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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

4 Consequences of Child Abuse and Neglect

Since the 1993 National Research Council (NRC) report on child abuse and neglect was issued, dramatic advances have been made in understanding the causes and consequences of child abuse and neglect, including advances in the neural, genomic, behavioral, psychologic, and social sciences. These advances have begun to inform the scientific literature, offering new insights into the neural and biological processes associated with child abuse and neglect and in some cases, shedding light on the mechanisms that mediate the behavioral sequelae that characterize children who have been abused and neglected. Research also has expanded understanding of the physical and behavioral health, academic, and economic consequences of child abuse and neglect. Knowledge of sensitive periods—the idea that for those aspects of brain development that are dependent on experience, there are stages in which the normal course of development is more susceptible to disruption from experiential perturbations—also has increased exponentially. In addition, research has begun to explore differences in individual susceptibility to the adverse outcomes associated with child abuse and neglect and to uncover the factors that protect some children from the deleterious consequences explored throughout this chapter. An important message is that factors relating to the individual child and to the familial and social contexts in which the child lives, as well as the severity, chronicity, and timing of abuse and neglect experiences, all conspire to impact, to varying degrees, the neural, biological, and behavioral sequelae of abuse and neglect.

This chapter begins by exploring background topics that are important to an understanding of research on the consequences of child abuse and neglect, including an ecological framework and methodological attributes of studies in this field. Next is a review of the research surrounding specific outcomes across the neurobiological, cognitive, psychosocial, behavioral, and health domains, many of which can be seen in childhood, adolescence, and adulthood. The chapter then examines outcomes that are specific to adolescence and adulthood, reviews factors that contribute to individual differences in outcomes, and considers the economic burden of child abuse and neglect. The final section presents conclusions.

• CASCADING CONSEQUENCES

Newborns are almost fully dependent upon parents to help them regulate physiology and behavior. Under optimal conditions, parents buffer young children from stress and serve as “co-regulators” of behavior and physiology ( Hertsgaard et al., 1995 ; Hofer, 1994 , 2006 ). Over time, children raised by such parents gradually assume these regulatory capacities. They typically enter school well regulated behaviorally, emotionally, and physiologically; thus, being prepared for the tasks of learning to read, write, and interact with peers.

For some children, parents cannot fill these roles as buffer and co-regulator effectively. When children have caregivers who cannot buffer them from stress or who cannot serve as co-regulators, they are vulnerable to the vicissitudes of a challenging environment. Although children can cope effectively with mild or moderate stress when supported by a caregiver, conditions that exceed their capacities to cope adaptively often result in problematic short- or long-term consequences.

Studies conducted with some nonhuman primate species and rodents have shown that the young are dependent on the parent for help in regulating behavior and physiology ( Moriceau et al., 2010 ). Thus, young infants are dependent on parents fulfilling the functions of carrying, holding, and feeding. The period of physical immaturity and dependence lasts an extended time in humans. Even beyond the point at which young children are physically dependent, they remain psychologically dependent throughout childhood and adolescence. Thus, inadequate or abusive care can have considerable consequences in terms of children's health and social, psychological, cognitive, and brain development.

Children who have experienced abuse and neglect are therefore at increased risk for a number of problematic developmental, health, and mental health outcomes, including learning problems (e.g., problems with inattention and deficits in executive functions), problems relating to peers (e.g., peer rejection), internalizing symptoms (e.g., depression, anxiety), externalizing symptoms (e.g., oppositional defiant disorder, conduct disorder, aggression), and posttraumatic stress disorder (PTSD). As adults, these children continue to show increased risk for psychiatric disorders, substance use, serious medical illnesses, and lower economic productivity.

This chapter highlights research supporting the association between these outcomes, among others, and experiences of child abuse and neglect. The potential dramatic and pervasive consequences of child abuse and neglect underscore the need for research to illuminate the myriad pathways by which these ill effects manifest in order to guide treatment and intervention efforts. However, it is important to note at the outset that not all abused and neglected children experience problematic outcomes. As discussed in the section on individual differences later in this chapter, a body of research is devoted to uncovering the factors that distinguish children who do not experience problematic outcomes despite facing significant adversity in the form of abuse or neglect. Further, as discussed in Chapter 6 , the past two decades have seen substantial growth in proven models for treatment of the consequences of child abuse and neglect, indicating that these effects are potentially reversible and that there is opportunity to intervene throughout the life course.

Several key concepts need to be considered in attempting to understand potential pathways that lead from abuse and neglect to the various consequences discussed in this chapter and the context in which those consequences manifest. First, positive and negative influences found among individual child characteristics, within the family environment, and in the child's broader social context all interact to predict outcomes related to child abuse and neglect. Second, child abuse and neglect occur in the context of a child's brain development, and their potential effects on developing brain structures can help explain the onset of certain negative outcomes. Finally, abused and neglected children often are exposed to multiple stressors in addition to experiences of abuse and neglect, and potential consequences may manifest at different points in a child's development. Therefore, the most rigorous research on this topic attempts to account for the many factors that may be confounded with abuse or neglect.

Ecological Framework

Since 1993, transactional-bioecological or ecological models have guided attempts to conceptualize the relative contributions of risk and protective factors to children's developmental outcomes, particularly in relation to child abuse and neglect ( Belsky, 1993 ; Cicchetti and Lynch, 1993 ; Cicchetti and Toth, 1998 ). Versions of this approach consider the development of the child in the context of the broader social environment in which he or she functions, within the context of a family; in turn, children and families are embedded in a larger social system that includes communities, neighborhoods, and cultures. The assumption underlying these models is that behavior is complex, and development is multiply determined by characteristics of the individual, parents and family, and neighborhood and/or community and their interactions.

In examining the role of contextual factors in the onset of consequences due to child abuse and neglect, Cicchetti and Lynch's (1993) ecological/transactional model is particularly useful because it successfully incorporates multiple etiological frameworks ( Lynch and Cicchetti, 1998 ). This model is based on Belsky's (1980 , 1993 ) ecological model and Cicchetti and Rizley's (1981) transactional model. It expands on these models by highlighting the nature of interaction among risk factors and the ecology in which child maltreatment occurs. The ecological/transactional model describes four interrelated, mutually embedded categories that contribute to abuse and neglect and the potential associated consequences:

• Ontogenic development—Reflects factors within the individual that influence the achievement of competence and adaptation.
• Microsystem—Defined as the “immediate context” (i.e., the family) in which the child experiences abuse or neglect, including the bidirectional influence of parent and child characteristics and other relationships (such as marriage) that may impact parent-child interactions directly or indirectly.
• Exosystem—The exo- and macrosystemic levels reflect social or cultural forces that contribute to and maintain abuse or neglect. The exosystem encompasses the effects of broader societal systems (e.g., employment, neighborhoods) on parent and child functioning.
• Macrosystem—Mirrors temporally driven, sociocultural ideologies (e.g., cultural views of corporal punishment), or a “larger cultural fabric,” that inevitably shape functioning at all other levels. It is represented by social attitudes (such as attitudes toward violence or the value of children).

The model is based on the fact that a child's multiple ecologies influence one another, affecting the child's development. Thus, the combined influence of the individual, family, community, and larger culture affect the child's developmental outcomes. Parent, child, and environmental characteristics combine to shape the probabilistic course of the development of abused and neglected children.

At higher, more distal levels of the ecology, risk factors increase the likelihood of child maltreatment. These environmental systems also influence what takes place at more proximal ecological levels, such as when risk and protective factors determine the presence or absence of maltreatment within the family environment. Overall, concurrent risk factors at the various ecological levels (e.g., cultural sanction of violence, community violence, low socioeconomic status, loss of job, divorce, parental substance abuse, maladaptation, and/or child psychopathology) act to increase or decrease the likelihood that abuse will occur.

The manner in which children handle the challenges associated with maltreatment is seen in their own ontogenic development, which shapes their ultimate adaptation or maladaptation. Although the overall pattern is that risk factors outweigh protective factors, there are infinite permutations of these risk variables across and within each level of the ecology, providing multiple pathways to the sequelae of child abuse and neglect.

Types of Evidence

Many studies of the consequences of abuse and neglect have been conducted with methodologies ranging from prospective to retrospective designs, from observational measures to self-report, and from experimental to case-controlled designs to no-control designs. The strongest conclusions could be reached with experimental designs whereby children would be randomly assigned to different abusive or neglectful experiences; however, this is obviously neither desirable nor possible.

Nonhuman studies involving primates and other species have allowed experimental assessment of different rearing conditions that may parallel human conditions of neglect and abuse (e.g., Sanchez, 2006 ; Suomi, 1997 ). One salient human study involved random assignment of children abandoned to institutions to high-quality foster care (a randomized controlled trial of foster care as an alternative to institutional care) ( Nelson, 2007 ). In this prospective, longitudinal study, known as the Bucharest Early Intervention Project, 136 children abandoned at or around the time of birth and then placed in state-run institutions were extensively studied when they ranged in age from 6 to 31 months (mean age = 21 months), as was a sample of 72 never-institutionalized children who lived with their families in the greater Bucharest community. Following the baseline assessment, half of the institutionalized children were randomly assigned to a high-quality foster care program that the investigators created, financed, and maintained, and half were randomly assigned to remain in care as usual (institutional care). These children were followed extensively through age 12 (for discussion, see Fox et al., 2013 ; Nelson et al., 2007a , b ; Zeanah et al., 2003 ). Although at first glance it may not be obvious why the study of children reared in institutions is relevant to a report on child abuse and neglect, institutional care, which affects as many as 8 million children around the world, can involve an extreme and specific form of neglect—broad-spectrum psychosocial deprivation. Therefore, neglectful institutional care settings can serve as a model system for understanding the effects of neglect on brain development. The neglect experienced by children in such settings should not serve as a proxy for the type of neglect experienced by noninstitutionalized children in the United States, who are more likely to experience neglect in such domains as food, shelter, clothing, or medical care rather than broad-spectrum psychosocial deprivation. Nevertheless, this study can provide important insight into the effects of neglect on behavioral and neurological development because of its randomized, controlled, and longitudinal nature.

The discussion in this chapter necessarily relies primarily (although not exclusively) on the strongest nonexperimental studies conducted. These studies involve longitudinal prospective designs, which assess child abuse and neglect objectively at the time of occurrence and assess outcomes longitudinally. A good example is the study of Widom and colleagues (1999) , which followed a large cohort of abused and neglected children and a matched comparison sample from childhood into adulthood. Other examples include the studies of Johnson and colleagues (1999 , 2000 ), Noll and colleagues (2007) , and Jonson-Reidz and colleagues (2012) . Retrospective designs that ask participants to recall whether abuse and neglect were experienced are more troublesome because recall of child abuse and neglect can be affected by a variety of factors and open to a number of potential biases ( Briere, 1992 ; Offer et al., 2000 ; Ross, 1989 ; Widom, 1988 ). Results of studies based on treatment samples of adults who experienced maltreatment as children may be potentially biased because not all victims of child abuse and neglect seek treatment as adults, and because people who do seek treatment may have higher rates of problems than people who do not seek treatment ( Widom et al., 2007a ). When participants are asked to report on conditions such as current depression and previous history of child abuse and neglect, the added problem of shared method variance arises. On the other hand, use of official records raises the problem of underreporting ( Gilbert et al., 2009a ).

The federal government has supported an effort, launched since the 1993 NRC report was issued—the National Survey of Child and Adolescent Well-Being (NSCAW)—to expand understanding of the consequences of child abuse and neglect. This study includes use of multiple data sources and record reviews, as well as interviews with children and youth who have experienced child abuse and neglect, their caretakers, and child welfare workers. Several of its findings are discussed in Chapter 5 .

This chapter contains an extensive review of the more recent biologically based studies of child abuse and neglect because of the important advances that have been made in this area. To the extent possible, the discussion relies on findings from studies characterized by the greatest methodological rigor.

Despite recent methodological advances, researchers face many challenges in attempting to understand the short- and long-term consequences of the various types of child abuse and neglect (e.g., physical abuse, sexual abuse, neglect from caregivers) for child functioning and development. One of those challenges is teasing apart the impact of child abuse and neglect from that of other co-occurring factors. For example, children involved with child protective services because of neglect or abuse often face a number of overlapping and concurrent risk factors, including poverty, prenatal substance exposure, and parent psychopathology, among others ( Dubowitz et al., 1987 ; Lyons et al., 2005 ; McCurdy, 2005 ). These concurrent risk factors can make it particularly difficult to draw causal inferences about the specific consequences of abuse and neglect for children's functioning, but need to be disentangled from the specific effects of abuse and neglect ( Widom et al., 2007a ). Controlling for other relevant variables becomes vital, since failure to take such family variables into account may result in reporting spurious relationships ( Widom et al., 2007a ). Some studies consider and covary other risk factors, and some do not. Considering the course of abuse and neglect may also be particularly important, as Jonson-Reid and colleagues (2012) found that the number of child abuse and neglect reports powerfully predicted adverse outcomes across a range of domains.

Finding: Risk factors that co-occur with child abuse and neglect, such as poverty, prenatal substance exposure, and parent psychopathology, can confound attempts to draw causal inferences about the specific consequences of abuse and neglect for children's functioning. These factors need to be controlled for in studies seeking to identify the specific consequences of child abuse and neglect.

• NEUROBIOLOGICAL OUTCOMES

An adequate caregiver is needed to support developing brain architecture and the developing ability to regulate behavior, emotions, and physiology for young children. When children experience abuse or neglect, such development can be compromised. The effects of abuse and neglect are seen especially in brain regions that are dependent on environmental input for optimal development, and on aspects of functioning especially susceptible to environmental input. Early in development, infants are completely reliant on input from their caregivers for help in regulating arousal, neuroendocrine functioning, temperature, and other basic functions. With time and with successful experiences in co-regulation, children increasingly take over these functions themselves. Abuse and neglect represent the absence of adequate input (as in the case of neglect) or the presence of threatening input (as in the case of abuse), either of which can compromise development. The following sections present a review of evidence with respect to key neurobiological systems that are altered as a result of abuse and neglect early in life: the hypothalamic-pituitary-adrenal (HPA) axis of the stress response system; the amygdala, involved in emotion processing and emotion regulation; the hippocampus, involved in learning and memory; the corpus callosum, involved in integrating functions between hemispheres; and the prefrontal cortex, involved in higher-order cognitive functions. The discussion begins, however, with a brief overview of brain development.

Overview of Neurobiological Development

The construction of the brain.

Brain development begins just a few weeks after conception, starting with the construction of the neural tube. This is followed by the generation of different classes of brain cells—neurons and glia. Once formed, these immature neurons begin their migratory phase (generally away from the ventricular zone, which is their point of origin) to build the cerebral cortex. Much of cell migration is completed by the end of the second trimester of pregnancy, eventually leading to the construction of the six-layered cerebral cortex. After these immature cells have migrated to their target destination, they can differentiate; that is, they develop cell bodies and processes (axons and dendrites). Once processes have been formed, synapses begin to form; synapses are the connections between neurons that allow for the transmission of signals across the synaptic cleft, which is the small space that exists between two adjacent brain cells, generally between a dendrite and an axon. The synapse permits one neuron to communicate with another, and eventually, entire circuits are built, followed by neural networks (i.e., organized units). Finally, some axons in the brain develop a coating called myelin that speeds the flow of information along the length of the axon. Sensory and motor pathways begin to myelinate during the last trimester of pregnancy, whereas association areas of the brain, particularly the prefrontal cortex, continue to myelinate through the second decade of life. Neural elements (e.g., axons) that are coated with myelin are referred to as white matter , whereas most of the rest of the brain is referred to as grey matter .

Many aspects of brain development (particularly those that occur before birth) fall under genetic control (although some are affected by experience—prenatal exposure to neurotoxins such as alcohol being but one example). After birth, however, much of brain development becomes dependent on experience. For example, although the generation of synapses—which are massively overproduced early in development—is largely under genetic control, the pruning of synapses—which occurs primarily after birth—is largely under experiential control. Thus the prefrontal cortex of the 1-year-old child has many more synapses than the adult brain, but over the next one to two decades, these synapses are pruned back to adult numbers, based largely on experience ( Nelson et al., 2011 ).

Neural Plasticity and Sensitive Periods

Many aspects of brain development depend on experiences occurring during particular time periods, often the first few years of life. These so-called sensitive or critical periods represent vital inflection points in the course of development, such that if specific experiences fail to occur within some narrow window of time (or the wrong experiences occur), development can go awry. This leads to the concept that plasticity “cuts both ways,” meaning that if the child is exposed to good experiences, the brain benefits, but if the child is exposed to bad experiences or inadequate input, the brain may suffer ( Nelson et al., 2011 ). Prenatally, an example of a bad experience is exposure to neurotoxins such as alcohol or drugs of abuse. An example of a good experience is access to good nutrition, including the many micronutrients that facilitate brain development (e.g., iron, zinc). Postnatally, the topic of this report represents examples of bad experience (i.e., abuse and neglect). Conversely, examples of good experiences include providing a child with consistent, sensitive caregiving; a nurturing home in general; and adequate stimulation.

The Time Course of Development

In general, most sensory systems develop early in life; thus the ability to see and to discriminate and recognize faces and speech sounds come on line in the first months and years of life, based on appropriate experiences occurring during that time window (e.g., exposure to faces, to speech). This is not surprising given how vitally important these functions are to subsequent development (e.g., language is not learned until children can discriminate the basic units of sound, such as one consonant from another). Critical to the discussion in this chapter, however, is that the functions subserved by some other regions of the brain, most notably the prefrontal cortex—executive control, planning, cognitive flexibility, emotion regulation—have a much more protracted course of development for the simple reason that both synaptogenesis and myelination of these cortical regions do not mature until mid- to late adolescence, perhaps even a bit later. As a result, the sensitive period for prefrontal cortical functions may be far more prolonged than is the case for sensory functions, extending well into the adolescent period. One example of the differential time course of different brain regions, and perhaps their corresponding sensitive periods, is illustrated in Figure 4-1 .

The time course of key aspects of brain development. SOURCE: Thompson and Nelson, 2001 (reprinted with the permission of American Psychologist ).

These concepts are important to the study of the neurobiological toll of early childhood abuse and neglect because children who experience considerable adversity early in life may be exposed to environments/experiences that the species has not come to expect (such as abusive caregivers) or worse, environments that are largely lacking in key experiences (i.e., neglect). In both cases, when the expectable environment is violated by either gross alterations in the type of care received or a complete lack of care, subsequent development can be seriously derailed.

