Child abuse and neglect pose an increasingly recognized and
serious threat to the nation's children. In the last 10 years
the reported cases of abused and neglected children more than
doubled, from 1.4 million in 1986 to more than 3 million in 1997;
substance abuse was involved in more than 70 percent of the cases.
A recent survey of State child welfare administrators found
that parental substance abuse was a factor in at least 50 percent
of substantiated cases of child abuse and neglect. Moreover,
80 percent reported that substance abuse and poverty were the
two primary factors contributing to abuse and neglect (U.S.
Department of Health and Human Services [DHHS], 1999).
Children whose parents abuse substances are almost three times
more likely to be abused and four times more likely to be neglected
than other children (National Center on Addiction
and Substance Abuse at Columbia University [CASA], 1999).
Substance abuse is a contributing factor to the abuse of at
least one third of the children in the child welfare system
(DHHS, 1999). It is estimated that each
day five children die as a result of child abuse or neglect--up
from three a day reported in 1994 (CASA, 1999; McCurdy and Daro, 1994). In reported
cases, the most pervasive form of child maltreatment is neglect
(60 percent), followed by physical abuse (25 percent), sexual
abuse (13 percent), and emotional maltreatment (5 percent).
More than 50 percent of the victims were 7 years old or younger;
slightly more than half of victims were girls (Sedlak
and Broadhurst, 1996).
Statistics will vary because of differences in criteria and
methodology and because many cases of child maltreatment involve
overlapping forms of abuse or neglect. (More details regarding
the prevalence of child abuse and neglect are provided later
in this chapter, along with specific definitions of what is meant
by the terms "child abuse" and "neglect.") For the same reasons,
it is difficult to determine if the incidence of child maltreatment
is actually continuing to rise or not. However, researchers,
counselors, and program administrators agree that the rise in
substance abuse disorders as a factor in child abuse and neglect
cases has severely complicated efforts by child welfare systems
to protect children and rehabilitate families (CASA,
1999; DHHS, 1999).
Parents with substance abuse problems are less educated and
less likely to be employed full time; they are much less likely
than other parents to be married and much more likely to be involved
in the welfare system (DHHS, 1999). However,
these statistics may result from a population's reliance on public
welfare systems; parents in higher socioeconomic classes can
afford private systems where reporting is not mandated.
Many clients in substance abuse treatment have histories of
child abuse or neglect that might affect their chances for recovery.
There is accumulating research and clinical evidence that physical,
sexual, and emotional abuse and neglect during childhood increase
a person's risk of developing substance abuse disorders (DHHS,
1999). In addition, relapse and treatment complications
may be more likely if issues related to maltreatment are not
identified and treated (Brown, 1991; Rose, 1991;Young, 1995). The counselor might have more difficulty engaging clients
with abuse histories, and these clients may have a variety of
disabling comorbid conditions, such as posttraumatic stress disorder
(PTSD) and dissociative disorders.
Given the presence of substance abuse in the majority of child
abuse or neglect cases, alcohol and drug counselors may also
have reason to suspect, or may discover, that clients are abusing
or neglecting their own children. The children of substance-abusing
parents will also face an increased risk of developing a substance
abuse disorder themselves. A recent study confirms what has
long been suspected, that children of alcoholics (whether or
not they have been abused) have an altered brain chemistry that
may make them more likely to become alcoholics themselves (Wand et al., 1998).
If the cycle of intergenerational substance abuse and child
abuse and neglect is to be broken, counselors must address these
issues. This is discussed in Chapter 5.
Counselors will sometimes find it challenging to maintain the
therapeutic alliance with clients that is central to successful
treatment while meeting their legal obligations to report suspected
or known maltreatment (see Chapter 6).
Treatment providers have observed that a large proportion
of their clients report being physically, emotionally, or sexually
abused as children. This clinical knowledge is increasingly
supported by research findings. Most of this research has focused
on one of two questions:
Are people with substance abuse disorders more likely
to have been abused or neglected as children than are people
without substance abuse disorders?
Are those who report a history of childhood abuse or neglect
more likely than their peers to have a substance abuse disorder?
Specific answers to these questions depend to some extent
on gender, and therefore the literature for men and women should
be examined separately. Because most of the available information
in this area focuses on childhood sexual and physical abuse,
this TIP primarily addresses these two forms of maltreatment.
As noted above, however, neglect is the most prevalent type
of child maltreatment, and witnessing domestic violence is also
a common (and potentially damaging) form of childhood trauma.
(See TIP 25, Substance Abuse Treatment and Domestic Violence[CSAT, 1997b] for more information
on how to deal with this significant problem.)
