research paper on child abuse

The Devastating Clinical Consequences of Child Abuse and Neglect: Increased Disease Vulnerability and Poor Treatment Response in Mood Disorders

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“It is not the bruises on the body that hurt. It is the wounds of the heart and the scars on the mind.” —Aisha Mirza “We can deny our experience but our body remembers.” —Jeanne McElvaney, Spirit Unbroken: Abby’s Story

Prevalence and Consequences of Childhood Maltreatment

Childhood Maltreatment Increases Risk for Illness Severity and Poor Treatment Response in Mood Disorders

Timing of childhood maltreatment: are there periods of heightened sensitivity, experiencing single subtypes of abuse and neglect versus experiencing multiple types, underlying mechanisms by which childhood maltreatment increases risk for mood disorders and contributes to disease course.

Biological Abnormalities Associated With Childhood Maltreatment

Pathways to mood disorder outcomes, childhood maltreatment and associated alterations in neural structure and function, limitations and future directions, acknowledgments, information, published in.

• Maltreatment
• Bipolar Disorder
• Posttraumatic Stress

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Open Access

Peer-reviewed

Research Article

Improving measurement of child abuse and neglect: A systematic review and analysis of national prevalence studies

Roles Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Director, Childhood Adversity Research Program, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia, Adjunct Professor, Johns Hopkins University, Bloomberg School of Public Health, Baltimore MD, United States of America

Roles Conceptualization, Formal analysis, Methodology, Writing – review & editing

Affiliation Institute for Lifecourse Development, University of Greenwich, Greenwich, London, United Kingdom

Affiliation School of Public Health, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia

Roles Data curation, Formal analysis, Project administration, Writing – review & editing

Affiliation Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia

Affiliation Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom

• Ben Mathews, 
• Rosana Pacella, 
• Michael P. Dunne, 
• Marko Simunovic, 
• Cicely Marston

• Published: January 28, 2020
• https://doi.org/10.1371/journal.pone.0227884
• Reader Comments

Child maltreatment through physical abuse, sexual abuse, emotional abuse, neglect, and exposure to domestic violence, causes substantial adverse health, educational and behavioural consequences through the lifespan. The generation of reliable data on the prevalence and characteristics of child maltreatment in nationwide populations is essential to plan and evaluate public health interventions to reduce maltreatment. Measurement of child maltreatment must overcome numerous methodological challenges. Little is known to date about the extent, nature and methodological quality of these national studies. This study aimed to systematically review the most comprehensive national studies of the prevalence of child maltreatment, and critically appraise their methodologies to help inform the design of future studies.

Guided by PRISMA and following a published protocol, we searched 22 databases from inception to 31 May 2019 to identify nationwide studies of the prevalence of either all five or at least four forms of child maltreatment. We conducted a formal quality assessment and critical analysis of study design.

This review identified 30 national prevalence studies of all five or at least four forms of child maltreatment, in 22 countries. While sound approaches are available for different settings, methodologies varied widely in nature and robustness. Some instruments are more reliable and obtain more detailed and useful information about the characteristics of the maltreatment, including its nature, frequency, and the relationship between the child and the person who inflicted the maltreatment. Almost all studies had limitations, especially in the level of detail captured about maltreatment, and the adequacy of constructs of maltreatment types.

Conclusions

Countries must invest in rigorous national studies of the prevalence of child maltreatment. Studies should use a sound instrument containing appropriate maltreatment constructs, and obtain nuanced information about its nature.

Citation: Mathews B, Pacella R, Dunne MP, Simunovic M, Marston C (2020) Improving measurement of child abuse and neglect: A systematic review and analysis of national prevalence studies. PLoS ONE 15(1): e0227884. https://doi.org/10.1371/journal.pone.0227884

Editor: Abraham Salinas-Miranda, University of South Florida, UNITED STATES

Received: September 10, 2019; Accepted: December 31, 2019; Published: January 28, 2020

Copyright: © 2020 Mathews et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Child maltreatment is common and causes substantial adverse health, educational and behavioural consequences [ 1 ]. Understanding its prevalence and characteristics in nationwide populations is essential to plan and evaluate interventions to reduce maltreatment. However, measurement of child maltreatment is known to be far from universal, and when performed must confront methodological challenges. This study systematically reviews the most comprehensive national studies of the prevalence of child maltreatment, and critically appraises their methodologies to help inform future measurement.

Child maltreatment in its five recognised forms is a major public health issue [ 2 ]. Physical and mental diseases are caused through proximal and distal pathways. Immediate physical injuries and conditions include brain injury and failure to thrive, and a panoply of psychological disorders include anxiety, depression, and suicidality. Studies have found serious effects of physical abuse [ 3 , 4 , 5 ], sexual abuse [ 6 , 7 ], emotional abuse [ 5 , 8 – 10 ], neglect [ 5 , 9 , 11 ], and exposure to domestic violence [ 12 – 14 ]. Experiencing multiple forms of maltreatment is common [ 12 ], and is associated with more severe outcomes [ 14 , 15 ], including alcohol and drug abuse, mental illness, interpersonal violence, and sexual risk taking [ 16 ].

The adoption of coping mechanisms such as smoking, alcohol and drug use can compound the damage by causing diseases in the medium to long term; and chronic stress can cause coronary artery disease, pulmonary fibrosis, and inflammation [ 17 – 22 ]. Potent mediators include prolonged psychological distress, risky behaviours, social withdrawal and dysfunction, impaired cognitive development, low educational and occupational attainment, and interpersonal relationship difficulties. A growing body of evidence is showing child maltreatment affects brain development, shortens telomeres, and produces epigenetic neurobiological changes [ 23 – 26 ]. The disease and economic burdens are substantial: a recent estimate of the cost of disability-adjusted life years (DALYs) lost across East Asia and the Pacific was 1.88% of the region’s GDP, equating to $194 billion in 2012 dollars [ 27 ].

As a global policy imperative, the United Nations recognises the gravity of child maltreatment and its consequences. The United Nations Agenda for Sustainable Development includes a target of ending abuse of children [ 28 ]. Reliable scientific data on national prevalence is essential to measure progress against this goal, and to inform policy efforts aimed at prevention, early identification and response [ 29 – 30 ].

Nationwide studies of the experience of childhood maltreatment can identify baseline prevalence stratified by maltreatment type, as well as important contextual features including the child’s sex, age, and relationship with the abusive person. Without good measurement techniques and repeated measures over time, we lack understandings of baseline measures, of whether maltreatment is increasing or declining, of changes in maltreatment types over time, and of the efficacy of policy and practice interventions designed to reduce child maltreatment for the whole population and for key sub-populations.

Despite the necessity for good data in public health generally and in child maltreatment in particular, approximately half of all countries have failed to report any kind of robust prevalence estimates [ 2 ], and extant studies are often limited to measuring one or few maltreatment types [ 31 ]. Accordingly, prevalence estimates are often inadequately specified, and are almost certainly underestimated. In addition, existing studies vary widely in design, sample and methods, and often use non-standardized instruments [ 5 , 32 ]. Where an instrument is non-standardized and untested, the risk may be heightened that the study will fail to capture experiences that constitute maltreatment, and may capture experiences that do not constitute maltreatment, hence producing unreliable results. Importantly, the use of unsound maltreatment constructs and operational definitions also compromises the reliability of recorded measures [ 33 – 34 ]. As an example of this, studies of sexual abuse that do not include non-contact sexual abuse will underestimate prevalence; conversely, studies that include as sexual abuse genuinely consensual acts between peers will overestimate prevalence. Similarly, studies of neglect that do not consider medical neglect will underestimate prevalence. Studies of emotional abuse that include non-abusive yelling will overestimate prevalence.

Optimal methodologies for measuring population characteristics of child maltreatment can ensure adequate detail is captured to yield reliable, detailed, useful data. For best quality estimates, prevalence studies should adopt robust conceptual understandings of maltreatment types and their operational definitions [ 33 ]. In addition, prevalence studies need to ask a series of items to obtain accurate data, rather than a single question which will tend to underestimate prevalence [ 35 ]. Similarly, to avoid underestimates, items should be behaviourally specific, rather than vague, ambiguous or non-specific [ 36 ]. All national prevalence studies face methodological and practical challenges, and studies take different approaches [ 2 , 12 , 14 , 30 ]. Ideally, however, all five forms of child maltreatment should be measured simultaneously, since many children experience such poly-victimization and its heightened consequences [ 1 , 14 , 16 ]. To provide nuanced, useful information, studies should ask about prevalence, and about the specific nature of the acts, their severity, frequency, and timing, and the relationship of the child to the person inflicting the abuse [ 33 ]. These factors influence health outcomes and provide evidence about specific risk and protective factors and how these may best be targeted. Rigorous measurement of child maltreatment is complex, but is essential to inform prevention efforts and drive nationwide social change [ 2 , 14 , 29 , 36 , 37 ].

Recent research has reviewed global prevalence estimates [ 2 , 31 ], the nature of population health surveys exploring consequences of child maltreatment [ 37 ], and approaches in studies of youth [ 38 ]. However, to date, there has not been a systematic review and methodological appraisal of high quality national population prevalence studies of child maltreatment to provide a baseline for future measurement efforts.

This study aimed to investigate three questions. First, what national studies have been conducted of the prevalence and nature of all five, or at least four, major forms of child maltreatment? Second, what methodologies were used in these studies? Third, what does a critical analysis of these studies indicate about the methodological rigour, quality, and practical viability of different approaches? The results of our investigation can inform future efforts to generate baseline prevalence estimates, design policy responses, and chart trends over time, as more societies confront the challenge of childhood maltreatment.

Search strategy

Our systematic review was guided by PRISMA [ 39 ] ( S1 Fig ). We developed a protocol, registered at PROSPERO [ 40 ]. #CRD42017068120, https://www.crd.york.ac.uk/PROSPERO ). Adopting our search strategy ( S1 File ), we searched 22 databases from their inception to 31 May 2019.

Eligibility criteria

We searched for quantitative studies of the prevalence of child maltreatment. Included studies met four criteria: (1) primary empirical studies of the prevalence of four or five types of child maltreatment: ((i) physical abuse; (ii) emotional or psychological abuse; (iii) neglect; (iv) exposure to domestic violence; and (v) sexual abuse; (2) studies conducted nationwide using a representative sample of the population; (3) studies involving adult or child participants providing self-reported information about their experience, or studies where adults provided information about their child’s experience; (4) peer-reviewed studies or substantial grey literature.

As detailed in our search strategy ( S1 File ), in Phase 1, MS, JD and ED screened records by title. We removed duplicates using electronic software (Endnote), and removed remaining duplicates about the same study, selecting the publication providing the most detailed account. In Phase 2, BM and RP independently screened records by title and abstract. Disagreements were discussed between BM and RP to achieve consensus. To identify any further potential eligible studies at this stage that may not have been captured in the search, all co-authors considered if there were any further known studies requiring inclusion that were not in the Phase 2 shortlist. In Phase 3, BM and RP independently assessed full text of screened in articles. Disagreements were discussed between BM and RP to achieve consensus, with reasons recorded. We screened reference lists of included studies to identify any further potential eligible studies. We used a translator to assist in screening non-English studies. This process resulted in 23 eligible studies ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0227884.g001

Data extraction and analysis

We developed a template to extract 60 data items from each study considering design, procedure, sample, instrument, ethics, and subpopulation analysis ( S2 File ). We extracted 45 items about the instrument, including: name, psychometric data, definitions of maltreatment constructs, number of questions asked about each type, and whether questions explored: (a) the relationship between the child and the person inflicting maltreatment; (b) nature of the acts; (c) severity (e.g., if they caused injuries); (d) frequency. MS and BM extracted these data. We separately tabulated the extracted items each study asked about maltreatment, with BM conducting a final double-check regarding these ( S3 File ).

Our critical analysis included an appraisal of the construct validity of study items and the soundness of their operational definition. To inform this analysis, we identified robust conceptual understandings of each maltreatment type as established in the scholarly literature, and adopted these as an evaluative standard. Physical abuse involves intentional acts of physical force by a parent or caregiver, excluding lawful corporal punishment [ 41 ]. Sexual abuse involves contact and non-contact sexual acts, inflicted by any adult or child in a position of power over the victim, to seek or obtain physical or mental sexual gratification, when the child does not have capacity to provide consent, or has capacity but does not provide consent [ 42 ]. Emotional or psychological abuse is inflicted by a parent or caregiver, and includes emotional unavailability, hostile interaction, developmentally inappropriate interaction, failure to acknowledge the child’s individuality, and failure to integrate the child into the social world [ 43 ]. Neglect involves parental or caregiver omissions to provide the basic necessities of life suited to the child’s developmental stage, as recognised by the child’s cultural context, including physical, emotional, medical, environmental, supervisory, and educational neglect [ 44 ]. Exposure to domestic violence involves the child witnessing a parent or other family member being subjected to assaults, threats or property damage by another adult or teenager normally resident in the household [ 12 ].

Our critical analysis was also informed by an understanding that prevalence studies must be conducted with low risk of bias to obtain reliable findings. In our analysis, we assessed study rigour, quality and practicability, and used a quality assessment tool designed to assess risk of bias in population-based prevalence studies [45, S4 File ]. Using our quality assessment tool, we created an overall risk of bias score for each study which summed scores for individual items (maximum score 10). RP and CM independently assessed each study considering four external validity items and five internal validity items. Disputes were resolved through an independent third assessor (MD, BM). Our critical analysis further considered suitability of approach, considering: methodology to recruit the sample and accommodate high-risk sub-samples; administration method; instrument; soundness of conceptual constructs; ethics; and practical viability.

Systematic review

This review identified 23 articles reporting the results of national studies of the prevalence of all five or four of the recognized forms of child maltreatment. One of these articles reported the results of a study conducted simultaneously in nine countries in the Balkan Peninsula, and eight of these national studies met our eligibility criteria [ 46 ]. Accordingly, in total, our review identified 30 national studies, conducted in 22 countries. Studies were published between 2005 and 2019. Extracted data revealed study location, scope, participants, data collection method, and instrument. Table 1 presents the extracted information from included studies. The supporting information details the prevalence rates reported by each study ( S5 File ).

https://doi.org/10.1371/journal.pone.0227884.t001

There were four studies in the USA [ 47 – 50 ], three in the UK [ 51 – 53 ], two in Hong Kong [ 54 – 55 ] two in Taiwan [ 56 – 57 ], and two in Germany [ 58 , 59 ]. There was one study in Denmark [ 60 ], the Netherlands [ 61 ], Switzerland [ 62 ], Japan [ 63 ], Suriname [ 64 ], Saudi Arabia [ 65 ], Israel [ 66 ], South Africa [ 67 ], and Hungary [ 68 ]. In the Balkans study [ 46 ], eight met eligibility criteria based on the number of types of maltreatment studied: Albania, Bosnia & Herzegovina, Bulgaria, Croatia, the Former Yugoslavian Republic of Macedonia, Greece, Romania, and Serbia; in general for our purposes, we treat these as one study. The Turkish study involved three forms of maltreatment, so was excluded from our analyses.

Fourteen studies measured all five maltreatment types [ 47 – 51 , 53 , 56 – 57 , 61 , 64 – 68 ]. Of nine studies measuring four maltreatment types, seven omitted EDV [ 46 , 52 , 58 – 60 , 62 – 63 ], and two omitted sexual abuse [ 54 – 55 ]. Eleven studies measured prevalence throughout childhood and in the past year; nine measured prevalence through childhood only, and three measured past year incidence only.

Only nine studies explored all five types of maltreatment across childhood, defined as aged under 18 [ 48 – 50 , 53 , 64 – 68 ]. These studies occurred in seven countries (USA, UK, Suriname, Saudi Arabia, Israel, South Africa and Hungary), and only three involved a sample of adults providing data about experiences over their entire childhood [ 53 , 65 , 68 ]. Four studies in Germany, the UK and Japan obtained information from adults about all maltreatment across childhood except EDV [ 52 , 58 – 59 , 63 ].

Eight studies involved only child participants aged under 18 providing self-report data. Three studies included child and adult participants each providing self-report data. Five studies involved a household’s child participant aged under 18 providing self-report data (four involved children aged 10–17 and one involved children aged 11–17) and the household’s parents providing proxy data about a child aged under the cut-off. Five studies involved only adults providing self-report data (24 year olds; 18–24 year olds; 20–49 year olds; 18 and over). Sample sizes ranged from 1094 to 12,035 participants. Five studies adopted measures to recruit high-risk sub-populations [ 48 , 56 , 60 , 62 , 64 ].

Seven studies were conducted in schools: Taiwan [ 56 – 57 ], the Netherlands [ 61 ]. Switzerland [ 62 ], Suriname [ 64 ], and the Balkans study [ 46 ]. Eleven studies were conducted in households by interviews, in Hong Kong [ 54 – 55 ], Hungary [ 68 ], the UK [ 51 – 53 ], Germany [ 58 – 59 ], Japan [ 63 ], Saudi Arabia [ 65 ], and South Africa [ 67 ]. Five studies used remote computer assisted telephone interviews (CATI), with four in the USA [ 47 – 50 ], and one in Denmark [ 60 ]. Data collection time ranged from 1 month to 2 years.

Methodologies to recruit the sample and accommodate high-risk subpopulations also varied. In most studies, the target population was a close representation of the national population. Studies in schools were done in countries with high school attendance. All studies used random selection. However, few studies used strategies to capture participants from culturally and linguistically diverse groups, or from high-risk groups such as those in out of home care.

Response rates for household studies generally ranged from 56% to 78%, with one reporting a participation rate of 94.8% [ 67 ]. Rates in school-based studies showed schools’ participation rate ranging from 49%-79%, and then with almost 100% response rates from children in participating schools. Response rates in CATI studies ranged from 60% to 79.5%, with more recent studies having lower rates [ 47 – 49 ].

Regarding consent to participate, 18 of the studies involved child participants exclusively or with adult participants. Nine studies involved only child participants; in these, two required only the child’s consent [ 56 , 62 ], one required the child’s consent and parental passive consent [ 64 ], one required the child’s consent and either passive or active parental consent [ 46 ], and five required parental active consent and the child’s consent [ 54 – 55 , 57 , 61 , 66 – 67 ].