Hypothalamic-Pituitary-Adrenocortial (HPA) Axis and Biological Regulation

There is strong evidence across species that the HPA axis is affected by experiences of early childhood abuse and neglect (e.g., Bruce et al., 2009 ; Gunnar and Vazquez, 2001 ; Levine et al., 1993 ; Shonkoff et al., 2012 ). Glucocorticoids (cortisol in humans, corticosterone in rodents) are steroid hormones produced as an end product of the HPA system. The HPA axis serves two orthogonal functions: mounting a stress response and maintaining a diurnal rhythm. A cascade of events is designed to promote survival behavior by directing energy to processes that are critical to immediate survival (e.g., metabolism of glucose) and away from processes that are less critical to immediate survival, such as immune functioning, growth, digestion, and reproduction ( Gunnar and Cheatham, 2003 ).

Glucocorticoids also serve an important role in maintaining circadian patterns of daily activity, such as waking up, sleeping, and energy regulation ( Gunnar and Cheatham, 2003 ). Diurnal species, including humans, have a diurnal pattern of cortisol production that enhances the likelihood of being awake at the same time in the day. In humans, diurnal cortisol levels peak about 30 minutes after waking up, decrease sharply by mid-morning, and continue to decrease gradually until bedtime ( Gunnar and Donzella, 2002 ). The higher morning values of cortisol reflect greater metabolism of glucose early in the day, providing energy for the day's activities.

The HPA axis is highly sensitive to the effects of early experiences. Diurnal effects typically have been examined as wake-up values and bedtime values because those time points allow assessments of change from nearly the highest reliable waking time point (with 30 minutes post wake-up being the highest) to the lowest waking time point. Daytime values are affected by a number of factors, such as exercise, naps, and travel to work ( Larson et al., 1991 ; Watamura et al., 2002 ). The most consistent findings involve flatter, more blunted patterns of diurnal regulation among abused or neglected children relative to low-risk children ( Bernard et al., 2010 ; Bruce et al., 2009 ; Dozier et al., 2006 ; Fisher et al., 2007 ; Gunnar and Vazquez, 2001 ). Similar flattened diurnal rhythms have been found in institutionalized children ( Bruce et al., 2000 ; Carlson and Earls, 1997 ). Flattened diurnal cortisol patterns may reflect down-regulation of HPA axis activity following earlier hyperactivation ( Carpenter et al., 2009 ; Fries et al., 2005 ).

Cicchetti and colleagues ( Cicchetti and Rogosch, 2001a , b ) examined changes across the day among abused and neglected children attending summer camp. The time points included when children first arrived at camp (at about 9 AM) and before they left camp for the day (at about 4 PM), likely tapping diurnal change within a challenging environment. The authors report complex findings regarding cortisol in this setting. Differences were found in some studies related to subtype and/or psychopathology and/or aggression ( Cicchetti and Rogosch, 2001b ; Murray-Close et al., 2008 ).

Animal models have been used to study experimentally the effects of neglect and abuse on HPA functioning (e.g., Levine et al., 1993 ). Experiences of abuse or neglect, depending on age of pup/infant, duration, chronicity, and subsequent response of dam/mother differentially affect short- and long-term effects on the HPA axis ( Sanchez, 2006 ). Under naturally occurring conditions (about 10 percent of rhesus monkeys abuse their infants), a 1-year-old rhesus monkey that was abused (primarily in the first month of life) showed higher cortisol levels under basal and stress conditions than a 1-year-old that had not been abused. These effects were not seen at older ages. (The age translation from rhesus to human is about 1 to 4, so a 1-year-old rhesus is developmentally similar to about a 4-year-old human child.) In other studies that have manipulated rearing conditions (such as isolation rearing), differences between conditions of abuse or neglect have been inconsistent. In some studies, higher cortisol values were observed in basal and/or stress conditions; in some, lower basal and/or stress conditions; and in some, no differences between the monkeys that had undergone deprivation and those that had not ( Champoux et al., 1989 ; Clarke, 1993 ; Higley et al., 1992 ; Shannon et al., 1998 ).

Disrupted HPA axis regulation may have negative effects on a number of other biological systems. High levels of circulating cortisol resulting from early life stress may cause damage to developing brain regions ( Teicher et al., 2003 ; Twardosz and Lutzker, 2010 ). Several brain regions, including limbic regions such as the amygdala and hippocampus and prefrontal regions, may be particularly susceptible to the effects of high levels of circulating cortisol because of the high number of glucocorticoid receptors in these areas ( Brake et al., 2000 ; Schatzberg and Lindley, 2008 ; Wellman, 2001 ).

High levels of circulating cortisol may affect telomere length as well. Telomeres are the repeated sequences of DNA that cap the ends of chromosomes. Telomeres shorten each time cells divide, a process generally associated with aging, but also with stress ( Epel et al., 2004 ). If telomeres become too short, the cell may become senescent (grow old) or may become malfunctional, for example, triggering inflammation or tumor development. Children who have been exposed to neglect show shortened telomeres ( Asok et al., 2013 ; Drury et al., 2011 ). Drury and colleagues (2011) found shorter telomeres among children in institutional care. Similarly, Asok and colleagues (2013) found that children living in highly challenging environments showed shorter telomeres than comparison children, but that mothers could buffer children from the environment challenge. When mothers of neglected children were sensitive to challenging environments, their children's telomeres were as long as those of low-risk children, but when mothers were insensitive, children's telomeres were shorter. Clearly, then, sensitive caregiving serves as a protective factor even under difficult conditions of adversity.

There is as yet no compelling empirical evidence among humans that high levels of cortisol result from abuse or neglect and persist long enough to affect brain development adversely, leaving these arguments speculative. Nonetheless, the evidence is compelling that the HPA axis is perturbed in many cases, and perturbations are associated with a range of health and mental health problems ( McEwen, 1998 ; Yehuda et al., 2002 ).

Studies (e.g., McGowan et al., 2008 , 2009 , 2011 ; Meaney and Szyf, 2005 ; Weaver et al., 2004 ) have found that the effects of abuse on the stress response are mediated by epigenetic programming of glucocorticoid receptor expression. Differential methylation of the glucocorticoid receptor gene promoter in the hippocampus was found to be associated with different rearing conditions in rodents, and was reversed by changes in caregiving conditions ( McGowan et al., 2008 ). Paralleling these findings among rodents are nonexperimental findings among humans examined in postmortem analyses ( McGowan et al., 2009 ; Szyf and Bick, 2013 ). Adult suicide victims who had experienced abuse as children differed in glucocorticoid receptor mRNA from adult suicide victims who had not experienced abuse as children and from controls. These findings are consistent with the experimental rodent findings, and suggest that methylation of receptor sites mediates the association between early care and stress responsiveness.

The amygdala performs a primary role in the formation and storage of memories associated with emotional events. The amygdala undergoes rapid development within the first several years of life and is particularly susceptible to early adversity (e.g., Chareyron et al., 2012 ). Relative to low-risk children, abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety, and emotional reactivity ( Ellis et al., 2004 ; Kaplow and Widom, 2007 ; Tottenham et al., 2009 ; van Ijzendoorn and Juffer, 2006 ; Zeanah et al., 2009 ) and deficits in emotional processing ( Dalgeish et al., 2001 ; Pollak et al., 2000 ; Vorria et al., 2006 ). Figure 4-2 illustrates structures in the medial temporal lobe critically involved in emotion (amygdala) and learning and memory (hippocampus).

Illustration of brain structures.

Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect ( De Bellis et al., 2001b ; Tottenham and Sheridan, 2010 ; Woon and Hedges, 2008 ). However, Tottenham and colleagues (2010) and Mehta and colleagues (2009) found that amygdala volume was enlarged among children following institutionalized care, although this finding was not replicated by Sheridan and colleagues (2012) among a similar population. Importantly, both the Mehta et al. and Sheridan et al. studies did find a dramatic reduction in total brain volume, meaning that these children had physically smaller brains.

Functional magnetic resonance imaging (fMRI) studies have shown that early adversity leads to a sensitized amygdala. Relative to comparison children, previously institutionalized children showed heightened amygdala activity in response to fearful faces compared with neutral faces ( Tottenham et al., 2011 ). Similarly, Maheu and colleagues (2010) found that children with a history of abuse or neglect showed greater activation of the left amygdala in response to fearful and angry relative to neutral faces.

Hippocampus, Learning, and Memory

The hippocampus (see Figure 4-2 ) plays an important role in learning and memory ( Andersen et al., 2007 ; Ghetti et al., 2010 ; Otto and Eichenbaum, 1992 ) and, like the amygdala, matures rapidly over the first months and years of life ( Lavenex et al., 2007 ). The hippocampus appears to be particularly susceptible to stress early in life ( Gould and Tanapat, 1999 ; Sapolsky et al., 1990 ) and plays a role in modulating the response of the HPA axis to stressors, as binding of cortisol to hippocampal receptors serves to turn off the HPA axis response ( Kim and Yoon, 1998 ). Damage to the hippocampus due to abuse or neglect can have negative consequences for its roles in regulation of the stress response system and in memory formulation ( de Quervain et al., 1998 ; Sheridan et al., 2012 ).

Most studies have found no evidence of hippocampal volume deficits among abused children compared with healthy, nonabused control children ( De Bellis et al., 1999 , 2001a , 2002 ). Among adults, however, decreased hippocampal volume has been linked with the experience of childhood physical and sexual abuse ( Andersen and Teicher, 2004 ; Andersen et al., 2008 ; Schmahl et al., 2003 ; Woon and Hedges, 2008 ). Nonetheless, relatively smaller hippocampal volumes in abused adults may be specific to PTSD rather than abuse itself ( Kitayama et al., 2005 ).

Prefrontal Cortex and Executive Functions

The prefrontal cortex (see Figure 4-2 ) is responsible for a variety of higher-order “executive” functions ( Miller and Cohen, 2001 ). The development of the prefrontal cortex is protracted, extending from birth into the third decade of life ( Gogtay et al., 2004 ; Rubia et al., 2006 ; Sowell et al., 2003 ). Prefrontal systems are especially sensitive to experiences of early adversity ( Hart and Rubia, 2012 ; McLaughlin et al., 2010 ).

Evidence is mixed with regard to structural changes in the prefrontal cortex following abuse and neglect, with some studies showing smaller volumes of the right orbitofrontal cortex, right ventral-medial prefrontal cortex, and dorsolateral prefrontal cortex ( Hanson et al., 2010 ); some showing decreased grey matter volume in the prefrontal cortex in children with interpersonal trauma and PTSD symptoms ( Carrion et al., 2008 ); some showing the opposite effect ( Carrion et al., 2009 ; Richert et al., 2006 ); and still others showing no effect after controlling for total brain volume ( De Bellis et al., 2002 ). Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and related brain regions. In particular, children with trauma experiences show patterns of neural activation during tasks requiring executive function that are similar to patterns observed in children with attention-deficit hyperactivity disorder (ADHD) (e.g., Carrion et al., 2008 ).

Consistent with these findings among abused and neglected children, previously institutionalized children and adolescents have been found to demonstrate disruptions in the prefrontal network that is associated with inhibitory control. For example, Mueller and colleagues (2010) found that children with a history of neglect or institutional care showed greater activation in several regions of the prefrontal cortex (e.g., left inferior frontal cortex, anterior cingulate cortex) during response inhibition trials of a go/no-go task compared with children without a history of neglect. Similar findings have been reported by McDermott and colleagues (2012) and Loman and colleagues (2009) among currently and previously institutionalized children.

Corpus Callosum

The corpus callosum facilitates communication between the two hemispheres of the brain ( Giedd et al., 1996a , b ; Kitterle, 1995 ). The white matter fibers composing the corpus callosum are myelinated throughout childhood and adulthood ( Giedd et al., 1996a ; Teicher et al., 2004 ), which allows faster, more efficient transmission ( Bloom and Hynd, 2005 ). Myelinated regions such as the corpus callosum are susceptible to the impacts of early exposure to high levels of cortisol, which suppress the glial cell division critical for myelination.

Retrospective/cross-sectional studies have found abuse and neglect to be associated with structural changes in the corpus callosum. Teicher and colleagues (2004) compared corpus callosum volume in adults with different abuse and neglect experiences. The total corpus callosum area of the abused children was smaller than that of both healthy control children and children with psychiatric disorders and no abuse or neglect. Other findings suggest that gender may moderate these effects, with the effects being more pronounced among males than females ( De Bellis and Keshavan, 2003 ; De Bellis et al., 1999 , 2002 ; Teicher et al., 1997). Sheridan and colleagues (2012) performed structural MRIs on children enrolled in the Bucharest Early Intervention Project, described previously in this chapter. In a follow-up of 8- to 11-year-olds, Sheridan and colleagues (2012) found smaller total white and gray matter volume and smaller posterior corpus callosum volume among children who had been institutionalized relative to those who had never been institutionalized. By middle childhood, however, there were no significant differences in total white matter volume or posterior corpus callosum volume between the never-institutionalized (community) children and the foster care children. These early differences in corpus callosum may be associated with less efficient cognitive functioning among children who experience early adversity.

Influence of Early Profound Neglect on Brain Electrical Activity

The influence of profound neglect early in life has been examined using electroencephalography (EEG) and event-related potentials (ERPs).

Electroencephalography

EEG measurements of the brain's electrical activity can serve as a coarse metric for brain development. Most work on EEG in the context of neglect has been performed on children with a history of institutional care. The most extensive study of brain electrical activity among children with a history of institutional care was conducted with the children enrolled in the prospective, longitudinal Bucharest Early Intervention Project. At baseline (mean age 20 months), prior to random assignment to continued institutional care or foster care, institutionalized children showed higher levels of theta power (low-frequency brain activity) and lower levels of alpha and beta power (high-frequency activity) compared with children who were not institutionalized ( Marshall et al., 2004 ). The pattern of activity observed in institutionalized children suggests a maturational delay or deficit in cortical development associated with an extreme form of neglect ( Marshall et al., 2004 ). The profiles are similar to patterns found among children with ADHD ( Barry et al., 2003 ; Harmony et al., 1990 ).

At follow-up, as a group, children assigned to foster care did not differ from the care-as-usual group ( Marshall et al., 2008 ). However, the subset of children placed in foster care before 2 years of age showed EEG activity that more closely resembled that of the never-institutionalized group than the care-as-usual group. Overall, then, “institutionalization led to dramatic reductions in brain activity (as reflected in the EEG), whereas placement in foster care before 2 years of age led to a more normal pattern of EEG activity” ( Nelson et al., 2011 , p. 139). This last finding was replicated when the children were 8 years old ( Vanderwert et al., 2010 ). Specifically, previously institutionalized children placed in foster care before about 2 years of age had patterns of brain activity that resembled those of never-institutionalized children, whereas children placed in foster care after 2 years of age had patterns of brain activity that resembled those of children randomly assigned to institutional care.

Event-Related Potentials

ERPs measure changes in the brain's electrical activity in response to an internal or external stimulus or event. The components of the ERP (i.e., positive and negative deflections) can be quantified in terms of latency, amplitude, and location/distribution on the scalp. The P300 (i.e., positive deflection occurring approximately 300 ms after a stimulus) is associated with attention to emotionally evocative visual stimuli, such as emotional faces ( Eimer and Holmes, 2007 ; Olofsson et al., 2008 ). Whereas nonabused children show similar P300 activity across emotional expressions, abused children show larger P300s to angry target faces ( Pollak et al., 1997 , 2001 ), a finding consistent with behavioral evidence of enhanced attention to angry faces among abused children.

Finding: Across human and nonhuman primate studies, perturbations to the HPA system often are seen to be associated with child abuse and neglect. The findings are complex, moderated by a number of factors and seen at some ages and not others. Further, the perturbations sometimes are reflected in atypically high production of cortisol across either basal or reactive contexts and sometimes in atypically low production. Recent work in epigenetics suggests that this may well be an area of future inquiry into the mechanisms whereby abuse or neglect alters gene expression and, in turn, behavior. Finding: Abused and neglected children show behavioral and emotional difficulties that are consistent with effects on the amygdala, such as internalizing problems, heightened anxiety and emotional reactivity, and deficits in emotional processing. Most studies have found no evidence that the structure of the amygdala is affected by abuse or neglect; however, fMRI studies have shown that early adversity leads to a sensitized amygdala. Finding: Despite mixed evidence regarding structural changes in the prefrontal cortex, a number of studies suggest that abuse and neglect are associated with functional changes in the prefrontal cortex and associated brain regions, often affecting inhibitory control. Finding: Examination of patterns of brain electrical activity in institutionalized children suggests that extreme forms of neglect are associated with a maturational delay or deficit in cortical development.

• COGNITIVE, PSYCHOSOCIAL, AND BEHAVIORAL OUTCOMES

Cognitive Development

There is a long history of research exploring the effects of child abuse and neglect on cognitive development. Studies have examined executive functioning and attention, as well as academic achievement.

Executive Functioning and Attention

As discussed earlier, some studies have found that child abuse and neglect have effects on the prefrontal cortex, a brain structure centrally involved in executive functioning. Executive functioning refers to higher-order cognitive processes that aid in the monitoring and control of emotions and behavior ( Lewis-Morrarty et al., 2012 ). Included among executive functions are “holding information in working memory, inhibiting impulses, planning, sustaining attention amid distraction, and flexibly shifting attention to achieve goals” ( Lewis-Morrarty et al., 2012 , p. 2). Executive functioning abilities develop rapidly between the ages of 3 and 6 years, but continue to develop through at least the second decade of life.

Children who experience abuse and neglect appear to be especially at risk for deficits in executive functioning, which have implications for behavioral regulation. Extreme neglect, as seen in institutional care, has been related to executive functioning in a number of studies conducted by the Bucharest Early Intervention Project team ( McDermott et al., 2012 ). For example, McDermott and colleagues (2012) found that children who were randomly assigned to foster care showed better performance on an executive functioning task (i.e., a go/no-go task requiring inhibitory control) than children who were randomly assigned to treatment as usual. The assessments of executive functioning were conducted when children were 8 years old. Similar findings among comparably aged internationally adopted children (with histories of institutionalization) have been reported (e.g., Loman et al., 2013 ). These findings suggest that extreme forms of neglect may interfere with the development of executive functioning.