A review of several studies found that women who abuse alcohol
reported higher rates of childhood sexual and physical abuse
than their peers without such disorders (Langeland
and Hartgers, 1998). The likelihood of substance abuse disorders
was directly related to the severity of childhood abuse as well.
A more exhaustive literature review found that women with substance
abuse disorders were nearly two times more likely than women
in the general population to report childhood sexual abuse.
These women were also more likely to have experienced physical
abuse (Simpson and Miller, in press).
Miller and her colleagues found that 70 percent of women in
treatment for alcohol use disorders reported some form of childhood
sexual abuse, while only 35 percent of the women in the general
population did the same (Miller et al., 1993). Twelve percent of the women with alcohol use disorders
did not suffer any form of sexual or physical abuse, compared
with 41 percent of the control sample. The study concluded that
parental alcoholism and child abuse were both independent risk
factors for problematic drinking among adults, suggesting that
childhood abuse itself contributes uniquely to the genesis of
substance abuse disorders.
A 1995 literature review reveals a link between childhood
sexual abuse and substance abuse (Polusny and
Follette, 1995). In community samples, the authors found
that the lifetime diagnosis rate of substance abuse disorders
was 14 to 31 percent among women who had been sexually abused
and 3 to 12 percent among women who had not been abused. In
clinical samples, the rate of lifetime substance abuse diagnoses
among sexual abuse survivors ranged from 21 to 57 percent, compared
with a range of 2 to 27 percent for women without such histories.
Another representative study of young adults found that 43.5
percent of the women who had been sexually abused as children
met diagnostic criteria for an alcohol abuse disorder, while
the criteria were met by only 8 percent of those who had not
been sexually abused (Silverman et al., 1996).
The available research does indicate that women with substance
abuse disorders are more likely than other women to report childhood
abuse and women with childhood abuse histories are more likely
than other women to have substance abuse disorders. Despite
these findings, it is unclear to what extent the relationship
between childhood abuse and the development of substance abuse
is causal. Genetics, for example, might account for the association--child
abuse might simply be incidental to the process in which the
genetic propensity for drinking is passed from parent to child.
Childhood stress from sources other than abuse and neglect might
also contribute to substance abuse among adults (Malinosky-Rummell
and Hansen, 1993). However, even when parental history of
alcohol problems and measures of childhood stress are statistically
controlled, childhood sexual and physical abuse still seem to
contribute significantly to the alcohol-related problems of women
(Bennett and Kemper, 1994; Miller
et al., 1993).
There are fewer studies of child abuse among boys and men
with substance abuse disorders, and findings are less consistent
than those generated for girls and women. One group of researchers
believes that data are insufficient to determine (1) whether
men with alcohol abuse disorders are more likely than their peers
to have suffered childhood abuse, or (2) whether men with childhood
abuse histories are more likely than other men to have alcohol
abuse disorders (Langeland and Hartgers, 1998).
Simpson and Miller found 27 studies that addressed the issue
of childhood abuse and neglect among men with substance abuse
disorders (Simpson and Miller, in press). Only 10 of these studies
found childhood sexual abuse rates higher than the national average
of 16 percent (Finkelhor et al., 1990),
and only six of these studies found rates above 10 percent.
Most studies reveal that men with substance abuse disorders actually
suffered less sexual abuse than their peers; however, these men
did report unusually high rates of childhood physical abuse.
The few prospective studies of childhood abuse among men suggest
that abuse does increase the risk of alcohol abuse (Simpson
and Miller, in press).
Men who report childhood abuse also may be more likely to have
a substance abuse disorder, but this conclusion is not certain.
Societal expectations of self-reliance and fear of homosexual
stigmatization may prevent these men from disclosing childhood
sexual abuse (Briere et al., 1988).
Current trends, however, suggest that men are becoming more willing
to disclose histories of sexual abuse.
Although the incidence of abuse has remained stable for women,
far more men are reporting sexual abuse than have done so in
the past (Simpson and Miller, in press).
Men with substance abuse disorders are also reporting more childhood
physical abuse.
Current study techniques simply may be more sensitive for sexual
abuse among men, but further study is needed.
Most studies that have examined the rates of substance abuse
among men with child abuse histories have found elevated rates
of substance abuse disorders (Simpson and Miller,
in press).
One important exception to this pattern is a study that examined
the rates of arrest for alcohol- and drug-related offenses among
young adults with and without documented histories of childhood
abuse or neglect (Ireland and Widom, 1994).
This study found no relationship between a history of childhood
abuse and neglect and substance abuse problems among men.
It should be mentioned, however, that Ireland and Widom did not
assess whether the study participants experienced child abuse
or neglect that was not officially reported.
Some of those who were classified as not having been abused or
neglected may have experienced such maltreatment, and the results
of this study are therefore difficult to interpret.
