viewing of the child's genitalia without physical contact, or using a child to produce child pornography. Selling the sexual services of children may be viewed and treated as child abuse with services offered to the child rather than simple incarceration.

Effects of child sexual abuse include guilt and self-blame, flashbacks, nightmares, insomnia, fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.), self-esteem issues, sexual dysfunction, chronic pain, addiction, self-injury, suicidal ideation, somatic complaints, depression, post-traumatic stress disorder, anxiety, other mental illnesses (including borderline personality disorder and dissociative identity disorder, propensity to re-victimization in adulthood, bulimia nervosa, physical injury to the child, among other problems. Approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.  Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, mothers, uncles or cousins; around 60% are other acquaintances such as friends of the family, babysitters, or neighbours; strangers are the offenders in approximately 10% of child sexual abuse cases.

Psychological/emotional abuse
Out of all the possible forms of abuse, emotional abuse is the hardest to define. It could include name-calling, ridicule, degradation, destruction of personal belongings, torture or destruction of a pet, excessive criticism, inappropriate or excessive demands, withholding communication, and routine labeling or humiliation.

Victims of emotional abuse may react by distancing themselves from the abuser, internalizing the abusive words, or fighting back by insulting the abuser. Emotional abuse can result in abnormal or disrupted attachment development, a tendency for victims to blame themselves (self-blame) for the abuse, learned helplessness, and overly passive behavior.

Prevalence
According to the (American) National Committee to Prevent Child Abuse, in 1997 neglect represented 54% of confirmed cases of child abuse, physical abuse 22%, sexual abuse 8%, emotional maltreatment 4%, and other forms of maltreatment 12%.

A UNICEF report on child wellbeing stated that the United States and the United Kingdom ranked lowest among industrial nations with respect to the wellbeing of children. It also found that child neglect and child abuse were far more common in single-parent families than in families where both parents are present.

In the USA, neglect is defined as the failure to meet the basic needs of children including housing, clothing, food and access to medical care. Researchers found over 91,000 cases of neglect in one year (from October 2005 to 30 September 2006) using information from a database of cases verified by protective services agencies.

Neglect could also take the form of financial abuse by not buying the child adequate materials for survival.

The U.S. Department of Health and Human Services reports that for each year between 2000 and 2005, "female parents acting alone" were most likely to be perpetrators of child abuse.

Fatalities
A child abuse fatality is when a child’s death is the result of abuse or neglect, or when abuse and/or neglect are contributing factors to a child’s death. In the United States, 1,730 children died in 2008 due to factors related to abuse; this is a rate of 2.33 per 100,000 U.S. children. Child abuse fatalities are widely recognized as being under-counted; it is estimated that between 60-85% of child fatalities due to maltreatment are not recorded as such on death certificates. Younger children are at a much higher risk for being killed, as are African Americans. Girls and boys, however, are killed at similar rates. Caregivers, and specifically mothers, are more likely to be the perpetrators of a child abuse fatality, than anyone else, including strangers, relatives, and non-relative caregivers [source needed]. Family situations which place children at risk include moving, unemployment, having non-family members living in the household. A number of policies and programs have been put into place to try to better understand and to prevent child abuse fatalities, including: safe-haven laws, child fatality review teams, training for investigators, shaken baby syndrome prevention programs, and child abuse death laws which mandate harsher sentencing for taking the life of a child.

History
Also known as Tardieu's Syndrome in homage to the French medical doctor Auguste Ambroise Tardieu

Causes
Child abuse is a complex phenomenon with multiple causes. Understanding the causes of abuse is crucial to addressing the problem of child abuse. Parents who physically abuse their spouses are more likely than others to physically abuse their children. However, it is impossible to know whether marital strife is a cause of child abuse, or if both the marital strife and the abuse are caused by tendencies in the abuser.

Children resulting from unintended pregnancies are more likely to be abused or neglected. In addition, unintended pregnancies are more likely than intended pregnancies to be associated with abusive relationships, and there is an increased risk of physical violence during pregnancy. They also result in poorer maternal mental health, and lower mother-child relationship quality.

Substance abuse can be a major contributing factor to child abuse. One U.S. study found that parents with documented substance abuse, most commonly alcohol, cocaine, and heroin, were much more likely to mistreat their children, and were also much more likely to reject court-ordered services and treatments. Another study found that over two thirds of cases of child maltreatment involved parents with substance abuse problems. This study specifically found relationships between alcohol and physical abuse, and between cocaine and sexual abuse.

Unemployment and financial difficulties are associated with increased rates of child abuse. In 2009 CBS News reported that child abuse in the United States had increased during the economic recession. It gave the example of a father who had never been the primary care-taker of the children. Now that the father was in that role, the children began to come in with injuries.