Of the studies involving child participants, seven reported the measures used by research teams when a child was suspected to have been harmed or at risk [ 46 – 50 , 53 , 67 ]. Nine studies reported other measures to assist any distressed participants [ 46 , 48 , 52 , 54 , 56 , 60 , 62 , 64 ].

Studies used a range of instruments and approaches to measuring each maltreatment type. Table 2 presents key data extracted from the instrument used in each study. Comprehensive details about the maltreatment items are detailed in the supporting information ( S3 File ).

https://doi.org/10.1371/journal.pone.0227884.t002

Eight studies used the Juvenile Victimization Questionnaire (JVQ). These studies used different versions of the JVQ, either using its original form [ 72 ], an enhanced form [ 48 – 50 ], or an adapted version [ 53 , 62 , 66 – 67 ]. Two studies used the Conflict Tactics Scale Parent-Child version (measuring physical abuse, emotional abuse, and neglect), and the CTS2 (EDV) [ 54 – 55 ]. Two studies used the ICAST-C, in either its original form [ 56 ] or an adapted version [ 46 ]. Two studies used the Childhood Trauma Questionnaire [ 58 – 59 ]. Single studies used the Adverse Childhood Experiences International Questionnaire [ 65 ], the Adverse Childhood Experiences questionnaire [ 68 ], and the Lifestyle and Attitudes Towards Sexual Behavior instrument [ 63 ]. Four studies used a blend of instruments [ 51 , 57 , 61 , 64 ]. Two studies used self-developed instruments [ 52 , 60 ].

Six studies did not report psychometric data on instrument validity and reliability. Six studies reported psychometric data on the instrument as used [ 46 , 54 – 56 , 58 , 72 ]. Studies using enhanced or adapted versions of instruments generally cited the original instrument’s data but did not report further psychometric tests.

Most studies did not define overarching concepts of each form of maltreatment, instead operationalising these concepts into questions about the participant’s experiences. Approaches to some but not all forms of maltreatment broadly aligned with the nature of maltreatment concepts as established by the scholarly literature. Approaches to physical abuse and sexual abuse were generally sound. Approaches to the construct and operationalisation of emotional abuse were generally sub-optimal, with some exceptions (e.g., [ 46 , 52 ]). Neglect was also rarely well-operationalised, with some exceptions (e.g., [ 49 , 52 – 53 , 58 – 59 , 66 ].

Studies explored maltreatment experiences in varying depth, reflected by the number and nature of questions asked ( Table 2 ). For sexual abuse, 12 studies asked between five and eight questions. Most studies asked about the relationship with the person inflicting the abuse, and the nature of the acts; more than half asked about frequency; but few asked about severity. Other notable differences included: two studies being limited to sexual abuse by a parent/guardian [ 51 , 60 ]; most studies including contact and non-contact acts, but three studies included contact abuse only [ 62 , 65 , 68 ]; four studies asking only one question [ 51 , 62 – 63 , 68 ].

For physical abuse, eight studies asked only one question, although these included multiple distinct concepts [ 47 – 51 , 62 , 63 , 68 ]. Six studies asked between five and nine questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. A notable difference was in the treatment of spanking on a child’s bottom: seven studies excluded “spanking on your bottom” from the definition of physical abuse [ 47 – 50 , 53 , 62 , 66 ]; four studies included spanking with a bare hand as physical abuse [ 46 , 54 – 56 ]; and four studies included as physical abuse being hit or spanked on the bottom but only when done with an implement or hard object [ 51 , 52 , 57 , 64 ].

For emotional or psychological abuse, eight studies asked between five and eight questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Other notable differences included: three studies being limited to a single generic question [ 51 , 61 , 64 ]; seven studies using a single compound question [ 47 – 51 , 62 , 67 ]; and only two studies using a detailed scale of items closely aligned with a sound conceptual model [ 46 , 52 ].

For neglect, 12 studies asked between five and 11 questions. Five studies asked one question [ 47 – 48 , 62 , 63 , 68 ]. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Six studies asked detailed questions about multiple dimensions of neglect, and their severity [ 49 – 50 , 52 , 58 – 59 , 66 ]. Other notable differences included: some studies operationalising neglect very broadly, including a parent having low aspirations [ 51 ], or not helping with homework [ 64 ]; only one study asking about educational neglect [ 64 ]; and one study omitting physical and nutritional neglect [ 46 ].

For exposure to domestic violence, six studies asked between six and eight questions. Most asked about relationship and nature; more than half asked about frequency; but few asked about severity. Notable differences were: two studies used the comprehensive CTS2 scale of 39 items originally devised for use with adult couples [ 54 – 55 ]; and the original JVQ had two physical assault items [ 72 ], and later added six items about threats or property damage by other family members [ 48 – 50 ].

Risk of bias

Table 3 sets out the quality assessment and scoring results for each study. Scores ranged from 6 to 10. Most studies had relatively high internal and external validity. We concluded that studies scoring 9.5 or 10 had minimal bias. Five studies achieved scores of 10: two in Hong Kong [ 54 – 55 ], and one each in Taiwan [ 56 ], Israel [ 66 ] and South Africa [ 67 ]. Five studies achieved scores of 9.5: three in the USA [ 48 – 50 ], one in the UK [ 53 ], and the Balkans study [ 46 ]. Five other studies achieved scores of 9, from Saudi Arabia [ 65 ], the UK [ 52 ], Germany [ 62 ], Hungary [ 68 ], and Taiwan [ 57 ]. Four studies scored 7, and two scored 6; here we concluded risk of bias was high, particularly regarding selection bias and non-response bias.

https://doi.org/10.1371/journal.pone.0227884.t003

This systematic review identified 30 studies of the prevalence of either four or five forms of child maltreatment, conducted in 22 nations. In addition, many other studies have been conducted of three or fewer maltreatment types, such as studies of sexual, physical and emotional abuse. These have been conducted on a stand-alone basis [ 76 ], or as part of a systematic campaign supported by a global public private partnership [ 77 ]. By 2019, the Violence Against Children Surveys (VACS), which also measure the prevalence of physical, sexual and emotional abuse, had been conducted in 16 countries and were being planned in a further eight countries in Africa, Asia and the Caribbean [ 30 , 77 – 78 ]. Other studies have considered the prevalence of a mixture of peer violence and maltreatment by parents or caregivers [ 79 – 80 ]. Accordingly, a good deal of evidence has been generated about the prevalence of child maltreatment in several dozen nations, representing substantial progress in the international understanding of the epidemiology of child maltreatment. However, this review has highlighted the fact that the vast majority of nations lack reliable benchmark national prevalence data on a comprehensive assessment of maltreatment, including measurement of four or five of the recognised five types of maltreatment, and almost all lack follow-up studies to establish trends over time. This study demonstrates the urgent need to conduct more rigorous prevalence studies, particularly those by measuring all relevant types of maltreatment, to generate more accurate understandings of the extent of maltreatment, and to enable progress in reducing child maltreatment against the SDG target.

Our review also shows that there is substantial variation in study participants across the different studies, limiting comparability and introducing certain strengths and limitations which are important to consider in designing future work. Several studies obtained data using parents as proxies for children under 10, and reported reliable responses. This approach may capture data about very young children’s experiences that is otherwise unattainable, although accurate estimates rely on parents being both knowledgeable and truthful in their responses [ 47 ]. Yet, the literature reports no evidence of reporter bias in comparisons of adult proxy and youth self-report data [ 47 , 48 ].

Arguably, from a public health perspective, studies provide most comprehensive and reliable estimates when capturing prevalence data over the entire span of childhood up to age 18. Furthermore, where a study’s participants are children and or young adolescents, past year incidence data is useful. Over half of the studies in this review included children as respondents. In these studies, responses benefitted from being direct and proximate to the experience as well as capturing useful stratified data about single year incidence in a closely contemporaneous time period. Developmental evidence suggests children’s and adolescents’ participation is entirely appropriate. While adolescents may generally differ from adults in the attainment of psychosocial capacities to understand long-term consequences, regulate conduct, and withstand social and emotional pressures, their cognitive capacity is not substantially different from that of adults [ 81 – 84 ]. Similarly, apart from those still in early developmental stages, children’s cognition and reliable episodic memory is sufficiently developed to enable participation in survey research [ 85 – 86 ]. This justifies the design of instruments for child and adolescent participants, including the careful approach of the developers of the Juvenile Victimization Questionnaire in designing an instrument suitable for participants as young as eight [ 72 ].

Ethically, there is no impediment to involving child and adolescent participants [ 87 ]. Adolescents and children are cognitively capable of providing their own consent, and are ethically entitled to do so as autonomous individuals. Moreover, adolescents and children have rights to freedom of expression, and bear the right of participation in matters affecting them. While there remains no consensus on the most justifiable approach to confidentiality and welfare [ 87 – 90 ], we assert that studies can adopt robust measures to balance imperatives of attaining sufficient study participation, while ensuring participant welfare and confidentiality. While confidentiality is a foundational principle in these studies, the exception to this, conveyed to youth participants at the outset, that cases of current or imminent significant risk of danger may be referred to welfare authorities, has been found not to affect response rates [ 38 , 53 ]. Alongside this, studies can adopt stepwise approaches drawing on multiple psychological and legal resources to support participants who disclose severe incidents or who experience distress [ 87 ]. However, it is important not overstate the frequency of distress. Several studies have found low rates of distress among youth participants in studies of maltreatment, and the level of youth distress does not differ significantly from that of adults. Furthermore, even distressed participants mostly maintain their involvement was worthwhile [ 38 , 91 ]. A recent US study, for example, found only 0.8% of participants aged 10–17 reported being “pretty or a lot” upset by answering the questions, and even this did not unduly affect their reported willingness to participate [ 91 ]. An associated finding is that children in high-risk sub-populations, such as those in out-of-home care, have not been well represented, leading to likely underestimates of prevalence and scarce evidence about specific risk profiles.

Studies that rely on adults’ retrospective accounts offer the substantial benefit of capturing data about experiences across childhood. One limitation of such studies is that they will not obtain recent proximal data of single year incidence. An additional potential limitation, yet to be fully analysed, may be that retrospective accounts are affected by various kinds of recall bias. We acknowledge that some have argued that retrospective studies do not provide data about child abuse experiences that is as accurate as prospective studies [ 92 – 93 ] and have cautioned against sole reliance on retrospective accounts, especially where prevalence estimates are used to draw causal inferences about the effect of maltreatment on biomedical diseases. A recent systematic review and meta-analysis concluded that prospective and retrospective measures of childhood maltreatment identify different groups of individuals [ 94 ]. However, it was also recognised that prospective measures may have lower sensitivity than retrospective measures of the experience of maltreatment, and concluded that “the low agreement between prospective and retrospective measures cannot be interpreted to directly indicate poor validity of retrospective measures” and that retrospective measures could have greater ability to identify true cases [ 94 ]. The well-known discrepancies between true maltreatment rates and those recorded in many data sources used for prospective studies is attributable to the low correlation between actual experiences and their representation in official data such as crime statistics and child protection service records. Few maltreatment experiences are ever brought to the attention of criminal justice agencies or child protection services. The caution urged regarding retrospective reports appropriately appears more directed towards studies considering causation of disease than estimation of population prevalence. It is also accepted that lack of validity tends to underreport the experience of abuse [ 95 – 97 ], and studies of test-retest reliability regarding retrospective accounts have indicated general stability over time [ 98 ]. We acknowledge that retrospective reports may have compromised validity for various reasons, including motivational factors and memory biases, and measurement features including poorly worded questions [ 92 , 94 ]. Overall, however, our view is that retrospective studies of child maltreatment, especially when well-designed with behaviourally-specific questions grounded in sound constructs of maltreatment, with representative samples of the population, offer the opportunity to obtain sufficiently accurate estimates of the prevalence of child maltreatment experiences.

The fourth finding is that while considerable investment is required for all kinds of approach, viable approaches to survey administration are available for diverse geographical settings to accommodate large and small nations, and attain sufficient participation. The implications of this are clear for future study design. School-based studies appeared most often in small nations, which may more readily facilitate centralised educational sector endorsement for the research, or which may have a high commitment to social research. When school leaders agree for their school to participate, children generally participate at a very high rate. Similarly, household studies identified in this review generally occurred in small nations. Both school-based and household studies require substantial numbers of staff, but may be most feasible where labour costs are manageable and where the social ecology is of sufficient strength to support and perhaps even require direct personal involvement in such research. In larger nations, for reasons of practicability and cost, studies used CATI and achieved satisfactory response rates. Perhaps for reasons of cost, and practical difficulty, a challenge remains to capture the experience of culturally and linguistically diverse sub-populations, and hard to reach groups such as children who are not in school, or who are in out of home care. Future research could consider optimal local strategies to respond to this challenge.

Our fifth finding is that selection, design and testing of an appropriate instrument appears an enduring challenge. In this regard, two coexisting needs must be balanced by any study: first, to be practicable in terms of the time and cost required to design, test and administer an instrument and minimise missing data; and second, to achieve sufficient comprehensiveness and ensure construct validity by describing maltreatment types in a way congruent with conceptual understandings [ 33 ]. Our review showed that a wide variety of instruments have been used, with psychometric data often not reported. The JVQ was the instrument most often used in either full-form or short-form; moreover, several studies adapted the original JVQ, sometimes adding a considerable number of items. These adapted versions did not appear to have been subjected to testing. While inconsequential modification of a proven instrument obviates the need for re-testing, substantial modification may be further supported by cognitive testing and test-retest reliability. What is relatively clear is that a proven, sound instrument offers both practicable and methodological benefits over a blended tool, or a new unproven instrument.

Our sixth finding is that instruments must soundly operationalise constructs of each maltreatment type by describing them in a way congruent with sound conceptual understandings. This review and critical appraisal found that instruments most often adopted unsound constructs and operationalisation of neglect, and emotional abuse. In particular, many studies did not consider sufficient operational categories of these maltreatment types as required by sound conceptual models, which will lead to under-estimates of prevalence, and will miss the opportunity to capture important information about the nature of specific experiences. Other studies used broad or vague conceptual expressions, which will have the opposite effect of over-estimating prevalence. This finding provides a contextual demonstration of the problem of unsound constructs compromising reliability and validity in general [ 33 , 34 ], and of the ongoing challenge to this field to adopt sound constructs of maltreatment and sound behaviourally-specific examples of these constructs [ 99 ]. Additionally in this regard, many studies asked only one question about a maltreatment type, which leads to underestimates of prevalence [ 36 ]. Single-item assessment, even through a compound question involving multiple elements of a construct, cannot capture accurate or nuanced data and should be avoided wherever possible. Finally, we found few questions about educational neglect. Arguably, since education is a human right recognised by the United Nations Convention on the Rights of the Child article 28, and is a condition for human flourishing [ 100 ] and a protective factor against multiple adversities such as child marriage [ 101 ], this is a significant dimension of neglect warranting greater priority. We recommend particularly close attention to how future studies conceptualise and operationalise these forms of maltreatment.

A seventh finding is that few studies asked detailed follow-up questions about the child’s relationship with the person inflicting the acts, and the severity and frequency of the acts. Generally, studies using the JVQ asked the most detailed follow-up questions. Obtaining information about the severity, frequency, timing, and relational setting of abuse and neglect is important, since the closeness of the relationship between the person maltreating the child and the child can have significant effects [ 102 – 103 ], and the timing of maltreatment is also important, with studies finding effects for both sex and age [ 104 ]. From a public health perspective, the measurement of maltreatment should ideally move beyond raw prevalence, and yield sufficiently sensitive and nuanced information about these key contextual features of the maltreatment to inform future public health policy and prevention efforts, including the indication of priority areas for responses. The addition of such questions presents challenges for instrument design and implementation, including the time to administer additional questions. However, we recommend such questions wherever possible.

Limitations

We reviewed studies measuring the traditional forms of child maltreatment, and excluded studies of adverse childhood experiences conceptualised more broadly, such as peer bullying and community violence. Some researchers recommend that studies include both maltreatment and these other adversities [ 37 ] on the basis that chronic exposure to multiple adversities influences developmental trajectories through the lifespan. However, we applied rigorous eligibility criteria of four or five of the recognized maltreatment categories, all clearly associated with adverse sequelae, and which most closely reflect specific SDG targets of caregiver abuse and any sexual violence. Recent outcomes of the ACE study itself have only focused on these five types and three classes of household dysfunction [ 18 ]. Additionally, our data extraction method for the quality assessment was not formally validated, but we adopted an approach similar to that used elsewhere [ 32 , 35 , 45 ] considering key variables in detail. Similarly, while there were no previously validated risk of bias measures for this specific type of prevalence study, we used a method with high interrater agreement that has been used elsewhere [ 45 ], including in prevalence studies of abuse and interpersonal violence [ 105 – 106 ]. Our approach to risk of bias adopted a conservative approach, and reasonably concluded that studies scoring 9.5 or 10 had minimal bias.

This systematic review and analysis has shown nationwide studies of the prevalence of child maltreatment have been conducted, using methods of administration suited to the setting, and involving child participants, adult participants, or both. However, there are few such nationwide studies of all five or even four maltreatment types, leaving substantial gaps in knowledge about the experience of childhood maltreatment in nearly all countries. Overall, our review and analysis indicates many of the completed studies are generally sound, but some take a more comprehensive and conceptually robust approach to provide nuanced, useful data for researchers and policymakers. To enable measurement of progress against the United Nations Agenda for Sustainable Development Goal 16 of reduction of child abuse, many countries need to invest in robust national prevalence studies. Such studies should measure exposure to domestic violence in addition to physical abuse, sexual abuse, emotional abuse, and neglect. Studies should use an instrument with demonstrated validity and reliability, and must ensure maltreatment types are operationalised appropriately in the questions asked. If participants are children or adolescents under age 18, studies should capture past year incidence, as well as childhood prevalence. Information should be captured about the specific nature, severity and frequency of the maltreatment, and the relationship of the child to the person who inflicted the acts. Such data can best inform the development and monitoring of nationwide prevention efforts.