Most of the available literature indicates that men with childhood
abuse histories are more likely to have substance abuse disorders
than men without childhood abuse histories (Simpson
and Miller, in press).
The rates of childhood physical abuse appear to be higher among
men with substance abuse disorders than among men from the general
population.
However, men with substance abuse disorders do not report more
childhood sexual abuse than other men.
Holmes and his colleagues uncovered several factors that contribute
to the reluctance of men to report sexual abuse (Holmes
et al., 1997).
The shame, homosexual stigmatization, and perceptions of weakness
associated with disclosure are perceived by many men to be more
burdensome than the secret of abuse.
Also, men are prone to minimize the negative effects that childhood
sexual abuse may have, though men who were sexually abused as
children are at greater risk than their nonabused peers for later
psychological and emotional difficulties.
Holmes and colleagues found that when men disclose a history
of child abuse to their mental health counselors, its importance
is often dismissed.
The researchers concluded that the childhood sexual abuse of
males is viewed with far less gravity then the childhood abuse
of girls and women (Holmes and Slap, 1998;Holmes et al., 1997).
Adults with histories of child abuse and neglect may differ
from other clients in a number of ways.
Although the research base is still limited, clients with childhood
abuse histories have been found to have more severe substance
abuse disorders, to have started using at younger ages, and to
use substances for reasons that differ from other clients.
They are also more likely to have attempted suicide, to have
PTSD, and to have personality or relationship problems that make
them hesitant to accept help (Felitti et al.,
1998), which also makes them more vulnerable to relapse.
Clients who have been sexually or physically abused as children
often attribute at least part of their substance abuse to their
childhood victimization.
Hayek found that more than two thirds of women with incest histories
believed that the abuse contributed to their alcoholism (Hayek,
1980).
Another study revealed that 25 percent of incest victims in alcohol
treatment programs believed their drinking problems were caused
by their incest experiences (Janikowski and
Glover, 1994).
Individuals with alcohol abuse disorders and histories of sexual
or physical abuse believe that their trauma was a considerable
factor in causing their drinking problems and that it was a moderate
factor in precipitating their most recent relapses (Brown
et al., 1993).
Researchers who have focused on women and girls have found
that those with histories of childhood abuse are likely to have
developed their substance abuse problems at a younger age (Edwall and Hoffman, 1987; Jarvis
et al., 1998; Paone et al., 1992) and
that adolescent girls in this group are more likely than their
nonabused peers to use cocaine, amphetamines, sedatives, and
tranquilizers (Harrison et al., 1989a).
Women in substance abuse treatment programs who were sexually
abused as children use alcohol to facilitate sexual encounters
more often than do other women (Hayek, 1980; Hurley, 1990; Lammers
et al., 1995).
They are also more likely than their nonabused peers to use substances
to alleviate pain (Jarvis et al., 1998),
escape family turmoil, and calm tremors (Harrison
et al., 1989a).
Women might also use substances to escape memories of sexual
abuse (Miller and Downs, 1995; Young,
1995).
People abused as children are also prone to dissociative disorders
(Polusny and Follette, 1995), but it is
unclear whether people who have substance abuse disorders and
childhood abuse histories engage in more dissociative behaviors
than those without childhood abuse histories.
Research on male clients in substance abuse treatment has found
that those with childhood abuse histories do not report more
dissociation than their nonabused peers (Dunn
et al., 1993, 1995), but research on
female clients in substance abuse treatment suggests that those
who were abused as children use a wider variety of dissociative
behaviors than other women in treatment (Jarvis
et al., 1998).
Ostendorf, however, found that female incest victims with alcohol
problems scored lower on an index of dissociation than those
without alcohol problems (Ostendorf, 1995).
Alcohol, the author suggested, may serve the same functions for
some as dissociation does for others.
More research is needed in this area to clarify the importance
of dissociative disorders among clients with childhood abuse
histories.
Relapse is common during the treatment of substance abuse,
and few clients achieve permanent abstinence on their first attempt.
Although clinicians have applied a variety of promising pharmacotherapeutic
and psychosocial strategies to prevent relapse (Carroll,
1997), relapse rates remain high (Miller
et al., 1995a).
Many in the field believe that recovery from substance abuse
is even more difficult for people who were abused as children
(Brown, 1991;Rose, 1991;Young, 1995).
There is fairly strong evidence that men who were abused as children
enter treatment more often than other men (Krinsley
et al., 1994; Simpson et al., 1994).
This suggests that these men may be at greater risk for posttreatment
relapse.
Studies that combined males and females have also found poorer
treatment compliance and outcomes for those who were victimized
as children (Carran et al., 1996; Glover
et al., 1996; Palmer et al., 1995).