Effects
There are strong associations between exposure to child abuse in all its forms and higher rates of many chronic conditions. The strongest evidence comes from the Adverse Childhood Experiences (ACE's) series of studies which show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions, high-risk health behaviors and shortened lifespan. A recent publication, Hidden Costs in Health Care: The Economic Impact of Violence and Abuse, makes the case that such exposure represents a serious and costly public-health issue that should be addressed by the healthcare system.Child abuse is a major life stressor that has consequences involving the mental health of an adult but, the majority of studies examining the negative consequences of abuse have been focused on adolescences and young adults. Sexual abuse is the form of abuse that can cause the most damage, as it’s not seen, it can hurt a person emotionally, psychologically and physically. It has been identified that childhood sexual abuse is a risk factor for the development of substance related problems during adolescence and adulthood. The early experiences of child abuse can be one mechanism that triggers the development of an internalizing disorder, such as anxiety and depression. For example adults who have a history of some form of child abuse, whether it is sexual abuse, physical abuse, or neglect have increased chances of developing depression, then an adult who has never been abused. Child abuse can also cause problems with the neurodevelopment of a child. Research shows that children who have been abused often develop deficits with language, deregulation of mood, behaviour and also social/emotional disturbances. These risks are elevated when the combination of child abuse, traumatic events and/or fetal alcohol exposure. Children, who have been abused, in any form, are more likely to repeat the cycle of abuse, then children who have never been abused. When a child gets hit, to them it can become normal for a parent to treat their child in this matter, when they grow up they may turn to the same method of their parents as for them that is the right thing to do, no one has ever showed them otherwise.

Psychological effects
Children with a history of neglect or physical abuse are at risk of developing psychiatric problems, or a disorganized attachment style. Disorganized attachment is associated with a number of developmental problems, including dissociative symptoms, as well as anxiety, depressive, and acting out symptoms. A study by Dante Cicchetti found that 80% of abused and maltreated infants exhibited symptoms of disorganized attachment. When some of these children become parents, especially if they suffer from posttraumatic stress disorder (PTSD), dissociative symptoms, and other sequelae of child abuse, they may encounter difficulty when faced with their infant and young children's needs and normative distress, which may in turn lead to adverse consequences for their child's social-emotional development. Despite these potential difficulties, psychosocial intervention can be effective, at least in some cases, in changing the ways maltreated parents think about their young children.

Victims of childhood abuse, it is claimed, also suffer from different types of physical health problems later in life. Some reportedly suffer from some type of chronic head, abdominal, pelvic, or muscular pain with no identifiable reason. Even though the majority of childhood abuse victims know or believe that their abuse is, or can be, the cause of different health problems in their adult life, for the great majority their abuse was not directly associated with those problems, indicating that sufferers were most likely diagnosed with other possible causes for their health problems, instead of their childhood abuse.

The effects of child abuse vary, depending on the type of abuse. A 2006 study found that childhood emotional and sexual abuse were strongly related to adult depressive symptoms, while exposure to verbal abuse and witnessing of domestic violence had a moderately strong association, and physical abuse a moderate one. For depression, experiencing more than two kinds of abuse exerted synergetically stronger symptoms. Sexual abuse was particularly deleterious in its intrafamilial form, for symptoms of depression, anxiety, dissociation, and limbic irritability. Childhood verbal abuse had a stronger association with anger-hostility than any other type of abuse studied, and was second only to emotional abuse in its relationship with dissociative symptoms. More generally, in the case of 23 of the 27 illnesses listed in the questionnaire of a French INSEE survey, some statistically significant correlations were found between repeated illness and family traumas encountered by the child before the age of 18 years. According Georges Menahem, the French sociologist who found out these correlations by studying health inequalities, these relationships show that inequalities in terms of illness and suffering are not only social. Health inequality also has its origins in the family, where it is associated with the degrees of lasting affective problems (lack of affection, parental discord, the prolonged absence of a parent, or a serious illness affecting either the mother or father) that individuals report having experienced in childhood.

Physical effects
Children who are physically abused are likely to receive bone fractures, particularly rib fractures, and may have a higher risk of developing cancer. Children who experience child abuse & neglect are 59% more likely to be arrested as juveniles, 28% more likely to be arrested as adults, and 30% more likely to commit violent crime.

The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. The long-term effects can be:

Shaken baby syndrome. Shaking a baby is a common form of child abuse that often results in permanent neurological damage (80% of cases) or death (30% of cases). Damage results from intracranial hypertension (increased pressure in the skull) after bleeding in the brain, damage to the spinal cord and neck, and rib or bone fractures (Institute of Neurological Disorders and Stroke, 2007).

Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have long-term consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006). NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/OPRE, 2004a).

Poor physical health. Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).

On the other hand, there are some children who are raised in child abuse, but who manage to do unexpectedly well later in life regarding the preconditions. Such children have been termed , as inspired from the way that dandelions seem to prosper irrespective of soil, sun, drought, or rain. Such children (or currently grown-ups) are of high interest in finding factors that mitigate the effects of child abuse.