Supporting information

S1 fig. prisma checklist..

https://doi.org/10.1371/journal.pone.0227884.s001

S1 File. Search strategy.

https://doi.org/10.1371/journal.pone.0227884.s002

S2 File. Data extraction template.

https://doi.org/10.1371/journal.pone.0227884.s003

S3 File. Extracted survey items.

https://doi.org/10.1371/journal.pone.0227884.s004

S4 File. Quality assessment tool.

https://doi.org/10.1371/journal.pone.0227884.s005

S5 File. Prevalence rates of included studies.

https://doi.org/10.1371/journal.pone.0227884.s006

Acknowledgments

We acknowledge Juliet Davis, Elizabeth Dallaston, and Andrea Boskovic for providing research assistance. We also thank the journal reviewers for their helpful comments.

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Recent Research on Child Neglect

• First Online: 22 February 2022

Cite this chapter

• Howard Dubowitz 5 ,
• Julia M. Kobulsky 6 &
• Laura J. Proctor 7  

Part of the book series: Child Maltreatment ((MALT,volume 14))

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5 Citations

Neglect is the most common form of child maltreatment, adversely affecting multiple domains of functioning throughout the lifespan. Repeated calls have implored the scientific community to remedy the “neglect of neglect,” which refers to the paucity of research on neglect relative to abuse, particularly regarding prevention and intervention. Barriers to the advancement of scientific knowledge and to tackling this intractable public health problem include the difficulties defining neglect and inadequate concern regarding its relative harm. Despite these challenges, numerous studies on the nature and consequences of child neglect have been conducted. This review focuses on recent advances in research regarding child neglect’s nature, measurement, prevalence, etiology, consequences, prevention, and intervention. It is guided by the question: What is new about neglect? Although much work remains to be done, noteworthy advances have been made.

With permission, this chapter builds upon what we wrote for R. Geffner, et al. (Eds) (2021). Handbook of interpersonal violence and abuse across the lifespan . New York: Springer Nature.

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Dubowitz, H., Kobulsky, J.M., Proctor, L.J. (2022). Recent Research on Child Neglect. In: Krugman, R.D., Korbin, J.E. (eds) Handbook of Child Maltreatment. Child Maltreatment, vol 14. Springer, Cham. https://doi.org/10.1007/978-3-030-82479-2_2

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Understanding Child Abuse and Neglect (1993)

Chapter: 1 introduction, 1 introduction.

Child maltreatment is a devastating social problem in American society. In 1990, over 2 million cases of child abuse and neglect were reported to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive long-term social, behavioral, and cognitive consequences of child abuse and neglect. Reports of child maltreatment alone also reveal little about the interactions among individuals, families, communities, and society that lead to such incidents.

American society has not yet recognized the complex origins or the profound consequences of child victimization. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, are expensive and are often subsidized by governmental funds. The General Accounting Office (1991) has estimated that these services cost more than $500 million annually. Equally disturbing, research suggests that child maltreatment cases are highly related to social problems such as juvenile delinquency, substance abuse, and violence, which require additional services and severely affect the quality of life for many American families.

The Importance Of Child Maltreatment Research

The challenges of conducting research in the field of child maltreatment are enormous. Although we understand comparatively little about the causes, definitions, treatment, and prevention of child abuse and neglect, we do know enough to recognize that the origins and consequences of child victimization are not confined to the months or years in which reported incidents actually occurred. For those who survive, the long-term consequences of child maltreatment appear to be more damaging to victims and their families, and more costly for society, than the immediate or acute injuries themselves. Yet little is invested in understanding the factors that predispose, mitigate, or prevent the behavioral and social consequences of child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central nexus of more comprehensive research activity.

Research On Child Maltreatment Is Currently Undervalued And Undeveloped

Research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, so-

cial welfare, and criminal violence. Although no specific theory about the causes of child abuse and neglect has been substantially replicated across studies, significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment.

Efforts to improve the quality of research on any group of children are dependent on the value that society assigns to the potential inherent in young lives. Although more adults are available in American society today as service providers to care for children than was the case in 1960, a disturbing number of recent reports have concluded that American children are in trouble (Fuchs and Reklis, 1992; National Commission on Children, 1991; Children's Defense Fund, 1991).

Efforts to encourage greater investments in research on children will be futile unless broader structural and social issues can be addressed within our society. Research on general problems of violence, substance addiction, social inequality, unemployment, poor education, and the treatment of children in the social services system is incomplete without attention to child maltreatment issues. Research on child maltreatment can play a key role in informing major social policy decisions concerning the services that should be made available to children, especially children in families or neighborhoods that experience significant stress and violence.

As a nation, we already have developed laws and regulatory approaches to reduce and prevent childhood injuries and deaths through actions such as restricting hot water temperatures and requiring mandatory child restraints in automobiles. These important precedents suggest how research on risk factors can provide informed guidance for social efforts to protect all of America's children in both familial and other settings.

Not only has our society invested relatively little in research on children, but we also have invested even less in research on children whose families are characterized by multiple problems, such as poverty, substance abuse, violence, welfare dependency, and child maltreatment. In part, this slower development is influenced by the complexities of research on major social problems. But the state of research on this topic could be advanced more rapidly with increased investment of funds. In the competition for scarce research funds, the underinvestment in child maltreatment research needs to be understood in the context of bias, prejudice, and the lack of a clear political constituency for children in general and disadvantaged children in particular (Children's Defense Fund, 1991; National Commission on Children, 1991). Factors such as racism, ethnic discrimination, sexism, class bias, institutional and professional jealousies, and social inequities influence the development of our national research agenda (Bell, 1992, Huston, 1991).

The evolving research agenda has also struggled with limitations im-

posed by attempting to transfer the results of sample-specific studies to diverse groups of individuals. The roles of culture, ethnic values, and economic factors pervade the development of parenting practices and family dynamics. In setting a research agenda for this field, ethnic diversity and multiple cultural perspectives are essential to improve the quality of the research program and to overcome systematic biases that have restricted its development.

Researchers must address ethical and legal issues that present unique obligations and dilemmas regarding selection of subjects, provision of services, and disclosure of data. For example, researchers who discover an undetected incident of child abuse in the course of an interview are required by state laws to disclose the identities of the victim and offender(s), if known, to appropriate child welfare officials. These mandatory reporting requirements, adopted in the interests of protecting children, may actually cause long-term damage to children by restricting the scope of research studies and discouraging scientists from developing the knowledge base necessary to guide social interventions.

Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can improve the quality of social service efforts and public policy decisions affecting the health and welfare of abused and neglected children and their families. Most important, collaborative long-term research ventures are necessary to diminish social, professional, and institutional prejudices that have restricted the development of a comprehensive knowledge base that can improve understanding of, and response to, child maltreatment.

Dimensions Of Child Abuse And Neglect

The human dimensions of child maltreatment are enormous and tragic. The U.S. Advisory Board on Child Abuse and Neglect has called the problem of child maltreatment ''an epidemic" in American society, one that requires a critical national emergency response.

The scale and severity of child abuse and neglect has caused various public and private organizations to mobilize efforts to raise public awareness of individual cases and societal trends, to improve the reporting and tracking of child maltreatment cases, to strengthen the responses of social service systems, and to develop an effective and fair system for protecting and offering services to victims while also punishing adults who deliberately harm children or place them in danger. Over the past several decades, a growing number of state and federal funding programs, governmental reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment.

The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Organizational mechanisms are also needed to facilitate the application and integration of research on child maltreatment in related areas such as child development, family violence, substance abuse, and juvenile delinquency.

Child maltreatment is not a new problem, yet concerted service, research, and policy attention toward it is just beginning. Although isolated studies of child maltreatment appeared in the medical and sociological literature in the first half of the twentieth century, the publication of "The Battered Child Syndrome" by C. Henry Kempe and associates (1962) is generally considered the first definitive paper in the field in the United States. The efforts of Kempe and others to publicize disturbing medical experience with child abuse and neglect led to the passage of the first Child Abuse Prevention and Treatment Act in 1974 (P.L. 93-247). The act, which has been amended several times (most recently in 1992), established a governmental program designed to guide and consolidate national and state data collection efforts regarding reports of child abuse and neglect, conduct national surveys of household violence, and sponsor research and demonstration programs to prevent, identify, and treat child abuse and neglect.

However, the federal government's leadership role in building a research base in this area has been complicated by changes and inconsistencies in research plans and priorities, limited funding, politicized peer review, fragmentation of effort among various federal agencies, poorly scheduled proposal review deadlines, and bias introduced by competing institutional objectives. 1 The lack of comprehensive, long-term planning for a research base has resulted in a field characterized by contradictions, conflict, and fragmentation. The role of the National Center for Child Abuse and Neglect as the lead federal agency in supporting research in this field has been sharply criticized (U.S. Advisory Board, 1991). Many observers believe that the federal government lacks leadership, funding, and an effective research program for studies on child maltreatment.

The Complexity Of Child Maltreatment

Child maltreatment was originally seen in the form of "the battered child," often portrayed in terms of physical abuse. Today, four general categories of child maltreatment are generally recognized: (1) physical

abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. Each category covers a range of behaviors, as discussed in Chapter 2.

These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own typology and framework of reference terms, revealing certain similarities (such as the importance of developmental perspectives in considering the consequences of maltreatment) but also important differences (such as the predatory behavior associated with some forms of sexual abuse that do not appear in the etiology of other forms of child maltreatment).

In addition to the category of child maltreatment, the duration, source, intensity, timing, and situational context of incidents of child victimization are now recognized as important factors in studying the origin and consequences of child maltreatment. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment. Furthermore, research is often weakened by variation in research definitions of child maltreatment, bias in the recruitment of research subjects, the absence of information regarding circumstances surrounding maltreatment reports, the absence of measures to assess selected variables under study, and the absence of a developmental perspective in many research studies.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent. Relatively little is known about areas of similarity and differences in terms of causes, consequences, prevention, and treatment of selected types of child abuse and neglect. Inconsistencies in definitions often preclude comparative analyses of clinical studies. For example, studies of sexual abuse have indicated wide variations in its prevalence, often as a result of differences in the types of behavior that might be included in the definition adopted by each research investigator. Emotional abuse is also a matter of controversy in some quarters, primarily because of broad variations in its definition.

Research on child maltreatment is also complicated by the fragmentation of services and responses by which our society addresses specific reports of child maltreatment. Cases may involve children who are victims or witnesses to single or repeated incidents of child abuse and neglect. Sadly, child maltreatment often involves various family members, relatives, or other individuals who reside in the homes or neighborhoods of the affected children. Adult figures may be perpetrators of offensive incidents or mediators in intervention or prevention efforts.

The importance of the social ecological framework of the child has only recently been recognized in studies of maltreatment. Responses to child abuse and neglect involve a variety of social institutions, including commu-

nities, schools, hospitals, churches, youth associations, the media, and other social structures that provide services for children. Such groups and organizations present special intervention opportunities to reduce the scale and scope of the problem of child maltreatment, but their activities are often poorly documented and uncoordinated. Finally, governmental offices at the local, state, and federal levels have legal and social obligations to develop programs and resources to address child maltreatment, and their role is critical in developing a research agenda for this field.

In the past, the research agenda has been determined predominantly by pragmatic needs in the development and delivery of treatment and prevention services rather than by theoretical paradigms, a process that facilitates short-term studies of specialized research priorities but impedes the development of a well-organized, coherent body of scientific knowledge that can contribute over time to understanding fundamental principles and issues. As a result, the research in this field has been generally viewed by the scientific community as fragmented, diffuse, decentralized, and of poor quality.

Selection of Research Studies

The research literature in the field of child maltreatment is immense—over 2000 items are included in the panel's research bibliography, a portion of which is referenced in this report. Despite this quantity of literature, researchers generally agree that the quality of research on child maltreatment is relatively weak in comparison to health and social science research studies in areas such as family systems and child development. Only a few prospective studies of child maltreatment have been undertaken, and most studies rely on the use of clinical samples (which may exclude important segments of the research population) or adult memories. Both types of samples are problematic and can produce biased results. Clinical samples may not be representative of all cases of child maltreatment. For example, we know from epidemiologic studies of disease of cases that were derived from hospital records that, unless the phenomenon of interest always comes to a service provider for treatment, there exist undetected and untreated cases in the general population that are often quite different from those who have sought treatment. Similarly, when studies rely on adult memories of childhood experiences, recall bias is always an issue. Longitudinal studies are quite rare, and some studies that are described as longitudinal actually consist of hybrid designs followed over time.

To ensure some measure of quality, the panel relied largely on studies that had been published in the peer-reviewed scientific literature. More rigorous scientific criteria (such as the use of appropriate theory and methodology in the conduct of the study) were considered by the panel, but were not adopted because little of the existing work would meet such selection

criteria. Given the early stage of development of this field of research, the panel believes that even weak studies contain some useful information, especially when they suggest clinical insights, a new perspective, or a point of departure from commonly held assumptions. Thus, the report draws out issues based on clinical studies or studies that lack sufficient control samples, but the panel refrains from drawing inferences based on this literature.

The panel believes that future research reviews of the child maltreatment literature would benefit from the identification of explicit criteria that could guide the selection of exemplary research studies, such as the following:

For the most part, only a few studies will score well in each of the above categories. It becomes problematic, therefore, to rate the value of studies which may score high in one category but not in others.

The panel has relied primarily on studies conducted in the past decade, since earlier research work may not meet contemporary standards of methodological rigor. However, citations to earlier studies are included in this report where they are thought to be particularly useful and when research investigators provided careful assessments and analysis of issues such as definition, interrelationships of various types of abuse, and the social context of child maltreatment.

A Comparison With Other Fields of Family and Child Research

A comparison with the field of studies on family functioning may illustrate another point about the status of the studies on child maltreatment. The literature on normal family functioning or socialization effects differs in many respects from the literature on child abuse and neglect. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations. Family functioning studies have focused predominantly on large, nonclinical populations, exploring styles of parenting and parenting practices that generate different kinds and levels of competence, mental health, and character in children. Studies of family functioning have tended to follow cohorts of subjects over long periods to identify the effects of variations in childrearing practices and patterns on children's

competence and adjustment that are not a function of social class and circumstances.

By contrast, the vast and burgeoning literature on child abuse and neglect is applied research concerned largely with the adverse effects of personal and social pathology on children. The research is often derived from very small samples selected by clinicians and case workers. Research is generally cross-sectional, and almost without exception the samples use impoverished families characterized by multiple problems, including substance abuse, unemployment, transient housing, and so forth. Until recently, researchers demonstrated little regard for incorporating appropriate ethnic and cultural variables in comparison and control groups. In the past decade, significant improvements have occurred in the development of child maltreatment research, but key problems remain in the area of definitions, study designs, and the use of instrumentation.

As the nature of research on child abuse and neglect has evolved over time, scientists and practitioners have likewise changed. The psychopathologic model of child maltreatment has been expanded to include models that stress the interactions of individual, family, neighborhood, and larger social systems. The role of ethnic and cultural issues are acquiring an emerging importance in formulating parent-child and family-community relationships. Earlier simplistic conceptionalizations of perpetrator-victim relationships are evolving into multiple-focus research projects that examine antecedents in family histories, current situational relationships, ecological and neighborhood issues, and interactional qualities of relationships between parent-child and offender-victim. In addition, emphases in treatment, social service, and legal programs combine aspects of both law enforcement and therapy, reflecting an international trend away from punishment, toward assistance, for families in trouble.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected. By focusing this report on research priorities and the needs of the research community, the panel's efforts were distinguished from related activities, such as the reports of the U.S. Advisory Board on Child Abuse and Neglect, which concentrate on the policy issues in the field of child maltreatment.

The request for recommendations for research priorities recognizes that existing studies on child maltreatment require careful evaluation to improve the evolution of the field and to build appropriate levels of human and financial resources for these complex research problems. Through this review, the panel has examined the strengths and weaknesses of past research and identified areas of knowledge that represent the greatest promise for advancing understanding of, and dealing more effectively with, the problem of child maltreatment.

In conducting this review, the panel has recognized the special status of studies of child maltreatment. The experience of child abuse or neglect from any perspective, including victim, perpetrator, professional, or witness, elicits strong emotions that may distort the design, interpretation, or support of empirical studies. The role of the media in dramatizing selected cases of child maltreatment has increased public awareness, but it has also produced a climate in which scientific objectivity may be sacrificed in the name of urgency or humane service. Many concerned citizens, legislators, child advocates, and others think we already know enough to address the root causes of child maltreatment. Critical evaluations of treatment and prevention services are not supported due to both a lack of funding and a lack of appreciation for the role that scientific analysis can play in improving the quality of existing services and identifying new opportunities for interventions. The existing research base is small in volume and spread over a wide variety of topics. The contrast between the importance of the problem and the difficulty of approaching it has encouraged the panel to proceed carefully, thoroughly distinguishing suppositions from facts when they appear.

Research on child maltreatment is at a crossroads—we are now in a position to merge this research field with others to incorporate multiple perspectives, broaden research samples, and focus on fundamental issues that have the potential to strengthen, reform, or replace existing public policy and social programs. We have arrived at a point where we can

recognize the complex interplay of forces in the origins and consequences of child abuse and neglect. We also recognize the limitations of our knowledge about the effects of different forms of social interventions (e.g., home visitations, foster care, family treatment programs) for changing the developmental pathways of abuse victims and their families.

The Importance Of A Child-Oriented Framework

The field of child maltreatment studies has often divided research into the types of child maltreatment under consideration (such as physical and sexual abuse, child neglect, and emotional maltreatment). Within each category, researchers and practitioners have examined underlying causes or etiology, consequences, forms of treatment or other interventions, and prevention programs. Each category has developed its own typology and framework of reference terms, and researchers within each category often publish in separate journals and attend separate professional meetings.

Over a decade ago, the National Research Council Committee on Child Development Research and Public Policy published a report titled Services for Children: An Agenda for Research (1981). Commenting on the development of various government services for children, the report noted that observations of children's needs were increasingly distorted by the "unmanageably complex, expensive, and confusing" categorical service structure that had produced fragmented and sometimes contradictory programs to address child health and nutrition requirements (p. 15-16). The committee concluded that the actual experiences of children and their families in different segments of society and the conditions of their homes, neighborhoods, and communities needed more systematic study. The report further noted that we need to learn more about who are the important people in children's lives, including parents, siblings, extended family, friends, and caretakers outside the family, and what these people do for children, when, and where.