Gutierres and colleagues, however, did not find a connection
between childhood abuse and treatment completion among males
and females (Gutierres et al., 1994).
Childhood abuse does not seem to affect treatment outcomes
among women.
Women who were sexually assaulted as children do not relapse
any more frequently than other women in the year following treatment
(Stephenson, 1990).
Childhood sexual abuse is not associated with either the likelihood
of a woman attending her first referral appointment following
detoxification (Hien and Scheier, 1996)
or the likelihood that she will complete subsequent treatment
(Wallen and Berman, 1992).
Childhood abuse is also unrelated to the number of times a woman
enters treatment (Brabant et al., 1997;
Simpson et al., 1994).
Incest victims, moreover, do not report having tried more
treatment modalities or having had more relapses than other women
(Jarvis et al., 1998; Kovach,
1983).
However, Haver reported poorer treatment outcomes among women
who were physically abused by their mothers (Haver,
1987). In a study of aftercare compliance following childbirth,
67 percent of noncompliant women reported some form of childhood
abuse while only 25 percent of compliant mothers did the same
(Killeen et al., 1995).
The Consensus Panel recommends that alcohol and drug counselors
be aware of childhood abuse and the issues involved in its treatment
for the following five reasons:
People who were abused as children are more likely
than others to attempt and reattempt suicide, as noted earlier.
Alcohol and drug counselors, therefore, must watch for signs
of suicidal ideation. Counselors should work to help clients
ease the emotional burdens of past abuse in order to diminish
the likelihood of suicide.
Counselors may need to address childhood sexual and physical
abuse in order to reduce clients' risk of abusing their own children.
Most abuse survivors do not abuse their own children (Kaufman
and Zigler, 1987), although people with substance abuse disorders
are at greater risk of doing so.
As reported above, substance abuse contributes to almost three
fourths of the incidences of child abuse and neglect (CASA,
1999;Famularo et al., 1992; Finkelhor
et al., 1983; McCurdy and Daro, 1994).
At least 675,000 children are abused or neglected each year by
parents or caretakers with substance abuse disorders, and more
than 8 million children (11 percent) in the United States are
being raised by substance-abusing parents
(Kropenske and Howard, 1994).
Although it is not known how many of these parents are struggling
with their own abuse histories, counselors should be able to
address their clients' abuse issues in order to break the cycle
of addiction and violence.
Clients often suspect that childhood abuse contributed to
their substance abuse disorders and relapses. Although they
are not likely to identify precise clinical syndromes, clients
may seek help in overcoming the emotional pain of childhood abuse.
Counselors should be able to help these clients so that they
do not turn to substances for relief.
By addressing child abuse issues, the risk of relapse among
clients who were abused as children might actually drop below
that of their nonabused peers. Preliminary evidence suggests
that people with childhood abuse histories use substances as
a means of "chemical dissociation." Once trauma issues are resolved,
substance use may clear substantially (Roesler
and Dafler, 1993).
People who were severely sexually or physically abused as
children often develop PTSD (Rowan et al.,
1994; Wolfe et al., 1994), and this
disorder increases their risk of relapse because it engenders
intrusive memories and attempts to avoid those memories through
self-medication (Kuyken and Brewin, 1994).
Therefore, clients suffering from abuse-related PTSD are likely
to have endured the most severe forms of abuse. Counselors should
be aware of this and know how to help such clients.
Few researchers have studied the influence of ethnic and racial
factors on childhood abuse and substance abuse disorders, but
specific populations have been the object of several recent studies.
For example, Carol Boyd and her colleagues researched crack cocaine
addiction among African-American women (Boyd
et al., 1997).
Boyd's findings for this group are consistent with the larger
body of research described earlier.
The limited evidence in community-based samples suggests that
there are not significant ethnic or racial differences in the
base rate of childhood sexual abuse between African-Americans
and Whites and between Hispanics and Whites (Arroyo
et al., 1997).
Another study reveals similar rates of emotional, physical,
and sexual abuse among Native Americans, Mexican-Americans, and
European-Americans in treatment for substance abuse (Gutierres
and Todd, 1997).
However, Native American women reported substantially more physical
abuse than other women, and European-American men reported more
sexual abuse than other men.
This research, along with Boyd's work, points to the possibility
of problems specific to groups, as well as the likelihood of
differences in group reporting.
Treatment providers must be sensitive to the ways in which
cultural factors interact with a client's child abuse or neglect
history.
In a review on the relationship between racism and mental health,
racism was found to be a major contributor to psychopathology
among ethnic minorities (Carter, 1994;
Landrine and Klonoff, 1996; Thompson,
1996).