Problems in regulating attention represent one of the most striking deficits seen among children who have experienced severe early deprivation in institutional settings ( Gunnar et al., 2007 ; Kreppner et al., 2001 ). Gunnar and colleagues (2007) found that problems with inattention or overactivity were more pronounced among children who had experienced early institutional care than among those who had been adopted internationally without early institutional care. Kreppner and colleagues (2007) found that many children who had been adopted following institutional care showed problems with inattention or overactivity, but that such problems were usually seen in combination with reactive attachment disorder, quasi-autistic behaviors, or severe cognitive impairment.

Using NSCAW data, Heneghan and colleagues (2013) examined mental health problems in teens older than age 12 who were the subject of a child welfare agency investigation. They found that 18.6 percent of abused and neglected teens scored positively for ADHD, compared with 5 percent of children and 2.5 percent of adults in the general U.S. population ( APA, 2013c ). Likewise, Briscoe-Smith and Hinshaw (2006) studied a sample of 228 girls with and without ADHD and with and without a history of abuse and neglect, finding that the girls with ADHD had a statistically significant heightened risk of having a documented history of abuse or neglect, as indicated by substantiated child protective services, parental, or school report. Some studies have found preliminary differences in the characteristics of ADHD displayed by children with and without a history of abuse or neglect ( Webb, 2013 ). For example, Becker-Blease and Freyd (2008) studied a small community sample of 8- to 11-year-old children in which ADHD and abuse history were assessed by parent report. They found that children with a history of abuse displayed more severe impulsivity and inattention than nonabused children with ADHD, but the groups did not differ on measures of hyperactivity ( Becker-Blease and Freyd, 2008 ).

A number of studies have found evidence that children who experience abuse and neglect show deficits in executive functioning and attention ( Arseneault et al., 2011 ; De Bellis et al., 2009 ; Fisher et al., 2011 ; Lewis et al., 2007 ; Spann et al., 2012 ). Pears and colleagues (2008) found that abuse and neglect were associated with generally lower cognitive functioning among preschoolers. Lewis and colleagues (2007) found that 4-year-old children who had experienced abuse or neglect and were in foster care showed poorer inhibitory control on a Stroop-like task relative to comparison children, despite similar levels of performance on a control task. Spann and colleagues (2012) found that physical abuse and neglect were associated with diminished cognitive flexibility on the Wisconsin Card Sorting Task among adolescents.

Academic Achievement

Abuse and neglect increase children's risk for experiencing academic problems. Several studies suggest that abuse versus neglect matters, with neglect being especially predictive of academic underachievement ( Briere et al., 1996 ; Jonson-Reid et al., 2004 ; Nikulina et al., 2011 ). Other studies failed to find differences between abuse and neglect, with both predicting achievement problems (e.g., Barnett et al., 1996 ; Crozier and Barth, 2005 ; Eckenrode et al., 1993 ; Jaffee and Gallop, 2007 ; Kurtz et al., 1993 ; Leiter and Johnsen, 1997 ). On balance, the evidence suggests that both abuse and neglect are predictive of academic problems. Perez and Widom (1994) found that child abuse and neglect had a significant impact on reading ability, IQ scores, and academic achievement. For example, 42 percent of abused and neglected children completed high school, compared with two-thirds of the matched comparison group without histories of abuse and neglect. The average IQ score for the abused and neglected children was about one standard deviation below the average for the control group; this association was significant after controlling for age, race, gender, and social class ( Perez and Widom, 1994 ). Using NSCAW data, Jaffee and Maikovich-Fong (2011) found that chronically abused or neglected children had lower IQ scores than situationally abused or neglected children. The effect of chronic abuse or neglect on IQ scores remained significant after controlling for the effects of caregiver educational level on IQ. Leiter and Johnsen (1997) found that effects of abuse and neglect on school performance were cumulative, with more episodes of abuse and neglect being associated with poorer outcomes. Abuse and neglect predicted entry into special education after controlling for early medical conditions ( Jonson-Reid et al., 2004 ). Jonson-Reid and colleagues (2004) found that 24 percent of the abused and neglected children entered special education, compared with 14 percent of those with no record of abuse or neglect. Further, every additional report of abuse or neglect before the age of 8 led to an increase of 7 percent in entry into special education. Thompson and colleagues (2012) found that expectations of future academic success were adversely affected by previous experiences of abuse and neglect, with these expectations having powerful self-fulfilling possibilities ( Ross and Hill, 2002 ).

Psychosocial and Behavioral Outcomes

Given that child abuse and neglect are social experiences that undermine the ability to trust in caregivers, either because caregivers are frightening (as in cases of abuse) or because they fail to protect or provide care (as in cases of neglect), it makes sense that children who experience abuse and neglect are at risk for interpersonal problems. At the most proximal level, problems are seen in children's ability to form trusting attachments to their parents. But not surprisingly, the effects also are seen in such areas as children's processing of emotion (e.g., overly vigilant of angry faces), their attributions of others' intent (e.g., assuming that intentions are malevolent when they are ambiguous), and difficulties with peers (e.g., being the victim or perpetrator of bullying or violence). Problems also are seen in internalizing symptoms, such as anxiety and depression, and externalizing symptoms, such as conduct disorder and substance use.

Children develop secure attachments to parents who are responsive to them when they are distressed ( Ainsworth, 1978 ). Children typically develop insecure (avoidant or resistant) attachments when parents are unresponsive or inconsistent in responsiveness, but not frightening or bizarre (e.g., Lyons-Ruth et al., 1993 ; Schuengel et al., 1998 ). Secure, avoidant, and resistant attachments are referred to as organized attachment strategies because they are organized around the caregiver's availability and provide a child a template for dealing with distress. On the other hand, disorganized attachment represents a breakdown in or a lack of strategy for dealing with distress when in the parent's presence ( Main and Solomon, 1990 ). Disorganized attachments are the most problematic in terms of outcomes for children. Relative to organized attachment, disorganized attachment is most predictive of long-term problems, especially externalizing symptoms ( Fearon et al., 2010 ). Fearon and colleagues (2010) found strong evidence for a link between disorganized attachment and later externalizing symptoms through a meta-analysis of 34 studies involving 3,778 participants.

Child abuse and neglect are predictive of disorganized attachment, as well as insecure attachment more generally. A meta-analysis conducted by Cyr and colleagues (2010) included the 10 studies that have examined attachment quality with samples of children who have experienced abuse and neglect. The effect size was large for both disorganized and insecure attachment. Although abuse was more strongly related to disorganized attachment and neglect to insecure attachment, both abuse and neglect were associated with both types of attachment. These results are consistent with theory and with other empirical findings suggesting that when parents are either frightening or unavailable, children fail to develop a secure attachment to them. Nonetheless, the effects of having more than five socioeconomic risk factors were comparable to those of child abuse and neglect, indicating that multiple challenges to parental functioning had significant effects on attachment regardless of whether these effects were seen in child abuse and neglect.

In early childhood, abused or neglected children may develop attachment disorders resulting from and following pathogenic care that inhibits a young child's ability to form selective attachments ( Hornor, 2008 ). Childhood attachment disorders are phenomena distinct from insecure, disorganized, or nonexistent attachment types; they have been redefined in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-V) to include two distinct disorders: reactive attachment disorder and disinhibited social engagement disorder ( APA, 2013a , b ). Reactive attachment disorder involves inhibited or emotionally withdrawn behavior, including rarely seeking and responding to comforting; it results from a lack of or incompletely formed selective attachments to adult caregivers ( APA, 2013a ). Disinhibited social engagement disorder is marked by a pattern of overly familiar behavior with strangers; it may occur even in children with established or secure attachments. Previously, each attachment disorder was considered the inhibited or disinhibited type of reactive attachment disorder, respectively.

Zeanah and colleagues (2004) studied the prevalence of attachment disorders among 94 toddlers in foster care whose abuse or neglect cases had been substantiated and who were enrolled in an intervention program; they found that the prevalence of attachment disorders reached 38-40 percent. Lyons-Ruth and colleagues (2009) examined socially indiscriminate attachment behavior in a sample of mother-child dyads that included pairs referred to a clinical service because of problematic caregiving and comparison pairs matched on socioeconomic status. They found that 18-month-olds displayed socially indiscriminate attachment behavior only if they had a history of abuse or neglect, or their mother had a history of psychiatric hospitalizations. Both disorders also have been identified in children exposed to neglectful institutional care in Romania who were later adopted into middle-class families in the United Kingdom ( Smyke et al., 2002 ; Zeanah et al., 2002 ), although the disinhibited type of reactive attachment disorder (as defined in DSM-IV) has been found to be much more prevalent than the inhibited type ( O'Connor et al., 2003 ). Furthermore, findings from the Bucharest Early Intervention Project study indicate that the inhibited type of reactive attachment disorder declined significantly once institutionalized children were placed in foster care, but the disinhibited type proved more persistent ( Smyke et al., 2002 ; Zeanah and Gleason, 2010 ).

Emotion Regulation

Infants have limited capacities to regulate their own emotions and are dependent on caregivers to help them deal effectively with distress ( Tronick, 1989 ). Indeed, infants and young children are highly attuned and responsive to their parents' emotions and use parental emotional signals to guide their behavior ( Klinnert et al., 1983 ; Malatesta and Izard, 1984 ). The scaffolding important for the development of emotion regulation is challenged in abusing or neglecting families. When children feel upset or distressed, parents' availability and soothing presence can help them feel that they can cope with the strong negative affect, such that they are able to develop autonomous and effective means of regulating emotions over time. When children regulate their emotions well, they react to challenge with flexible and socially acceptable responses ( Cole et al., 1994 ; Kim and Cicchetti, 2010 ). Abused and neglected children, however, may not have such scaffolding experiences. It is likely that abused and neglected children experience not only a lack of modeling and support and an absence of positive affect but also harsh, inconsistent, and insensitive parenting ( Shipman and Zeman, 2001 ). In the case of abuse, parents often respond in threatening or unpredictable ways to children's distress ( Milner, 2000 ). In the case of neglect, parents may be unresponsive or nonempathic. As a result of either response, children are at risk of failing to develop effective strategies for regulating emotions ( Cicchetti et al., 1995 ; Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ).

An initial, key task in regulating emotions is processing of cues. Studies have examined differences among children who have experienced abuse and neglect in how readily they identify angry, sad, and happy faces ( Pollak and Sinha, 2002 ; Pollak and Tolley-Schell, 2003 ; Pollak et al., 2000 ; Shackman et al., 2007 ). Pollak and Sinha (2002) found that the threshold for detecting anger in the face was lower among abused than nonabused children; there were no differences in processing happy faces. Thus, these children appear to have a bias toward angry faces rather than a general deficit in processing faces. Pollak and Sinha (2002) point out that it is useful to identify emotions in others based on less than full information. Abused children's bias toward attributing angry or sad affect may be adaptive when living with parents whose anger may be an important threat cue ( Belsky et al., 2012 ); nonetheless, it comes at the cost of assuming hostile intent too readily under benign conditions, leading to aggressive responses that would not have been evoked had attributions been different ( Dodge et al., 1995 ). Neglected children, on the other hand, generally are not as good as nonneglected children at identifying facial expressions, showing a general deficit ( Pollak et al., 2000 ).

Emotion regulation can be seen as key to a number of the constructs considered in this chapter. Problems in regulating emotion are associated with externalizing behaviors, such as aggression and behavior problems ( Eisenberg et al., 2001 ; Kim and Cicchetti, 2010 ); internalizing behaviors, such as depression ( Cole et al., 2008 ; Maughan and Cicchetti, 2002 ); and challenges in peer relations ( Kim and Cicchetti, 2010 ; Rogosch et al., 1995 ). Emotion regulation can be seen, then, to have effects both on children's own affect and on their behavioral reactions, which then have implications for their relationships with others.

Peer Relations

Children's relationships with their peers are critical to their sense of well-being. Abused and neglected children have problematic peer relations at disproportionately high rates ( Kim and Cicchetti, 2010 ), as do children with a history of institutional care ( Almas et al., 2012 ). Chronicity of child abuse and neglect predict peer relations, as reported by teachers, at age 8 ( Graham et al., 2010 ). Problematic emotion regulation ( Shields and Cicchetti, 2001 ) and higher levels of aggression and withdrawal ( Rogosch et al., 1995 ) found in abused and neglected children can become apparent to peers when frustrations and challenges arise in school and playground environments.

Externalizing Problems

Externalizing behavior refers to problem behaviors that are manifested externally (rather than internally, as in the case of depression and anxiety). Findings from several studies indicate that children who have experienced abuse and neglect are at greater risk for a number of externalizing behaviors, including conduct disorders, aggression, and delinquency ( Lansford et al., 2002 , 2009 ; Lynch and Cicchetti, 1998 ; Stouthamer-Loeber et al., 2001 ; Thornberry et al., 2010 ).

Oppositional defiant disorder and conduct disorder Studies have reported significant associations between a history of childhood abuse or neglect and various conduct problems, including those classified as oppositional defiant disorder or conduct disorder. Oppositional defiant disorder is indicated by a frequent or persistent pattern of angry or irritable mood, argumentative or defiant behavior, and vindictiveness ( APA, 2013a ). Its symptoms usually first appear during early childhood, and it often precedes conduct disorder, anxiety disorders, or major depressive disorder. Conduct disorder is indicated by a repetitive or persistent pattern of behavior that violates the basic rights of others or major societal norms or rules, including aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules ( APA, 2013a ). Conduct disorder can begin in childhood or adolescence; however, childhood-onset conduct disorder is more often preceded by oppositional defiant disorder, more persistent into adulthood, and more likely to include aggressive behavior than adolescence-onset conduct disorder. Both disorders also frequently co-occur with ADHD.

In a study using a community sample, Dodge and colleagues (1995) found that children who were physically abused before age 5 were 4 times more likely than nonabused children to display externalizing conduct problems in grade 3 and 4. Likewise, Kaplan and colleagues (1998) found that adolescents (aged 12-18) with substantiated cases of physical abuse were more likely to display conduct disorder or oppositional defiant disorder at the time of the study (odds ratio = 5.98) than the matched nonabused comparison group. Fergusson and colleagues (2008) found that childhood sexual abuse was associated with higher rates of conduct disorder in young adulthood. Furthermore, they found that childhood physical abuse was not associated with conduct disorder when sexual abuse was included in the model. Additional environmental and individual factors that interact with abuse or neglect to increase the likelihood of conduct disorder or oppositional defiant disorder include exposure to parental divorce ( Afifi et al., 2009 ), interparental violence ( Boden et al., 2010 ), and community violence ( McCabe et al., 2005 ), as well as gender, with males more likely to display conduct disorder ( Boden et al., 2010 ).

Aggression Manly and colleagues (2001) found that children who had experienced severe emotional abuse only as infants or severe physical abuse only as toddlers were more aggressive and showed more externalizing symptoms as school-aged children than children without a history of abuse or neglect. The severity of abuse experienced predicted aggressiveness and externalizing symptoms in middle childhood. Although abuse experienced only in early childhood had lasting effects, abuse experienced beyond early childhood also had effects on aggression and externalizing symptoms, and the most problematic effects were seen for children subjected to chronic, severe abuse ( Manly et al., 2001 ). Rogosch and colleagues (1995) found that physically abused children showed both aggressive behaviors and social withdrawal during peer interactions. Along these lines, abused and neglected children were disproportionately likely to be both bullies and victims of aggression, effects that were mediated by emotion dysregulation ( Shields and Cicchetti, 2001 ). At odds with these findings, Kotch and colleagues (2008) found that children who experienced neglect in their first 2 years of life showed more aggression toward peers at ages 4, 6, and 8 relative to children without a history of abuse or neglect. Indeed, in that study, other subgroups (children who were abused or who were neglected at older ages) did not show an increased likelihood of aggression.

Hostile attributional bias refers to the tendency to assume that someone intended harm when circumstances were ambiguous but a negative outcome was experienced. For example, if a peer spilled milk on a child, the child could assume that the action was benign (unintentional) or intentional, with the latter representing a hostile attributional bias. When children assume that such an action was intentional, they are likely to act aggressively in response ( Dodge et al., 1995 ). Physically abused children are more likely than other children to show such attributional biases ( Dodge et al., 1995 ). Price and Glad (2003) found that these effects were seen in boys only and were associated with frequency of abuse. Such biases can lead to a self-fulfilling prophecy whereby children anticipate that someone intends them harm and react in a hostile way, which then elicits a hostile response ( Dodge et al., 1995 ).

Internalizing Problems

Internalizing problems—problems that are manifested internally—include symptoms of depression and anxiety. Child abuse and neglect have been found to put children at increased risk of internalizing symptoms from early childhood through adolescence and adulthood ( Dubowitz et al., 2002 ; Thornberry et al., 2001 ; Widom et al., 2007a ).

Dubowitz and colleagues (2002) found that neglect was associated with internalizing problems for 3- and 5-year-old children. Swanston and colleagues (1997) found that sexually abused children had a significantly higher average score on depression measures than a control group just 5 years after the abuse occurred, after adjusting for individual differences in age and sex, as well as contextual factors such as socioeconomic status, family functioning, mother's mental health, and number of negative life events. Trickett and colleagues (2001) found that a sample of sexually abused girls had significantly higher rates of self-reported depression than a comparison group of nonabused females. At follow-up, approximately 7 years later, rates of depression were found to be significantly higher among the sexually abused group, excluding a subset whose experience of abuse was characterized chiefly by multiple perpetrators and a relatively short duration.

The heightened risk of depression extends beyond childhood to adolescence and adulthood. Multiple studies have found clear links between child abuse and neglect and depression in adolescence (e.g., Fergusson et al., 2008 ; Heneghan et al., 2013 ; Lansford et al., 2002 ). Brown and colleagues (1999) found that child abuse and neglect were associated with a nearly threefold increase in the rate of depression in adolescence, although this risk was diminished after controlling for other adverse conditions. Gilbert and colleagues (2009b) cite a body of studies reporting adjusted odds ratios ranging from 1.3 to 2.4 for depression after childhood among those subjected to abuse and neglect as children. Among adults, Brown and colleagues (1999) found that the increased risk of depression associated with child abuse and neglect remained when other factors were covaried, consistent with findings that more than one-third of abused or neglected children show symptoms of major depressive disorder by their late 20s ( Gilbert et al., 2009b ). Likewise, Widom and colleagues (2007a) followed a group of individuals who had experienced abuse and/or neglect in childhood and a matched comparison group into young adulthood and found that experiencing childhood physical abuse and multiple types of abuse increased the lifetime risk for a diagnosis of major depressive disorder.