These same conclusions can be applied to studies of child maltreatment. Our panel considered, but did not endorse, a framework that would emphasize differences in the categories of child abuse or neglect. We also considered a framework that would highlight differences in the current system of detecting, investigating, or responding to child maltreatment. In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom mal-

treatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

An Ecological Developmental Perspective

The panel has adopted an ecological developmental perspective to examine factors in the child, family, or society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors merit attention in shaping a research agenda on child maltreatment. We have adopted a perspective that recognizes that dysfunctional families are often part of a dysfunctional environment.

The relevance of child maltreatment research to child development studies and other research fields is only now being examined. New methodologies and new theories of child maltreatment that incorporate a developmental perspective can provide opportunities for researchers to consider the interaction of multiple factors, rather than focusing on single causes or short-term effects. What is required is the mobilization of new structures of support and resources to concentrate research efforts on significant areas that offer the greatest promise of improving our understanding of, and our responses to, child abuse and neglect.

Our report extends beyond what is, to what could be, in a society that fosters healthy development in children and families. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

The fundamental theme of the report is the recognition that research efforts to address child maltreatment should be enhanced and incorporated into a long-term plan to improve the quality of children's lives and the lives of their families. By placing maltreatment within the framework of healthy development, for example, we can identify unique sources of intervention for infants, preschool children, school-age children, and adolescents.

Each stage of development presents challenges that must be resolved in order for a child to achieve productive forms of thinking, perceiving, and behaving as an adult. The special needs of a newborn infant significantly differ from those of a toddler or preschool child. Children in the early years of elementary school have different skills and distinct experiential levels from those of preadolescent years. Adolescent boys and girls demon-

strate a range of awkward and exploratory behaviors as they acquire basic social skills necessary to move forward into adult life. Most important, developmental research has identified the significant influences of family, schools, peers, neighborhoods, and the broader society in supporting or constricting child development.

Understanding the phenomenon of child abuse and neglect within a developmental perspective poses special challenges. As noted earlier, research literature on child abuse and neglect is generally organized by the category or type of maltreatment; integrated efforts have not yet been achieved. For example, research has not yet compared and contrasted the causes of physical and sexual abuse of a preschool child or the differences between emotional maltreatment of toddlers and adolescents, although all these examples fall within the domain of child maltreatment. A broader conceptual framework for research will elicit data that can facilitate such comparative analyses.

By placing research in the framework of factors that foster healthy development, the ecological developmental perspective can enhance understanding of the research agenda for child abuse and neglect. The developmental perspective can improve the quality of treatment and prevention programs, which often focus on particular groups, such as young mothers who demonstrate risk factors for abuse of newborns, or sexual offenders who molest children. There has been little effort to cut across the categorical lines established within these studies to understand points of convergence or divergence in studies on child abuse and neglect.

The ecological developmental perspective can also improve our understanding of the consequences of child abuse and neglect, which may occur with increased or diminished intensity over a developmental cycle, or in different settings such as the family or the school. Initial effects may be easily identified and addressed if the abuse is detected early in the child's development, and medical and psychological services are available for the victim and the family. Undetected incidents, or childhood experiences discovered later in adult life, require different forms of treatment and intervention. In many cases, incidents of abuse and neglect may go undetected and unreported, yet the child victim may display aggression, delinquency, substance addiction, or other problem behaviors that stimulate responses within the social system.

Finally, an ecological developmental perspective can enhance intervention and prevention programs by identifying different requirements and potential effects for different age groups. Children at separate stages of their developmental cycle have special coping mechanisms that present barriers to—and opportunities for—the treatment and prevention of child abuse and neglect. Intervention programs need to consider the extent to which children may have already experienced some form of maltreatment in order to

evaluate successful outcomes. In addition, the perspective facilitates evaluation of which settings are the most promising locus for interventions.

Previous Reports

A series of national reports associated with the health and welfare of children have been published in the past decade, many of which have identified the issue of child abuse and neglect as one that deserves sustained attention and creative programmatic solutions. In their 1991 report, Beyond Rhetoric , the National Commission on Children noted that the fragmentation of social services has resulted in the nation's children being served on the basis of their most obvious condition or problem rather than being served on the basis of multiple needs. Although the needs of these children are often the same and are often broader than the mission of any single agency emotionally disturbed children are often served by the mental health system, delinquent children by the juvenile justice system, and abused or neglected children by the protective services system (National Commission on Children, 1991). In their report, the commission called for the protection of abused and neglected children through more comprehensive child protective services, with a strong emphasis on efforts to keep children with their families or to provide permanent placement for those removed from their homes.

In setting health goals for the year 2000, the Public Health Service recognized the problem of child maltreatment and recommended improvements in reporting and diagnostic services, and prevention and educational interventions (U.S. Public Health Service, 1990). For example, the report, Health People 2000 , described the four types of child maltreatment and recommended that the rising incidence (identified as 25.2 per 1,000 in 1986) should be reversed to less than 25.2 in the year 2000. These public health targets are stated as reversing increasing trends rather than achieving specific reductions because of difficulties in obtaining valid and reliable measures of child maltreatment. The report also included recommendations to expand the implementation of state level review systems for unexplained child deaths, and to increase the number of states in which at least 50 percent of children who are victims of physical or sexual abuse receive appropriate treatment and follow-up evaluations as a means of breaking the intergenerational cycle of abuse.

The U.S. Advisory Board on Child Abuse and Neglect issued reports in 1990 and 1991 which include national policy and research recommendations. The 1991 report presented a range of research options for action, highlighting the following priorities (U.S. Advisory Board on Child Abuse and Neglect, 1991:110-113):

This report differs from those described above because its primary focus is on establishing a research agenda for the field of studies on child abuse and neglect. In contrast to the mandate of the U.S. Advisory Board on Child Abuse and Neglect, the panel was not asked to prepare policy recommendations for federal and state governments in developing child maltreatment legislation and programs. The panel is clearly aware of the need for services for abused and neglected children and of the difficult policy issues that must be considered by the Congress, the federal government, the states, and municipal governments in responding to the distress of children and families in crisis. The charge to this panel was to design a research agenda that would foster the development of scientific knowledge that would provide fundamental insights into the causes, identification, incidence, consequences, treatment, and prevention of child maltreatment. This knowledge can enable public and private officials to execute their responsibilities more effectively, more equitably, and more compassionately and empower families and communities to resolve their problems and conflicts in a manner that strengthens their internal resources and reduces the need for external interventions.

Report Overview

Early studies on child abuse and neglect evolved from a medical or pathogenic model, and research focused on specific contributing factors or causal sources within the individual offender to be discovered, addressed, and prevented. With the development of research on child maltreatment over the past several decades, however, the complexity of the phenomena encompassed by the terms child abuse and neglect or child maltreatment has become apparent. Clinical studies that began with small sample sizes and weak methodological designs have gradually evolved into larger and longer-term projects with hundreds of research subjects and sound instrumentation.

Although the pathogenic model remains popular among the general public in explaining the sources of child maltreatment, it is limited by its primary focus on risk and protective factors within the individual. Research investigators now recognize that individual behaviors are often influenced by factors in the family, community, and society as a whole. Elements from these systems are now being integrated into more complex theories that analyze the roles of interacting risk and protective factors to explain and understand the phenomena associated with child maltreatment.

In the past, research on child abuse and neglect has developed within a categorical framework that classifies the research by the type of maltreatment typically as reported in administrative records. Although the quality of research within different categories of child abuse and neglect is uneven and problems of definitions, data collection, and study design continue to characterize much research in this field, the panel concluded that enough progress has been achieved to integrate the four categories of maltreatment into a child-oriented framework that could analyze the similarities and differences of research findings. Rather than encouraging the continuation of a categorical approach that would separate research on physical or sexual abuse, for example, the panel sought to develop for research sponsors and the research community a set of priorities that would foster the integration of scientific findings, encourage the development of comparative analyses, and also distinguish key research themes in such areas as identification, incidence, etiology, prevention, consequences, and treatment. This approach recognizes the need for the construction of collaborative, long-term efforts between public and private research sponsors and research investigators to strengthen the knowledge base, to integrate studies that have evolved for different types of child maltreatment, and eventually to reduce the problem of child maltreatment. This approach also highlights the connections that need to be made between research on the causes and the prevention of child maltreatment, for the more we learn about the origins of child abuse and neglect, the more effective we can be in seeking to prevent it. In the same manner, the report emphasises the connections that need to be made between research on the consequences and treatment of child maltreatment, for knowledge about the effects of child abuse and neglect can guide the development of interventions to address these effects.

In constructing this report, the panel has considered eight broad areas: Identification and definitions of child abuse and neglect (Chapter 2) Incidence: The scope of the problem (Chapter 3) Etiology of child maltreatment (Chapter 4) Prevention of child maltreatment (Chapter 5) Consequences of child maltreatment (Chapter 6) Treatment of child maltreatment (Chapter 7)

Human resources, instrumentation, and research infrastructure (Chapter 8) Ethical and legal issue in child maltreatment research (Chapter 9)

Each chapter includes key research recommendations within the topic under review. The final chapter of the report (Chapter 10) establishes a framework of research priorities derived by the panel from these recommendations. The four main categories identified within this framework—research on the nature and scope of child maltreatment; research on the origins and consequences of child maltreatment; research on the strengths and limitations of existing interventions; and the need for a science policy for child maltreatment research—provide the priorities that the panel has selected as the most important to address in the decade ahead.

1. The panel received an anecdotal report, for example, that one federal research agency systematically changed titles of its research awards over a decade ago, replacing phrases such as child abuse with references to maternal and child health care, after political sensitivities developed regarding the appropriateness of its research program in this area.

Bell, D.A. 1992 Faces at the Bottom of the Well: The Permanence of Racism . New York: Basic Books.

Children's Defense Fund 1991 The State of America's Children . Washington, DC: The Children's Defense Fund.

Daro, D. 1988 Confronting Child Abuse: Research for Effective Program Design . New York: The Free Press, Macmillan. Cited in the General Accounting Office, 1992. Child Abuse: Prevention Programs Need Greater Emphasis. GAO/HRD-92-99.

Daro, D., and K. McCurdy 1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey . Chicago: National Committee for Prevention of Child Abuse.

Fuchs, V.R., and D.M. Reklis 1992 America's children: Economic perspectives and policy options. Science 255:41-46.

General Accounting Office 1991 Child Abuse Prevention: Status of the Challenge Grant Program . May. GAO:HRD91-95. Washington, DC.

Huston, A.C., ed. 1991 Children in Poverty: Child Development and Public Policy . New York: Cambridge University Press.

Kempe, C.H., F.N. Silverman, B. Steele, W. Droegemueller, and H.R. Silver 1962 The battered child syndrome. Journal of the American Medical Association 181(1): 17-24.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman 1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

National Commission on Children 1991 Beyond Rhetoric: A New American Agenda for Children and Families . Washington, DC: U.S. Government Printing Office.

National Research Council 1981 Services for Children: An Agenda for Research . Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

U.S. Advisory Board on Child Abuse and Neglect 1990 Child Abuse and Neglect: Critical First Steps in Response to a National Emergency . August. Washington, DC: U.S. Department of Health and Human Services. August. 1991 Creating Caring Communities . September. Washington, DC: U.S. Department of Health and Human Services.

U.S. Public Health Service 1990 Violent and abusive behavior. Pp. 226-247 (Chapter 7) in Healthy People 2000 Report . Washington, DC: U.S. Department of Health and Human Services.

The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

• Definitions and scope —exploring standardized classifications, analysis of incidence and prevalence trends, and more.
• Etiology, consequences, treatment, and prevention —analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.
• Infrastructure and ethics —including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25.

New Directions in Child Abuse and Neglect Research.

• Hardcopy Version at National Academies Press

2 Describing the Problem

Child abuse and neglect is well established as an important societal concern with significant ramifications for the affected children, their families, and society at large (see Chapter 4 ). A critical step in devising effective responses is reasonable agreement on the definition of the problem and its scope. Yet achieving clarity in the area of child abuse and neglect has been an ongoing challenge. Legal definitions vary across states; researchers apply diverse standards in determining incidence and prevalence rates in clinical and population-based studies; and substantial obstacles hamper learning about the experiences of children, especially young children, with caregiver-inflicted abuse or neglect. As a result, definitions of the characteristics of the problem and determinations of its scope will differ depending on the data source used for analysis. This challenge was articulated in the 1993 National Research Council (NRC) report ( NRC, 1993 ) and continues to impede a full understanding of the nature of the child abuse and neglect problem. The purpose of this chapter is to describe briefly what is known about the problem from current data sources and to highlight issues that remain problematic, as well as identify areas in which advances have been made. The chapter addresses, in turn, definitions of child abuse and neglect, incidence rates and the problem of underreporting, trends in the incidence of child abuse and neglect, and how cases are determined by medical and mental health professionals and the legal system. The final section presents conclusions.

• DEFINITIONS

A key definition of child abuse and neglect is contained in Section 3 of the Child Abuse Prevention and Treatment Act (CAPTA) 1 :

At a minimum, any recent act or set of acts 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.

This definition is especially important because it is enshrined in federal legislation. To be eligible to receive funding under Section 106 2 of the act, states must, at a minimum, include the conduct described in Section 3 in their state child abuse and neglect authorizing legislation. All 50 states, as well as American Samoa, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, the District of Columbia, Guam, and the Virgin Islands, have mandatory child abuse and neglect reporting laws that define the terms slightly differently for their jurisdiction and lay out the requirements for mandatory reporting ( CWIG, 2011 ). Federal law defines child abuse and neglect and identifies reporting requirements on tribal lands 3 (see CWIG, 2012b , for further information) and on military installations 4 (see Military OneSource, n.d., for further information); in some circumstances, state laws on child abuse and neglect reporting also apply to tribal lands and military installations. The Victims of Child Abuse Act 5 (also see Chapter 8 ) lays out requirements for reporting child abuse that occurs on federal lands and in federal facilities.

The National Child Abuse and Neglect Data System (NCANDS) is the official government data source to which all states must contribute information about child abuse and neglect reports. To collect data on reported and confirmed cases of child abuse and neglect uniformly from all states, NCANDS provides the following somewhat more comprehensive definition of child abuse and neglect:

An act or failure to act by a parent, caregiver, or other person as defined under State law that results in physical abuse, neglect, medical neglect, sexual abuse, emotional abuse, or an act or failure to act which presents an imminent risk of harm to a child. ( ACF, 2012 )

Many states, reflecting the words “at a minimum” in CAPTA, have more expansive definitions of the conduct that legally constitutes child abuse and neglect for purposes of mandatory reporting. In some states, for example, only conduct by current caregivers is defined as reportable child abuse and neglect; in other states, the conduct must be reported regardless of the perpetrator's relationship to the child. Pennsylvania, for example, considers only acts of abuse as reportable acts of maltreatment and uses a different mechanism for capturing neglect. CAPTA permits states to limit reporting to “recent” acts, but most states have no time limit on when the conduct occurred for the mandatory reporting requirement to be invoked. A summary of the differences in states' child abuse and neglect reporting laws is available ( CWIG, 2011 ).

How child abuse and child neglect are defined and who is obligated to report them are subject to changes in awareness or level of concern about possible abuse- and neglect-related hazards faced by children. It is common for a specific case, especially one involving an egregious situation not addressed by extant law, to prompt advocacy for legislative change ( Gainsborough, 2010 ). Newly identified problem areas, changes in societal consensus about child protection, and revelations that certain groups of professionals are not included in mandatory reporting laws are typical scenarios for bringing about statutory reforms. In 2012, 107 bills addressing child abuse and neglect reporting were introduced in 30 states and the District of Columbia ( NCSL, 2012 ). For example, a number of states expanded mandatory reporting to apply to university employees in response to the Penn State Sandusky scandal.

In some cases, such changes have unintended consequences. An example is the occasional inclusion of exposure to domestic violence as a statutorily specified form of reportable child abuse and neglect, a result of increasing awareness of the association between domestic violence and child abuse and neglect and concern for the welfare of children exposed to this violence, so that affected children would receive protection and services. The Minnesota state legislature instituted such a change in 1999. The result was a dramatic increase in the number of referrals, emanating mainly from law enforcement officials who responded to reports of domestic violence and, as mandated, reported the family to child protective services. Parents, primarily mothers, who themselves were victims of domestic violence thus became the subjects of neglect reports based on their alleged failure to protect their children from exposure to the violence. This was not the intent of the legislation, and the provision was quickly rescinded ( Edleson et al., 2006 ).

Child abuse and neglect laws are for the most part concerned with parental behaviors of omission or commission that place children in jeopardy. Acts of omission usually are characterized as neglect. They include failing to provide adequate supervision; not protecting children from known dangers; and not providing for basic needs, such as proper medical care, adequate food and clothing, safe/hygienic shelter, and school attendance. Child neglect reports may also be made in some states if a child is born affected by illegal drug or alcohol abuse by the mother or if a child is living where drugs are being manufactured and/or distributed.

Child abuse, on the other hand, refers to acts of commission by a caregiver. Physical abuse encompasses physical assaults that exceed permitted corporal punishment. States may define explicitly the types of behavior that fall in this category. In some cases for example, the age of the child may determine whether a behavior is acceptable discipline (e.g., slapping an infant versus an older child across the face). Sexual abuse generally includes the range of sexual behaviors that are defined by criminal statutes, including sexual exposure, sexual touching, rape, and sexual exploitation. Emotionally abusive behaviors include threatening, terrorizing, or deliberately frightening a child; rejecting, ridiculing, shaming, or humiliating behaviors; extreme isolating or restricting behaviors; and corruption or encouraging involvement in illegal behaviors. However, of the 48 states that mention emotional abuse in law, only Delaware identifies specific emotionally abusive caregiver behaviors; most states define emotional abuse by its impact on the child's mental health ( CWIG, 2011 ). Because the involvement of the child protection system focuses on caregivers, cases of abuse committed by non-family members or siblings may be classified as neglect. In those cases, it is the presumed or alleged failure of the caregiver to protect the child that drives the designation. For example, the majority of sexual abuse and a notable proportion of serious physical abuse cases involve non-family members as perpetrators ( Finkelhor and Dziuba-Leatherman, 1994 ). Instances of abuse committed by a non-family member, a sibling, or another person regularly present in the household are classified as neglect if it is determined that the caregiver failed to protect the child victim from that individual.