Sensitivity to such cultural phenomena helps facilitate effective
interventions for ethnic minorities who have experienced childhood
abuse (Manson, 1997).
The Consensus Panel urges alcohol and drug counselors to be aware
of how clients' backgrounds may affect treatment.
Some of the challenges faced by culturally diverse populations
seeking treatment are disparities in access and availability
of services, and language and literacy differences.
It is also important for counselors to be aware that sensitivity
to cultural issues includes avoiding a double standard--being
overly tolerant or flexible because of uncertainty about unfamiliar
social norms.
Cultural differences should not be allowed to excuse abusive
or neglectful behavior by parents.
Child protective services (CPS) agencies received reports
of over 3 million suspected cases of child abuse and neglect
in 1996.
CPS staff investigated 75 percent of these reports and substantiated
more than 970,000 cases of child maltreatment in that year alone
(DHHS, 1999;Sedlak and
Broadhurst, 1996).
The reported incidence of child abuse and neglect climbed from
41 children per 1,000 in 1990 to 44 children per 1,000 in 1996.
Even more disturbing, researchers agree that most incidents--as
many as 70 percent--of child abuse and neglect still go unreported
(Briere, 1992a; DHHS,
1999).
It is estimated that 42 of every 1,000 children in the United
States (under age 18) have been either abused or neglected.
The number of sexually abused girls is three times the number
of boys, but boys are more likely than girls to be seriously
injured by abuse (Holmes and Slap, 1998).
Boys are also more likely to be emotionally neglected.
As noted above, there seem to be no significant differences among
racial and ethnic groups in the incidence of maltreatment or
maltreatment-related injuries (Sedlak and Broadhurst,
1996).
Child maltreatment may not necessarily be on the rise; society
may be more informed about reporting procedures, and victims
may be more educated on resources, safety in disclosure, and
ability to seek help in comparison to the past.
Some researchers suspect that the tremendous rise in child abuse
rates may be largely due to heightened awareness of the issue
by society in general (Van Dam et al., 1985).
Some of the increase in reported cases may also stem from greater
sensitivity among researchers to the subtle cues of abuse and
neglect.
However, the rate of serious injuries due to child abuse has
risen dramatically (Sedlak and Broadhurst,
1996), and (as noted above) the incidence of abuse and neglect
might be underestimated as a result of underreporting.
Indeed, in one review of children's death certificates, 85 percent
of abuse- and neglect-related deaths had been attributed to other
causes (McClain et al., 1993).
Given the high incidence of documented abuse and neglect among
children, it is reasonable to assume that a sizable proportion
of adults experienced similar childhood trauma.
However, the true incidence of childhood abuse and neglect among
adults is unknown.
Research definitions have not been consistent, and this makes
estimations difficult (Wyatt and Peters, 1986a).
Inclusive definitions yield substantially higher estimates of
abuse and neglect, while narrow definitions yield lower ones.
Variations in research methods (e.g., questionnaires versus interviews)
and populations studied also affect estimates (Wyatt
and Peters, 1986b).
A large national study of randomly identified adults in the
United States estimates that 27 percent of women and 16 percent
of men were sexually abused as children (Finkelhor
et al., 1990).
Additional estimates of childhood sexual abuse among women range
from approximately 7 percent (Burnam et al.,
1988) to 54 percent (Russell, 1983).
The actual incidence of childhood sexual abuse is unknown (Trickett and Putnam, 1993).
The true incidence among adults of other forms of childhood abuse
and neglect is also unclear.
Physical maltreatment has been studied less than childhood sexual
abuse, and inconsistent methods and definitions have made the
results uncertain.
The incidence of emotional abuse and neglect among adults has
not been significantly studied.
Although a causal relationship has been difficult to establish,
investigators report that childhood abuse and neglect are associated
with later problems.
Sexual abuse, for instance, has been linked to depression, anxiety,
and sexual dysfunction as well as eating, personality, dissociative,
and substance abuse disorders (Beitchman et
al., 1992; Browne and Finkelhor, 1986;
Cahill et al., 1991; Polusny
and Follette, 1995).
People sexually abused as children are more likely than others
to have social difficulties, and their risk of physical and sexual
assault is greater (Polusny and Follette, 1995).
One review of the physical abuse literature found that physically
abused boys are more likely to become substance abusers, though
the reviewers did not include any studies of the risk of substance
abuse among physically abused girls (Malinosky-Rummell
and Hansen, 1993).
Low self-esteem (Briere and Runtz, 1990b)
and depression (Braver et al., 1992) are
relatively common among college students who were emotionally
abused.
In fact, they are more common among those who were emotionally
abused than they are among those who were physically abused (
Gross and Keller, 1992; Ney
et al., 1993).