A growing body of research examines whether different types and combinations of abuse or neglect in childhood result in different levels of risk for the development of depressive symptoms. The results in this domain are mixed, with strong evidence that sexual and physical abuse in childhood are associated with depression later in life (e.g., Heneghan et al., 2013 ), but mixed evidence that neglect increases risk for depression independent of contextual factors. Many studies have found child sexual abuse to have large and independent effects on risk for depression later in life. For example, Fergusson and colleagues (2008) found that young adults who reported a history of childhood sexual abuse had mental health disorders, including depression, at a rate 2.4 times higher than that among those not exposed to such abuse. By contrast, Widom and colleagues (2007a) found that child sexual abuse was not associated with an elevated risk of major depressive disorder relative to matched controls, although physical abuse or multiple kinds of abuse did increase the risk for lifetime major depressive disorder. Additional studies have found that physical abuse increased the risk for adult depression (e.g., Brown et al., 1999 ). Some studies have found that neglect did not increase the risk for depression when statistical models included contextual factors ( Nikulina et al., 2011 ), although Widom and colleagues (2007a) found that neglect increased risk for current major depressive disorder relative to matched controls in adulthood.

As discussed in the section on individual differences later in this chapter, researchers also have examined how the timing ( Dunn et al., 2013 ; Thornberry et al., 2001 ) and severity ( Fergusson et al., 2008 ) of abuse and neglect affect the risk of developing depression. Other factors throughout the life course, such as the presence or absence of social support ( Sperry and Widom, 2013 ) and exposure to multiple traumas ( Banyard et al., 2001 ) or stressful life events in adulthood ( Power et al., 2013 ), have been found to interact with childhood experiences of abuse and neglect to influence the risk of developing depression later in life.

Dissociation

Dissociation is defined as a “disruption of and/or discontinuity in the normal, subjective integration of one or more aspects of psychological functioning, including—but not limited to—memory, identity, consciousness, perception, and motor control” ( Spiegel et al., 2011 , p. 19). Dissociation can be measured reliably and validly in children, adolescents, and adults ( Briere et al., 2001 ; Keck Seeley et al., 2004 ; Lanktree et al., 2008 ; van Ijzendoorn and Schuengel, 1996 ; Wherry et al., 2009 ).

Child abuse and neglect have been associated with dissociation among both preschool-aged and elementary-aged children ( Hulette et al., 2008 , 2011 ; Macfie et al., 2001 ), as well as among adults ( van Ikzendoorn and Schuengel, 1996 ). The existence of a subgroup of PTSD patients with high levels of dissociation has been demonstrated in clinical ( Lanius et al., 2013 ; Putnam, 1997 ), psychophysiological ( Griffin et al., 1997 ), neuroimaging ( Lanius et al., 2013 ), and epidemiological ( Stein et al., 2013 ) research. As a result, DSM-V is adding a dissociative subtype to the PTSD diagnosis ( Spiegel et al., 2011 a) (see the discussion of PTSD on p. 139).

High scores on dissociation measures have proven to be a predictor of externalizing behavior in children ( Kisiel and Lyons, 2001 ; Shapiro et al., 2012 ; Yates et al., 2008 ). In adults, high levels of dissociation are associated with refractoriness to standard treatments for a number of psychiatric conditions, as well as increased comorbidity ( Jans et al., 2008 ; Kleindienst et al., 2011 ; Wolf et al., 2012 ; Zanarini et al., 2011 ).

A meta-analysis of 55 studies ( Cyr et al., 2010 ) links abuse with disorganized attachment. Grienenberger and colleagues (2005) found that mothers who engaged in disrupted affective communication with their infants at 4 months (as measured using the AMBIANCE scale) were more likely to have toddlers who were classified as disorganized at 14 months. In turn, disorganized attachment at 14 months predicted high dissociation scores at age 20 years ( Lyons-Ruth, 2008 ). Disorganized attachment assessed during the child's second year predicted elevated levels of self-reported dissociation in mid-adolescence (age 16 years) ( Carlson, 1998 ) and early adulthood (age 19) ( Ogawa et al., 1997 ).

Based on findings from the Minnesota Mother-Child Project, Egeland and Susman-Stillman (1996) propose that dissociation may act as a mediator of child abuse across generations. In a longitudinal study of sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, a tentative generational loop can be hypothesized in which harsh and abusive parenting increases the risk for higher levels of dissociation in childhood and adolescence, which in turn increases the risk for impulsive behavior and harsh parenting of offspring. Further research, especially with a longitudinal design, is warranted to determine whether this hypothesized generational pattern of transmission represents an early opportunity for prevention of abuse in the next generation.

Posttraumatic Stress Disorder

In DSM-V, PTSD is classified as a trauma- and stressor-related disorder, a change from its previous classification as an anxiety disorder. PTSD develops following “exposure to actual or threatened death, serious injury, or sexual violation,” including directly experiencing the traumatic event, witnessing the event firsthand, learning that an actual or threatened violent or accidental death occurred to a family member or close friend, and experiencing repeated or extreme firsthand exposure to the details of the traumatic event ( APA, 2013c ). Behavioral symptoms of PTSD are divided into four categories: intrusion or reexperiencing, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity ( National Center for PTSD, 2013 ). Experiences of child abuse and neglect involve traumatic events that are often violent, invasive, and coercive ( Kearney et al., 2010 ). Furthermore, secondary trauma may result from experiences of child abuse and neglect, including separation from family or homelessness, which may also trigger a PTSD response ( Wechsler-Zimring et al., 2012 ).

A number of prospective and retrospective studies have found elevated rates of PTSD among individuals with a history of abuse and neglect ( Chen et al., 2010 ; Kearney et al., 2010 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Numerous studies have found that PTSD was preceded by abuse and neglect; links with sexual abuse were especially strong ( Chen et al., 2010 ; Gregg and Parks, 1995 ; Kendall-Tackett et al., 1993 ; Tolin and Foa, 2006 ; Weich et al., 2009 ; Widom, 1999 ). Kearney and colleagues (2010) report PTSD rates of 20-50 percent among youth who had been sexually abused, 50 percent among youth who had been physically abused, and 33-50 percent among youth who had experienced neglect combined with exposure to domestic violence. Kolko (2010) found that nearly 20 percent of youth in out-of-home care showed posttraumatic symptoms. Widom (1999) found increased risk for PTSD among adults who had experienced abuse and neglect as children, with 23 percent of those who had been sexually abused, 19 percent of those who had been physically abused, and 17 percent of those who had been neglected meeting criteria for PTSD at age 29, compared with 10 percent of the comparison group.

Some evidence indicates that PTSD may mediate the association between childhood abuse and neglect and later adverse outcomes. Wolfe and colleagues (2004) found that boys who had been abused or neglected in childhood and displayed a greater number of PTSD symptoms were at higher risk of perpetrating emotional abuse in a dating relationship compared with abused or neglected boys who displayed fewer trauma symptoms. Weierich and Nock (2008) found that the specific PTSD symptoms of reexperiencing, avoidance, and numbing mediated the relationship between childhood experiences of abuse and neglect and nonsuicidal self-injury. In a study of adult women survivors of childhood sexual abuse, Ginzburg and colleagues (2006) found that severe childhood maltreatment, including sexual abuse as well as other types of abuse or neglect, was significantly associated with experiencing high levels of dissociation in conjunction with PTSD, while less severe childhood maltreatment was not significantly associated with the dissociative subtype. Avery and colleagues (2000) examined PTSD and key areas of functioning based on interviews with sexually abused children and their nonoffending parents. Compared with sexually abused girls with low scores on the Child Posttraumatic Stress Reaction Index, sexually abused girls with higher scores expressed more worries; reported increased problems with sleep, appetite, headaches, and stomachaches; reported increased depression and suicidal ideation; displayed more problems in school functioning; and had higher levels of family disruption.

Personality Disorders

Evidence links child abuse and neglect with personality disorders. Johnson and colleagues (1999) found that adults with a history of abuse and neglect (as indicated by records and/or self-report) had a fourfold increase in personality disorders relative to those without a history of abuse or neglect. Physical abuse was associated with elevated antisocial and depressive personality disorder symptoms; sexual abuse was associated with elevated borderline personality disorder symptoms; and neglect was associated with elevated symptoms of antisocial, avoidant, borderline, narcissistic, and passive-aggressive personality disorders, as well as with attachment difficulties and other interpersonal and psychological problems. Widom (1998) reports an increase in risk for antisocial personality disorder for both males and females with a history of abuse and neglect. In a subsequent study, Widom and colleagues (2009) report an increase in risk for borderline personality disorder in males only, suggesting that there may be sex differences in the consequences of abuse and neglect. Natsuaki and colleagues (2009) found that personality problems, although not diagnosed personality disorders, worsened as adolescence progressed.

Finding: Abuse and neglect have profound effects on selected aspects of children's cognitive development. Although many attempts have been made to disentangle the effects of abuse and neglect, the balance of findings suggests that severe neglect may interfere with the development of executive functioning, and both neglect and abuse increase the risk for attention regulation problems and ADHD, lower IQ, and poorer school performance. Finding: As a result of abusive or neglectful responses from caregivers, children have a difficult time developing organized and secure attachments. As a result, abused and neglected children are at higher risk for the development of attachment disorders, particularly disinhibited social engagement disorder. Finding: Abused and neglected children often fail to develop effective strategies for emotion regulation, partly as a result of differences in processing of emotional cues. Difficulties with emotion regulation can lead to further problems, including externalizing and internalizing problems and challenges in peer relations. Finding: Children who experience abuse or neglect have been found to be at higher risk for the development of externalizing behavior problems, including oppositional defiant disorder, conduct disorder, and aggressive behaviors. Abused and neglected children also have been found to be at increased risk for internalizing problems, particularly depression, in childhood, adolescence, and adulthood. Finding: Among preschool- and elementary school–aged children, as well as adults, a history of childhood abuse and neglect has been associated with dissociation, which increases the risk for externalizing behavior in childhood and resistance to treatment for psychiatric conditions later in life. It has been suggested that dissociation may act as a mediator of harsh or abusive parenting across generations, although this hypothesis requires further research. Finding: A number of studies have found elevated rates of PTSD among individuals with a history of abuse and neglect. PTSD has been associated with physical, cognitive, psychological, social, and behavioral problems among youth who were abused or neglected in childhood.

• HEALTH OUTCOMES

Child abuse and neglect have effects on a number of health outcomes, from growth to illness to obesity. Connections have been found between problematic neurobiological outcomes of child abuse and neglect and health. One plausible mechanism for these effects relates to the purported frequent or chronic activation of the HPA axis. As discussed previously, the HPA axis is designed for responding in crises.

Growth and Motor Development

In their most extreme forms, abuse and neglect are associated with stunted growth. Children living in institutional environments ( Johnson et al., 2010 ) or adopted from highly neglecting institutional environments ( Johnson and Gunnar, 2011 ) sometimes show very delayed growth in height and head circumference. Olivan (2003) found that children placed in foster care between ages 24 and 48 months were significantly below normal for height, weight, and head circumference. Similarly, Chernoff and colleagues (1994) found that most children entering foster care had an abnormal physical screen involving at least one body system, and on average weighed less and were shorter than comparison children.

Gross motor development often is delayed among children with a history of institutional care who have then been adopted internationally ( Dobrova-Krol et al., 2008 ; Roeber et al., 2012 ). Roeber and colleagues (2012) found that children adopted from institutional settings showed motor system delays, with greater balance delays being predicted by length of time institutionalized and bilateral coordination delays being predicted by severity of deprivation. Rapid gains are seen after placement in adoptive homes, however ( Pomerleau et al., 2005 ). Although somewhat canalized (less responsive to genetic or environmental variations), the development of these gross motor abilities is dependent upon opportunities to engage in motor activities. Note that these findings regarding motor delays may be limited in their application to extreme cases of neglect in which young children are left alone in their cribs or otherwise neglected for extended periods of time.

Child abuse and neglect have been linked to various forms of physical illness as well as various indicators of physical health problems. Adolescents with a history of childhood abuse or neglect report a lower rating of their own health compared with low-risk peers ( Bonomi et al., 2008 ; Hussey et al., 2006 ). Likewise, more gastrointestinal symptoms were reported by adults who reported having been abused or neglected as children ( Walker et al., 1999 ). To examine whether this association resulted from shared method variance, van Tilburg and colleagues (2010) used data collected from multiple informants among a sample of 845 children enrolled in the longitudinal, prospective Longitudinal Studies of Child Abuse and Neglect. Across informants, youth who had experienced abuse or neglect had an increased likelihood of gastrointestinal symptoms, which often followed or coincided with sexual abuse.

In a longitudinal prospective study, childhood abuse and neglect predicted health indices among middle-aged adults ( Widom et al., 2012 ). Both physical abuse and neglect predicted hemoglobin A1C (a biomarker for diabetes) and albumin (a biomarker for liver and kidney function); physical abuse uniquely predicted malnutrition and blood urea nitrogen (a marker for kidney function); neglect uniquely predicted poor peak airflow; and sexual abuse uniquely predicted hepatitis C ( Widom et al., 2012 ).

Findings from the Adverse Childhood Experiences study indicate a heightened risk for liver disease, lung cancer, and ischemic heart disease among adults who report multiple adverse experiences in childhood ( Brown et al., 2010 ; Dong et al., 2003 , 2004 ). The adverse experiences measured in the study include emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect, as well as indicators of household dysfunction, such as domestic violence, parental divorce or separation, household member mental illness, household member substance abuse, and household member incarceration. Dong and colleagues (2003) found that the adjusted odds ratio for ever having liver disease ranged from 1.4 to 1.6 for different types of abuse and neglect; among individuals with more than 6 adverse childhood experiences, the adjusted odds ratio was 2.6. Notably, the risk of liver disease was substantially mediated by risk behaviors for liver disease, such as alcohol and drug use and various sexual behaviors. Brown and colleagues (2010) found an association between adverse childhood experiences and an increased risk of lung cancer, which was partially mediated by smoking behavior. In particular, exposure to a large number of adverse childhood experiences was strongly associated with premature death from lung cancer; among individuals who died from lung cancer, those with 6 or more adverse childhood experiences died an average of 13 years earlier than those with no adverse childhood experiences. Likewise, Dong and colleagues (2004) found that adverse childhood experiences increased the likelihood of ischemic heart disease. The association was substantially mediated by both traditional (diabetes, hypertension, physical inactivity, smoking, and obesity) and psychological (anger and depressed affect) risk factors, but the psychological risk factors of anger (adjusted odds ratio of 2.1) and depression (adjusted odds ratio of 2.5) had stronger associations with heart disease than the traditional risk factors.

In various studies, different forms of child abuse and neglect have been linked with increased body mass index and higher rates of obesity in childhood, adolescence, and adulthood. Some studies link neglect but not abuse to obesity (e.g., Johnson et al., 2002 ; Lissau and Sorensen, 1994 ), and some link physical abuse but not neglect ( Bentley and Widom, 2009 ). These differences may be the result of differences in the time points at which obesity is assessed, in sample characteristics, or in the adequacy of controls, or other factors. Knutson and colleagues (2010) found that specific types of neglect (supervisory versus care) predicted obesity at different ages. Care neglect, defined as inattention to such things as provision of adequate food and clothing, predicted body mass index at younger ages, whereas supervisory neglect, defined as parental lack of availability, predicted body mass index at older ages.

Finding: Experiences of child abuse and neglect have effects on many health outcomes, including risks for long-term chronic and debilitating diseases and, in extreme cases, stunted growth.

• ADOLESCENT AND ADULT OUTCOMES

While a number of the consequences of child abuse and neglect discussed previously in this chapter can be present across childhood, adolescence, and adulthood, this section focuses on behavioral outcomes that manifest specifically in either adolescence or adulthood.

Delinquency and Violence

Maxfield and Widom (1996) found that abuse and neglect experienced in childhood predicted violence and arrests in early adulthood. Adults with a history of abuse and neglect were more likely than adults without such a history to have committed nontraffic offenses (49 percent versus 38 percent) and violent crimes (18 percent versus 14 percent). Victims of childhood physical abuse and neglect were more likely to be arrested for violence (odds ratios 1.9 and 1.6, respectively) after controlling for age, race, and sex. These authors also found that abused and neglected girls were at increased risk for being arrested for violence relative to girls who had not been abused and neglected, with an odds ratio of 1.9. Smith and colleagues (2005) also found that abuse and neglect increase the risk of violent offending in late adolescence and early adulthood. Jonson-Reid and colleagues (2012) found a powerful effect for the number of child abuse reports predicting violent delinquency, with the association being linear for up to three reports. Two of these prospective longitudinal studies also found that sexual abuse increased the risk for general offending, but not violent offending ( Smith et al., 2005 ). Physical abuse appears to be strongly related to violence in girls, as demonstrated in a meta-analysis ( Hubbard and Pratt, 2002 ).

There is evidence that childhood abuse increases the risk for crime and delinquency. A number of large prospective investigations in different parts of the United States have documented a relationship between childhood abuse and neglect and juvenile and/or young adult crime ( English et al., 2002 ; Lansford et al., 2007 ; Maxfield and Widom, 1996 ; Smith and Thornberry, 1995 ; Stouthamer-Loeber et al., 2001 ; Widom, 1989 ; Widom and Maxfield, 2001 ; Zingraff et al., 1993 ). Despite differences in geographic region, time period, youths' age and sex, definition of child maltreatment, and assessment technique, these prospective investigations provide evidence that childhood maltreatment increases later risk for delinquency and violence. Replication of this relationship across a number of well-designed studies supports the generalizability of and increases confidence in the results.

Alcohol and Substance Use

As adolescents and adults, those with a history of abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect ( Gilbert et al., 2009b ; Jonson-Reid et al., 2012 ). The effects tend to be stronger for women, being seen even when other factors are covaried ( Simpson and Miller, 2002 ; Widom et al., 1995 ). For example, Widom and colleagues (1995) found no association between a history of abuse and neglect and alcohol use by young men, but found an association for women even after controlling for parental substance use and other correlated variables. A similar pattern of results emerged in a follow-up with these participants about 10 years later, when they were approximately 40 years old. Women with a documented history of child abuse and/or neglect were more likely to drink excessively in middle adulthood than those without such a history ( Widom et al., 2007b ); again, this difference was not seen in men. Girls with a history of physical abuse tend to start using substances (including alcohol, marijuana, tobacco, etc.) at younger ages than youth without such a history ( Lansford et al., 2010 ). Work by Lansford and colleagues (2010) suggests that this early initiation serves as the mechanism for later substance use in adulthood.

