Child abuse in America: Prevalence and consequences

Tags: sexual abuse, physical abuse, Abuse & Neglect, abused children, sexually abused children, child abuse and neglect, Child Maltreatment, child sexual abuse, Journal of Consulting and Clinical Psychology, Psychosomatic Medicine, childhood trauma, PTSD, psychiatric symptoms, depression, risk, Psychiatric Disorders, American Academy of Child and Adolescent Psychiatry, sexual behavior problems, Journal of Interpersonal Violence, Journal of Adolescence, Maltreatment, physical child abuse, Child Psychology, Journal of Clinical Child Psychology, abuse and neglect, National Center on Child Abuse and Neglect, U.S. Department of Health and Human Services, Journal of Child and Family Studies, Administration for Children and Families, American Journal of Psychiatry, Child and Adolescent Psychiatry, Journal of Family Violence, Journal of American Child Adolescent Psychiatry, Journal of Experimental Psychology, American Journal of Orthopsychiatry, conduct disorder, A.J. & Broadhurst, Center on Child Abuse Prevention Research, Harvard Rev Psychiatry, emotional and behavioral disorders, attention deficit hyperactivity disorder, antisocial personality disorder, American Humane Society, American Psychological Association, traumatic experience, Childhood Trauma Questionnaire, child protective services, American Humane Association, childhood victimization, emotional abuse, post traumatic stress disorder, childhood neglect, chronic health problems, Cycle of Violence, Childhood & Adolescence, longitudinal study, DSM criteria, prevalence, separation anxiety disorder, bipolar disorder, major depression, borderline personality disorder, oppositional defiant disorder, neglected children, dissociative disorders
Content: Journal of Aggression, Maltreatment, and Trauma, 2001. CHILD ABUSE IN AMERICA: PREVALENCE AND CONSEQUENCES Bessel A. van der Kolk, M.D. James Hopper, Ph.D. Joseph Crozier, BA Trauma Center; 227 Babcock Street Brookline, MA 02446 Dept of Psychiatry, Boston University School of Medicine ABSTRACT Childhood abuse and neglect is a serious problem in the United States; each year, over three million children are reported abused and/or neglected. One million of these reports are substantiated; however, more than half of the confirmed cases are closed on the day of substantiation. Research has shown that a range of psychiatric symptoms and disorders in child- and adulthood are associated with early trauma, including depression, posttraumatic stress disorder, borderline personality disorder, substance use, suicidality, selfmutilation, somatization, sexual behavior problems, dissociative disorders, and learning disorders. Moreover, abusive childhood experiences have been associated with increased risks of violent offending and being a victim of violence. Childhood abuse and neglect is a major public health problem cannot only dramatically affect the quality of life of many individuals, but also is enormously expensive for society at large. The present paper reviews both the prevalence of childhood abuse and neglect as well as its psychiatric and general health sequelae in child- and adulthood. 1
Demographics of Child Maltreatment in America Total Incidences of Reported and Substantiated Abuse in America In 1997, an estimated 3,195,000 children were reported to the Child Protective Services (CPS) nationwide for being abused and/or neglected (Wang and Daro, 1997). The number of child abuse/neglect cases being reported to the CPS has risen steadily since 1988. Despite the marked increase in cases being reported for investigation, the number of substantiated cases of child abuse and neglect has remained virtually unchanged since 1993 (see Figure 1). From 1993 to 1997, the number of substantiated cases has involved 15 out of every 1,000 children each year (Wang and Daro, 1997). Wang and Daro further estimated that 1185 children died in 1996 due to child abuse and neglect. This represents a 34% increase over the estimate of 798 children in
1985.
Total Reported and Confirmed Cases of Child Maltretament (1988 - 1997)
3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 1988 1990 1992 1994 1996
Reported Confirmed
Types of Abuse
A breakdown of the different types of abuse occurring in substantiated CPS cases is shown in Figure 2. Neglect was the most common form of abuse accounting for 52% of all cases. Physical abuse ranked second and occurred in 26% of cases. Sexual abuse cases were the third most common, representing 7% of all cases. Emotional abuse cases represented 4% of all reports, and 11% of cases fell into a miscellaneous "other" category. Types of cases that fell into the "other" category included multiple types of maltreatment, medical and educational neglect, substance and/or alcohol abuse or dependency, lack of supervision, threat of harm, "bizarre" discipline and imminent risk (Wang and Daro, 1997).
