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The issue of child abuse and neglect in the united states

Page 86 Unreported Abuse Given that only the most serious episodes of abuse are reported, such as those observed by outsiders such as physicians, neighbors, and teachers, child maltreatment is most likely underreported and underestimated in official records Nagi, 1975; Widom, 1988; Wilbur, 1985.

The 1975 National Family Violence Survey, for example, found a prevalence rate for physical abuse of 140 per 1,000 children per year, which is 21 times greater than the 6. Many severely abused children are brought to emergency rooms by parents or relatives who blame injuries on accidents that, in reality, never occurred. Children are reluctant to reveal abuse for fear of removal from their homes, feelings of shame, protection of their parents, selective inattention, or loss of memory of the event Berger et al.

Few pediatricians and child psychiatrists are trained to elicit abuse histories, although the American Medical Association has recently recommended that these kinds of questions should be part of routine adolescent, pediatric, and psychiatric evaluations.

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Such procedures as looking at a child's or adolescent's back, inquiring about the origin of visible scars, and asking, "Are there any scars I can't see? Confusion of Prevalence and Incidence Measuring the occurrence of child abuse and neglect has been difficult not only because of a lack of definitions but also because of confusion of what measure of occurrence is under investigation.

To count an outcome under study, epidemiologists commonly use two measures: Incidence, the number of new cases detected in a defined time period divided by the number of children who are eligible to become new cases, is the ideal measure for identifying etiologic factors.

By using new cases, investigators can determine which features are related to occurrence of maltreatment rather than trying to disentangle features related to occurrence from those related to the continuation of maltreatment. In contrast, child protection services often rely on total occurrences, a different measure of incidence: Previously maltreated children are included in the denominator because they are at risk for new occurrences Bertolli et al.

Page 87 Share Cite Suggested Citation: Understanding Child Abuse and Neglect.

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The National Academies Press. Use of prevalence data causes confusion between risk factors that are associated with new cases of abuse and neglect and those that influence continuation of the problem Bertolli et al. Research in this area does not always distinguish between incident and prevalent cases. It is sometimes difficult to distinguish between new and existing cases because the exact time of the occurrence must be arbitrarily determined.

One approach for dealing with the confusion between incident and prevalent cases is to use a measure called period prevalence. In it the numerator is individuals in the population who, at any time in a defined period, experienced abuse or neglect divided by the total population. This strategy is commonly used by researchers in this field when they estimate the proportion of adults in a particular age group who have been maltreated at any time during childhood Bertolli et al.

Use of Administrative Data With the exception of a relatively small number of primary data collection efforts, the vast amount of information on the occurrence of child abuse and neglect is based on state child protective services records. The accuracy with which these data reflect the true incidence or prevalence of maltreatment is questionable for a number of reasons.

First, although all states have mandatory reporting laws, the definitions of abuse and neglect vary across and within states chiefly as a result of the absence of structured assessment tools, the casework burdens of social services personnel, inaccurate or missing information, and the limited availability of services for families who are identified Hoaglin et al.

Second, the segments of the population at risk are subject to unequal surveillance. Specifically, families who, because of their demographic characteristics e.

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Consequently, the overrepresentation of families who are poor and members of minority groups in child protective services caseloads may be less likely to be due to poverty being a risk factor for maltreatment and more likely to be due to undetected abuse and neglect in more affluent families Gelles, 1982; Newberger et al. Conflicting evidence exists as to whether differences occur in rates of maltreatment by culture or ethnicity.

The two National Incidence Studies did not find a significant relationship between race5 and the incidence, type, or severity of child maltreatment NCCAN, 1981, 1988. Some studies have reported that ethnic minorities are disproportionately reported for child Page 88 Share Cite Suggested Citation: Others indicate that such overrepresentation is equivalent to the representation of ethnic minorities among the poor, thus supporting the confounding nature of ethnicity and poverty in child abuse and neglect reports Horowitz and Wolock, 1981.

Cultural and ethnic groups that are at the greatest risk of poverty, then, appear to have disproportionate incidence and prevalence rates of child maltreatment. Convincing evidence that disaggregates socioeconomic status and cultural or ethnic identity in rates of reported child abuse and neglect has not been developed, although socioeconomic status may be strongly associated with some forms of child maltreatment. For example, child neglect occurs among the poorest of the poor Giovannoni and Billingsley, 1970and physical abuse is more severe among the poorest families Straus, 1980.

Surveillance bias further complicates the issue. Poor and ethnic minority children are more likely to be identified as maltreated than more affluent white families e. A reanalysis of the first National Incidence Study 1981 found that class and race were the best predictors of whether an incident was reported by hospitals, with impoverished black families more likely to be reported than affluent white families, regardless of the severity of the incident Hampton and Newberger, 1985.