Alcohol and drug counselors must understand the definitions
of abuse and neglect in order to adequately screen and assess
clients who were exposed to them as children.
Counselors must also know the definitions because they, like
all clinicians, are required by law to report suspected or known
child abuse (see Chapter 6).
Clinicians who understand the definitions of child abuse and
neglect can also help clients who might not recognize that they
were abused or neglected as children.
According to researchers, some adults tend to deny, minimize,
or forget experiences of abuse (Brown et al.,
1999; Della Femina et al., 1990; Kufeldt and Nimmo, 1987).
For example, Williams interviewed a sample of women in the early
1990s who had documented histories of sexual abuse occurring
between 1973 and 1975 (Williams, 1994).
Forty percent of the women failed to report the documented abuse
during their assessments.
Many of the women in this subgroup, however, did report other
instances of childhood sexual abuse, leading the author to suggest
that these women may in fact have traumatically forgotten the
documented abuse.
Both Federal and State legislation define child abuse and
neglect.
The Federal legislation provides a foundation for States by identifying
a minimum set of acts or behaviors that constitute maltreatment.
The Child Abuse Prevention and Treatment Act (42 U.S.C., §5106g),
enacted in 1974 and reauthorized in 1996, defines child abuse
and neglect as, at minimum, any recent act or failure to act
that results in "imminent risk of serious harm, death, serious
physical or emotional harm, sexual abuse or exploitation" (Courtney, 1998) to a child under the age of
18, or, except in the case of sexual abuse, under the age specified
by the child protection law of the State, by a parent or caretaker
(including any employee of a residential facility or any staff
person providing out-of-home care) who is responsible for the
child's welfare.
The act defines sexual abuse as
Employment, use, persuasion, inducement,
enticement, or coercion of any child to engage in, or to assist
any other person to engage in, any sexually explicit conduct
or any simulation of such conduct for the purpose of producing
any visual depiction of such conduct
Rape, prostitution, and in cases of caretaker or interfamilial
relationships, statutory rape, molestation, or other form of
sexual exploitation of children
Incest with children (although legal definitions may vary
from State to State, incest can be broadly defined as the imposition
of sexually inappropriate acts, or acts with sexual overtones,
by one or more persons who derive authority through ongoing emotional
bonding with that child--or any use of a minor child to meet
the sexual or emotional needs of such persons)
Each State is responsible for providing definitions of child
abuse and neglect within this civil and criminal context.
Laws vary widely from State to State, and treatment providers
must be familiar with the definitions outlined in their own State's
laws.
In particular, they must understand reporting laws, which
describe the circumstances and conditions under which they are
obligated to report known or suspected abuse or neglect.
These laws also list the conditions under which counselors are
allowed to report known or suspected cases described to them
by a third party.
Counselors should also be familiar with juvenile/family court
acts that dictate when a court is allowed to take custody of
a child alleged to have been abused or neglected.
The definitions in these acts are often the same as those in
the reporting law.
Finally, treatment providers should know the criminal law in
their State that defines criminally punishable forms of abuse
and neglect--such as sexual abuse, severe physical abuse, and
child endangerment--and the reporting requirements (see Chapter
6 for further information).
Neglect is the failure to provide for a child's basic
needs. Neglect can be physical, educational, medical, or emotional.
Physical neglect is the most common type of neglect,
and it includes the failure to meet a child's basic needs for
food, shelter, and clothing that is not due to a lack of financial
resources. Physical neglect also encompasses inadequate supervision
and abandonment of a child, expulsion from home, and rejection
of a runaway who wishes to return home. Educational neglect is the second most frequent type of neglect and includes
failing to enroll a child in school, allowing chronic truancy,
and not attending to a child's special educational needs. Medical
neglect involves the refusal of, noncompliance with, or avoidable
delay in seeking health care. Emotional neglect, which,
like emotional abuse, is difficult to document, includes marked
inattention to a child's needs for affection, refusal of or failure
to provide needed psychological care, or chronic or extreme spousal
abuse in the child's presence.
The assessment of child neglect requires consideration of
cultural values and standards of care, as well as recognition
of the role of poverty in failure to provide the necessities
of life. In substance-abusing families, neglect is a much more
common reason than physical abuse for a parent to be reported
to CPS agencies. In one study of children in foster care who
had substance-abusing parents, neglect or abandonment accounted
for 70 percent of placements, whereas physical abuse accounted
for only 15 percent. For children placed in foster care from
families in which substance abuse was not a factor, neglect or
abandonment accounted for 37 percent of the cases and physical
abuse accounted for 33 percent (Walker et al.,
1994).