2
Other 11% Emotional Abuse 4% Neglect 52%
Physical Abuse 26% Sexual Abuse 7%
Types of Abuse
Relationship of the Victim to the Perpetrator in Substantiated Cases of Abuse The overwhelming majority of perpetrators of violence against children were the parents of the children themselves, constituting 81% of the total population of child abuse/neglect perpetrators. Other relatives of the child made up 10.6 % of the total perpetrator population. Only 8.4% of perpetrators, therefore, were not related to the child they abuse/neglect in any way. The relationships of victims to perpetrators are summarized in Figure 3 (CWLA, 1997). Among substantiated cases of maltreated children, 65% were victimized by a female and 54% by a male. The type of abuse was related to the gender of the perpetrator. Children were twice as likely to be neglected by females than males, 87% versus 43%, respectively. This is consistent with the fact that women still represent the vast majority of primary caregivers. Males were more likely to physically abuse children than females, 67% versus 40%, respectively. Sexual abuse was the category most strongly linked with males: 89% of sexually abused children were abused by males and 12% by females (Abbreviated NIS-3). According to NIS-3, girls were sexually abused three times more often than boys, while boys had a 24% greater risk of serious injury from abuse and were 18% more likely to be emotionally neglected.
FIGURE 3: Relationship of Victims to Perpetrators
90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0%
81.0% 10.6% 5.0% 1.1% 0.5% 0.4% 3.4%
Unknown Facility Staff Foster Parents Child Day Care Providers Noncaregivers Other Relative Parents
3
The Relationship Between Family Structure/Income and Maltreatment Coming from a single-parent household was a grave risk factor for child maltreatment. Children in single-parent families had a greater risk of being harmed by physical abuse, emotional neglect, educational neglect, and sexual abuse. Furthermore, within single-parent homes, if the single parent was a father rather than a mother, the children had an approximately one to two thirds greater chance of being physically abused. Obvious explanations for why single parenting is such an aggravating factor in child maltreatment include the added stresses of being a single parent and having inadequate social, emotional and financial support (NIS-3). Family Size was also an important consideration. The relationship was non-linear. Children from large families (with 4 or more children) were at greatest risk for educational and physical neglect. Children from medium-sized families (2-3 children) were at lowest risk for maltreatment. Children from large families were 3 times more likely than their peers from medium sized families to be educationally neglected and more than two times more likely to be physically neglected. According to a DHHS study performed in 1993, between 40 and 50% of child maltreatment incidences occurred in families with income below the poverty level (less than 15% of all families have income in this range). Another 40 to 50% of maltreatment incidences occurred in approximately 35% of American families whose income is less than national median, but above the poverty level. Thus, approximately 90% of all child maltreatment incidences occur in families whose income is below the national median while less than 10% of maltreatment incidences occur in families whose income is greater than the national median. Compared to children in families whose income is above the national median, children in families below the median but above poverty level are five to seven times more likely to be abused; children in families below poverty level are 13 to 17 times more likely to be abused. Consequences of Child Maltreatment Psychobiology of Maltreatment A detailed discussion of the psychobiology of maltreatment is beyond the scope of the present paper; therefore, only a brief summary of the psychobiological effects of maltreatment will be presented here. Maltreatment of children has been suggested to not only impair the normal development of the brain but also to have lasting effects on cognition, behavior, affect and social interaction (Perry et al., 1996). It is generally well accepted that the organizing brains of infants or young children are more malleable to experience than are mature brains. It is therefore not surprising that early traumatic events can have significant long lasting effects. In fact, early traumatic experiences have been shown to have chronic effects on several physiological systems, including certain neurotransmitter systems, neuroendocrine systems, and the immune system (Putnam and Trickett, 1997). Putnam and Trickett reported elevated 24-hour urinary catecholamines in sexually abused girls compared to controls. When corrected for height, only homovanillic acid levels were significantly different; however, there were trends for total catecholamine synthesis, metananephrine, and vanillylmandelic acid. With regards to neuroendocrine systems, significant dysregulation of the hypothalamic-pituitary axis (HPA) has been shown in sexually abused girls. Maltreated girls showed increases in cortisol secretion to minor stressors compared to controls. In addition, they showed significantly lower basal- and 4