Furthermore, service availability and severity of worker caseloads may affect reporting by ethnicity Light, 1973; Wolock and Horowitz, 1979. Finally, use of substantiated administrative data is problematic because all cases of abuse and neglect are not pursued with equal rigor Eckenrode et al. The availability of resources within individual state child protective service agencies clearly affects which cases are investigated and confirmed.

Rate of Occurrence Versus Rate of Reporting Much of the tremendous increase in maltreatment rates is probably due to increased reporting Straus and Gelles, 1986. Recent work by Leventhal and colleagues 1993 suggests that for two cohorts of adolescent mothers, one whose children were born from 1967-1970 and the other whose children were born 1979-1981, no differences in rates of maltreatment were detected when injury events were rated using predefined criteria by physicians who were blind to the issue of child abuse and neglect in the united states social characteristics of the mothers.

However, over the 14 year time span, reports of maltreatment to the Connecticut Department of Children and Youth Services tripled indicating little real difference in rates of maltreatment but considerable differences in reported rates of maltreatment. A recent study of the classification of child death rates also suggests that although the number of deaths from child abuse and neglect has been consistently underestimated because they are often misclassified Page 89 Share Cite Suggested Citation: Changes in the proportion of child maltreatment reports that are substantiated may provide evidence as to whether the increased reported incidence involves changes in the rate of occurrence as well.

One study conducted by Eckenrode and colleagues 1988a,b observed that the percentage of substantiated reports declined from 1974 to 1984, although the number of reports filed increased significantly during the same period. The authors concluded that the reporting and investigation process was ''cutting further into the tip of the iceberg of child maltreatment, but proportionally more social resources are being used to uncover new cases" Eckenrode et al.

Their findings are consistent with the summary findings of the NIS-2 study, which reported that although little change was reported between 1980 and 1986 in the severe categories of maltreatment such as fatalities and serious injuriesdramatic increases occurred at the level of mild to moderate injury and impairment, where there was greater potential for improved recognition of cases NCCAN, 1988.

In summary, the increase in reported incidence of child maltreatment is probably the result of a combination of factors: Increases in rate of occurrence cannot be ruled out since the number of children living in poverty has increased significantly since the 1970s and poverty is thought to be significantly associated with child maltreatment see discussion in Chapter 4 National Commission on Children, 1991.

Changes over time in the proportion of reports for each type and severity of abuse, the source of the complaints, and the characteristics of perpetrators and victims can provide insight into whether significant increases in reported rates of maltreatment reflect increases in the actual occurrence of maltreatment Knudsen, 1992. However, data for each of these factors are so limited that it currently provides no insight into the relative contributions of increased rates of reporting and increased rates of occurrence of child maltreatment.

Sampling and Design Issues The design of a study is the blueprint through which the investigator achieves specific research objectives. These objectives determine what groups are to be compared, how subjects are selected, what factors should be measured, and what conclusions can be drawn Bertolli et al. A number of investigators have pointed out the inadequacy of the sam- Page 90 Share Cite Suggested Citation: The use of volunteers and college students in cross-sectional studies has produced disparate estimates of the problem, an inconsistent picture of the etiologic factors associated with these problems, and an inability to generalize findings to other population groups.

An ideal design for investigating etiology and sequelae of maltreatment would be a large, prospective cohort study in which random samples of children from different types of communities, and ethnic and sociodemographic groups would be followed from birth to adulthood.

The study would measure all known and hypothesized risk factors for abuse and neglect at birth and at prespecified follow-up interviews, and all new cases of abuse and neglect would be identified as they occur with no loss to follow-up Bertolli et al.

Although cohort studies are being conducted in this area, key factors of the ideal design, such as ascertainment of representative samples of cases of abuse and neglect, are missing due to reliance on administrative data for cases. Incidents of child maltreatment may also remain undetected and unreported if subgroups of the population at risk for abuse and neglect are not recruited into longitudinal studies.

In the issue of child abuse and neglect in the united states area of abuse and neglect, cross-sectional designs are more common than cohort studies. These studies interview respondents about past experiences of abuse and neglect and risk factors of interest. While quicker, less costly, and easier than cohort studies, cross-sectional designs are not usually used to estimate incidence and, furthermore, because exposure variables are measured after the abuse or neglect occurred, the temporal ordering of cause and effect is problematic.

Finally, retrospectively collected data are often subject to recall errors Briere, 1992; Widom, 1989; Wolfe and Mosk, 1983. Two other study designs are used less frequently in this area of research but should be mentioned because they are useful for studying phenomena with low base rates. The case-control study is a design in which two groups of individuals are selected separately one with the outcome, the other without it and then compared to determine the effects of hypothesized risk factors.

To draw accurate conclusions about the effects of the risk factors, the controls should be representative of the population from which the study cases came Bertolli et al.

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This design is far more efficient than prospective cohort studies for studying statistically rare outcomes like abuse and neglect but it is subject to measurement error because exposure variables are measured after the outcome of interest has occurred.