As noted, child abuse and neglect laws also vary in how mandated reporters are defined. Some states define all adult citizens as mandated reporters, but most specify certain groups of professionals and others who work with children ( CWIG, 2012a ). State laws usually exempt from a reporting obligation priests acting in the role of receiving confession; states vary, however, as to whether reporting is required of priests or pastors acting in other capacities. Regardless of the groups specified, anyone not listed as a mandated reporter can still make a report. Both mandated reporters and others are legally protected for good faith reports, while mandated reporters who fail to report may be prosecuted for that failure. No evidence-based research has assessed whether the breadth of inclusion in mandatory reporting laws makes a difference in rates of reporting, although it may affect substantiation rates ( McElroy, 2012 ; also see the discussion of mandatory reporting laws in Chapter 8 ).

Some acts of child abuse and neglect are also crimes. The specific statutory definitions and names of those crimes vary by state, but in general, criminal statutes cover the same acts in all states. Sexual abuse is always a crime; most cases are classified as felonies. Physical abuse is a crime unless the behavior falls within the discipline exception for corporal punishment. Most cases of physical abuse are likely to be classified as misdemeanors unless a child is seriously injured or dies. A minority of neglect cases involve criminal conduct. When the failure to supervise, protect, or provide care for a child rises to a certain level of negligent treatment, it may meet the criteria for violation of criminal codes (e.g., child endangerment or criminal neglect) and can be prosecuted. Just because child abuse and neglect falls within the statutory definition of a crime, however, does not mean it will be fully investigated by law enforcement and prosecuted. Law enforcement investigations and prosecutions tend to focus on sexual abuse and on serious physical abuse and very serious neglect that have resulted in a child's experiencing physical harm or death (e.g., starvation, inflicted medical trauma).

As with state laws, child abuse and neglect is defined in various ways for research purposes. The National Incidence Study (NIS)-4 ( Sedlak et al., 2010a ) applies two definitional standards: a harm standard and an endangerment standard. The harm standard is restricted to cases in which children have been harmed by child abuse and neglect, whereas the endangerment standard encompasses children who have not yet been harmed under certain circumstances. The numbers vary depending on which definition is used (NIS-4 harm standard = 1.25 million children; endangerment standard = 3 million children). Under both standards, alleged instances of abuse or neglect are classified according to eight major categories. Table 2-1 lists actions or failures to act that are representative of each type of abuse or neglect and, for the purposes of this chapter, provides examples of how these forms of maltreatment can be defined in a research setting.

National Incidence Study (NIS)-4 Abuse and Neglect Classifications.

A widely used method of defining child abuse and neglect in research is the classification scheme developed by Barnett and colleagues (1993) . Many studies focused specifically on child abuse and neglect use these definitions rather than the officially reported labels (e.g., English et al., 2005 ). The Centers for Disease Control and Prevention (CDC) also has recommended a set of uniform definitions for public health purposes to allow for monitoring of incidence over time and detection of trends ( Leeb et al., 2008 ). Notably, both the classification scheme developed by Barnett and colleagues and the CDC recommendations are designed for analysis of existing information from public sources, primarily child protective services case records.

Slack and colleagues (2003) note that research definitions developed for analysis of child protective services case records may not be applicable to survey research. They argue that these definitions may capture risk factors associated with the detection of child abuse and neglect rather than risk factors associated with the commission of child abuse and neglect. They have built on the framework created by Barnett and colleagues (1993) to develop a set of research definitions for neglect that they intend for use in survey research.

Likewise, other investigators develop their own study-specific designations. These definitions vary in comprehensiveness and behavioral specificity. For example, a study not focused specifically on child abuse and neglect but interested in it as one of many independent variables may use a single general question to get at the construct.

Finding: Child abuse and neglect are defined differently for different purposes. Legal definitions at the state level are properly subject to the legislative process. In research, however, the variability in definitions compromises learning the true scope and characteristics of the problem, understanding trends over time, and determining the relationship between child abuse and neglect and various outcomes. Finding: State laws vary in what groups are specified as mandated reporters of child abuse and neglect. No evidence-based research has assessed whether the breadth of inclusion in mandatory reporting laws makes a difference in rates of reporting, although it may affect substantiation rates.

• INCIDENCE RATES AND THE PROBLEM OF UNDERREPORTING

Determining the true incidence of child abuse and neglect is problematic for the same reason encountered in attempting to quantify any social problem: discrepancies between actual rates and the number of cases reported to authorities. It is well established that most crimes (the exception being homicide) are not reported ( Langton et al., 2012 ). Data on the incidence of child abuse and neglect are derived from three primary sources: NCANDS, the official reporting system for cases of child abuse and neglect referred to state child protective services; two U.S. government surveys—the Uniform Crime Reporting (UCR) system, administered by the Federal Bureau of Investigation (FBI), and the National Crime Victimization Survey (NCVS), administered by the Bureau of Justice Statistics (BJS) to a large representative sample of U.S. citizens aged 12 and older; and the NIS, a study conducted every decade by the Department of Health and Human Services on a nationally representative sample that captures both cases of abuse and neglect reported to child protective services and unreported cases identified by professionals working with children.

National Child Abuse and Neglect Data System

Each state receiving a federal Basic State Grant for child abuse and neglect prevention and treatment programs is required to submit data annually to NCANDS. 6 In fiscal year (FY) 2011, all states, the District of Columbia, and all territories contributed to NCANDS counts of the number of cases referred to child protective services, the number accepted for investigation, the number substantiated, the case characteristics, and the case outcomes. As previously noted, the definitions of child abuse and neglect used by child protective services vary by state, as do reporting requirements. Because NCANDS collects information from child protective services case files in each state, the data reflect inconsistencies in state-level definitions of types of maltreatment, reporting requirements, and procedures for responding to reports of child abuse and neglect.

NCANDS reports are issued annually. According to the FY 2011 NCANDS report ( ACF, 2012 ), there were 3.4 million referrals involving 6.2 million children; some of the children were the subject of more than one referral. Nationally, more than three-quarters of these cases are classified as neglect, 18 percent as physical abuse, and 9 percent as sexual abuse. The specific rates vary among states but overall reflect the general pattern that a substantial majority of cases are neglect, with physical and sexual abuse representing much smaller groups.

Based on NCANDS, victims of child abuse and neglect are approximately evenly divided between males and females. The highest rates of child abuse and neglect occur among the very youngest children (see Table 2-2 ). Perpetrators are mainly parents (81 percent) and among parents are primarily biological parents (88 percent), which reflects the legal definition for reportable cases. Somewhat more than half of perpetrators are female ( ACF, 2012 ). These demographic characteristics are also reflected in other data sources, such as the NIS-4 ( Sedlak et al., 2010a ).

Child Maltreatment Cases/Victims, Rates per Thousand Population Ages 0-17, by Various Characteristics, 2002-2011.

In FY 2011, NCANDS reported 1,545 child fatalities resulting from abuse and neglect. Again, young children were at greatest risk: 80 percent of victims were less than 4 years old. Deaths were higher among boys than girls. About 70 percent of the fatalities are associated with neglect and nearly half are attributed to physical abuse, either exclusively or in combination. A Government Accountability Office ( GAO, 2011 ) report notes that the NCANDS method relies only on cases reported to child protective services for these figures. The report states that not all child fatalities due to abuse and neglect are known to the child welfare system, suggesting that the actual figure is likely higher, although it acknowledges the difficulty of obtaining an accurate count.

An important limitation of NCANDS is that it does not capture accurate rates of child abuse and neglect among American Indian children. Only states submit information to NCANDS; there are no mechanisms for tribal child welfare systems to submit data to the system. American Indian and Alaska Native families and children whose cases are reported to and investigated by state child protection authorities and who self-identify as American Indian or Alaska Native are included in NCANDS. Children served by tribal child welfare systems, the Bureau of Indian Affairs, or the Indian Health Service are not. Thus, “it is estimated that 40 percent of all cases of child abuse and neglect among American Indian and Alaska Native children are not reported to NCANDS” ( Cross and Simmons, 2008 , p. 3; also see Earle and Cross, 2001 ). NCANDS is further limited in its ability to reveal the levels of abuse and neglect suffered by American Indian and Alaska Native children by the fact that state or county employees, rather than tribal workers, collect the data reported to NCANDS. Therefore, not only does NCANDS lack data on many cases that occur on tribal lands, but the data it does include may be flawed because non-Native workers with American Indian or Alaska Native culture often are tasked with making determinations of abuse or neglect in such settings ( Fox, 2004 ).

U.S. Government Surveys

The U.S. government uses the two surveys noted above to learn about crime rates. The UCR covers crimes reported to police, whereas the NCVS is a household survey of a large representative sample of individuals aged 12 and older that asks about both reported and unreported crimes. Self-reported rates of crime victimization frequently are several times the rates of official reports, with the discrepancies being especially high for sexual assault.

The ability of such surveys to capture cases accurately hinges, in part, on how the question is asked. Using official terminology or labels for acts of child abuse and neglect requires respondents to label their own experiences as abusive or neglectful. In some cases, respondents may not know the official definitions or exactly what they encompass. For example, many children and adults may consider hitting a child with a belt appropriate corporal punishment. In other cases, the victim may be reluctant to define what happened as abusive. For example, evidence suggests that labeling acts as intentionally abusive is associated with increased distress in children ( Kolko et al., 2002 ).

These labeling considerations are particularly acute in cases of sexual assault. Asking a single question—such as “Have you ever been raped?”—yields far fewer responses than a series of behaviorally specific questions about acts that meet the legal definition of sexual abuse and rape. For example, rates of endorsement of child sexual abuse in self-report research vary substantially based on how the question is posed. A meta-analysis of studies that used self-report surveys to examine childhood sexual abuse experiences around the world found that differences in the way sexual abuse was defined and the specific questions asked produced dramatically different rates of sexual abuse prevalence ( Stoltenborgh et al., 2011 ).

In addition to these survey design issues, the point in time and circumstances under which respondents provide information about child abuse and neglect are crucial. Surveys of adults about their childhood experiences may yield very different rates than surveys of children. For example, population-based telephone interviews of youth aged 10 and older provide extensive information about self-reported victimization and exposure to violence ( Finkelhor, 2009 ; Kilpatrick and Saunders, 1995 ). However, the rates of intrafamilial sexual and physical abuse reported in these studies are relatively low compared with the rates reported among adult samples when asked their childhood abuse experiences. Children may be less likely to report intrafamilial crimes when they are still children and are living at home.

Another method of learning about child abuse and neglect is asking adults about their behavior toward their children. Surveys using the Conflict Tactics Scale can provide a picture of self-reported corporal punishment and parental acts that would meet legal criteria for child physical abuse ( Straus and Stewart, 1999 ; Straus et al., 1998 ; Theodore et al., 2005 ). This method has the obvious limitation, however, that even when responding to anonymous surveys, parents may underreport socially undesirable or illegal acts.

Discrepancies between official reports and child and adult self-reports can be in either direction. Children or adults may not define their experiences as child abuse and neglect because they do not know better or believe the conduct was deserved or acceptable, or because of the distress associated with reporting that caregivers are behaving abusively toward them. Adults may not define their own behavior as abusive or neglectful because of fears of being reported, social undesirability, or shame about the conduct. On the other hand, substantial evidence shows that careful and detailed questioning of children about their experiences produces substantially higher rates than official reports. For example, computer-assisted interviews were used to obtain self-reports of abuse and neglect from a sample of youth aged 12-13 enrolled in a prospective study of high-risk and abused children ( Everson et al., 2008 ). This method yielded rates that were four to six times higher than those in the official child protective services records. At the same time, close to half of adolescents in the sample with confirmed child protective services reports failed to note that experience in the interview.

The National Incidence Study

The NIS is a congressionally mandated report on the incidence of child abuse and neglect that has been issued periodically since 1974 ( OPRE, 2009 ). It estimates national rates of reported and unreported child abuse and neglect based on a representative sample of counties. The study uses official data and also collects information from “sentinels” representing community professionals who may encounter child abuse and neglect victims during the course of their work. The methodology of the NIS is explicitly designed to uncover child abuse and neglect that may not have been reported to authorities but was identified by professionals. The most recent report, issued in 2010, is based on data collected in 2005-2006 ( Sedlak et al., 2010a ). As noted above, the NIS defines child abuse and neglect differently from federal and state law, applying both a harm and an endangerment standard. All cases sampled in the study—both those identified by child protective services agencies and those reported by sentinels—are evaluated to determine whether they meet the definitional standards of the NIS for physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, and educational neglect. The NIS considers only abuse and neglect perpetrated or permitted by a parent or caregiver, aligning its definitions with those of child protective services.

The primary investigators of the NIS-4 note that findings of differential incidence rates for abuse and neglect of black and white children are limited by the range of risk factors available for analysis in multifactor risk models, which exclude such key elements as neighborhood characteristics, social isolation, substance use, and mental illness ( Sedlak et al., 2010b ). Likewise, many children's records lacked information on socioeconomic status, and the socioeconomic status measures used classified black and white children differently, limiting the utility of the data for examining socioeconomic status as a risk factor for child abuse and neglect.

Reasons for Underreporting

It is well known that not all child abuse and neglect cases come to the attention of authorities at the time they happen. Retrospective reports from adults abused or neglected as children reveal that most cases are not reported to anyone, and fewer still are reported and investigated by child protection workers or law enforcement officials (e.g., Finkelhor, 1994 ; MacMillan et al., 2003 ). Adults abused or neglected as children give a variety of explanations for why they did not tell anyone or make an official report, including not realizing that what was happening was wrong, illegal, or a form of child abuse and having fears or concerns about what would happen if they reported the experience or attempted to seek help.

Child abuse and neglect can sometimes be identified without a child's making a statement about it. Examples include certain types of injuries or medical conditions that are noticed by others or become known to a medical provider. Some types of neglect can also be detected through observable behaviors, such as young children found wandering the streets or coming to school unclean or very disheveled. But detection of many cases of physical abuse and neglect and almost all cases of sexual abuse depends largely on children making statements and adults acting on those statements. The statements may be made spontaneously or may be in response to adult inquiries about behaviors, circumstances, or injuries observed in the children. Once abuse or neglect has been detected, many variables can affect whether adults take action, including personal attitudes and beliefs about what will happen as a result of reporting, the relationship of the adult to the child or the caregiver who may have committed the abuse or neglect, the certainty of the concern about maltreatment, and understanding of the child abuse reporting laws ( Alvarez et al., 2004 ; Khan et al., 2005 ; Sedlak et al., 2010a ).

Therefore, official reports do not capture all instances in which child abuse and neglect is suspected or even is detected and acted upon. For example, adults in a child's life may learn about child abuse and neglect and take informal actions on behalf of the child without necessarily reporting to authorities. Although citizens are protected if they make a good faith report of suspected child abuse or neglect, there are many reasons why they might be hesitant about or deterred from making an official report even if strong evidence or suspicion exists. For example, they may fear retaliation or rejection by the abuser or negative consequences for the child or family. Indeed, despite the fact that relatives, neighbors, and friends are most likely to observe or hear about child abuse or neglect because of their proximity and involvement in children's lives, they account for only a minority (18 percent) of reporters of cases to child protective services ( ACF, 2012 ).

Professionals account for the other three-fifths of child abuse and neglect reports, with teachers (16 percent), law enforcement officials (17 percent), and social service providers (11 percent) making the majority of these reports ( ACF, 2012 ). However, mandated reporters do not always make a report when they suspect child abuse or neglect. Among mandated reporters involved as sentinels in the NIS-4, a significant percentage have had suspicion and not made a report. Professionals identify a variety of reasons for not reporting their suspicions ( Sedlak et al., 2010a ). The most common reasons given are concerns that intervention by child protective services will be more harmful than helpful and the professionals' belief that they can do a better job of addressing the suspected child abuse or neglect on their own without involving the authorities. Rates of reporting also may vary by profession and relationship with the family. In one state survey of pediatricians, only 10 percent had ever not reported a suspected case of abuse or neglect; the most common reason given was not feeling that the evidence for suspicion was strong enough or believing that the case could be better handled by the physician or family without the involvement of child protective services ( Theodore and Runyan, 2006 ). For mental health providers, the dilemma may be more acute. For example, Steinberg and colleagues (1997) found that among psychologists who had made a report to child protective services, 27 percent stated that their client ended the therapy relationship because of the child abuse report.

In addition to the concerns of professionals about the consequences of reporting for themselves and their practice, a lack of clarity exists as to what constitutes reasonable suspicion as defined by the law. There is little dispute about suspicion when the basis for concern is clear-cut (e.g., the child makes a credible statement about being sexually abused or has hand print bruises on the cheek). In many cases, however, the information available to the reporter is vague, inconclusive, or only suggestive. Is it neglect when a child comes to school in dirty clothes and smelling bad? How young a child can be left alone at home? What if a child says, “I am afraid to go home”? If a child is engaging in highly sexualized behavior, is that indicative of abuse? There is a substantial gray area that is open to interpretation with respect to whether a statement or behavior meets criteria for triggering a legally mandated report of child abuse and neglect. A lack of consensus exists even among expert child abuse doctors. Levi and Crowell (2011) found no agreement among experts on how high child abuse and neglect would have to be on the list of differential diagnoses and how certain the provider would have to be that child abuse and neglect accounted for the child's presentation to meet the reporting criterion of reasonable suspicion.

On the other hand, only about 60 percent of referrals to child protection authorities are accepted and screened in for some type of official response ( ACF, 2012 ). Cases may be screened out because they do not meet the legal criteria for child abuse and neglect or state standards for accepting cases, or because information about the case is insufficient to enable completing a report. Among states, screen-in rates range from a low of 25 percent to a high of virtually all referrals ( ACF, 2012 ). Thus citizens and professionals likely recognize many situations in which they suspect child abuse and neglect, but their suspicions do not meet the threshold of concern required by local statute to justify an investigation.