CRF-stimulated ACTH levels as well as reduced ACTH responses. Their 24-hour urinary free cortisol levels did not differ from those of controls. Even though these data differ somewhat from those reported for combat-related PTSD, they are compatible with the overall finding of HPA dysregualtion in PTSD (see below for details). In terms of immune function, DeBellis et al. have demonstrated a twofold increase of plasma antinuclear antibodies in abused subjects compared to controls. The presence of high antinuclear antibody levels is thought to reflect failure of the immune system to suppress autoreactive lymphocytes. In adults, traumatic experiences have also been shown to affect neurotransmitter and neuroendocrine systems. Kosten et al. (1987) reported elevated 24-hour excretions of urinary norepinephrine and epinephrine in PTSD combat veterans, compared to patients with other psychiatric diagnoses. In support of these data, Perry et al. (1987) reported a down-regulation of alpha 2-adrenergic receptors in platelets of combat vets compared to normal controls. Moreover, yohimbine has been shown to precipitate panic attacks and flashbacks in PTSD patients. Yehuda et al. also found that dopamine levels were significantly correlated with intrusive flashbacks, avoidance, and hyperarousal symptoms in Vietnam veterans. Evidence for a role of serotonin in PTSD comes from a study that showed metacholorophenylpiperazine (m-CPP), a serotonin agonist, resulted in panic attacks and flashbacks in approximately one third of subjects. In addition, serotonin reuptake blockers have been reported to be effective in the treatment of PTSD. The opioid system has also been shown to be affected by traumatic experiences. Studies demonstrated that patients with PTSD developed opioid-mediated analgesia in response to a stimulus resembling the traumatic stressor, which correlated with a secretion of endogenous opioids equivalent to 8 mg of morphine (van der Kolk et al., 1989). Data also support a role for the HPA axis in the pathophysiology of PTSD. To date, several studies have shown significantly lower urinary cortisol levels in trauma survivors with PTSD than in similarly exposed trauma survivors without PTSD and/or non-psychiatric comparison subjects. It is interesting to note that in studies of combat veterans and Holocaust survivors, cortisol levels were significantly associated with the severity of PTSD symptoms. The expected compensatory up-regulation of glucocorticoid receptors in response to decreased levels of cortisol have also been demonstrated in three studies of combat veterans and one study of adult survivors of childhood sexual abuse. Consistent with the findings of low cortisol and increased glucocorticoid receptor number, the cortisol response to dexamethasone was also shown to be enhanced in PTSD. The augmented cortisol response to dexamethasone in PTSD has been suggested to result from a reduced ability of dexamethasone to exert negative feedback inhibition on the release of CRF and ACTH. Reduced glucocorticoid receptor activity is likely to play a role in this negative feedback inhibition. Further evidence for negative feedback inhibition of the HPA axis comes from studies that have demonstrated increased CRF release in PTSD. It has further been hypothesized that the blunted ACTH response of CRF results from a decreased number of CRF receptors in the pituitary gland. In conclusion, the previously discussed literature suggests that trauma, whether of childhood origin or adult origin, has similar effects on sympathetic nervous system activity and the HPA axis. Moreover, since studies of adult survivors of childhood sexual abuse have shown similar neuroendocrine and neurotransmitter abnormalities to those found in maltreated children (Stein 5
et al., Putnam), it is likely that the psychobiological effects of childhood trauma are pervasive and continue to have a negative impact on adult functioning. Effects of Maltreatment in Childhood & Adolescence Psychiatric Sequelae of Maltreatment in Childhood & Adolescence The devastating consequences of child maltreatment are manifested in numerous facets of a child's life from decreased performance at school to diminished physical and mental health to increased deviant behavior. Multiply abused infants and toddlers often experience developmental delays across a broad spectrum, including cognitive, language, motor, and socialization skills (Culp, Heide, and Richardson, 1987). Research has also shown that a range of psychiatric symptoms and disorders are associated with early trauma, including depression, post-traumatic stress disorder, borderline personality disorder, substance use, suicidality, selfmutilation, somatization, sexual