Evidence linking abuse and neglect to substance abuse in adulthood is mixed ( Gilbert et al., 2009b ; Widom et al., 1999 ), with retrospective and prospective findings differing. For example, Widom and colleagues (1999) describe findings based on defining child abuse and neglect prospectively and retrospectively using self-reports (i.e., following their sample forward and asking adults whether they had been abused or neglected as children). The findings based on these two types of data differed dramatically. The prospective data showed no increase in risk of substance abuse at age 29, whereas the retrospective data showed significant differences. Interestingly, a later follow-up with this sample ( Widom et al., 2006 ) found that in middle adulthood, abused and neglected individuals compared with controls were about 1.5 times more likely to report using any illicit drug (in particular, marijuana) during the past year, and reported use of a greater number of illicit drugs and more substance use–related problems. Findings such as these provide support for the importance of longitudinal studies because without the subsequent follow-up, there would have appeared to be no increase in risk for adults who had experienced childhood abuse or neglect; these findings also illustrate the importance of contextual factors in understanding consequences.

Suicide Attempts

Experiences of abuse and neglect in childhood have a large effect on suicide attempts in adolescence and adulthood ( Brown et al., 1999 ; Fergusson et al., 2008 ; Gilbert et al., 2009b ; Widom, 1998 ). Among adults in their late 20s, Widom (1998) found that 19 percent of those with a history of abuse or neglect had made at least one suicide attempt, as compared with 8 percent of a matched community sample. Fergusson and colleagues (2008) found high rates of suicide among a New Zealand sample as well. These effects are seen for physical and sexual abuse even after accounting for other associated risk factors ( Fergusson et al., 2008 ). Trickett and colleagues (2011) found, through a prospective design, more incidents of self-harm and suicidal behaviors among women who had been sexually abused than among a control group of women who had not been sexually abused.

Sexual Behavior

Studies have investigated the association between child abuse and neglect and several aspects of sexual behavior, including early sexual initiation and sexual risk behavior, teen pregnancy, and prostitution and the risk for commercial sexual exploitation of children and adults.

Early Sexual Initiation and Sexual Risk Behavior

Children who experience abuse and neglect may initiate sexual activity at earlier ages than other children ( Lodico and DiClemente, 1994 ; Noll et al., 2003 ; Springs and Friedrich, 1992 ; Wilson and Widom, 2008 ). In addition, there is limited evidence of an association between child abuse and neglect and increased risky sexual behaviors ( Jones et al., 2010 ; Senn et al., 2008 ). This association has been studied most frequently for sexual abuse; however, Jones and colleagues (2010) found that physical and emotional abuse, but not neglect, contributed to risky behaviors over and above the effects of sexual abuse. Trickett and colleagues (2011) undertook one of the most extensive longitudinal studies of developmental outcomes for female victims of sexual abuse. The majority had experienced severe sexual abuse, defined by the type of abuse (with vaginal and anal penetrative abuse seen as most severe), the length of time over which the abuse occurred, and the relationship of the abuser to the victim. In addition to earlier initiation of sexual activity among women who had been sexually abused in childhood, the authors found less use of birth control ( Noll et al., 2003 ). For both abused and nonabused women, having a large number of male peers in childhood networks was associated with a lack of birth control use in adolescence ( Trickett et al., 2011 ). For abused females, however, having high-quality relationships with male peers and nonpeers in childhood was associated with greater birth control use in adolescence; in the comparison group, this association was not found.

Teen Pregnancy

Evidence linking childhood sexual abuse and increased risk for teen pregnancy has been mixed. Trickett and colleagues (2011) found that severely sexually abused females reported significantly higher rates of teen pregnancy and teen motherhood than nonabused females (abused = 39 percent, nonabused = 15 percent). In a meta-analysis of previously published studies of sequelae of child sexual abuse, Noll and colleagues (2009) found an increased risk for early pregnancy among girls who had been sexually abused. In contrast, using a prospective cohort design that followed children with documented cases of abuse and neglect into young adulthood, Widom and Kuhns (1996) found no evidence that childhood sexual abuse was a significant risk factor for multiple early sexual partners or teenage pregnancy.

Prostitution and Risk for Commercial Sexual Exploitation of Children and Adults

In a prospective study, Widom and Kuhns (1996) found that sexual abuse and neglect, but not physical abuse, were associated with later prostitution. In a subsequent study, Wilson and Widom (2010) examined the role of problem behaviors as a pathway to adult prostitution and found that adult victims who had experienced child abuse and neglect were more likely than nonvictims to report having been involved in prostitution as adults or prostituted as juveniles ( Wilson and Widom, 2008 ). Stoltz and colleagues (2007) found a significant relationship between child abuse and neglect (sexual, physical, and emotional) and later involvement in prostitution among a sample of 361 drug-using, street-involved youth in Canada.

While an important topic, evidence that child abuse and neglect increase the risk for commercial sexual exploitation of children is very limited and comes primarily from retrospective studies of sexually exploited youth. Some older studies have reported that experiences of childhood sexual abuse influenced the decision of young women to become involved in commercial sex work ( Bagley and Young, 1987 ; Silbert and Pines, 1983 ). A comprehensive look at those issues will be presented in a forthcoming Institute of Medicine report from the Committee on Commercial Sexual Exploitation and Sex Trafficking of Minors in the United States.

Finding: Experiences of abuse and neglect in childhood have a large effect on delinquency, violence, and suicide attempts in adolescence and adulthood. Finding: Adolescents and adults with a history of child abuse and neglect have higher rates of alcohol abuse and alcoholism than those without a history of abuse and neglect, although this relationship has been found most frequently in women. Finding: Children who experience abuse and neglect may initiate sexual activity at earlier ages than comparison groups. Childhood sexual abuse also has been found to be associated with heightened risks for a range of adverse outcomes related to sexual risk-taking behaviors. Finding: Studies seeking an association between child abuse and neglect and teen pregnancy or adult prostitution have reported mixed results.

• INDIVIDUAL DIFFERENCES IN OUTCOMES

This chapter has presented extensive evidence that children who are abused or neglected, as a group, are at increased risk for a variety of problematic outcomes. However, not all children who experience abuse or neglect experience these negative consequences. Not surprisingly (given what is known about typical development), children vary in the outcomes they experience even when exposed to the same type of abuse or neglect, with outcomes ranging from the most problematic to functioning well across domains. As discussed earlier in this chapter, an ecological-transactional model is helpful for understanding outcomes related to abuse and neglect as influenced by the interplay of risk and protective factors that occur at multiple levels of a child's ecology. Through examination of compensatory resources in children and their environment, an ecological-transactional framework can aid in understanding children who exhibit resilient outcomes despite having been abused or neglected ( Cicchetti and Toth, 2009 ; Luthar et al., 2000 ). Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. However, neither a child's individual strengths nor the surrounding environment alone can predict resilient outcomes. As noted by Jaffee and colleagues (2007 , p. 233), “the fit between the child and the environment is the best predictor of children's psychological well-being.” The following sections describe research examining explanatory factors for differences in outcomes related to child abuse and neglect.

Characteristics of Abuse or Neglect Experiences

Characteristics of a child's exposure to abuse or neglect have been shown to influence the risk for problematic outcomes. Such characteristics include the point within the course of a child's development at which an experience of abuse or neglect occurs; the chronicity of abuse or neglect experiences, taking into account their duration and frequency; the severity of the experiences; and the type of abuse or neglect ( Bulik et al., 2001 ; Collishaw et al., 2007 ; Keiley et al., 2001 ; Manly et al., 2001 ).

Among a sample of adult female twins, Bulik and colleagues (2001) found an association between characteristics of the abuse experience (e.g., a high level of severity of child sexual abuse, such as attempted or completed intercourse and the use of force or threats) and certain psychiatric disorders. In examining the effect of timing on outcomes related to child physical abuse, Keiley and colleagues (2001) found that children who experienced such abuse while under the age of 5 were at higher risk for negative outcomes than those who experienced the same type of abuse at age 5 or older. Jonson-Reid and colleagues (2012) found that nearly all children who experienced chronic, persisting abusing or neglect showed adverse outcomes in adulthood: 91.9 percent of children showed at least one negative outcome if they had 12 or more reports of abuse or neglect ( Jonson-Reid et al., 2012 ).

The concept of resilience serves as a useful lens for evaluating the differing outcomes of children exposed to abuse and neglect. By examining factors that contribute to whether children experience maladaptive outcomes in response to abuse or neglect, researchers can gain a better understanding of how better to prevent and treat these consequences. While resilience has been defined in various ways, it can be understood as “a good outcome in spite of high risk, sustained competence under stress, and recovery from trauma” ( McGloin and Widom, 2001 , p. 1022).

The study of resilience in the context of child abuse and neglect must take into account several factors. First, as shown throughout this chapter, consequences of child abuse and neglect can manifest in multiple domains of functioning. Therefore, a child's subsequent adaptation or maladaptation following abuse or neglect must be assessed in terms of multiple outcomes rather than a single indicator, such as depression ( Afifi and Macmillan, 2011 ; McGloin and Widom, 2001 ). Second, resilience is not a static construct, meaning that a child can exhibit resilient outcomes at a certain point in the course of development but may still experience problematic outcomes at a later time. It follows that analysis of resilience in abused and neglected children should include a temporal component ( McGloin and Widom, 2001 ). Third, many factors believed to promote resilience in response to child abuse and neglect can also serve to promote positive adaptation more generally in response to other childhood stressors, making it imperative for studies to include a comparison group that has not been abused or neglected ( Collishaw et al., 2007 ). Finally, resilience might usefully be considered from the perspective of allostatic load ( Danese and McEwen, 2012 ). That is, some children who experience abuse or neglect do not show problematic outcomes, but as abuse, neglect, and other adverse childhood experiences accumulate, they challenge children's ability to cope with the negotiation of life tasks.

Results from a study of adults who were the subjects of substantiated cases of child abuse or neglect as children indicate that 22 percent of abused and neglected individuals met the criteria for resilience, which required successful functioning in 6 of 8 domains ( McGloin and Widom, 2001 ). A study by Collishaw and colleagues (2007) examined resilience to adult psychopathology within a representative community sample, finding that 44 percent of adults who reported abuse during childhood reported no psychiatric problems in adulthood and demonstrated positive adaptation in other domains.

Protective factors supporting resilience have been examined at the levels of the individual, family, and social environment, with resilience being measured in childhood, adolescence, and early adulthood. In a review of protective factors for resilience following child abuse and neglect, Afifi and Macmillan (2011) identify three protective factors that are best supported by findings from longitudinal and cross-sectional studies: a stable family environment, supportive familial relationships, and personality traits that support social skills.

Individual-level protective factors identified among those displaying resilience following child abuse and neglect include personality traits (e.g., high ego control, high self-esteem, internal locus of control, external attributions of blame, and attribution of success to own efforts); gender (females more resilient than males); and relationship capabilities ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee and Gallop, 2007 ; Jaffee et al., 2007 ). There is some evidence that intelligence or cognitive ability functions as a protective factor ( Masten and Tellegen, 2012 ), but it has not always been found to be significant in supporting resilience ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ). Jaffee and colleagues (2007) found that children with protective individual-level characteristics were likely to be resilient in low-stress environments (59 percent), but children with the same protective individual-level characteristics were less likely to be resilient in highly challenging environments.

Family-level protective factors include a caring and safe home environment; positive changes in family structure (e.g., intervention, cessation of visiting rights, or removal to foster care); and supportive familial relationships at the time of abuse ( Afifi and Macmillan, 2011 ; Collishaw et al., 2007 ; Jaffee et al., 2007 ). In a sample of sexually abused girls in foster care, family support was not found to be a protective factor, but peer influences, school plan certainty, and positive future orientation were ( Edmond et al., 2006 ). Other social-level protective factors include supportive relationships with non-family members, such as teachers or camp counselors, and supportive relationships with peers in adolescence ( Flores et al., 2005 ; Jaffee et al., 2007 ).

Gene x Environment Interactions

Historically, those working in the field of child abuse and neglect were unable to examine whether such adverse experiences interacted with biological risk or protective factors (e.g., so-called risk or protective genes)—specifically, whether experience interacted with underlying genetics. This situation has changed over the past 20 years as advances in molecular genetics have enabled a search for gene x environment (GxE) interactions. A number of such interactions have been studied in the last several decades in relation to early adversity generally and child abuse and neglect in particular. Critics of these approaches charge, among other things, that examining single gene and single environment combinations in interactions capitalizes on chance. In addition, some experts in genetics argue that the action of any single gene is likely to be very small, and to detect its effects will likely require very large sample sizes. Nonetheless, some GxE findings have emerged as robust and apparently replicable.

The 5-HTT gene is perhaps at the top of this list. This gene regulates reuptake of serotonin (a neurotransmitter that has various functions, including regulation of mood and sleep and some cognitive functions, such as memory and learning) at the synaptic cleft. The gene has long and short allelic variants that confer differential reuptake efficiency. Rodent, nonhuman primate, and human studies (e.g., Caspi et al., 2003 ) have shown that two alleles confer advantage among animals raised in stressful environments. Caspi and colleagues (2003) found that adults who had experienced stressful life events as children were more likely to have a major depressive disorder if they had one or two short alleles. Those who had two long alleles were no more likely to develop depression than individuals who had not experienced stressful life events.

A second genetic polymorphism that has received much attention is a functional polymorphism in the promoter region of the monoamine oxidase A (MAOA) gene. MAOA encodes the MAOA enzyme and selectively degrades serotonin, norepinephrine, and dopamine. Abused and neglected boys with the genotype conferring low levels of MAOA expression were found to be more likely to develop a range of externalizing behaviors, including conduct disorder, antisocial personality disorder, and violent criminality ( Caspi et al., 2002 ). However, subsequent studies have failed to replicate these findings or have demonstrated only partial replications ( Huizinga et al., 2006 ; Widom and Brzustowicz, 2006 ). For a recent review of the GxE literature concerned with child depression and abuse, see Dunn and colleagues (2011) .

Finding: Not all children who experience abuse or neglect show problematic outcomes. Factors that influence resilience among abused and neglected children have been identified at the level of the individual child, the family, and the child's broader social context. These factors, along with risks and stressors at each level, interact with one another to predict resilient outcomes. Finding: There is a positive association between the number of risk factors for abuse and neglect to which a child is exposed and the likelihood of experiencing adverse outcomes. Finding: The timing, chronicity, and severity of child abuse and neglect, as well as the context in which they occur, have been shown to impact the associated outcomes.

• ECONOMIC BURDEN

Although the total costs of child abuse and neglect are difficult to gauge because much abuse is unreported ( Waters et al., 2004 ), a number of studies over the last few decades have attempted to document the economic burden of child abuse and neglect on society ( Corso and Fertig, 2010 ; Fang et al., 2012 ; Wang and Holton, 2007 ; Waters et al., 2004 ). Economic burden or economic impact analyses typically quantify burden by aggregating the direct medical expenditures resulting from a condition, the direct nonmedical expenditures associated with a condition, and the subsequent indirect losses in productivity potential for society. These analyses often are called cost of illness/injury analyses .

Examples of direct medical expenditures include inpatient and outpatient hospital care, mental health care, medical transport required in the event of an emergency, medications and medical devices, and the medical treatment of chronic conditions resulting from the abuse. Multiple studies since the 1993 NRC report was issued have assessed the direct medical costs associated with child abuse and neglect ( Brown et al., 2011 ), particularly the inpatient costs associated with severe abuse ( Courtney, 1999 ; Evasovich et al., 1998 ; Irazuzta et al., 1997 ; Libby et al., 2003 ; New and Berliner, 2000 ; Rovi et al., 2004 ).

Direct nonmedical expenditures include use of the child welfare system, law enforcement, and the criminal justice system. Studies have included nonmedical costs in their assessment of the economic burden of child abuse and neglect ( Staudt, 2003 ; Zagar et al., 2009 ).

Productivity losses include the child's missing school or performing at subpar levels in school because of the abuse, parents missing work or performing at subpar levels at work because of the abuse situation or having to deal with child welfare and criminal justice services, and permanent losses in lifetime productivity potential because of premature death. Productivity losses and economic well-being have been incorporated into a number of analyses of the economic burden of child abuse and neglect ( Brown et al., 2011 ; Corso and Fertig, 2010 ; Corso et al., 2011 ; Currie and Widom, 2010 ; Fang et al., 2012 ).

Gelles and Perlman (2012) estimate that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion each year—$33.3 billion in direct costs and $46.9 billion in indirect costs. An analysis by the Centers for Disease Control and Prevention found that the average lifetime cost of a case of nonfatal child abuse and neglect is $210,012 in 2010 dollars, most of this total ($144,360) due to lost productivity but also encompassing the costs of child and adult health care, child welfare, criminal justice, and special education ( Fang et al., 2012 ). The average lifetime cost of a case of fatal child abuse and neglect is $1.27 million, due mainly to loss of productivity.

Currie and Widom (2010) found that adults who had experienced abuse and neglect in childhood had lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect. A higher percentage of adults who had been abused or neglected as children worked in menial, semiskilled positions at age 29 compared with adults who had not been abused or neglected—62 versus 45 percent, respectively. More of the abused and neglected group has been unemployed at some point during the previous 5 years (41 versus 58 percent, respectively). And fewer of those from the abused or neglected group were currently employed or had a bank account, owned a car, or owned their home. Larger effects were seen for women than for men.

Analyses of the economic burden of child abuse and neglect could be strengthened by greater transparency in the study methods, including a full accounting of all cost categories that may be impacted by abuse and neglect and transparency in the unit cost estimates for each cost category, as well as a methodologically sound choice of study design for estimating economic burden ( Corso and Fertig, 2010 ; Corso and Lutzker, 2006 ; Fang et al., 2012 ). Several approaches could be taken to estimate economic burden, each of which has advantages and disadvantages that could potentially result in overestimating or underestimating the true economic cost of child abuse and neglect. Options include using cross-sectional data to compare the medical costs for an abused/neglected population compared with a nonabused/nonneglected population, including only those health care costs that can be explicitly linked to diagnosis-specific health care utilization (and costs) through the use of diagnosis and external cause codes used in inpatient settings, and supplementing either of these two approaches by including the costs of the fraction of other health conditions attributed to child abuse and neglect.