Disproportionality

Concerns have been raised about possible racial and ethnic bias in child abuse and neglect reporting and investigations because African American and American Indian children are referred to child protective services at higher rates than their representation in the population, whereas Asian American and Latino children are referred at lower rates. A recent study used a birth cohort methodology and linked vital statistics and child abuse report records for young children ( Putnam-Hornstein, 2011 ). Prior child abuse reports were associated with an almost sixfold increase in the probability of intentional death and double the rate of unintentional fatal injury; the rates were higher for African American and American Indian children and lower for Asian American and Latino children relative to the general population. In other words, the racial/ethnic patterns of injury and death mirror the child abuse and neglect reporting rates by racial and ethnic group. Moreover, the overall underrepresentation of Latino children in referrals to the child welfare system masks significant differences between the experiences of Latino children of U.S.-born mothers and Latino children of foreign-born mothers, both in rates of referral ( Putnam-Hornstein et al., 2013 ) and in type of abuse or neglect ( Dettlaff and Johnson, 2011 ). Authoritative commentators ( Drake et al., 2011 ; Putnam-Hornstein, 2012 ; Putnam-Hornstein et al., 2013 ) agree that there are real group differences in the rates of child abuse and neglect and conclude that these differences reflect the higher burden of social ills borne by some groups. As Putnam-Hornstein concludes: “The findings suggest that the overrepresentation of black and Native American children in the child welfare system may be a manifestation of historical and contemporary racial inequities that place these minority children at a disproportionate risk of maltreatment” (2012, p. 171).

Disproportionality extends beyond referrals. Miller (2011) examined disproportionality in Washington state at both the referral point and key decisions points after cases had been screened in (e.g., risk rating, placement, length of time in care). As with other states, disproportional rates of referral were seen. When disproportionality from the point of referral was examined, virtually no differences were found among whites, Asians, and Latinos following case entry into the child welfare system. After case receipt, rates of disproportionality were reduced for African American families at most decision points, with the largest discrepancy remaining in length of time in care. For American Indian cases, the disproportionality continued at every decision point following case acceptance. These results suggest that the observed disproportionality may have a variety of causes, some that reflect larger social forces and others that may be more reflective of professional assumptions and local practices. Disproportionality is discussed further in Chapter 5 of this report.

Finding: According to NCANDS data from FY 2011, there were 3.4 million child abuse and neglect referrals involving 6.2 million children. Nationally, more than three-quarters of these cases are classified as neglect, 18 percent as physical abuse, and 9 percent as sexual abuse. The highest rates of child abuse and neglect occur among young children, specifically those less than 3 years old. Finding: Tribal child welfare systems, the Bureau of Indian Affairs, and the Indian Health Service do not report to NCANDS and are therefore not included in the datasets, thus limiting the ability to determine levels of abuse and neglect among many American Indian and Alaska Native populations. Moreover, non-Native workers report on cases of child abuse and neglect without familiarity with or consideration of the culture in these communities. Finding: Difficulties arise in determining rates of child abuse and neglect. When researchers attempt to identify instances of child abuse and neglect through survey instruments, results can vary based on the types of questions asked and the point in time and circumstances under which respondents provide the information. Conducting retrospective surveys of childhood experiences, asking children about recent experiences, and surveying parents about their behaviors toward children all can yield different results. Finding: African American and American Indian children are referred to child protective services at disproportionate rates relative to their representation in the general population.

• INCIDENCE TRENDS

Questions about whether child abuse and neglect are increasing, decreasing, or being detected and reported more often have become prominent in recent years. At the time of the 1993 NRC report, there was a general consensus that child abuse and neglect was underreported. Since that time, substantial changes have occurred in the social climate with regard to awareness of child abuse and neglect, attitudes toward reporting it, and the availability of programs and services for children and families affected by it. These developments have explicitly been intended to increase reporting of child abuse and neglect by victims, the general public, and professionals. However, establishing whether changes in official reporting represent true changes in incidence is complicated by the limitations of the reporting systems discussed above, as well as the difficulties inherent in ascertaining rates of events that happen to children, many of whom are very young, and that occur mainly in the private context of family life. As revealed by the review below, discrepancies exist in some areas and considerable ambiguity in others regarding the conclusions to be drawn from the available trend data, suggesting outstanding questions that would benefit from more systematic empirical analyses of these trends over time.

Sexual abuse has shown the largest decline in reported rates. NCANDS reports a decline of 62 percent since 1992 ( Finkelhor and Jones, 2012 ). The sharpest declines occurred during the late 1990s, but the downward trajectory has continued, with a 3 percent decline being reported between 2009 and 2010. This same pattern is demonstrated in the NIS-4, issued in 2010, which reported a 47 percent decline from the mid-1990s through 2005, when the data for that report were collected ( Finkelhor and Jones, 2012 ).

Additional information on trends in sexual abuse is derived from surveys of youth. The NCVS documents a 68 percent decrease in reported and unreported sexual assault or rape of 12- to 17-year-olds between 1993 and 2010 ( White and Lauritsen, 2012 ). In a national survey on sexual and reproductive activity, young women (aged 15-24) reported a 39 percent decline in sexual experiences with a partner 3 or more years older before the age of 15 ( Finkelhor and Jones, 2012 ). This survey follows the same pattern as NCANDS, with the declines being steepest in the 1990s and tapering off although still continuing in the 2000s. Finkelhor and colleagues (2010b) compare results from the National Survey of Children Exposed to Violence (NatSCEV) in 2003 and 2008 and find that reports of sexual assault declined from 3.3 percent of all children aged 2-17 in 2003 to 2.0 percent of children in 2008. In contrast, the National Survey of Adolescents (NSA), a survey of a large nationally representative sample of youth, found no decline in self-reported sexual assault between 1995 and 2005 ( Finkelhor and Jones, 2012 ).

The trend data are more ambiguous with respect to physical abuse. NCANDS reports a decline of 56 percent in physical abuse reports from the early 1990s through 2010 ( Finkelhor et al., 2010a ). The decrease for physical abuse began somewhat later than that for sexual abuse but has followed the same slope, with steep declines in the late 1990s that tapered off by 2009. Likewise, the NIS-4 reported a 29 percent drop in endangerment-standard physical abuse starting in the early 1990s ( Finkelhor and Jones, 2012 ).

Survey results produce a somewhat different picture. The NCVS reports a 69 percent decline in aggravated physical assaults on children (aged 12-17) from 1993 through 2008; however, these events are mainly peer and sibling assaults rather than physical abuse by parents ( Finkelhor and Jones, 2012 ). Zolotor and colleagues (2011) compared results from a 2002 survey of parents in North Carolina (Carolina Survey of Abuse in the Family Environment) using the Parent-Child Conflict Tactics Scale with the findings of a Gallup survey completed in 1995 and the results of two National Family Violence Surveys, conducted in 1975 and 1985, that used the same scale. The results show a decline in parental reports of physical abuse. On the other hand, neither the NatSCEV nor the NSA found significant declines in youth-reported physical abuse by caregivers ( Finkelhor and Jones, 2012 ).

Another source of data on physical abuse is admissions to a hospital for abuse-related injury. Physical abuse encompasses a broad range of acts. The most common is striking a child such that bruising results—ranging from relatively minor, temporary, and localized marks caused by pinching or slapping to significant marks caused by whipping or hitting with an object that may leave scars. These types of injuries do not typically entail admission to a hospital or even require medical care. On the other hand, a relatively small percentage of physical abuse cases involve injuries, such as fractures, burns, blunt trauma, and abusive head trauma (formerly known as shaken baby syndrome), that require medical care and possibly hospitalization ( Zolotor and Shanahan, 2011 ). Approximately 1.4 percent of physical abuse cases are estimated to result in hospitalization ( Leventhal et al., 2012 ).

A number of studies have investigated changes in rates of admission for head injuries resulting from child physical abuse—the most common reason for child abuse-related hospital admission. Leventhal and Gaither (2012) found a small but concerning increase in the rate of serious injuries as documented in coding on medical records in a series of children's hospitals (from 6.1 to 6.4/100,000) from 1997 to 2009. Additional studies, attempting to show an association between economic indicators and child abuse, similarly have found increases in rates of injuries coded as child abuse occurring during the 2000s ( Berger and Waldfogel, 2011 ; Berger et al., 2011 ; Wood et al., 2012 ). A national study conducted in Taiwan also found a significant increase from 1996 to 2007, but only for infants and largely accounted for by changes in coding practices since 2003 ( Chiang et al., 2012 ).

Neglect reports show the most mixed trends picture. NCANDS neglect reports declined by 10 percent between 1990 and 2010 ( Finkelhor et al., 2010a ), but there was significant variability across states. From 1992 to 2010, for example, fluctuations ranged from a 90 percent decline in neglect in Vermont to a 189 percent increase in Michigan. These dramatic state variations are not mirrored in the sexual and physical abuse rates, which declined across almost all states over the same period. The NIS-4 found no decline in neglect cases ( Sedlak et al., 2010a ). Self-report survey data are not available for neglect to permit comparisons over time. In part, this is due to the fact that retrospective self-report surveys are poorly suited to gathering information about neglect involving very young children, which is the most frequent form of child abuse and neglect.

Child maltreatment–related fatalities include deaths caused by both physical abuse and neglect, with a majority being attributed to neglect. NCANDS reports an increase of 46 percent in abuse- and neglect-related fatalities between 1993 and 2007 ( Finkelhor and Jones, 2012 ). In contrast, homicide rates for children fell by 43 percent during the same period, with a 26 percent decline for the youngest children (aged 0-5) ( Finkelhor and Jones, 2012 ); between 1980 and 2008, 63 percent of murdered children aged 0-5 were killed by a parent ( Cooper and Smith, 2011 ). It is unclear to what extent cases officially reported by law enforcement as homicides correspond to cases included in the NCANDS child abuse and neglect dataset, most of which, as noted, are attributed to neglect.

Trends in child abuse and neglect occur in the larger context of rates of crime and violence in the United States. The consensus is that crime has decreased substantially, although there are some year-to-year fluctuations and pockets where these results are not seen. Both official reports as reflected in the UCR and population-based counts of reported and unreported crime as determined by the NCVS reveal declines in virtually all crime categories since the mid-1990s ( FBI, 2010 ; Truman and Planty, 2012 ). These declines extend to sexual assault and domestic violence, crimes that share characteristics of child sexual and physical abuse and often involve people in close interpersonal relationships or family members. As with child abuse and neglect, extensive efforts have been undertaken to change the social climate around these crimes, encourage reporting, and expand service availability. The NCVS shows a 68 percent decline in the number of children aged 17 and younger living in households in which someone aged 12 and older was the victim of sexual assault or violent crime between 1993 and 2010 ( Truman and Smith, 2012 ).

In sum, trends are inconsistent across types of child abuse and neglect, and in the case of neglect are inconsistent across states. Sexual abuse reporting appears to indicate a clear decline that is not reflected in only a single data source. Although most sexual abuse is not committed by immediate family members, the declines here appear to extend equally to family and nonfamily sexual assaults. It is worth noting that the declines in child sexual abuse began about the same time as general declines in crime and have followed a similar slope. Physical abuse presents a more complicated picture, with some official sources showing overall declines and several surveys not showing declines. Although physical assaults in general (e.g., nonfamily assault, bullying) appear to be down, it is not clear that these trends extend to intrafamilial physical abuse.

Increases in child abuse-related hospital admissions are especially concerning because these data represent the most severe assaults, even though they make up a very small subgroup of child abuse cases. There are several possible explanations for these increases. First, they may represent actual increases in serious injury. Several studies have directly examined the correlation between the increases in identified cases and larger economic forces ( Berger and Waldfogel, 2011 ; Berger et al., 2011 ; Wood et al., 2012 ). Berger and colleagues (2011) hypothesize an association between the economic recession and rising rates of child abuse-related injury, citing increases in child abuse and neglect reports from the prerecession to the recession period. However, they find no association with local unemployment rates. Wood and colleagues (2012) link data on child abuse-related hospital admissions to mortgage delinquency, foreclosures, and unemployment rates between 2000 and 2009. They find increases in admission rates to be correlated with mortgage foreclosure and delinquency rates but not with unemployment rates. Another possibility is that the increases reflect greater awareness and willingness of health care providers to label injuries as child abuse. The increases coincide with the advent of growing use of hospital diagnostic and billing codes that specify child abuse as the injury cause and a period when a child abuse subspecialty was created in pediatrics. These changes may have contributed to greater willingness to identify child abuse as the cause of injury in official records. Now that abusive head trauma is being captured more accurately in administrative data, it could potentially account for a decline in other forms of head injury ( Leventhal and Gaither, 2012 ). It is also possible that caregivers who inflict severe injuries have more severe psychopathology or are otherwise different from the typical child abuser, and are therefore less amenable to the influences associated with general societal changes and less likely to accept offers of voluntary assistance.

The lack of a significant decline in child neglect and the large jurisdictional variations in this area remain the least understood. The past two decades have seen a growing emphasis on encouraging recognition of neglect as its deleterious effects have increasingly been documented. Awareness campaigns have been undertaken to encourage reporting of neglect, and in some cases its definition has been expanded to incorporate a variety of risky circumstances and conditions. For example, the relationship of parental substance abuse to child abuse and neglect has received widespread attention. These forces may have contributed to increased reporting of a broader spectrum of neglect cases. Greater awareness and expanded definitions may have offset any declines in reports of traditionally defined neglect.

Poverty often is considered a major contributor to neglect, yet there is little empirical support for a strong relationship between changes in indicators of poverty and neglect reporting rates. For example, there was a great deal of concern that welfare reform, especially the timelines for receiving Temporary Assistance for Needy Families (TANF), would produce an increase in cases of neglect as parents were forced off income support. However, no significant change in neglect rates was seen during this period. And as mentioned, two separate investigations failed to find a relationship between unemployment rates and child abuse and neglect reports.

A better understanding is needed of whether and why rates of physical and sexual abuse are declining while no change in neglect is being observed. Criminologists have focused on understanding the substantial declines in crime rates as well as the occasional fluctuations or stubborn persistence of high crime rates in a few areas. Multiple commentators have examined possible causes and explanations ( Finkelhor et al., 2010b ; Levitt, 2004 ; Oppel, 2011 ; Zimring, 2008 , 2011 ). Other fields, such as medicine, would certainly have devoted extensive scientific inquiry to understanding an epidemiological phenomenon as significant and inconsistent across different forms of the same problem area. Yet there has been no similar focus in the field of child abuse and neglect. Attention to the topic has been limited to a few investigators who have repeatedly reported on trends (e.g., Finkelhor and Jones, 2012 ) and to targeted examinations of specific subareas, such as hospital admissions (e.g., Chiang et al., 2012 ; Leventhal and Gaither, 2012 ). A greater focus on understanding the fluctuations in child abuse reporting data and other indicators of child injury both nationally and within specific communities and populations could have important implications for the design and targeting of intervention and prevention efforts.

Finding: Strong evidence indicates that sexual abuse has declined substantially in the past two decades; the balance of evidence favors a decline in physical abuse, especially its more common and less serious forms. There is no evidence that neglect is declining overall; however, states vary significantly as to whether neglect is increasing, decreasing, or remaining constant. These disparate trends have important implications for understanding the nature of child abuse and neglect and the forces that potentially affect its trends. Social policy endeavors are hampered when insufficient attention is paid to understanding the various aspects of the problem. Finding: Understanding is incomplete with respect to whether and why rates of physical and sexual abuse are declining while no change in neglect is being observed. Research on these trends has received inadequate attention given their important implications for intervention and prevention efforts.

• DETERMINATION OF CHILD ABUSE AND NEGLECT

This section reviews the various methods of determining whether child abuse and neglect has occurred. The basis for the determination can range from a citizen's or family member's simply believing what a child says about being abused or neglected or being convinced by something observed, to a medical examination and diagnosis or the formation of a professional opinion, to the results of administrative or legal procedures. The process for making a determination by medical and mental health professionals is established by professional standards of practice, whereas legal standards of investigative practice, rules of evidence, and burdens of proof govern how legal determinations are made.

Determination by Medical and Mental Health Professionals

Medical determination or diagnosis is relevant in a small but very high-stakes minority of child abuse and neglect cases. A medical opinion is the only way to determine whether certain physical injuries—especially very serious injuries such as head injuries, fractures, and burns—are the result of child abuse and neglect in children who are too young to provide a verbal account of how the injury occurred. In certain cases involving children old enough to say what happened, a medical opinion may be necessary to distinguish accidental from nonaccidental injuries when the children's or parents' accounts are discrepant. In some neglect cases, such as those entailing malnutrition or failure to thrive, a medical opinion may be an essential component of the investigative process.

Taking a medical history is standard practice when medical professionals conduct a medical examination. In situations involving child abuse and neglect, especially when sexual abuse is suspected or the cause of an injury is in dispute, the child's history may be the primary basis for a medical professional's opinion or diagnosis. In such cases, although medical professionals may have specialized expertise in interviewing children, they, like other professionals and ordinary citizens, have no special ability to distinguish true from false or mistaken statements. However, statements made to a health care provider may be admissible in legal proceedings as an exception to the hearsay rule.

Overall, within the child abuse medical subspecialty, substantial consensus exists regarding the diagnostic criteria for forming a medical opinion about whether injuries or medical conditions are attributable to child abuse and neglect. However, there have been high-profile controversies about medical opinions in some child abuse cases. For example, questions have been raised about certain medical diagnoses, such as shaken baby syndrome, which as noted, is now called abusive head trauma. In some cases, child abuse experts have concluded that intentional injury has occurred, but other medical professionals have attributed the injuries to causes such as brittle bones or vitamin deficiencies. In large part, such conflicting opinions are due to the adversarial nature of the U.S. legal system. Opposing experts provide testimony to contradict a child abuse and neglect allegation and opine that alternative medical explanations account for the injuries, often, it has been argued, invoking scientifically unsupported assertions ( Chadwick et al., 1998 ). Although there have been some salient scientific developments in terms of the causes of injuries, in most cases these disputes do not reflect significant scientific uncertainties.

Outstanding questions do remain about the types of tests and procedures that are most appropriate for making a determination of child abuse and neglect. For example, radiographic skeletal survey is the standard procedure for detecting clinically unsuspected fractures in possible child abuse victims since a certain percentage of children will have occult fractures. Standards for additional tests and their timing have not been definitively established. Absent consensus standards, practice shows considerable variability.