behavior problems, dissociative disorders, and criminal behavior (Trickett and McBride-Chang; Putnam; Herman et al.; van der Kolk et al., 1996). The section below highlights some of the consequences of early trauma and presents evidence from the child and adolescent maltreatment literature. Table 1 illustrates the prevalence of psychopathology in maltreated and non-maltreated children. The results are presented for victims of sexual abuse, physical abuse, combined physical and sexual abuse, and controls. This table clearly shows that children who have been traumatized physically and/or sexually are at significantly increased risk for developing a variety of psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, major depression, dysthymia, separation anxiety disorder, bipolar disorder, phobias, obsessive-compulsive disorder, and PTSD. Similar results were found in a survey from an ongoing longitudinal study of 384 18-year old subjects from mostly white, working or lower middle income level families. Findings indicate that 43% experienced some form of trauma, and 6.3% of the total, or 14.5% of those experiencing trauma, were diagnosed with PTSD based on a DSM criteria survey (Giaconia et al., 1995). Tables 2 and 3 depict the prevalence of various psychiatric disorders and problem behaviors among the three groups of subjects in this study. The first group met criteria for PTSD, the second group had a trauma history but did not meet criteria for PTSD, and the third group had no history of trauma. Adolescents who met criteria for PTSD or had a trauma history showed a significantly increased prevalence of major depression, phobias, alcohol and drug dependence as well as multiple comorbid psychiatric diagnoses. Attempted suicide was 16 times more likely to occur in adolescents who met criteria for PTSD compared to adolescents with no trauma history (see Table 3). Table 1. 6
ABUSE GROUPS
Diagnoses ADHD Oppositional Defiant Disorder Conduct Disorder Major Depression Bipolar Disorders Dysthymia Separation Anxiety/Overanxious Phobic Obsessive-Compulsive PTSD
Total % 29 36 21 13 9 19 59 36 14 34
Sexual (N=127)
Boys Girls
%
%
40
22
46
22
44
11
12
11
4
9
16
13
44
58
44
36
0
14
20
35
Physical (N=43)
Boys Girls
%
%
36
10
56
20
21
10
12
20
9
20
24
20
48
100
24
30
18
20
18
50
Both (N=34)
Boys Girls
%
%
67
26
64
47
67
21
8
32
0
21
17
42
59
79
25
58
8
27
58
53
Control* % 3-5 6.5 3.9 0.4-8.3 1 2.9-4.6 2.4-9.2 0.5 >6
*Based on various studies. Source: Ackerman et al., 1998. Subjects included 62% outpatients, 25% inpatients, and 13% were referrals from local agencies.
Table 1: Prevalence of Psychiatric Disorders in Maltreated and Non-Maltreated Children
Table 2.
Lifetime Current (1 Yr)
Psychiatric Disorder % of Group % of Group
Major Depression
PTSD
41.7
29.2
Trauma Only
9.2
7.1
No Trauma
5.9
4.6
Phobia
PTSD
29.2
29.2
Trauma Only
12.1
10.6
No Trauma
8.7
7.8
Alcohol Dependence
PTSD
45.8
37.5
Trauma Only
31.4
27.9
No Trauma
16.6
15.7
Drug Dependence
PTSD
25.0
20.8
Trauma Only
14.9
12.8
No Trauma
3.7
1.8
Two or More Disorders
PTSD
45.8
41.7
Trauma Only
23.4
21.3
No Trauma
12.3
9.6
Three or More Disorders
PTSD
33.3
20.8
Trauma Only
7.1
3.5
7
No Trauma
2.3
0.9
Table 2: Prevalence of Psychiatric Disorders in Maltreated and Non-Maltreated Children
Table 3.
Risk Area
% of Group
Clinical Range on Internalizing Problems^
PTSD
16.8
Trauma Only
DNA
No Trauma
4.6
Clinical Range on Externalizing Problems^
PTSD
33.3
Trauma Only
13.5
No Trauma
4.1
Attempted Suicide
PTSD
16.7
Trauma Only
5.7
No Trauma
1.8
Rated Health as "Fair of Poor"
PTSD
37.5
Trauma Only
21.3
No Trauma
10.0
>= 3 Sick Days/Month in Past Year
PTSD
25.0
Trauma Only
12.2
No Trauma
5.1
Suspended/Expelled in Past Year*
PTSD
25.0
Trauma Only
37.6
No Trauma
26.9
*Not Statistically Significant
^Based on Youth Self Report (YSR)
Table 3: Prevalence of Problem Behaviors in Maltreated and Non-Maltreated Children Kendall-Tackett et al. (1991) reported that in a sample of sexually abused children, 68% exhibited anxiety symptoms, 41% had depressive symptoms, 31% showed regressive symptoms, and 36% engaged in inappropriate sexual behaviors. Wolfe et al. (1994) showed that in a sample of 90 abused children and adolescents 80% met DSM-based PTSD reexperiencing criteria, 64% met PTSD avoidant criteria, 67% met PTSD hyperarousal criteria, and 49% met PTSD criteria. Based on Wave II (new cases of abuse and neglect) of NIMH's Epidemiologic Catchment Area Study, 15% of abused children, 21% of neglected children, and 6% of the control group were found to have substance abuse disorders (Chaffin, Kelleher, and Hollenberg, 1996). Clark et al. (1997) also found elevated risks for alcohol dependence and alcohol abuse among victims of physical and sexual abuse. 8