Finding: Although the total costs of child abuse and neglect are difficult to gauge, a number of studies have attempted to document the economic burden of child abuse and neglect on society, including such measures as direct medical and nonmedical expenditures and productivity losses. One study estimates that cases of abuse or neglect impose a cumulative cost to society of $80.2 billion annually ( Gelles and Perlman, 2012 ). Finding: Some studies have shown that adults who experienced abuse and neglect in childhood have lower levels of education, employment, and earnings and fewer assets than adults without a history of abuse and neglect.

• CONCLUSIONS

Child abuse and neglect appear to influence the course of development by altering many elements of biological, cognitive, psychosocial, and behavioral development; in other words, child abuse and neglect “get under the skin” ( Hertzman and Boyce, 2010 ) to have a profound and often lasting impact on development. Brain development is affected, as is the ability to make decisions as carefully as one's peers, or executive functioning; the ability to regulate physiology, behavior, and emotions is impaired; and the trajectory toward more problematic outcomes is impacted. Effects are seen across domains, with the interplay across brain and behavioral systems being particularly striking.

Risk and protective factors across multiple levels of a child's ecology interact to influence outcomes related to child abuse and neglect. Factors that influence resilience across these domains are important to an understanding of how to protect children from the adverse outcomes discussed in this chapter. Evidence suggests that the timing, chronicity, and severity of the abuse or neglect matter in terms of outcomes. The more times children experience abuse or neglect, the worse are the outcomes ( Jonson-Reid et al., 2012 ). As Jonson-Reid and colleagues (2012) point out, it is not enough to know whether an event happened; one must also know how ongoing the problem is. The committee sees as hopeful the evidence that changing environments can change brain development, health, and behavioral outcomes. There is a window of opportunity, with developmental tasks becoming increasingly more challenging to negotiate with continued abuse and neglect over time.

Future research in this area needs to focus on disentangling the effects of child abuse and neglect from those of other conditions. There is a need to explore beneath the surface to understand the behavioral, neurobiological, social, and environmental mechanisms that mediate the association between exposure to abuse and neglect and their behavioral and neurobiological sequelae.

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Description of the MUSP Cohort

Inclusion criteria for original research publications, quality of supporting literature, predictors: maltreatment types, ethical approval, prevalence and co-occurrence of maltreatment subtypes, cognition and education outcomes, psychological and mental health outcomes, addiction and substance use outcomes, sexual health outcomes, physical health, magnitude of effects, abuse, neglect, and cognitive development, psychological maltreatment: emotional abuse and/or neglect, sexual abuse, physical abuse, limitations, conclusions, long-term cognitive, psychological, and health outcomes associated with child abuse and neglect.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Lane Strathearn , Michele Giannotti , Ryan Mills , Steve Kisely , Jake Najman , Amanuel Abajobir; Long-term Cognitive, Psychological, and Health Outcomes Associated With Child Abuse and Neglect. Pediatrics October 2020; 146 (4): e20200438. 10.1542/peds.2020-0438

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Video Abstract

Potential long-lasting adverse effects of child maltreatment have been widely reported, although little is known about the distinctive long-term impact of differing types of maltreatment. Our objective for this special article is to integrate findings from the Mater-University of Queensland Study of Pregnancy, a longitudinal prenatal cohort study spanning 2 decades. We compare and contrast the associations of specific types of maltreatment with long-term cognitive, psychological, addiction, sexual health, and physical health outcomes assessed in up to 5200 offspring at 14 and/or 21 years of age. Overall, psychological maltreatment (emotional abuse and/or neglect) was associated with the greatest number of adverse outcomes in almost all areas of assessment. Sexual abuse was associated with early sexual debut and youth pregnancy, attention problems, posttraumatic stress disorder symptoms, and depression, although associations were not specific for sexual abuse. Physical abuse was associated with externalizing behavior problems, delinquency, and drug abuse. Neglect, but not emotional abuse, was associated with having multiple sexual partners, cannabis abuse and/or dependence, and experiencing visual hallucinations. Emotional abuse, but not neglect, revealed increased odds for psychosis, injecting-drug use, experiencing harassment later in life, pregnancy miscarriage, and reporting asthma symptoms. Significant cognitive delays and educational failure were seen for both abuse and neglect during adolescence and adulthood. In conclusion, child maltreatment, particularly emotional abuse and neglect, is associated with a wide range of long-term adverse health and developmental outcomes. A renewed focus on prevention and early intervention strategies, especially related to psychological maltreatment, will be required to address these challenges in the future.

Child maltreatment is a major public health issue worldwide, with serious and often debilitating long-term consequences for psychosocial development as well as physical and mental health. 1   In the United States alone, 3.5 million children are reported for suspected maltreatment each year, with an annual substantiated maltreatment rate of 9.1 per 1000 children. 2   Some of the long-term adverse outcomes associated with maltreatment include cognitive disability, anxiety and depression, psychosis, teen-aged pregnancy, addiction disorders, obesity, and cardiovascular disease. 3   Understanding the distinctive impact of differing types of maltreatment may help medical professionals provide more wholistic care and treatment recommendations as well as identify more specific public health targets for primary prevention.

Unfortunately, however, little is known about the long-term effects of differing types of child maltreatment, which include sexual abuse, physical abuse, emotional abuse, and neglect. 4   According to a meta-analysis review, 5   research on child maltreatment has predominantly been focused on sexual abuse, with far less attention paid to psychological maltreatment (emotional abuse and/or neglect) and the co-occurrence of different types of maltreatment. In addition, most of the current evidence is derived from cross-sectional studies, which may be subject to recall bias, 6 – 8   in which an outcome status (such as depression) may influence recall of the exposure (ie, previous maltreatment). Few previous studies have adequately controlled for confounding variables, such as perinatal risk, socioeconomic adversity, parental psychopathology, and impaired early childhood development, which may predispose to both child maltreatment and later adverse health outcomes.

Longitudinal studies offer evidence that is more robust, but these studies are relatively few in number and have generally been limited to certain sociodemographic groups 9   or to specific types of child maltreatment, such as sexual abuse. 1 , 10   Other longitudinal studies have relied on retrospective recall of maltreatment rather than prospectively collected agency-reported data. 11 – 13   In studies in which prospective data have been collected, 7 , 13 – 17   only a few have compared different types of child maltreatment. 7 , 16 , 17  

In this special article, we review findings from the Mater-University of Queensland Study of Pregnancy (MUSP), a now 40-year longitudinal prenatal cohort study from Brisbane, Australia, involving >7000 women and their children. 18   Unique features of the MUSP include its use of a population-based sample, its use of prospectively substantiated child maltreatment reports, and its consideration of different subtypes of maltreatment. In addition, the study design controlled for a wide range of confounders and covariates, including both maternal and child sociodemographic and mental health variables. This combined body of work, which includes numerous publications over the past decade, has documented a broad range of adverse outcomes associated with child maltreatment, including deficits in cognitive and educational outcomes 19 – 21   ; mental health problems, such as anxiety, depression, posttraumatic stress disorder (PTSD), psychosis, delinquency, and intimate partner violence (IPV) 22 – 25   ; substance abuse and addiction 26 – 30   ; sexual health problems 31   ; physical growth and health deficits 32 – 35   ; and overall decreased quality of life. 36  

Our purpose for this special article is to compare the effects of 4 differing types of maltreatment on long-term cognitive, psychological, addiction, and health outcomes assessed in the offspring at ∼14 and/or 21 years of age. Rather than providing a systematic review or meta-analysis of the current literature, which would include diverse study designs and purposes, we report and compare the findings of individual articles that used a common data set and standard methodology to study a broad array of outcomes. We particularly highlight the long-term impact of emotional abuse and neglect, which has received far less attention in the literature.

Between 1981 and 1983, 8556 consecutive pregnant women who attended their first prenatal clinic visit at the Mater Mothers’ Hospital in Brisbane, Australia, agreed to participate ( Fig 1 ). After excluding mothers who did not deliver a singleton infant at the Mater Mothers’ Hospital or withdrew consent, the MUSP birth cohort consisted of 7223 mother-infant dyads, who were followed over 2 decades: at 3 to 5 days, 6 months, 5 years, 14 years and 21 years. Midway through the study, this rich data set was anonymously linked to state reports of child abuse and neglect, which identified some form of suspected maltreatment in >10% of cases. 37   Notified cases, which had been referred from the community or by general medical practitioners, were investigated by the Queensland government child protection agency. Substantiated maltreatment was determined after a formal investigation when there was “reasonable cause to believe that the child had been, was being, or was likely to be abused or neglected.” 38   Substantiated maltreatment occurred when a notified case was confirmed for (1) sexual abuse, “exposing a child to or involving a child in inappropriate sexual activities”; (2) physical abuse, “any non-accidental physical injury inflicted by a person who had care of the child”; (3) emotional abuse, “any act resulting in a child suffering any kind of emotional deprivation or trauma”; or (4) neglect, “failure to provide conditions that were essential for the healthy physical and emotional development of a child,” which encompassed physical, emotional and medical neglect. 37  

Overview of the MUSP enrollment and testing.

We searched PubMed from inception to April 2020 for published MUSP articles in which agency-reported child maltreatment was evaluated as the predictor of a range of outcomes. Studies needed to meet the following criteria for inclusion in the review: (1) notified or substantiated abuse and neglect was listed as a main predictor variable and (2) outcomes included standardized measurements of cognitive, psychological, behavioral, or health functioning. From ∼340 published MUSP studies, we identified 24 articles dealing with child maltreatment, of which 21 included state-reported maltreatment versus self-reported maltreatment data ( n = 3). Nineteen of the 21 articles met all inclusion criteria and were evaluated in this review ( Fig 2 ). One study was excluded because it only examined outcomes associated with sexual abuse. 8   Another article was excluded because its outcome measures were similar to another included study. 29  

Published studies from the Mater-University of Queensland Study of Pregnancy, linking long-term outcomes with specific maltreatment subtypes (adjusted coefficients or odds ratios ± 95% confidence intervals). CES-D, Center for Epidemiologic Studies–Depression Scale; CI, confidence interval; N , number of offspring in sample; N (Mal) , number of offspring who experienced maltreatment. a In different articles adjusting for co-occurrence of maltreatment subtypes was handled in different ways: (1) statistical adjustment: each maltreatment subtype predictor was statistically adjusted for the other maltreatment subtypes (eg, neglect was adjusted for the occurrence of physical, sexual, and emotional abuse) and is reflected in the table’s odds ratios and coefficients; (2) exclusive categories: different combinations of maltreatment types are included in mutually exclusive groups (eg, physical abuse only, physical abuse and emotional abuse only, physical and emotional abuse and neglect [without sexual abuse], etc; see Table 1 ); (3) nonexclusive categories: maltreatment categories may overlap with other categories (eg, any substantiated abuse [sexual, physical, or emotional] versus any substantiated neglect); and (4) none: no statistical adjustments or combined categories were presented for co-occurring maltreatment subtypes. b Adjusted coefficients (95% CI) were reported as statistical association measures rather than adjusted odds ratios. c Cases of notified (rather than substantiated) maltreatment. In the study by Mills et al, 26   a sensitivity analysis was performed after exclusion of unsubstantiated cases of maltreatment. The associations between any maltreatment and substance use were similar to those seen in the original analysis after full adjustment. d Medium effect size, based on magnitude of the adjusted odds ratio (2 ≤ odds ratio ≤ 4). e Large effect size, based on magnitude of the adjusted odds ratio (odds ratio > 4).

Each of the reviewed articles followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for the conduct of cohort studies. 41   The quality of the studies was also evaluated by using a modified version of the Newcastle-Ottawa Scale, which is used to assess the following domains: sample representativeness and size, comparability between respondents and nonrespondents, ascertainment of outcomes, and statistical quality. 42   On the basis of this assessment, all of the MUSP studies were determined to be of low risk of bias, with a score of 4 out of 5 points ( Supplemental Information ).

In all but 2 studies (which used notified maltreatment 21 , 26   ) events were dichotomized and coded as substantiated maltreatment versus no substantiated maltreatment. According to a validated classification of maltreatment types, 43   specific categories and co-occurring forms of childhood maltreatment 44   were used to predict outcomes. In 2 studies, 19 , 20   all types of abuse were combined into 1 category and compared to neglect, whereas in another study, sexual abuse was compared to any combination of nonsexual maltreatment. 21   In 2 other studies, 26 , 40   emotional abuse and neglect (examples of psychological maltreatment) were combined, partly because of overlapping definitional constructs from the government child protection agency (emotional abuse included “emotional deprivation,” and neglect included the failure to provide for “healthy…emotional development”). In all but 2 of the included articles, 25 , 33   co-occurrence of different types of maltreatment was considered, either by examining specific combinations of maltreatment types (in exclusive or nonexclusive overlapping categories) or by statistically adjusting for all remaining types of maltreatment ( Fig 2 ).

All of the odds ratios, mean differences, or coefficients were adjusted for potential confounding variables ( Fig 3 ). All articles adjusted for a variety of sociodemographic variables, such as age, race, education, income, and marital status. Perinatal and/or childhood factors, such as birth weight, gestational age, and breastfeeding status, were used as covariates, particularly in articles in which cognitive and educational outcomes were examined. Psychological and mental health variables (such as internalizing and externalizing behavior problems, maternal depression, chronic stress, or exposure to violence) were primarily included as covariates in mental health outcome studies, especially for psychosis. Addiction studies adjusted for youth and maternal alcohol or tobacco use, among other covariates, and physical health outcome studies adjusted for relevant covariates (such as BMI in a study of dietary fat intake and parental height when studying offspring height). In selected articles, maltreatment subtypes were also statistically adjusted for the other types of maltreatment to determine independent effects.

Covariates used in published articles from the MUSP to adjust for possible confounding. a Race: child’s race, parental race, and maternal or paternal racial origin at pregnancy. b Child age: child age and gestational age. c Maternal age: maternal age at the first visit clinic or at pregnancy. d Maternal education: maternal education (prenatal or at birth). e Family income: annual family income, familial income over the first 5 years or family poverty before birth or over the first 5 years of life, family income before birth, and annual family income. f Maternal marital status and social support: same partner at birth and 14 years and social support at 5 years. g Maternal depression: maternal depression during pregnancy, 3- to 6-month follow-up, or 21-year follow-up; chronic maternal depression. h Maternal alcohol use: maternal alcohol use at 3- to 6-month or 14-year follow-up and binge drinking. i Maternal cigarette use: cigarette use during pregnancy, 6 months postpartum, or at 14-year follow-up. ADHD, attention-deficit/hyperactivity disorder; CES-D, Center for Epidemiologic Studies–Depression Scale; IPV, intimate partner violence. Covariates used in published articles from the MUSP to adjust for possible confounding.

A total of 46 outcomes were assessed at 14 years ( n = 5200) and/or 21 years ( n = 3778) ( Fig 1 ) and were grouped into 5 domains ( Fig 2 ):

Cognition and education outcomes included reading ability and perceptual reasoning measured in adolescence, and, at age 21, receptive verbal intelligence and failure to complete high school or be either enrolled in school or employed; attention problems were measured at both time points.

Psychological and mental health outcomes at 21 years included internalizing and externalizing behavior problems (which were also assessed at 14 years), lifetime anxiety disorder, depressive disorder and symptoms, PTSD, lifetime psychosis diagnosis, psychotic symptoms (such as delusional experience or visual and/or auditory hallucinations), delinquency, experience of IPV or harassment, and overall quality of life.

Addiction and substance use, measured at both time points, included alcohol and cigarette use at 14 and 21 years, and cannabis abuse and/or dependence (including early onset) and injecting-drug use at the 21-year follow-up.

Sexual health was investigated at age 21 in terms of early initiation of sexual experience, having multiple sexual partners, youth pregnancy, and miscarriage or termination.

Physical health outcomes measured at 21 years included symptoms of asthma, high dietary fat intake, poor sleep quality, and height deficits.

The 14-year assessments included a youth questionnaire ( n = 5172) and in-person cognitive testing ( n = 3796). The 21-year visit included an in-person assessment of mental health diagnoses in a subset of the cohort ( n = 2531) with the World Health Organization Composite International Diagnostic Interview (CIDI), which is based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria 45   ( Fig 1 ). All of the questionnaire and interview measures were validated, except for reported frequencies of specific events (ie, pregnancy, number of cigarettes, etc).

Associations were described by using either adjusted odds ratios or mean differences and coefficients, along with the corresponding 95% confidence intervals, and were plotted to visualize and compare the statistical significance of each association across specific outcome categories and types of maltreatment ( Figs 4 – 8 ).

Child maltreatment and cognition and educational outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and psychological and mental health outcomes at 14 and 21 years. A, Adjusted coefficients ± 95% confidence intervals. B, Odds ratios ± 95% confidence intervals. * P < .05.

Child maltreatment and addiction and substance use outcomes at 14 and 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and sexual health outcomes at 21 years (adjusted odds ratio ± 95% confidence interval). * P < .05.

Child maltreatment and physical health outcomes at 21 years. A, Adjusted odds ratio ± 95% confidence interval. B, Adjusted coefficients ± 95% confidence interval. * P < .05.

The MUSP was approved by the Human Ethics Review Committee of The University of Queensland and the Mater Misericordiae Children’s Hospital. Ethical approval was obtained separately from the Human Ethics Review Committee of The University of Queensland for linking substantiated child maltreatment data to the 21-year follow-up data.

In this cohort of 7214 children ( Fig 1 ), 7.1% ( n = 511 children) experienced at least 1 episode of substantiated maltreatment. Substantiated sexual abuse was reported in 2.0% ( n = 147), physical abuse in 4.0% ( n = 287), emotional abuse in 3.7% ( n = 267), and neglect in 3.7% of cases ( n = 269) ( Table 1 ). Almost 60% of the children with substantiated maltreatment had multiple substantiated episodes (293 children; range: 2–14 episodes per child; median: 3 episodes per child 37   ). Of the 3778 young adults included in the 21-year follow-up, 4.5% ( n = 171) had a history of substantiated maltreatment, 39   including sexual abuse ( n = 53), physical abuse ( n = 60), emotional abuse ( n = 71), and neglect ( n = 89).