Physical abuse can range from minor bruising to killing
a child and may involve a single act or repeated occurrences.
It is characterized by physical injury inflicted by punching,
beating, kicking, biting, burning, or other actions. Such injuries
are not accidental, although caretakers may not believe that
they intended to harm the child. Physical abuse includes punishment
that is not appropriate to a child's age, size, or physical,
mental, or emotional condition. Normal disciplinary measures
do not require medical treatment, nor do they leave physical
marks, such as welts and bruises. Any punishment that involves
hitting with a closed fist or with an instrument, as well as
kicking, burning, or throwing the child is considered abuse regardless
of the severity of the injury.
Sexual abuse or incest involves a range of behaviors--including
all forms of oral-genital, genital, or anal contact with the
child (such as fondling a child's genitals), or nontouching abuse
(e.g., exhibitionism, voyeurism), as well as sexual penetration
(e.g., intercourse, rape, sodomy), and commercial exploitation
of the child via prostitution or the production of pornography.
It involves not only acts committed by the perpetrator but inappropriate
actions the child is forced or encouraged to perform on the adult.
Child sexual abuse means engaging a child in sexual activities
that the child cannot comprehend, for which the child is developmentally
unprepared, and for which he cannot give informed consent.
Most State laws distinguish between sexual abuse and sexual
assault: An act of abuse is perpetrated by a person who has some
responsibility for the child's care, whereas an assault is committed
by someone other than a caregiver. However, researchers and
survivors of childhood abuse perceive that caregivers or relatives
who engage a child in sexual activity by use of force, life threats,
and beatings are by definition committing sexual assault. For more information on consequences of sexual abuse and
assault, see Funk, 1980; Gomes-Schwartz
et al., 1985; Paradise et al., 1994;
and Sullivan et al., 1979.
Emotional or psychological abuse includes acts of commission
or omission by parents or caregivers that have caused, or could
cause, serious behavioral, cognitive, emotional, or mental disorders.
Examples include the verbal or emotional assault of a child
as well as the child's extreme confinement by ropes or other
means. Emotional abuse often coexists with other forms of abuse,
and it is the most difficult to identify. Many of its potential
consequences, such as learning and speech problems and delays
in physical development, can also occur in children who are not
being emotionally abused. In addition, the effects of such abuse
may not be evident until later in life. In some States, a CPS
agency can intervene in cases of emotional or psychological abuse
without evidence of harm to the child's behavior or condition.
Only proof of an extreme form of psychological punishment, such
as confining the child to a closet, is required. CPS agencies
in these States will not, however, intervene in cases of excessive
rejection, blame, or belittlement without proof of harm.
Variations in the definitions of child abuse and neglect have
made it difficult to assess the extent of the problem and its
prevalence in the histories of adults. Although definitions
have not yet been standardized (Briere, 1996; Whipple and Richey, 1997), researchers
recognize consistency in definitions as an important goal. At
present, researchers debate whether to define child abuse and
neglect by their impact on the child's development (Garbarino,
1977; Garbarino et al., 1986) or by
community standards for appropriate behavior toward children.
These distinctions have been central in trying to define emotional
abuse, but they have also helped frame discussions about other
forms of abuse and neglect. However, in an effort to discourage
overly zealous interventions, policymakers tend to advocate narrow
definitions of emotional abuse that require proof that the child
was harmed (see McGee and Wolfe, 1991,
for a discussion of the issues). Some researchers, however,
argue for definitions of emotional abuse that are independent
of the apparent effects of the abuse (Barnett
et al., 1991; Shaver et al., 1991).
Emotional abuse and neglect are often ranked on a continuum,
and participants are not typically categorized by the mere occurrence
or absence of maltreatment. This continuum approach is becoming
more common in the study of child abuse (Bernstein
et al., 1994).
Child sexual abuse is often defined broadly by researchers
as any unwanted sexual experience occurring before the age of
18, including genital exposure and verbal propositions (Wyatt
and Peters, 1986b). More restricted definitions typically
specify that the experience must have involved physical contact
with someone at least 5 years older than the victim if the victim
is under a certain age, usually 15 through 18 years old (Krinsley
et al., 1992; Rohsenow et al., 1988).
The broader conceptualization of sexual abuse yields substantially
higher rates of reporting than do more narrow definitions. Acts
of physical violence aimed by a parent or caretaker toward a
child are considered by most to be abuse, though many studies
also specify that the child must have been physically injured
(Straus and Gelles, 1990; Whipple
and Richey, 1997).
Simply asking clients if they were abused or neglected as
children is no longer considered an adequate evaluation of maltreatment
(Briere, 1992b; Miller
and Downs, 1995; Wyatt and Peters, 1986b). Instead, clients are provided clear behavioral descriptions
of experiences to which participants respond "yes" or "no."