Other presentations for which a medical opinion is absolutely necessary include complex conditions such as Munchausen syndrome by proxy, or medical child abuse ( Davis and Sibert, 1996 ; Fisher and Mitchell, 1995 ; Roesler and Jenny, 2008 ). While this condition is very rare (0.5/100,000 children), the potential consequences to children are extreme and severe ( McClure et al., 1996 ). Parents repeatedly take their children to medical providers, often many different ones, with reports of multiple and sometimes extremely serious symptoms or conditions. In some cases, the child has or had a legitimate underlying condition, and the parents have extreme anxiety and repeatedly seek out additional tests and procedures or exaggerate symptoms. In other cases, parents fabricate or cause the medical symptoms to obtain psychological gratification from the attention they receive in the role of concerned parent. Making a determination of medical child abuse in these cases is fraught with complications and frequently cannot occur until the child has suffered significant harm or endured unnecessary tests, procedures, and even surgeries. Suspicion does not even arise until the pattern of visits, procedures, and contacts with multiple providers emerges. Child abuse doctors face a daunting task in challenging the opinions and practices of other medical providers who may have been mistaken, but genuinely believed the child had a serious medical condition.

In sexual abuse cases, although medical assessment is the standard of care, medical diagnosis is relevant in only a small subset of cases. Physical signs or symptoms, such as genital changes or injuries, sexually transmitted diseases, pregnancy, or the presence of seminal fluids or sperm, are present in only about 4 percent of cases; the vast majority of children medically evaluated for sexual abuse have normal exams ( Heger et al., 2002 ). Even when there are genital findings, most are nonspecific and cannot be linked conclusively to sexual assault ( Heger et al., 2002 ). Cases with definitive medical evidence, such as the presence of semen or pregnancy, are exceedingly rare. Standards for making a medical determination of sexual abuse have been published ( Kellogg and Committee on Child Abuse and Neglect, 2005 ).

There are two important reasons beyond medical diagnosis why medical assessment of children who may have been or report being sexually abused is the standard of care. One purpose is to allay the child's and parents' worries about the potential physical effects of sexual contact. A visit with a medical provider creates a nonstigmatizing opportunity for support and validation, psychoeducation about the impact of sexual abuse, and encouragement to engage in available treatment services. The second is that citizens, judges, and juries assume that medical findings will be present in sexual abuse cases, even though this frequently is not the case. Child protection and criminal legal professionals believe it is often necessary to have a medical exam and expert medical testimony primarily to counter this widespread misconception.

Mental health professionals may be asked by parents or other professionals to provide a professional opinion as to whether a child was abused. Most such requests involve concern about sexual abuse. A diagnosis is not made because sexual abuse is an event, not a medical or psychiatric condition. In many cases, the mental health professional's opinion is sought in a forensic context when a report has been made to authorities or a legal action has been initiated, and the opinion is expected to help guide legal decision making or provide the basis for expert testimony in a legal proceeding. In other cases, however, the opinion is sought to determine whether to initiate reporting or other legal actions.

Typically in these situations, mental health providers consider a range of information, including what the child says in an interview, what the child has told others, the circumstances of the discovery of abuse concerns, results of medical examinations, and the emotional and behavioral functioning of the child based on a psychosocial assessment or administration of a standardized checklist of tests. The degree of thoroughness and the formality of the process depend largely on the purpose the opinion will serve.

Whereas child abuse mental health professionals do bring specialized expertise, knowledge, and skills to the evaluation process, there are scientific limits on the conclusions that can be drawn about whether an event occurred based on psychosocial assessment. No psychological profile has sufficient specificity to permit conclusions about an event as the cause of a presentation ( APA, 2013 ). In addition, the emotional and behavioral consequences of child abuse and neglect are varied and nonspecific (see Chapter 4 ). Conditions typically associated with child abuse and neglect, such as posttraumatic stress, anxiety, depression, and behavioral problems, are common mental health problems for children and have many other causes. The only behavioral problem that has a specific and significant relationship with child abuse and neglect is inappropriate sexual behavior. However, the majority of sexually abused children do not have sexual behavior problems, and there are other potential causes for sexual behavior in children ( Friedrich, 1993 ; Friedrich and Trane, 2002 ; Friedrich et al., 1998 , 2003 ).

To a large extent, professional opinions on child abuse and neglect rely heavily on determinations about the credibility of children's statements. There is no reason to believe that children cannot give reliable and accurate information about events or that they are prone to making false complaints about abuse ( Brown et al., 2007 ; Cederborg et al., 2008 ; Lamb et al., 2007 ; Lyon, 1999 ). On the other hand, it is well established that memory, especially in young children, is susceptible to error and distortion, and that children can form false beliefs that they have experienced events ( Cederborg et al., 2008 ; Lyon, 1999 ). It turns out that the characteristics of true and untrue statements have many commonalities; some true statements are not very credible, and some untrue statements are highly detailed and convincing. Mechanisms devised for rating child reports about abuse and neglect and classifying them as accurate or inaccurate have not proven reliable ( Hershkowitz et al., 2007 ). In other words, professionals have no special ability to detect truthfulness, nor is there a scientifically reliable method for doing so. This is why courts generally do not permit professionals to opine about the credibility of witnesses, but reserve that function for the fact finder ( Myers, 2012 ).

Standards have been established for conducting forensic assessments for purposes of providing an opinion about possible sexual abuse (e.g., Kuehnle and Connell, 2009 ; Sparta and Koocher, 2006 ). The standards cover the assessment process, interviewing approaches, the proper use of psychosocial information, and limits on the accuracy of opinions based largely on statements that cannot be verified and behaviors that are nonspecific. Unfortunately, the types of cases for which such assessments are sought are those that are most ambiguous and complex, such as when children are unable or unwilling to give a clear and credible history, they are very young, they have not made statements, their statements are vague or inconsistent, or they suffer from emotional and behavioral problems that affect their credibility.

Mental health professionals routinely form opinions on the basic truth of reports about historical events that are potentially relevant in explaining why clients present with emotional and behavioral problems. Mental health providers commonly inquire about a range of past events, such as child abuse and neglect; other forms of trauma; events and experiences such as divorce, family moves, and experiences at school or with peers; illness and hospitalization; and other relevant life experiences. This information is integrated with information derived from clinical observation and the results of assessment measures with respect to symptoms and behaviors. Except for what providers observe directly in session, nearly all the information that serves as the basis for an opinion about events and mental health problems is derived from self-reports. Reliance on self-reports, including reports of child abuse and neglect, is therefore a cornerstone of standard clinical practice.

Determination by the Legal System

Legal investigations.

Before a child abuse and neglect case arrives before a legal fact finder (judge or jury), an arm of the government investigates the case. Child protective services and law enforcement conduct the investigations that serve as the basis for the state's actions regarding dependency or prosecution. In many cases, the parents or defendants come to an agreement with the government, and no actual fact-finding hearing takes place. If it does, the official legal determination is made by civil or criminal court.

Child protective services usually is responsible for investigating civil dependency cases; such cases are screened in by the child welfare system, and they fall under the jurisdiction of the juvenile court. Given that the greatest number of reported cases involve neglect, and most do not involve criminal conduct, the child protective services investigation is the only process applied to making a determination about child abuse and neglect in the majority of cases. Caseworkers make home visits and observe the safety and hygiene status of the household; inspect bruises and injuries; and conduct interviews with children (when appropriate), caregivers, reporters, and others who may have relevant information (such as relatives, teachers, and health care providers). They then draw conclusions about whether the information and evidence thus obtained meet the legal standards for child abuse and neglect.

Law enforcement officials investigate crimes. They generally engage in the same activities as child welfare system caseworkers (e.g., interviewing victims and witnesses, examining home conditions); they may also collect evidence from crime scenes, undertake forensic analyses, and interrogate suspects. In many jurisdictions, child protective services and law enforcement officials conduct joint investigations ( Cross et al., 2005 ).

A key activity in many child abuse and neglect dependency and criminal investigations, especially in cases involving sexual abuse and some involving physical abuse, is interviewing the child. Interviewing methods most likely to lead to accurate and complete reports have been extensively investigated (e.g., Cronch et al., 2006 ; Lamb et al., 2009 ; Larsson and Lamb, 2009 ; Saywitz et al., 2002 ). The protocol of the National Institute for Child Health and Development (NICHD) is the approach that has been the most researched in real-life settings and in laboratory analogue experiments, and serves as the model for the current standard of practice ( Lamb et al., 2007 ). Other extant models, none of which has undergone the same level of empirical evaluation, share almost all the same procedures and practices as the NICHD protocol ( Anderson et al., 2010 ).

Legal Determinations

A legal determination of child abuse and neglect is based on the weighing of admissible evidence that is collected following the accepted procedures for the specific legal arena. The common law legal system in the United States is adversarial and is based on principles that protect the due process rights of those who are accused and risk loss of liberty, access to their children, or assets. The legal contexts vary by whether they are criminal or civil, the intended outcomes of the case, and the standard of proof that applies.

The two primary legal systems that make determinations about child abuse and neglect are the child protection system and the criminal justice system ( Myers, 2012 ). The child protection system carries out an administrative and civil justice process that involves the state's seeking to intervene in families, often but not always to assume temporary custody of children (e.g., establishing child abuse or neglect and then obtaining authority of the court for the child's placement) or in a small fraction of cases to terminate parental rights. In these court cases (often called dependency cases), the standard of proof typically is more probable than not; in a case involving termination of parental rights, a higher standard of clear and convincing evidence has been set by the U.S. Supreme Court. The goals of the criminal justice system are to hold lawbreakers accountable and punish them, to bring justice for victims, and to protect the community. The standard of proof here is the highest (beyond a reasonable doubt) because the case involves the government's restricting an adult's liberty, including the possibility of incarceration. Child abuse and neglect also may be addressed in family court custody matters when it is alleged by one parent seeking to restrict the other parent's access to the child. In addition, civil tort actions may be brought in which a child, or someone on his/her behalf, sues a caregiver, the government, or another entity for negligence, seeking monetary damages.

The large majority of both civil and criminal proceedings regarding child abuse and neglect do not progress to a formal fact-finding hearing or a trial. In many child protection cases, usually those not requiring a court order to remove a child from home against parental wishes, no formal legal process is even initiated; the family agrees to a voluntary service plan that is overseen by the state. Even when a dependency petition is filed in court, in the large majority of cases the parent reaches an agreement or case settlement regarding dependency, often without admitting to having committed an act of child abuse and neglect. On the criminal side, charges are not filed in many cases, even when prosecutors may believe a crime occurred, because of difficulties entailed in proving the case and in meeting the legal standard of proof of beyond a reasonable doubt. In the majority of cases when charges are filed, the accused pleads guilty to the crime or to a lesser crime.

Substantiation

The child protection system's classification of a child abuse and neglect case as substantiated is an administrative procedure for making a formal recorded determination about the validity of a child abuse and neglect report. In most states, the result of an investigation of a report is classified as substantiated or unsubstantiated, although some states use other terminology (e.g., founded/unfounded) to describe the investigative outcome. In 2011, approximately 19 percent of screened-in cases were substantiated, or “indicated” ( ACF, 2012 ). Substantiation can be legally disputed because the consequences of a substantiated report can be significant for caregivers (e.g., job loss or being barred from certain professions or by certain employers) ( CWIG, 2013 ; McCarthy et al., 2005 ).

No formal conclusion about whether child abuse and neglect occurred is recorded in cases that are referred for an alternative response (sometimes called a family assessment or differential response) and not formally investigated ( CWIG, 2013 ). In 2011, about 10 percent of all cases reported to NCANDS received an alternative response ( ACF, 2012 ), but that percentage is increasing. As of 2011, 17 states were implementing differential response at some level, and 6 states planned to implement it in the near future.

Rates of substantiation vary dramatically across states ( ACF, 2012 ), and there is little consensus on what accounts for this variation. Overall, every method used to determine the accuracy of child abuse and neglect allegations has weaknesses and cannot be considered definitive. To some extent, this does not matter as long as the victims are safe and receive needed services. For example, most crimes will not be reported or prosecuted or result in conviction of the perpetrator; however, crime victims will still have access to many services designed to help them recover from the effects of the crime, and most can take at least some steps toward protecting themselves from the perpetrator. Although child abuse victims are dependent on caregivers for future protection, many parents can and do take steps to protect their children from known perpetrators or correct their own neglectful or abusive behavior. In terms of access to needed services, what happens officially in a case is unrelated to receipt of services in the child welfare system. The National Survey of Child and Adolescent Well-Being, a large longitudinal study of a nationally representative sample of cases reported to child protective services, produced illustrative results. Comparisons of cases that were closed or kept open, or were substantiated or not, revealed no difference in key variables related to services or outcomes ( Hussey et al., 2005 ; Kohl et al., 2009 ).

The difficulty of ascertaining the validity of cases using official reporting or procedural outcomes may have more of an effect on research and interpretation of findings than on the lives of children who enter the child welfare system. For example, Kohl and colleagues (2009) argue that if substantiation does not discriminate true from untrue cases of child abuse and neglect, it is not a meaningful or accurate way of learning about the characteristics of actual abuse and neglect and its relationships to outcomes since the comparison group of unsubstantiated cases will contain many true cases. Therefore, child abuse research may benefit if consensus is achieved not only on definitions, but also on the meaning of different classification mechanisms for child abuse and neglect reports.

Finding: Significant advances have been made in dealing with children who may have been abused and neglected when they come in contact with medical, mental health, or social services professionals. It has become more common for these professionals to screen children routinely for abuse and other traumatic experiences. The children's accounts are generally accepted, at least for purposes of meeting the “reasonable suspicion” standard for making a child abuse report, except when there is significant evidence for coercion or contamination of their statements. Children who are suspected of being abused are commonly referred for specialized assessment, as well as clinical and support services. Finding: Overall, substantial improvements have been achieved in the assessment and investigative procedures for determining whether child abuse and neglect has occurred since the 1993 NRC report was issued. Widely accepted standards for proper interviewing have been adopted by child protective services, law enforcement officials, and forensic evaluators and are well known even among general health, mental health, and other professionals ( Lamb et al., 2007 ). Finding: Rates of substantiation of child abuse and neglect allegations by child protective services vary dramatically across states, and there is little consensus on what accounts for this variation. Overall, every method of determining the accuracy of child abuse and neglect allegations has weaknesses, and no method can be considered definitive. This limits the substantiation classification as a meaningful way to learn about the characteristics of actual abuse and neglect and their relationships to outcomes.

• CONCLUSIONS

Child abuse and neglect is a pervasive societal problem, with recent NCANDS data indicating that 3.4 million child abuse and neglect referrals involving 6.2 million children were made in a single year across the United States and its territories. As will be discussed in Chapter 4 , these incidents of child abuse and neglect entail a substantial risk for deleterious consequences that can hinder child development and lead to problems that persist across the life course.

Cases of child abuse and neglect are referred to child protective services based on mandatory reports by professionals such as teachers, law enforcement officials, social service providers, and physicians, as well as good-faith reports by citizens. Not all cases of child abuse and neglect are reported, and standards for reasonable suspicion of abuse and neglect are not always clear-cut. Therefore, official reports do not capture all cases in which child abuse and neglect is suspected or even is detected and acted upon. For research purposes, then, sole reliance on referral data from child protective services cannot capture the full scope of child abuse and neglect. Incorporating data from additional sources is necessary to determine the true incidence of the problem.

In addition, child abuse and neglect are defined differently for the varying purposes for which related information is collected, confounding attempts to portray the scope of the problem accurately or examine the surrounding circumstances. Results across studies based on surveys also may vary according to the survey methodology employed. Movement toward a reasonable degree of standardization in these areas is therefore needed.

Difficulties in ascertaining the scope of child abuse and neglect have contributed to uncertainties regarding whether the incidence of the problem is increasing or decreasing or cases are being detected and reported more frequently. Available trend data provide strong evidence that sexual abuse has declined substantially in the past two decades; the balance of evidence favors a decline in physical abuse, especially its more common and less serious forms. There is no evidence that neglect is declining overall. However, states vary significantly as to whether neglect is increasing, decreasing, or remaining constant. Discrepancies and ambiguity across analyses of different data sources highlight a need for more systematic empirical analyses of these trends over time. Research is needed to learn more about trends in child abuse and neglect and the variables that may account for decreases in the incidence of the problem or the lack thereof.

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42 U.S.C. § 5101 note.

42 U.S.C. § 52016a.

25 U.S.C. § 1169.

10 U.S.C. § 1787.

42 U.S.C. § 13001, et seq.

42 U.S.C. § 5106a(d).

• Cite this Page Committee on Child Maltreatment Research, Policy, and Practice for the Next Decade: Phase II; Board on Children, Youth, and Families; Committee on Law and Justice; Institute of Medicine; National Research Council; Petersen AC, Joseph J, Feit M, editors. New Directions in Child Abuse and Neglect Research. Washington (DC): National Academies Press (US); 2014 Mar 25. 2, Describing the Problem.
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Child abuse and neglect in a rapidly developing country

Parents’ perspectives.

Hendaus, Mohamed A. 1,2,3 ; Al-Khuzaei, Amna M. 1 ; Samarah, Osama 4, ; Hamad, Sara G. 4 ; Selim, Basma A. 4 ; El Ansari, Walid 5,6,7

1 Department of Pediatrics, Section of Academic General Pediatrics, Sidra Medicine, Doha, Qatar

2 Department of Pediatrics, Hamad General Corporation, Doha, Qatar

3 Department of Clinical Pediatrics, Weill- Cornell Medicine, Doha, Qatar

4 Pediatric Residency Program, Hamad General Corporation, Doha, Qatar

5 Department of Surgery, Hamad General Corporation, Doha, Qatar

6 College of Medicine, Qatar University, Doha, Qatar

7 School of Health and Education, University of Skövde, Skövde, Sweden

Address for correspondence: Dr. Osama Samarah, Hamad Medical Corporation, Doha, Qatar 3050. E-mail: [email protected]

Received November 03, 2019

Received in revised form November 20, 2019

Accepted May 02, 2020

Purpose: 

To identify parental awareness and knowledge regarding child abuse and neglect in the State of Qatar.

Methods: 

A cross-sectional study using a questionnaire was conducted at Hamad Medical Corporation, the only tertiary pediatric hospital in the State of Qatar at the time of the study. Parents of children of all ages were offered a questionnaire that included demographic details, parental knowledge, and awareness of child abuse and neglect.