More than half of the children who experienced substantiated maltreatment were reported for ≥2 co-occurring maltreatment types ( Table 1 ). Of the substantiated sexual abuse cases, 57.1% of the children experienced ≥1 additional maltreatment types (84 of 147); for physical abuse, this proportion was 79.1% (227 of 287); for emotional abuse, 83.5% (223 of 267); and for neglect, 73.6% (198 of 269). In particular, emotional abuse and neglect co-occurred, with or without other types of maltreatment, in ∼59% of cases. 46  

Nonexclusive and Exclusive Categorization of Child Maltreatment Subtypes (Single and in Combination) Within the MUSP Cohort

Abuse (a combined category) and neglect were both associated with significantly lower cognitive scores at both 14 and 21 years, as well as with negative long-term educational and employment outcomes in young adulthood. 19 , 20   This was after adjusting for factors such as the child’s race, sex, birth weight, breastfeeding exposure, and age; family income; and maternal education and alcohol and/or tobacco use ( Fig 3 ). Specifically, proxy measures of IQ, such as reading ability and perceptual reasoning, at age 14 years were adversely associated with both substantiated abuse and neglect. 19   Sexual abuse was associated with attention problems in adolescence, whereas nonsexual maltreatment was associated with attention problems at both time points. 21   Young adults who experienced substantiated child maltreatment had reduced scores on the Peabody Vocabulary Test at 21 years. In terms of educational outcomes in young adulthood, both abuse and neglect manifested a threefold to fourfold increase in odds of failing to complete high school and a twofold to threefold increase in the likelihood of being unemployed at age 21 years 20   ( Figs 2 and 4 ).

During adolescence, physical abuse, emotional abuse, and neglect were all significantly associated with both internalizing and externalizing behavior problems, although this was not the case for physical abuse notifications without co-occurring emotional abuse or neglect. 22   After adjustment for relevant sociodemographic variables, the associations with emotional abuse and neglect remained significant at 21 years. 39   No statistically significant association was found between sexual abuse and these behavior problems at either time point.

Psychological maltreatment in childhood was associated with all of the other 15 psychological and mental health outcomes in young adulthood, except for delinquency in women. This was true after adjustment for sociodemographic variables and psychological and mental health problems (such as attention-deficit/hyperactivity disorder, aggressive behavior problems, and maternal depression or adverse life events, in the case of psychosis and/or IPV exposure outcomes) ( Fig 3 ). Specifically, both emotional abuse and neglect were significantly associated at 21 years with all of the following outcomes: anxiety, depression, PTSD, psychosis (with some exceptions), delinquency in men, and experiencing IPV and harassment (except for neglect). 22 – 25 , 39   Emotional abuse and neglect were the only maltreatment subtypes associated with a significant decrease in quality-of-life scores. 36  

The only mental health outcomes associated with sexual abuse were clinical depression, lifetime PTSD, and experiencing physical IPV. 8 , 25 , 39   Physical abuse was associated with externalizing behavior problems and delinquency (in men), internalizing behavior problems and depressive symptoms, experience of IPV, and PTSD 22 , 24 , 25 , 39   ( Figs 2 and 5 ).

Overall, emotional abuse and/or neglect were associated with all categories of substance use and addiction at both 14 and 21 years, whereas physical and sexual abuse were associated with surprisingly few substance abuse outcomes. Specifically, childhood emotional abuse and neglect were associated with adolescent substance use at age 14, including alcohol use and smoking. 26   This was after adjustment for sociodemographic factors and youth and maternal drug use. The association with cigarette and alcohol use persisted from adolescence to adulthood. The category of "any cigarette use" was the only addiction outcome associated with all 4 types of maltreatment. 40   At 21 years, emotional abuse and neglect were both associated with the early onset of cannabis abuse after adjustment for maternal stress and cigarette use. Additionally, physical abuse, emotional abuse, and neglect all revealed increased odds of cannabis dependence at age 21, with early onset associated with physical abuse and neglect. 28   In contrast, only emotional abuse significantly predicted injecting-drug use in young adult men, after adjustment for maternal alcohol use and depression, whereas all types of substantiated childhood maltreatment were associated with injecting-drug use in women. 27   Sexual abuse was not associated with any addiction or substance use outcome except for cigarette use at 21 years ( Figs 2 and 6 ).

All forms of maltreatment were significantly associated, at 21 years, with early onset of sexual activity and subsequent youth pregnancy. This was after adjustment for factors such as gestational age, youth psychopathology, and drug use. Neglect was the only type of maltreatment associated with having multiple sexual partners and was the maltreatment type most strongly associated with most other sexual health outcomes, especially youth pregnancy. Pregnancy miscarriage was modestly associated with emotional abuse, whereas termination of pregnancy was not associated with any maltreatment subtype 31   ( Figs 2 and 7 ).

Reduced adult height at 21 years, adjusted for parental height, was associated with all maltreatment subtypes except sexual abuse (which was not associated with any of the physical health outcomes). At 21 years, physical abuse was also associated with high dietary fat intake, a risk factor for obesity (adjusted for BMI), and poor sleep quality in men (adjusted for psychopathology and drug use). Asthma at 21 years revealed a modest association with emotional abuse. The combined category of any maltreatment was also associated with high dietary fat intake ( Figs 2 and 8 ).

To estimate the magnitude of potential effects of child maltreatment on long-term outcomes, other studies have used a number of statistical techniques. In one Australian study that used the MUSP and other data sets, the population attributable risk of child maltreatment causing anxiety disorders in men and women, was estimated to be 21% and 31%, respectively, and 16% and 23% for depressive disorders. 46   Similarly, in the MUSP study on cognitive and educational outcomes of maltreated youth, the population attributable risk of child maltreatment leading to “failure to complete high school” was 13%, and 14% for “failure to be in either education or employment at 21 years.” 20  

Based on one published metric of effect size using the magnitude of the adjusted odds ratio, 47   77% of the statistically significant associations in this review were considered to have a medium to large effect size (odds ratio ≥2), including 10% with a large effect size (odds ratio >4) ( Fig 2 ).

In summary, over the past decade, the MUSP has revealed that child maltreatment is associated with a broad array of adverse outcomes during adolescence and young adulthood, including the following:

deficits in cognitive development, attention, educational attainment, and employment;

serious mental health problems, including anxiety, depression, PTSD, and psychosis, as well as delinquency and the experience of IPV;

substance use and addiction problems;

sexual health problems; and

physical health limitations and risk.

These results were seen after adjustment for a broad range of relevant sociodemographic, perinatal, psychological, and other risk factors ( Fig 3 ). Many of the studies also adjusted for the other subtypes of child maltreatment and demonstrated that specific maltreatment types were closely associated with particular outcomes.

Significant cognitive delays and educational failure were seen for both abuse and neglect across adolescence and adulthood. In another study, the authors concluded that preexisting cognitive impairments at 3 or 5 years may explain this association, rather than maltreatment per se. 16   However, other research has revealed that children neglected over the first 4 years of life show a progressive decline in cognitive functioning, which is associated with a significantly reduced head circumference at 2 and 4 years of age. 48   In rodent models, contingent maternal behavior is linked with infant cognitive development, and possible mechanisms include increases in synaptic connections within the hippocampus 49   and reduced apoptotic cell loss. 50   Prolonged maternal separation, in contrast, is associated with impaired cognitive development in rodent and primate models. 51 , 52  

One of the most striking conclusions from this review was the broad association between emotional abuse and/or neglect and adverse outcomes in almost all areas of assessment ( Fig 2 ). In stark contrast, physical abuse and sexual abuse were associated with far fewer adverse outcomes. Overall, quality of life was lower for those who had experienced emotional abuse and neglect but not for those who had experienced physical or sexual abuse. Although emotional abuse and neglect often co-occur with other types of maltreatment, 46   the associated outcomes were generally robust even after statistical adjustment or separation into differing maltreatment categories ( Fig 2 ).

Emotional abuse and neglect in early childhood may lead to psychopathology via insecure attachment, 53 , 54   which has been associated with externalizing behavior problems 55   and impaired social competence. 56 , 57   Emotional neglect, in particular, may lead to deficits in emotion recognition and regulation, as well as insensitivity to reward, 3   potentially influencing social and emotional development. Neglected children are less able to discriminate facial expressions and emotions, 58   whereas youth who have been emotionally neglected show blunted development of the brain’s reward area, the ventral striatum. 59   Reduced reward activation may predict risk for depression, 59   addiction, 60   and other psychopathologies. 61  

Neglect was also associated with the early onset of sexual activity, multiple sexual partners, and youth pregnancy, even after adjustment for other maltreatment subtypes. This suggests that neglect may result in compensatory efforts to obtain sexual intimacy, consistent with other studies revealing higher rates of unprotected sex 62   and adolescent pregnancy in neglected children. 63   In the animal literature, female rodents that experience maternal deprivation tend to have an earlier onset of puberty and increased sexual receptivity, leading to elevated reproductive activity to help offset an environment of higher offspring risk. 64 , 65  

As observed elsewhere, 66   sexual abuse was associated with early sexual experimentation and youth pregnancy as well as symptoms of PTSD and depression. Risky sexual behaviors were independent of other types of maltreatment but were not specific for sexual abuse. An additional MUSP study comparing self-reported and agency-notified child sexual abuse revealed consistent associations with major depressive disorder, anxiety disorders, and PTSD. 8   The absence of associations with other adverse outcomes, however, may be, in part, due to the lower prevalence of substantiated sexual abuse, especially at the 21-year follow-up.

Outcomes associated with physical abuse differed from those associated with sexual abuse, with increased odds of externalizing behavior problems, and delinquency in men. Jaffee 3   suggests that physical abuse, in particular, may lead to a hypervigilance response to threat, including negative attentional bias, disproportionate to relatively mild threat cues. Studies have revealed that physically abused children show selective attention to anger cues, 67   have difficulty disengaging from them, 58 , 68   and are more likely to misinterpret facial cues as being angry or fearful. 69  

Although these studies demonstrated significant associations between maltreatment and a range of long-term outcomes, association does not equal causality. The causal mechanisms proposed above are tentative and may relate to multiple types of maltreatment.

Other limitations should also be considered. Firstly, selective attrition of socioeconomically disadvantaged and maltreated young people was evident in the MUSP cohort ( Supplemental Information ). However, based on multiple imputation calculations and inverse probability weighting of MUSP data, 18 , 70   differences in the rate of loss to follow-up, for both dependent and independent variables, made little difference to either the estimates or their precision, mirroring findings from other longitudinal studies. 71   In addition, the findings were mostly unchanged when using propensity analysis, which is used to assess the effects of nonrandom sampling variation by analyzing the probability of assignment to a particular category within an observational study given the observed covariates. 72   Specifically, the sample was weighted so that it better resembled sociodemographic characteristics at baseline to minimize bias from differential attrition in those with greater socioeconomic disadvantage.

Secondly, differences in the prevalence of specific maltreatment subtypes might have influenced the statistical power to detect true effects, particularly regarding sexual abuse ( Table 1 ).

Finally, the co-occurrence of different types of maltreatment may have impacted the ability to accurately predict the associations between specific types of maltreatment and outcomes. Other studies have revealed that emotional abuse and neglect, in particular, are more likely to co-occur with each other and with other types of maltreatment. 73   However, even in those articles that statistically adjusted for other co-occurring maltreatment subtypes, the associated outcomes linked with emotional abuse and/or neglect were generally robust. In articles that did not adjust for these co-occurrences, some of the strongest associations were still observed for emotional abuse and/or neglect.

Child maltreatment, particularly psychological maltreatment, is associated with a broad range of negative long-term health and developmental outcomes extending into adolescence and young adulthood. Although these data do not establish causality, neurodevelopmental pathways are likely influenced by stress and early social experience through epigenetic mechanisms, which may affect gene expression and regulation and, ultimately, behavior and development. 3 , 74  

Understanding the developmental roots of these adverse outcomes may motivate physicians to more systematically inquire about early-life trauma and refer patients to more appropriate treatment services. 75 , 76   Even more importantly, early intervention and prevention programs, such as prenatal and infancy nurse home visiting, 77   have demonstrated, in randomized clinical trials, diminished rates of child abuse and neglect. 78 , 79   Long-term benefits to the offspring include decreased childhood internalizing problems, 80   reduced antisocial behavior and substance abuse in adolescence, 81   and improved cognitive skills extending into young adulthood. 80 , 82   Supporting at-risk parents and young children should thus be an urgent priority.

Dr Strathearn conceptualized and designed the original study linking the Mater-University of Queensland Study of Pregnancy data set with substantiated reports of child maltreatment, drafted the special article, and reviewed and revised the manuscript; Dr Giannotti assisted in drafting the manuscript and prepared all tables and figures; Drs Mills, Kisely, and Abajobir conceptualized and wrote the original research articles summarized in this article; Dr Najman was the original principal investigator of the Mater-University of Queensland Study of Pregnancy; and all authors critically reviewed the manuscript for important intellectual content and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Partially supported by the US National Institute on Drug Abuse (R01DA026437). The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute or the National Institutes of Health. Funded by the National Institutes of Health (NIH).

Composite International Diagnostic Interview

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• Published: 22 October 2015

Child abuse research 2015: it’s time for breakthroughs

• Robert D. Sege 1 , 2  

Pediatric Research volume  79 ,  pages 234–235 ( 2016 ) Cite this article

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Child abuse and neglect pose a grave threat to US children. The statistics are overwhelming: 4% of US children receive a child welfare system response each year ( 1 ). The Harvard Center for the Developing Child has demonstrated that abuse, neglect, and family dysfunction contribute to toxic stress, which affects brain development and subsequent health and well-being ( 2 ). The Centers for Disease Control and Prevention estimates that each year’s child abuse and neglect results in $125 billion in lifelong medical costs, and nearly $500 billion in overall economic consequences ( 3 ).

Despite these grim statistics, research involving child abuse and neglect is still in its infancy. In his commentary, Dr. Krugman describes the many structural problems that have led to this situation. He echoed the recent National Research Council report ( 4 ) in calling for a concerted effort to build child abuse research. Development of the national network of centers of excellence called for in these reports would radically improve the ability to conduct research.

What can we hope to accomplish through further research into the prevention, detection, and treatment of child abuse? Concrete examples of pressing questions illustrate the need for investment in scientific research. Not only do they illustrate important questions, but the answers are well within our grasp.

Child abuse prevention efforts have been modestly effective: rates of child abuse have undergone a gradual decline in the past decades, despite the recent recession ( 5 ). However, more rapid progress is hampered by a disconnect between best practices—which promote resilience, and available research instruments—which measure risk. The Centers for Disease Control and Prevention’s Essentials for Childhood promotes the importance of safe stable nurturing relationships or environments in the prevention of child abuse and neglect ( 6 , 7 ), the Center for the Study of Social Policy has disseminated the Strengthening Families approach ( 8 ). Despite their focus on improving resilience, the development of validated measures of social connection and parental capacity lag far behind measures of social isolation and parental mental illness. Validated measures of resilience and similar intermediate outcomes would simplify evaluation and speed progress. Techniques for developing validated measures have been well-developed; with sufficient funding, there is no reason to doubt that they could be rapidly produced.

The diagnosis of child abuse is complex, controversial, and subject to cognitive bias. Objective tests would help. For example, identification of serum markers for infant brain injury could direct the evaluation of infants with vomiting and lethargy, just as cardiac biomarkers direct the evaluation of adults with chest pain. Application of new analytic techniques, now used in the study of proteomics, combined with the ability of a new research network samples, should lead to the rapid identification of biochemical markers of brain injury.

Some infants with abusive head trauma may experience devastating brain damage in the first days following their initial injury ( 9 ). Knowledge of the cellular and biochemical pathways of “big black brain” would lay the foundation for treatments that might reduce this secondary brain injury. A variety of techniques have been developed to study intercellular signaling; while this problem is complex, there is little doubt that the techniques to approach the problem are well-developed.

As described, many of the answers to these and other research issues lie well within the capacity of modern science. Dr. Krugman highlights some of the historical reasons that have so far failed to develop a sustained national research effort to address child abuse and neglect. With so many children suffering adverse experiences, and becoming disfigured, disabled or dead, it is well past time to start working.

R.D.S is a member of the Board of Directors of Prevent Child Abuse America, Chicago, Illinois, and is employed by the Medical Foundation Division of Health Resources in Action, which administers health-related grant programs.

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Finkelhor D. Updated Trends in Child Maltreatment, 2013. http://www.unh.edu/ccrc/pdf/_Updatedtrends2013_dc-df-ks-df.pdf . Published 2015. Accessed 1 August 2015.

National Center for Injury Prevention and Control at the US Centers for Disease Control and Prevention. Essentials for childhood: Steps to creating safe, stable and nurturing relationships. http://www.cdc.gov/violenceprevention/pdf/efc-01-03-2013-a.pdf . Published 2013. Accessed 17 October 2013.

Sege R, Linkenbach J. Essentials for childhood: promoting healthy outcomes from positive experiences. Pediatrics 2014; 133 :e1489–91.

Center for the Study of Social Policy. Strengthening families: the protective factors framework. http://www.cssp.org/reform/strengthening-families/the-basics/protective-factors . Published 2014. Accessed 27 April 2014.

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Sege, R. Child abuse research 2015: it’s time for breakthroughs. Pediatr Res 79 , 234–235 (2016). https://doi.org/10.1038/pr.2015.204

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DOI : https://doi.org/10.1038/pr.2015.204

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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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Fast Facts: Preventing Child Abuse & Neglect

Child abuse and neglect are serious public health problems and adverse childhood experiences (ACEs) . They can have long-term impacts on health, opportunity, and wellbeing. This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

• Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities. Please see CDC’s Preventing Child Sexual Abuse webpage for more information.
• Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
• Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

For more information about preventing child abuse and neglect definitions please see Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements [4.12 MB, 148 Pages, 508] .

Child abuse and neglect are common. At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States. This is likely an underestimate because many cases are unreported. In 2020, 1,750 children died of abuse and neglect in the United States.

Children living in poverty experience more abuse and neglect. Experiencing poverty can place a lot of stress on families, which may increase the risk for child abuse and neglect. Rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status.

Child maltreatment is costly. In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018. This economic burden rivals the cost of other high-profile public health problems, such as heart disease and diabetes.

Children who are abused and neglected may suffer immediate physical injuries such as cuts, bruises, or broken bones. They may also have emotional and psychological problems, such as anxiety or posttraumatic stress.

Over the long term, children who are abused or neglected are also at increased risk for experiencing future violence victimization and perpetration, substance abuse, sexually transmitted infections, delayed brain development, lower educational attainment, and limited employment opportunities.

Chronic abuse may result in toxic stress, which can change brain development and increase the risk for problems like posttraumatic stress disorder and learning, attention, and memory difficulties.