For example, MacMillan and colleagues used the following questions
to assess physical abuse: "During childhood, did an adult often
or sometimes push, grab, or shove you? Throw something at you?
Hit you with something? Did an adult often, sometimes, or never
kick, bite, or punch you? Choke, burn, or scald you? Physically
attack you in any other way?" (MacMillan et
al., 1997). The number of and manner in which such questions
are asked influence the way they are answered. Also, spurious
links between child abuse and other symptoms can sometimes be
made. Patients with psychiatric disorders, for example, frequently
search their past lives for some explanation of their distress
(Pope and Hudson, 1992).
Underreporting of sexual abuse appears to be much more likely
than overreporting. A therapeutic alliance may have to exist
before a patient will disclose an incest history (Pribor
and Dinwiddie, 1992). It may be necessary to pose questions
at an intake history and then again later in the therapeutic
process. For the same reasons of client reticence, Miller and
Downs recommend a self-report questionnaire combined with an
interview (Miller and Downs, 1995). Each
method has been shown to identify cases of abuse missed by the
other. See Chapter 2 for more on this
issue.
One of the critical new areas of research on people with substance
abuse disorders is the study of "resilience factors" that permit
some sexually abused individuals to avoid addiction, while others
become addicted. Research demonstrates, for example, that victimized
women who become alcoholics experienced prolonged, severe sexual
abuse in isolation (Beckman and Ackerman, 1995). The courts' tendency to intervene minimally can perpetuate
isolation and make the development of resilient behavior less
likely. Another study notes a variety of specific factors that
affect resilience against addiction in individuals sexually abused
in childhood, including level of self-esteem, quality of adolescent
peer group, and extent to which PTSD symptoms are experienced
(Miller and Downs, 1995). A client's ability
to dissociate may actually promote resilience against addiction.
It will be very difficult to do any type of resilience studies
if "sexual abuse" is not defined as such unless there has been
some measurable negative outcome for the victim.
Counselors must recognize when it is appropriate or necessary
to report incidents of clients' maltreatment of their children
to government agencies, and for this they must know legal definitions
of abuse and neglect. However, a broader approach, especially
one that considers the meaning of the experience to the client,
may be more useful in treatment. Finkelhor, for example, notes
how sexual abuse may alter a child's perception of the world
(Finkelhor, 1987). It is this altered
perception, he argues, that leads to the devastating consequences
of abuse. The sexually abused child might well feel betrayed
and, as a result, no longer trust others (Springer,
1997). Stigmatization and shame may compromise the child's
self-esteem, as well. People who were traumatized might even
question their very right to exist (Greening,
1997).
Clinicians must, therefore, understand how clients interpret
their experiences. Not all abuse meets the legal or commonly
held criteria for abuse; nor will all clients perceive as abusive
those experiences which fit the legal definition. For example,
a client might report being spanked every day as a small child
and might feel that he deserved the spankings because he disobeyed
his mother. He might also explain that his mother loved him
and that the spankings occurred within a context of caring.
Such a client would deny that he had been abused as a child and
would not be well served by therapists who insisted otherwise.
In contrast, another client may have accepted chronic belittling
and criticism while growing up and may not understand its relationship
to career failures and repeated relapses.
Almost every theoretical model of child abuse and neglect
recognizes the contribution of stress to poor outcomes, and poverty
is a major source of family stress. Substandard and overcrowded
housing in unsafe neighborhoods strains families, as do unemployment
and discrimination. In some cases, impoverished families should
not be subjected to accusations of intentional child neglect
(Besharov and Laumann, 1997). CPS agencies
can help counselors understand which cases truly merit investigation
and which should be referred to other agencies. Counselors can
contact CPS agencies and discuss confusing cases without identifying
individuals and families. Counselors can also refer clients
to various agencies to help them secure child care, food stamps,
and free family health care as needed. (See "Role of Child Protective
Service Agencies" in Chapter 5 for more
information on working with the child welfare system.) Child
neglect and the conditions of poverty often overlap. Even when
there is no intent, physical and emotional injury can still occur.
Disenfranchisement may lead to deviance, such as criminal activity,
that may have an unintended impact on children, as when a parent
is arrested or incarcerated. It is the responsibility of the
counselor to report instances of reasonable suspicion of abuse
or neglect; however, counselors should use caution when distinguishing
cases of class and cultural differences from child abuse and
neglect. A comprehensive assessment should be conducted before
any conclusions are reached. Many CPS agencies provide training
for counselors on mandated reporting requirements, and some CPS
agencies have the resources for assisting families. See Chapter
6 for more information on requirements and guidelines for
reporting.