Results: 

300 questionnaires were completed (response rate = 95%). More than 70% of parents were older than 30 years of age, 60% of them were females, and 66% were college graduates. The majority of the participants stated their familiarity about child abuse, and 6% witnessed morbidity or mortality due to child abuse in the society. Despite the identified laws, only 50% of the parents were aware of laws restricting child abuse. In regards to children with special needs, only 16% of the participants agreed that disabled children are at a higher risk of abuse compared to healthy children, while 33% were neutral and 52% disagreed. In addition, one-fifth of the respondents stated that hitting is discipline, while 63% disagreed. Almost one-third of the respondents agreed that hitting hands and buttock or hitting with soft objects is acceptable form of discipline. Unexpectedly, one-quarter of participants stated that it is okay to hit a child as long as no damage incurs. As for verbal abuse, around one-third of parents stated that yelling is not a form of child abuse, and that yelling does not affect growth and development. Comparing both corporal and verbal abuse, approximately 70% of parents stated that yelling is less harmful than hitting. In terms of child neglect, around half of the respondents agreed with the statement “Leaving a child (<5 years) unattended at home is a form of neglect,” while 42% were neutral. Finally, approximately 50% of the participants believed that it is okay to depend on nannies in assisting their children in eating and using the bathroom.

Conclusion: 

Parents residing in the State of Qatar believe that they have a good knowledge regarding child abuse and neglect. However, this study shows many deficiencies in parental knowledge of child abuse and neglect. Parents’ attitudes and perceptions are considered indispensable targets for community health intervention.

Introduction

The Child Abuse Prevention and Treatment Act (CAPTA) has defined child abuse and neglect as “any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm.”[ 1 ] Abuse of a child's right to protection is a common issue and one of the paramount barriers to interfere in such a problem is the parental lack of knowledge on the use of positive attitudes as a way to discipline children.[ 2 ] The concept of child abuse and neglect (CAN) is a well-known issue globally. However, its implications are unidentified in many countries.[ 3 ] CAN might lead to repercussions related to mental and physical state and can lead to behavioral issues.[ 4 ]

Harsh abuse is linked to poor outcomes in adulthood. For instance, childhood sexual abuse has been linked, in adulthood, to body complaints such as chronic pain that are more likely associated with depression. Moreover, people with a history of childhood abuse, especially sexual abuse, are at higher risk compared to individuals with no history of abuse to become frequent users of medical care and emergency services.[ 5 ] In support, childhood maltreatment, particularly emotional abuse and neglect, has been highly detected in adults with migraine,[ 6 ] and all types of CAN are highly linked to depression and anxiety, and the link is stronger with a recurrent maltreatment.[ 6 ] In a recently published meta-analysis, Gardner et al .[ 7 ] studied the influence of childhood physical abuse, sexual abuse, emotional abuse, neglect, and exposure to intimate partner violence (IPV) on depression and anxiety disorder. The study showed that all methods of child maltreatment were linked to depressive disorders. Children and adolescents with a history of sexual abuse are at higher risk of having diagnoses of genitourinary infections, as well as more respiratory and ear infection.[ 8 ]

In spite of the proof of the far-reaching effects, CAN research remains rare.[ 4 ] Children in the Arab Peninsula are exposed to all methods of CAN.[ 9 ] In spite of this, the literature has shown that CAN research remains scant with few scattered studies in Saudi Arabia,[ 10 11 12 13 ] Turkey,[ 3 ] Egypt,[ 14 ] and Jordan.[ 15 16 ] Other studies in the region have evaluated the perception of possible CAN among a variety of populations such as medical students,[ 17 ] pediatric physicians,[ 18 ] and preschool teachers (rather than parents).[ 19 ]

The World health organization has reported that 25% of adults had experienced physical abuse as children, 36% had experienced emotional abuse, 26% had experienced sexual abuse, and 16% had experienced neglect.[ 20 ] In his report series, Kattan[ 21 ] concluded that abuse in the Arabian Peninsula might be ignored, tolerated, or even accepted as a form of discipline. A report from Yemen exposed the extensive use of physical castigation and brutality to children in schools, homes, and juvenile centers, reaching up to 80%.[ 9 ]

The State of Qatar has been tackling child abuse and neglect for a while and currently a very well-structured program has been established, the Sidra Medicine Child Advocacy Program (S-CAP). This program is leading child protection efforts in Qatar with the ultimate goal of supporting the health, wellbeing, and development of a child who has been the victim of abuse or neglect.[ 22 ]

Risk factors for child abuse and neglect can be numerous and include, but are not limited to, parental history of being abused themselves as children, low socioeconomic status, single parent, domestic violence, parental inadequate coping skills, parental stress and low education level, and child's medical condition.[ 23 ]

In Turkey, a study conducted by Sofuoǧlu et al .[ 3 ] has shown that child maltreatment is common and a substantial healthcare issue, but parents are lacking the knowledge of its magnitude. One of the concerning factors of the study was that parents tend to under-report child maltreatment. Such a finding underlines that parental perceptions and awareness of CAN are crucial. Knowledge and attitudes of accountable parents are important in the prevention of child abuse;[ 23 ] hence, it is crucial to establish if parents in the community lacked basic knowledge of CAN.

This study was conducted because, in spite of many reports of child abuse globally, parental perceptions of CAN have not been delineated properly. The specific objectives were to assess parental views and concerns on: general aspects of child abuse; specific aspects of child abuse and neglect; verbal abuse; sexual abuse; and, neglect. To the best of our knowledge, this is the first study in Qatar and one of the very few in the Middle East to investigate parental perceptions of CAN. The findings of this study will be incorporated into future interventions that aim to identify risk factors for CAN by monitoring parents’ attitudes. The study will also be used to develop prevention schemes such as testing and counseling for parents of children at risk for CAN.

Materials and Methods

Study design, ethics, and setting.

A cross-sectional prospective study was carried out at Hamad Medical Corporation, the only tertiary pediatric hospital at the time of the study provided on February 19, 2018. It was approved by the Medical Research Centre at Hamad Medical Corporation (IRB, protocol no. 17172) and conducted in the pediatric department between July 1, 2017 and June 30, 2018.

Research tool

The content of the questionnaire was adopted from published studies[ 24 25 ] and was validated by a group of experts at our institution. Translation and back translation of the questionnaire from English to Arabic and vice versa was carried out by the translation services at the research center in Hamad Medical Corporation. Parents were presented questionnaires in both Arabic and English languages. The self-administered questionnaire comprised 38 items that included the following:

• Parent and children demographics (7 questions)
• General questions about parental perception of child abuse (8 questions)
• Specific questions about parental perception of child abuse and neglect (23 questions)

Procedure and participants

Despite the fact that there are many manuscripts published related to CAN, there were no similar studies investigating the specific topics of our questionnaire within the context of parental perception and, thus, we could not extrapolate or calculate the needed sample size. We then chose a convenient sample of 300 participants. The inclusion criteria comprised parents of children of all ages visiting the outpatient pediatric clinic and the inpatient department; the exclusion criteria comprised parents of children with conditions such genetic disorders, developmental delay, diabetes, cerebral palsy, and metabolic disorders. We have excluded the above to minimize as possible any confounders. Parents were contacted during their visits to our pediatric outpatient department and inpatient ward, checked for eligibility and if eligible were invited to participate in the study.

After describing the aims and objectives of the study, verbal consent was acquired and parents were informed of why the data was being collected and how it would be used in future for interventions to prevent child abuse and neglect. Parents were told that their participation was voluntary and that their answers were confidential and anonymous. There was no monetary or non-monetary compensation for participating.

Statistical analysis

Statistical analyses were conducted using statistical package SPSS, version 21.0 (IBM corporation, Armonk, NY); a two-sided P value < 0.05 was statistically significant. Qualitative and quantitative data values were displayed as percentages. Descriptive statistics explained the demographics and other features of parents and children. Associations between two or more categorical variables were assessed using Chi-square test. For small cell frequencies, Chi-square test with continuity correction factor or Fisher's exact test was used. Univariate and multivariate logistic regression analyses were applied to assess the associations of various potential predictors and covariates. Missing data were not accounted in the analysis.

Around 50% of respondents were between 30 and 39 years of age, and 61% were females. About two-thirds had at least bachelor's degree, 60% were in full-time employment, and 30% were not employed. 30% of the respondents had one child, 30% had two children, 20% had three children, and around 22% had more than 4 children. The majority of the sample (88%) lived in the capital city, Doha [ Table 1 ].

While the majority of the parents had heard about child abuse, about half had actually witnessed child abuse. 90% of the respondents have never witnessed any morbidities or mortalities due to child abuse or neglect. Roughly half the sample was aware of laws restricting child abuse, a quarter agreed that boys were generally more abused than girls, and about half reported that disabled children were generally more abused than healthy children. While less than a quarter of the parents agreed that abuse is a common problem in Qatar, the majority felt that it is a serious problem that requires strict laws [ Table 2 ].

Around 20% of the respondents agree and strongly agree that hitting is discipline, while 63% disagree and strongly disagree. In addition, 90% of the respondents never witnessed disabilities due to child abuse. Table 3 shows answers related to physical abuse.

In terms of verbal abuse, around 44% strongly agree and 19% agree that “Yelling is a form of child abuse,” while 22% disagree and strongly disagree. Around 44% strongly agree and 27% agree that “Yelling affects child growth and development.” More answers related to verbal use are displayed in Table 4 .

The majority of respondents strongly agree and agree with the statement “Teach our children about child sexual abuse.” Furthermore, 51% strongly agree and 37% agree that “Child's exposure to pornography on social media is a form of abuse.”

In terms of child neglect, around half of the respondents agreed with the statement “Leaving a child (<5 years) unattended at home is a form of neglect,” while 42% were neutral. The majority of respondents strongly agree with the statements: “It's parents’ duty to make sure that children are safe,” “Parents should have at least 6 hours of direct interaction with children,” and “I often approach my children to talk about their daily problems.” Finally, one-half of the participants believed that it is okay to depend on nannies in assisting their children in eating and using the bathroom.

Discipline is a measure by which children are notified of both the morals of acceptable behavior and the consequences of not abiding by such measures. Children relate this information during their constant pursuit for independence.[ 26 ]

Childhood maltreatment can significantly affect long-term wellbeing,[ 27 28 ] and children suffering abusive parenting are at a high risk of becoming abusive parents themselves.[ 29 ] Hence, attempts to avert CAN are growing worldwide.[ 17 ]

The current study is the first to examine parental perceptions of CAN in Qatar. It assessed parental views and concerns on the general and specific aspects of child abuse and neglect, including verbal and sexual abuse.

The majority of our participants have heard about child abuse, consistent with the study in Saudi Arabia where the majority of Saudi parents had adequate knowledge and perception of child abuse,[ 11 ] and also with published studies in Jordan.[ 15 16 ] About half of our parents had actually witnessed child abuse in their society. This is considered less than other studies where the majority of the respondents agreed that child sexual abuse is common in their community.[ 11 30 31 ]

A quarter of our sample agreed that boys were generally more abused than girls. This is in contrast with other authors who observed that females were more likely than males to have experienced physical abuse during childhood.[ 3 32 ] Perhaps in countries of the Muslim tradition, females are generally more protective than in other countries and, hence, this might be why parents might have a different threshold in their views about females being the subject of CAN. Another reason could be the likelihood of under-reporting, where for instance, sexually abused girls were up to 2.2 times more likely to seek medical attention than sexually abused boys.[ 8 ]

Less than a quarter of the parents agreed that abuse is a common problem in Qatar. This low figure and percentage could be due to the fact that it is under-reported or perceived as child maltreatment. Efficacious adoption of a system of interference comprising child protection centers in the medical facilities, in combination with obligatory reporting and data collection plans, can increase the reporting rate. In a study conducted by Al-Eissa and Almuneef showed that the total number of referred cases to suspected child abuse and neglect team increased 10-fold from 6.4 cases per year in the first period to 61.5 cases per year using the above strategy.[ 10 ]

Other barriers that hinder reporting of child abuse and neglect are unfamiliarity about how to report, in addition to having previous unpleasant backlash after reporting.[ 33 ]

Risk factors for parental insufficient knowledge and weak perception linked to child sexual abuse (CSA) are low socio-economic status and low education. Protective factors comprise parental older age and size of the family. Poverty is not an issue in wealthy Qatar. However, all population can benefit from counseling. Education should be considered for parents and the community to augment the knowledge and perception of CSA.[ 11 ]

One of the surprising results of our study showed that more than two-thirds of participating parents believed that yelling is less harmful than hitting.

Parental tough verbal discipline can have a striking effect on the emotional and behavioral development of adolescents. Tough verbal discipline infers to the use of psychological force with the goal of instigating a child to experience emotional pain or distress with the intention of rectification or control of misbehavior.[ 34 ]

Parenting practices might increase a youth's involvement in problem behavior,[ 35 ] which is outlined by the lack of affection and by the existence of many psychologically and physically detrimental behaviors and affects.[ 36 ]

Our participants believe that parents should have at least 6 hours of direct interaction with children. This is a substantial number of hours. For working family, that number of hours could be unreasonable. In the State of Qatar, a large proportion of children are engaged in school extra-curricular activities with some arriving home around 4 pm. In addition, many parents work split shifts, one in the morning with 4 hours break and then resume work at late evening.

It is anticipated that higher educational levels are associated with a higher chance of employment opportunities and good living standards.[ 37 ] In our sample, higher educational status was correlated with laws that would restrict people from abusing their children ( P = 0.002), and that child abuse is a serious problem, and there should be strict implementable laws ( P = 0.002).

Moreover, the higher educational status was inversely correlated with the fact that it is ok to hit the child as long as it does not cause permeant pain, bruises, or fractures ( P = 0.007) and that using soft object to discipline a child is ok ( P = 0.01). In terms of sexual abuse, higher educated parents agree that children should be taught about child abuse ( P = 0.001).

Child abuse and neglect could be dealt with by a comprehensive range of services such as parental education and community perception. Prenatal education programs could be designed for expectant parents, and awareness campaigns must be organized to avert child abuse. Primary care clinicians can be the frontrunners in preventing child abuse and neglect by screening for risk factors and liaise referral services to provide available resources. The State of Qatar is a very well resourceful country and these programs are very feasible to be applied.

This study has limitations. There might be a likelihood that other characteristics pertaining to parental perceptions in this topic were not assessed in this study. In addition, parental perception of CAN may not mirror reality as different parents have different parenting styles. This current study also has considerable strengths. The findings will be used to benchmark parental perception of CAN, especially that the study included several domains within the context of physical, sexual, and emotional abuse. Moreover, the present study will contribute to creating a better framework of child abuse and neglect prevention programs in Qatar, particularly contributing to the well-funded suspected child abuse program. Further investigation with larger multicenter studies is required for a more definite conclusion.

Financial support and sponsorship

The publication of this article was funded by the Qatar National Library.

Conflicts of interest

There are no conflicts of interest.

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Research explores perception versus reality around parental alienation

By CSU MarComm Staff

Researchers at Colorado State University have published findings in the International Journal of Social Welfare that explore the public perception that courts often dismiss mothers’ allegations of domestic violence and child abuse when fathers claim parental alienation by the mother.

Graduate student Hesam Varavei was the first author on the paper and is a part of Associate Professor Jennifer Harman ’s group in the Department of Psychology. Harman’s team has studied parental alienation in multiple contexts for years, and the new paper expands that field of research. Parental alienation refers to a situation in which one parent intentionally manipulates a child to reject the other parent without justification. This behavior often occurs in the context of high-conflict divorces or custody battles.

To better understand how this phenomenon plays out in courtroom settings, the researchers analyzed 200 family court cases in Canada where fathers alleged parental alienation and were themselves accused of abuse. The findings show that the courts ultimately do not favor fathers accused of abuse when they allege parental alienation – despite broad perception otherwise.

We asked Varavei about the research, why he came to CSU and where the work goes from here:

What is your area of study at CSU, and why did you choose to come here for graduate school?

I am a third-year graduate student in the Applied Social and Health Program within the Department of Psychology. I am currently pursuing both my master’s and Ph.D. in psychology with a particular interest in parental alienation and social relationships. I came to CSU because of the great psychology program – especially when it comes to applied and social Psychology. I also wanted to study with Jennifer Harman as her work was very intriguing to me and fit the research interests that I had developed throughout my undergraduate studies.

What is parental alienation, and how does it fit with the research in this new paper?

Parental alienation is the refusal of a child to have a relationship with a specific parent due to untrue or illogical reasons that are influenced onto them by the other parent. This concept is integral to the paper, as we are testing whether claims that parental alienation allegations made by fathers are being used to nullify abuse allegations made by mothers. We wanted to test whether there are many court cases that reflect this idea, and if those court cases result in the mother losing custody of their child or children. There are arguments made that parental alienation is not a real scientific concept, but rather a manipulative tool used by abusive parents in court. This study aims to see if this claim can be found within existing court cases.

The paper also deals with the idea of “illusory correlation.” What is that concept, and how does it fit into this research?

An illusory correlation is the report of a relationship between two items that are either not actually statistically related or are only connected to a lesser extent. Here, we wanted to see if the claim that parental alienation is used to nullify abuse allegations is an illusory correlation – a perceived association between two events that is not supported by actual data.

Our findings show that the belief that courts favor fathers accused of abuse when they allege parental alienation does not reflect the reality when reviewing the outcomes of court cases. The study indicates that mothers are generally not losing custody to fathers accused of abuse in these cases.

Why did you use data from Canada? Could that be limiting on the application to other countries and situations?

We used data from Canadian court cases because they were publicly accessible, and because the courts within the United States are not required to publish trial-level decisions. Due to this paper responding to claims within the United States, we wanted to focus on similar court proceedings. A future consideration could be to replicate this study in other countries.

What approach did you take to organizing and working with data from the Canadian courts? What were some of the challenges?

We first narrowed the court cases down to those that fit the criteria for our sample size. Myself and two research assistants then worked on coding the data, which consisted of looking through the court cases to verify if parental alienation had been substantiated or unsubstantiated and then using a custom-made abuse allegation form to note if abuse had been substantiated or unsubstantiated, as well as the details surrounding the investigation and court findings. The data itself was very simple to handle as it was mainly binary entries (e.g., yes/no). We then used a chi-square analysis and logistic regression to analyze the data. To maintain our open access approach: the forms, court cases, etc. are included in the paper via Open Science Framework.

I would say that the only challenge that we faced was the amount of time it took. As previously mentioned, the next logical step for this research could be to replicate it in other countries. One key difference to study would be whether that country legally recognizes parental alienation versus places where it is not legally recognized.

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CSU MarComm Staff