Child abuse and neglect are preventable. Certain factors may increase or decrease the risk of perpetrating or experiencing child abuse and neglect. To prevent child abuse and neglect violence, we must understand and address the factors that put people at risk for or protect them from violence. Everyone benefits when children have safe, stable, nurturing relationships and environments. CDC developed Child Abuse and Neglect Prevention Resource for Action [4 MB, 50 Pages]  to help communities use the best available evidence to prevent child abuse and neglect. This resource is available in English and Spanish [21MB, 52 Pages, 508] and can impact individual behaviors and relationships, family, community, and societal factors that influence risk and protective factors for child abuse and neglect.

Different types of violence are connected and often share root causes. Child abuse and neglect are linked to other forms of violence through  shared risk and protective factors . Addressing and preventing one form of violence may have an impact on preventing other forms of violence.

See Child Abuse and Neglect Resources   for publications, data sources, and prevention resources for preventing child abuse and neglect.

• Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Child Abuse and Neglect Prevention Resource for Action: A Compilation of the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Note: The title of this document was changed in July 2023 to align with other Prevention Resources being developed by CDC’s Injury Center. The document was previously cited as “Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities”.
• Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.
• Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results from the National Survey of Children’s Exposure to Violence. JAMA Pediatr. 2015;169(8):746–754. doi:10.1001/jamapediatrics.2015.0676
• U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2022). Child Maltreatment 2020. Available from https://www.acf.hhs.gov/cb/researchdata technology/statistics-research/childmaltreatment .
• Klika JB, Rosenzweig J, Merrick M. Economic burden of known cases of child maltreatment from 2018 in each state. Child and adolescent social work journal. 2020 Jun;37(3):227-34.
• Centers for Disease Control and Prevention.(2022). Health and Economic Costs of Chronic Diseases. Available from https://www.cdc.gov/chronicdisease/about/costs/index.htm
• Shonkoff J, Garner A, & Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.
• Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots. (2016). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

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• Fact Sheets

Fact Sheet: How DHS is Combating Child Exploitation and Abuse

Every day, the Department of Homeland Security (DHS) leads the fight against child exploitation and abuse. As part of the Department’s mission to combat crimes of exploitation and protect victims, we investigate these abhorrent crimes, spread awareness, collaborate with interagency and international partners, and expand our reach to ensure children are safe and protected.

DHS battles child exploitation and abuse using all available tools and resources department-wide, emphasizing its commitment in April 2023 by adding “Combat Crimes of Exploitation and Protect Victims” as its sixth core mission.

As part of the Department’s ongoing work on this mission, today DHS is announcing Know2Protect, the U.S. government’s first prevention and awareness campaign to combat online child sexual exploitation and abuse. In recognition of April’s Child Abuse Prevention Month, DHS is committed to raising awareness, preventing child exploitation and abuse, and bringing perpetrators to justice.

Between October 2022 and April 2024, DHS:

• Expanded and unified the Department’s focus on combating cybercrimes by redesignating the HSI Cyber Crimes Center as the DHS Cyber Crimes Center to enhance coordination across all DHS agencies and offices to combat cyber-related crimes and further the Department’s mission to combat online child sexual exploitation and abuse (CSEA).
• The Blue Campaign, now part of the DHS Center for Countering Human Trafficking, increased national partnerships from 43 in FY22 to 64 in FY23. The campaign hosted 194 national trainings on the indicators of human trafficking and how to report these crimes with over 19,000 participants from the federal government, non-governmental organizations, law enforcement, and the general public. In April 2024, Blue Campaign announced a partnership with rideshare company Lyft to train their drivers, who interact with millions of riders per year, on how to recognize and report human trafficking. Read more accomplishments in the DHS Center for Countering Human Trafficking’s FY 2023 Annual Report .
• Identified and/or assisted 2,621 child victims of exploitation through the work of Homeland Security Investigations and made more than 6,100 arrests for crimes involving the sexual exploitation of children. Learn more in Immigration and Customs Enforcement (ICE) ’s FY2023 Annual Report .
• Joined the Biden-Harris Administration and interagency partners to collaborate on actions to keep children and teens safe as part of the Kids Online Health and Safety Task Force and the White House Online Harassment and Abuse Task Force.
• Tasked the Department’s external advisory bodies, including the Homeland Security Advisory Council , the Homeland Security Academic Partnership Council , and the Faith-Based Security Advisory Council , to each form a subcommittee to review DHS efforts to combat online child sexual exploitation and abuse. In the coming months, they will share their findings, which will help inform the Department’s future efforts to tackle these issues.
• Began implementing a trauma-informed and victim and survivor-centered multidisciplinary workplan through the Joint Council on Combating Child Sexual Exploitation, established by President Biden and Australian Prime Minister Albanese. The Council, co-chaired by Secretary Alejandro N. Mayorkas, is focused on building the capacity of countries in the Indo-Pacific region to combat this crime; jointly developing policy recommendations to tackle the issue; conducting joint investigations and operations; sharing research and development efforts; preventing victimization through education and awareness campaigns; and safety-by-design.

To accomplish this work, DHS coordinates with law enforcement at home and abroad to enforce and uphold our laws, protects victims with a victim-centered approach that prioritizes respect and understanding, and works to stop this heinous crime through public education and outreach.

Enforcing Our Laws

DHS works with domestic and international partners to enforce and uphold the laws that protect children from abuse. The Department works collaboratively with the Department of Justice, the FBI, U.S Marshals, Interpol, Europol, and international law enforcement partners to arrest and prosecute perpetrators.

• Increased U.S. government and law enforcement efforts to combat financial sextortion – a crime targeting children and teens by coercing them into sending explicit images online and extorting them for money. In the past two years HSI received 4500 sextortion tips from Cote d’Ivoire and 665 children have been identified and supported by HSI. Learn more about the crime of sextortion .
• Helped deny more than 1,400 convicted, registered U.S. child sex offenders entry to foreign countries through travel notifications sent by the HSI Angel Watch Center. These efforts build international cooperation to ensure all countries are safe from predators.
• Partnered with 61 regional Internet Crimes Against Children Task Forces to investigate people involved in the online victimization of children, including those who produce, receive, distribute and/or possess child sexual abuse material, or who engage in online sexual enticement of children.
• Researched and developed modern tools and technologies that equip domestic and international law enforcement partners with advanced forensic capabilities to accomplish their mission to identify victims and apprehend child sexual abusers. For example, DHS’s Science and Technology Directorate developed the StreamView application to help law enforcement more efficiently address child exploitation cases by helping investigators aggregate, organize, and analyze investigative leads to identify the location of a crime, the victim, and bring the perpetrator to justice. Since May 2023, StreamView has led to the rescue of 68 victims, 47 arrests, eight life sentences, and dismantled eight trafficking networks having up to one million registered users.
• The U.S. Secret Service provides forensic and technical assistance to the National Center for Missing and Exploited Children (NCMEC) and state/local law enforcement in cases involving missing and exploited children. 
• U.S. Customs and Border Protection screens all unaccompanied children and other arriving minors for indicators of abuse or exploitation, human trafficking, and other crimes, and all suspected criminal cases are referred to HSI.

Protecting and Supporting Victims

DHS incorporates a victim-centered approach into all Department programs, policies, and operations that involve victims of crime. This effort seeks to minimize additional trauma, mitigate undue penalization, and provide needed stability and support to victims.

HSI’s “ Operation Renewed Hope ” mission in July 2023 resulted in the generation of 311 probable identifications of previously unknown victims, including 94 positive contacts and several confirmed victim rescues from active abuse due to their locations being discovered through materials uncovered during the investigations. The investigation also led to the identification of perpetrators of child sexual abuse material. HSI completed “ Operation Renewed Hope II ” in Spring 2024, which resulted in the generation of 414 probable identifications of previously unknown victims, and positive identification of 30 previously unknown child sexual abuse victims, which included 8 victims rescued from active abuse.

• Once victims of child exploitation are identified and/or rescued, the HSI Victim Assistance Program (VAP) supports them and their non-offending caretaker(s) by using highly trained forensic interview specialists to conduct victim-centered and trauma-informed forensic interviews. In addition, VAP’s victim assistance specialists provide other resources to victims such as crisis intervention, referrals for short and long term medical and/or mental health care, and contact information for local social service programs for young victims, and agencies to assist in the healing process.
• The Center for Countering Human Trafficking hosted its second annual virtual DHS Human Trafficking Seminar for DHS employees who are part of the Department’s mission to end human trafficking or are interested in this work. Over 900 employees from across the Department attended to learn more about DHS’s work and victim-centered approach to combating this crime.
• HSI provides  short-term immigration protections to human trafficking victims , including victims of child sex trafficking. U.S. Citizen and Immigration Services (USCIS) provides victim-based or humanitarian-related immigration benefits to child victims of human trafficking, abuse, and neglect, including Special Immigration Juvenile (SIJ) classification, T visa, U visa, and VAWA immigrant classification.

Educating and Increasing Public Awareness

An integral part of this work is educating and expanding public awareness to help prevent this crime and hold perpetrators accountable. DHS does this important work every day.

• Trained more than 2,000 law enforcement officials and child advocacy personnel throughout the country to enhance their counter-child exploitation tactics.
• Educated over 186,000 kids, teens, parents, and teachers about internet safety and how to stay safe from sexual predators through the iGuardian program. DHS recently revamped Project iGuardian materials and using those materials, HSI has trained 419 special agents and completed presentations across 32 states and 8 countries. Presentations target kids aged 10 and up and their trusted guardians and focus on sharing information about the dangers of online environments, how to stay safe online, and how to report abuse and suspicious activity.
• USSS Childhood Smart Program Ambassadors educated more than 112,000 children, parents, and teachers across 31 states and the District of Columbia about how to prevent online sexual exploitation and child abduction. The Childhood Smart Program provides age-appropriate presentations to children as young as five as well as to adults. Presentations focus on internet and personal safety as well as other topics such as social media etiquette and cyber bullying.
• The HSI Human Rights Violations and War Crimes Center trained over 955 individuals across the interagency on female genital mutilation or cutting, a severe form of child abuse under federal law when done to individuals under the age of 18.
• The DHS Blue Campaign Blue Lighting Initiative, part of the Center for Countering Human Trafficking, trained over 260,000 aviation personnel to identify potential traffickers and human trafficking victims and report their suspicions to law enforcement in FY 2023. The Initiative added 31 new partners this past year, raising its total partners to 136 aviation industry organizations, including its first two official international partners.
• The Cybersecurity and Infrastructure Security Agency administers SchoolSafety.gov, an interagency website that includes information, guidance and resources on a range of school safety topics. SchoolSafety.gov houses a child exploitation section and corresponding resources to help school communities identify, prevent and respond to child exploitation. Since its launch in January 2023, the SchoolSafety.gov child exploitation section has been viewed more than 17,380 times.

What You Can Do and Resources Available

• Project iGuardians™: Combating Child Predators
• Childhood Smart Program
• Visit SchoolSafety.gov for resources to help educators, school leaders, parents, and school personnel identify, prevent, and respond to child exploitation. 
• Learn more about sextortion : it is more common than you think. 
• Learn more from the National Center for Missing and Exploited Children .

How to report suspected online child sexual exploitation and abuse in the United States:

• Contact your local, state, campus, or tribal law enforcement officials directly. Call 911 in an emergency.
• If you suspect a child has been abducted or faces imminent danger, contact your local police and the NCMEC tip line at 1-800-THE-LOST (1-800-843-5678) .
• If you suspect a child might be a victim of online sexual exploitation, call the HSI Tip Line at 1-866-347-2423 and report it to NCMEC’s CyberTipline .
• Law Enforcement
• Child Exploitation

• +1 202 467 8700
• [email protected]
• For victim services click here

The mission of the National Center for Victims of Crime is to forge a national commitment to help victims of crime rebuild their lives. We are dedicated to serving individuals, families, and communities harmed by crime.

Child sexual abuse statistics.

The prevalence of child sexual abuse is difficult to determine because it is often not reported; experts agree that the incidence is far greater than what is reported to authorities. CSA is also not uniformly defined, so statistics may vary. Statistics below represent some of the research done on child sexual abuse.

The U.S. Department of Health and Human Services’ Children’s Bureau report  Child Maltreatment 2010  found that  9.2%  of victimized children were sexually assaulted (page 24).

Studies by  David Finkelhor , Director of the  Crimes Against Children Research Center , show that:

• 1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse;
• Self-report studies show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident;
• During a one-year period in the U.S., 16% of youth ages 14 to 17 had been sexually victimized;
• Over the course of their lifetime, 28% of U.S. youth ages 14 to 17 had been sexually victimized;
• Children are most vulnerable to CSA between the ages of 7 and 13.

According to a  2003 National Institute of Justice report , 3 out of 4 adolescents who have been sexually assaulted were victimized by someone they knew well (page 5).

A  Bureau of Justice Statistics report  shows 1.6 % (sixteen out of one thousand) of children between the ages of 12-17 were victims of rape/sexual assault (page 18).

A study conducted in 1986 found that 63% of women who had suffered sexual abuse by a family member also reported a rape or attempted rape after the age of 14. Recent studies in 2000, 2002, and 2005 have all concluded similar results.

Children who had an experience of rape or attempted rape in their adolescent years were 13.7 times more likely to experience rape or attempted rape in their first year of college.

A child who is the victim of prolonged sexual abuse usually develops low self-esteem, a feeling of worthlessness and an abnormal or distorted view of sex. The child may become withdrawn and mistrustful of adults, and can become suicidal.

Children who do not live with both parents as well as children living in homes marked by parental discord, divorce, or domestic violence, have a higher risk of being sexually abused.

In the vast majority of cases where there is credible evidence that a child has been penetrated, only between 5 and 15% of those children will have genital injuries consistent with sexual abuse.

Child sexual abuse is not solely restricted to physical contact; such abuse could include  noncontact abuse , such as exposure, voyeurism, and child pornography.

Compared to those with no history of sexual abuse, young males who were sexually abused were five times more likely to cause teen pregnancy, three times more likely to have multiple sexual partners and two times more likely to have unprotected sex, according to the study published online and in the June print issue of the Journal of Adolescent Health.

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Child sexual abuse content growing online with AI-made images, report says

More children and families extorted with AI-made photos and videos, says National Center for Missing and Exploited Children

Child sexual exploitation is on the rise online and taking new forms such as images and videos generated by artificial intelligence, according to an annual assessment released on Tuesday by the National Center for Missing & Exploited Children (NCMEC), a US-based clearinghouse for the reporting of child sexual abuse material.

Reports to the NCMEC of child abuse online rose by more than 12% in 2023 compared with the previous year, surpassing 36.2m reports, the organization said in its annual CyberTipline report. The majority of tips received were related to the circulation of child sexual abuse material (CSAM) such as photos and videos, but there was also an increase in reports of financial sexual extortion, when an online predator lures a child into sending nude images or videos and then demands money.

Some children and families were extorted for financial gain by predators using AI-made CSAM, according to the NCMEC.

The center received 4,700 reports of images or videos of the sexual exploitation of children made by generative AI, a category it only started tracking in 2023, a spokesperson said.

“The NCMEC is deeply concerned about this quickly growing trend, as bad actors can use artificial intelligence to create deepfaked sexually explicit images or videos based on any photograph of a real child or generate CSAM depicting computer-generated children engaged in graphic sexual acts,” the NCMEC report states.

“For the children seen in deepfakes and their families, it is devastating.”

AI-generated child abuse content also impedes the identification of real child victims, according to the organization.

Creating such material is illegal in the United States, as making any visual depictions of minors engaging in sexually explicit conduct is a federal crime, according to a Massachusetts-based prosecutor from the Department of Justice, who spoke on the condition of anonymity.

In total in 2023, the CyberTipline received more than 35.9m reports that referred to incidents of suspected CSAM, more than 90% of it uploaded outside the US. Roughly 1.1m reports were referred to police in the US, and 63,892 reports were urgent or involved a child in imminent danger, according to Tuesday’s report.

There were 186,000 reports regarding online enticement, up 300% from 2022; enticement is a form of exploitation involving an individual who communicates online with someone believed to be a child with the intent to commit a sexual offense or abduction.

The platform that submitted the most cybertips was Facebook, with 17,838,422. Meta’s Instagram made 11,430,007 reports, and its WhatsApp messaging service made 1,389,618. Google sent NCMEC 1,470,958 tips, Snapchat sent 713,055, TikTok sent 590,376 and Twitter reported 597,087.

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In total, 245 companies submitted CyberTipline reports to the NCMEC out of 1,600 companies around the world who have registered their participation with the cybertip reporting program. US-based internet service providers, such as social media platforms, are legally mandated to report instances of CSAM to the CyberTipline when they become aware of them.

According to the NCMEC, there is disconnect between the volumes of reporting and the quality of the reports submitted. The center and law enforcement cannot legally take action in response to some of the reports, including ones made by content moderation algorithms, without human input. This technicality can prevent police from seeing reports of potential child abuse.

“The relatively low number of reporting companies and the poor quality of many reports marks the continued need for action from Congress and the global tech community,” the NCMEC report states.

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US receives thousands of reports of AI-generated child abuse content

J an 31 (Reuters) – The U.S. National Center for Missing and Exploited Children (NCMEC) said it had received 4,700 reports last year about content generated by artificial intelligence that depicted child sexual exploitation.

The NCMEC told Reuters the figure reflected a nascent problem that is expected to grow as AI technology advances.

In recent months, child safety experts and researchers have raised the alarm about the risk that generative AI tech, which can create text and images in response to prompts, could exacerbate online exploitation.

The NCMEC has not yet published the total number of child abuse content reports from all sources that it received in 2023, but in 2022 it received reports of about 88.3 million files.

“We are receiving reports from the generative AI companies themselves, (online) platforms and members of the public. It’s absolutely happening,” said John Shehan, senior vice president at NCMEC, which serves as the national clearinghouse to report child abuse content to law enforcement.

The chief executives of Meta Platforms  (META.O) , X, TikTok, Snap  (SNAP.N)  and Discord testified in a Senate hearing on Wednesday about online child safety, where lawmakers questioned the social media and messaging companies about their efforts to protect children from online predators.

Researchers at Stanford Internet Observatory said in a  report in June,  that generative AI could be used by abusers to repeatedly harm real children by creating new images that match a child’s likeness.

Content flagged as AI-generated is becoming “more and more photo realistic,” making it challenging to determine if the victim is a real person, said Fallon McNulty, director of NCMEC’s CyberTipline, which receives reports of online child exploitation.

OpenAI, creator of the popular ChatGPT, has set up a process to send reports to NCMEC, and the organization is in conversations with other generative AI companies, McNulty said.

Reporting by Sheila Dang in Austin, Editing by Kylie MacLellan.

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