The previously discussed literature clearly points out that Traumatized Children receive a multitude of psychiatric diagnoses as a result of the great range of symptoms they exhibit. However, none of these diagnoses allow the behavioral and psychiatric symptoms to be viewed in the context of the traumatic experience. Putnam (1988) has suggested that a wide range of symptoms, including depression, aggression, hypersexuality, suicide, self-mutilation (and risk taking), dissociation, problems with affect regulation, somatization, impulsivity, hyperactivity and attentional problems, low self-esteem, and other disturbances of self-image are among the more common symptoms reported in maltreated children. Unfortunately, however, the DSM not only includes an alternate set of developmentally relevant symptoms for children and adolescents, nor does it capture the wide range of symptoms patients with chronic abuse histories often demonstrate. Trauma researchers have recently proposed that a diagnosis of complex PTSD/ Disorder of Extreme Stress Not Otherwise Specified (DESNOS) be added as a new diagnostic category (van der Kolk et al., 1996). This diagnosis was developed to capture the range of symptoms patients with histories of chronic maltreatment often exhibit. The diagnosis consists of seven different problem areas which research has shown to be associated with early, chronic interpersonal trauma (REF): (1) problems with affect regulation, including difficulty with modulation of anger and self-destructiveness, (2) alterations in attention and consciousness leading to amnesias and dissociative episodes, (3) alterations in self-perception, including chronic feeling of guilt and shame, (4) difficulties with interpersonal relationships, including problems with trust and feelings of intimacy with other people, (5) somatization symptoms for which no medical problem can be found, and (6) alteration in the systems of meaning, including chronic feelings of hopelessness. Distinguishing the symptoms resulting from prolonged interpersonal trauma from single traumatic events such as car accidents or disasters may have important implications for the treatment of PTSD. PTSD patients who also have a diagnosis of DESNOS may be treatment resistant to conventional treatment such as prolonged exposure and cognitive restructuring (Ford and Kidd, 1998). It therefore becomes crucial to acknowledge the symptoms of complex PTSD in order to make use of appropriate treatment strategies (see also section on treatment implications). Effects of Maltreatment on Learning/Occupational Functioning Research has shown that maltreated children have more behavioral problems and perform significantly worse in school (Daro, 1988). Thirty percent of abused children have been reported to have some type of language or cognitive impairment, over 50% have difficulties in school, including poor attendance and misconduct, 22% have a learning disorder, and approximately 25% require special education services (Caldwell, 1992; Giaconia, 1995). These data are supported by Culbertson and Willis (1988), who demonstrated that abused children experience developmental delays in many areas, including cognitive and language skills. Neglected boys have also been reported to have lower IQ's than physically abused and nonmaltreated groups of boys, and physically abused and neglected girls have been shown to have lower IQ's than nonmaltreated girls (Rogeness, et al., 1986). With regards to occupational functioning during adulthood, a survey found that incest victims were twice as likely as nonvictims to be unemployed. Additionally, women who reported experiencing serious trauma were more likely 9
to have "negative socioeconomic outcomes" (Russell, 1986), and maltreated children showed higher rates of disability after their maltreatment (Sullivan and Knutson, 1998). Effects of Maltreatment on Criminal Behavior Abused and neglected children have been reported to have a higher likelihood of arrests for delinquency, adult criminality, and violent criminal behavior compared to matched controls (Widom and Maxfield, 1997). In a prospective study using a matched control group, Widom and Maxfield (1997) found that maltreated children were 1.8 times more likely to be arrested as a juvenile, 1.5 times more likely to be arrested as an adult, and 1.35 times more likely to be arrested for a violent crime. Results have also shown that the majority of juvenile offenders are arrested again as adults, although adult arrest rates for juvenile offenders differ slightly between maltreated and nonmaltreated groups, 71% for the maltreated group versus 66% for the nonmaltreated group (Widom and Maxfield, 1997). Maltreated children also have more involvement with the juvenile justice system (Lewis et al., 1989), and research has shown that 20% of maltreated children are convicted for a serious juvenile crime (McCord, 1983 and Lewis et al., 1989). It is also important to note that a strong correlation has been reported to exist between delinquent behavior and later criminal behavior (Loaber and LeBlanc, 1990). Effects of Child Maltreatment in Adulthood Psychiatric Sequelae of Child Maltreatment in Adulthood There is now substantial evidence that people with histories of childhood abuse and neglect suffer from profound