Prevention
Unintended conception increases the risk of subsequent child abuse, and large family size increases the risk of child neglect. Thus a comprehensive study for the National Academy of Sciences concluded that affordable contraceptive services should form the basis for child abuse prevention. "The starting point for effective child abuse programming is pregnancy planning," according to an analysis for US Surgeon General C. Everett Koop.

April has been designated Child Abuse Prevention Month in the United States since 1983. U.S. President Barack Obama continued that tradition by declaring April 2009 Child Abuse Prevention Month. One way the Federal government of the United States provides funding for child-abuse prevention is through Community-Based Grants for the Prevention of Child Abuse and Neglect (CBCAP).

Resources for child-protection services are sometimes limited. According to Hosin (2007), "a considerable number of traumatized abused children do not gain access to protective child-protection strategies." Briere (1992) argues that only when "lower-level violence" of children ceases to be culturally tolerated will there be changes in the victimization and police protection of children.

Treatment
A number of treatments are available to victims of child abuse. Trauma-focused cognitive behavioral therapy, first developed to treat sexually abused children, is now used for victims of any kind of trauma. It targets trauma-related symptoms in children including post-traumatic stress disorder (PTSD), clinical depression and anxiety. It also includes a component for non-offending parents. Several studies have found that sexually abused children undergoing TF-CBT improved more than children undergoing certain other therapies. Data on the effects of TF-CBT for children who experienced only non-sexual abuse was not available as of 2006.

Abuse-focused cognitive behavioral therapy was designed for children who have experienced physical abuse. It targets externalizing behaviors and strengthens prosocial behaviors. Offending parents are included in the treatment, to improve parenting skills/practices. It is supported by one randomized study.

Child-parent psychotherapy was designed to improve the child-parent relationship following the experience of domestic violence. It targets trauma-related symptoms in infants, toddlers, and preschoolers, including PTSD, aggression, defiance, and anxiety. It is supported by two studies of one sample.

Other forms of treatment include group therapy, play therapy, and art therapy. Each of these types of treatment can be used to better assist the client, depending on the form of abuse they have experienced. Play therapy and art therapy are ways to get children more comfortable with therapy by working on something that they enjoy (coloring, drawing, painting, etc.). The design of a child's artwork can be a symbolic representation of what they are feeling, relationships with friends or family, and more. Being able to discuss and analyze a child's artwork can allow a professional to get a better insight of the child.

Ethics
One of the most challenging ethical dilemmas arising from child abuse relates to the parental rights of abusive parents or caretakers with regard to their children, particularly in medical settings. In the United States, the 2008 New Hampshire case of Andrew Bedner drew attention to this legal and moral conundrum. Bedner, accused of severely injuring his infant daughter, sued for the right to determine whether or not she remain on life support; keeping her alive, which would have prevented a murder charge, created a motive for Bedner to act that conflicted with the apparent interests of his child. Bioethicists Jacob M. Appel and Thaddeus Mason Pope recently argued, in separate articles, that such cases justify the replacement of the accused parent with an alternative decision-maker.

Child abuse also poses ethical concerns related to confidentiality, as victims may be physically or psychologically unable to report abuse to authorities. Accordingly, many jurisdictions and professional bodies have made exceptions to standard requirements for confidentiality and legal privileges in instances of child abuse. Medical professionals, including doctors, therapists, and other mental health workers typically owe a duty of confidentiality to their patients and clients, either by law and/or the standards of professional ethics, and cannot disclose personal information without the consent of the individual concerned. This duty conflicts with an ethical obligation to protect children from preventable harm. Accordingly, confidentiality is often waived when these professionals have a good faith suspicion that child abuse or neglect has occurred or is likely to occur and make a report to local child protection authorities. This exception allows professionals to breach confidentiality and make a report even when the child or his/her parent or guardian has specifically instructed to the contrary. Child abuse is also a common exception to Physician–patient privilege: a medical professional may be called upon to testify in court as to otherwise privileged evidence about suspected child abuse despite the wishes of the child and his/her family.

Organizations
There are organizations at national, state, and county levels in the United States that provide community leadership in preventing child abuse and neglect. The National Alliance of Children's Trust Funds and Prevent Child Abuse America are two national organizations with member organizations at the state level.

Many investigations into child abuse are handled on the local level by Child Advocacy Centers. Started over 25 years ago at what is now known as the National Children's Advocacy Center in Huntsville, Alabama by District Attorney Robert "Bud" Cramer these multi-disciplinary teams have met to coordinate their efforts so that cases of child abuse can be investigated quickly and efficiently, ultimately reducing trauma to the child and garnering better convictions. These Child Advocacy Centers (known as CACs) have standards set by the National Children's Alliance.

Other organizations focus on specific prevention strategies. The National Center on Shaken Baby Syndrome focuses its efforts on the specific issue of preventing child abuse that is manifested as shaken baby syndrome. Mandated reporter training is a program used to prevent ongoing child abuse.