The last study design is considerably different from the other designs in that the areas of analyses are not individuals but rather geopolitical areas Page 91 Share Cite Suggested Citation: In this type of design the investigator does not know the joint distribution of exposure and outcomes but simply the number of exposed and unexposed cases and noncases.

These studies are quick and inexpensive but commonly subject to a problem called ecologic bias Morgenstern, 1982whereby correlations the issue of child abuse and neglect in the united states outcomes and observed characteristics of the area may be the spurious result of unmeasured characteristics. Furthermore, because they employ routinely collected data, they may be subject to problems resulting from the use of administrative data.

Measurement Research on child abuse and neglect has been severely hampered by the lack of instruments to measure the phenomena. Relatively few instruments have reported reliability and validity. Furthermore, inconsistency in the design of questions about sensitive social topics such as child sexual abuse contributes to extreme differences in estimates of the problem Peters et al. One recent study of methodological issues in the measurements used in U.

This same study noted that significant improvements in survey instruments can be achieved by focusing on the cognitive demands that individual survey questions make on respondents, and by relying more extensively on self-administered forms rather than interviewer-administered formats when research subjects can complete self-report questionnaires Turner et al. Effect of Mandatory Reporting In some cases, previously undetected or imminent incidents of abuse or neglect may be detected during an investigation.

As part of the informed consent procedure required in federally supported studies, participants in most child maltreatment studies should be informed of their rights and duties as research subjects see Chapter 9 for a full discussion of ethical issues in child maltreatment research. In addition, every state has adopted legislation that requires research investigators and other professionals who have contact with children to disclose to child welfare officials reports of suspected child abuse or neglect that have not been recorded.

  1. 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. Family sociology research has a coherent body of literature and reasonable consensus about what constitutes high-quality parenting in middle-class, predominantly White populations.
  2. Incidents of child maltreatment may also remain undetected and unreported if subgroups of the population at risk for abuse and neglect are not recruited into longitudinal studies.
  3. 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.

Whether such ''reason to believe" refers to a clinical hunch or firm evidence is open to conjecture, but a professional who fails to disclose suspected child maltreatment may be charged with criminal action Sieber, 1992. The requirements of mandatory reporting vary from state to state; in some cases, disclosure to child welfare authorities is not required if the individual who makes the disclosure is receiving therapeutic services such as family counseling.

There are also variations in the level of endangerment that constitute child maltreatment, as well as variations in evidentiary standards that warrant a report to child welfare authorities.

Empirical research studies on the conditions and circumstances that affect professional reports of privately disclosed incidents of child maltreatment are rare. But one survey study has indicated that a significant amount of "discretionary reporting" occurs, whereby professionals who come into contact with children may report some suspected cases of child maltreatment but not others Zellman, 1990.

Professionals who have made reports of child maltreatment cite various reasons for doing so, including stopping maltreatment, getting help for the family, helping the family to recognize the seriousness of their problems, and complying with legal requirements Zellman, 1990.

The issue of failure to report needs to be examined in light of its impact on incidence and prevalence estimates of child maltreatment as well as its significance for the conduct of research in this area.

For example, some potential research subjects may decide not to participate in the research project because of mandatory reporting requirements, while others may falsify or distort responses revealing reportable child maltreatment activity Sieber, 1992. The interests and safety of the child are obviously paramount to any research objectives. The primary reasons provided by professionals who have indicated failure to report include the lack of sufficient evidence to justify a report, treatment-related concerns i.

The impact of mandatory reporting requirements on research projects has not been studied. Many research investigators believe that the requirements of mandatory reporting may conflict with other fundamental prin- Page 93 Share Cite Suggested Citation: The dilemma, from the scientist's perspective, is tantamount to saying, "If you respond truthfully, I may report you to the appropriate authority" Sieber, 1992.

Many research scientists are reluctant to report disclosures of child abuse and neglect that occur in a research investigation unless the child is endangered. In the case of prior abuse incidents, research investigators sometimes believe that little benefit will be gained by recording earlier cases of abuse that may be quite dated, especially if the family or the offender is already in treatment for other reported cases, if the child does not want the incident reported, or if the perpetrator is not alive or not in contact with children.

Conclusions The panel concludes that much of the methodology for prevalence and incidence the issue of child abuse and neglect in the united states in the area of child abuse and neglect is seriously flawed. Definitional variations, variations in state cooperation with national data collection efforts, legal requirements for mandated reporting, scarce funding for methodological work specifically instrument developmentand the paucity of rigorous epidemiologic investigations have retarded progress in this field.

However, the limited available evidence suggests that child abuse and neglect is an important, prevalent problem in the United States, involving more than 1 million children each year in case reports and 2,000 child deaths annually. Child abuse and neglect are particularly important compared with other critical childhood health and mental health problems because the consequences of child maltreatment are often directly associated with adverse health and mental outcomes in children and families Institute of Medicine, 1989.