and pervasive psychiatric disturbances during adulthood (McCord; Roesler & McKenzie; McCauley et al.; Widom, Levitan). McCord conducted a 40-year follow up study of 97 abused or neglected boys. In this group, 44 (45%) had become criminal, alcoholic, mentally ill, or had died before reaching age 35 (McCord, 1983). Roesler and McKenzie (1994) used standardized symptom measures to determine the effect of childhood trauma experiences on adults sexually victimized as children. One hundred eighty-eight sexually abused individuals were tested for mean scores for depression, self-esteem, sexual dysfunction, PTSD symptoms, and dissociation. Even after controlling for nonsexual-abuse trauma, sexual abuse contributed significantly to all symptom measures with the most change in variance noted for dissociation (20.5%). In a study including 424 women with a history of childhood abuse, a clear association between early traumatic events and adult psychological problems was also established. Women who had been physically and/or sexually abused as children had higher scores for both depression and anxiety, lower scores for self-esteem, and were more likely to have attempted suicide than women who had not been traumatized as children (McCauley et al., 1997). Similar findings were reported by Levitan et al. (1998) who demonstrated that a history of physical or sexual abuse was associated with major depression with reversed neurovegetative features, including increased appetite, weight gain, and hypersomnia. A strong relationship between mania and childhood physical and sexual abuse was also demonstrated. Widom (1999) examined the extent to which childhood abuse and neglect increase a person's risk for subsequent PTSD and determined whether the relationship to PTSD persists despite 10
controls for family, individual, and lifestyle characteristics associated with both childhood victimization and PTSD. Results indicated that childhood victimization is associated with increased risk for lifetime PTSD. Approximately one third of childhood victims of sexual abuse, physical abuse and childhood neglect met DSM criteria for lifetime PTSD. The capacity for affect-regulation has often been shown to be impaired in patients with chronic abuse histories. Problems with affect-regulation are often associated with severe, rapid fluctuations in mood, ranging from overwhelming feelings of anger, despair, and hopelessness to feelings of calmness in a matter of hours. Patients exhibiting such difficulties commonly experience minor stressors as overwhelming and engage in self-destructive behaviors such as self-injury, attempting suicide, and binging, purging, or starving themselves in an attempt to gain mastery over their fluctuations of affect (van der Kolk, 1991; Garner and Garfinkel; Herzog et al; Deep et al., 1999). It is thus not surprising that childhood trauma has been associated with the development of Borderline Personality Disorder (Herman et al., 1989; Ogata et al., 1989), a disorder that often involves chronic affect dysregulation manifested by severe fluctuations in mood. Although the connection between early childhood victimization and subsequent alcohol use has led to contradictory findings (Bensley et al., 1999; Widon et al., 1995), data have shown a high prevalence of positive trauma histories in intravenous drug users (IVDU) (Medrano et al., 1999). Medrano et al. estimated the prevalence of positive trauma histories in a community sample of IVDU women for five subsets of childhood trauma, including emotional abuse or neglect, physical abuse or neglect, and sexual abuse and compared demographic variables between the abused and nonabused groups. Of the 181 women who completed the Childhood Trauma Questionnaire (CTQ), 109 (60.2%) were sexually abused, 100 (55.2%) were physically abused, 83 (45.9%) were emotionally abused, 151 (83.4%) were emotionally neglected, and 108 (59.7%) were physically neglected. Cycle of Violence Data have shown that 20% of parents who were abused as children go on to abuse their own children (Strauss et al., 1980). Seventy-five percent of perpetrators of child sexual abuse reported that they had been sexually abused themselves (Romano and De Luca, 1997). Various studies have demonstrated that men who have experienced or witnessed physical abuse in childhood are more likely to act violently against their female partners (Fagan, Stewart, and Hanson, 1983; Hamberger and Hastings, 1991; Hotaling and Sugarmen, 1986), and physical abuse and neglect are associated with the highest rates of arrest for violent offenses (Widom and Maxfield, 1997) as well as with the development of antisocial personality disorder (Luntz and Widom, 1994). Maxfield and Widom (1996) reported that by age 32 years, almost half of the victims of abuse and neglect were arrested for a nontraffic offense. These data clearly indicate that childhood abuse and neglect perpetuate violence in adulthood as well as in generations to come and thus promote a cycle of violence. Effects of Maltreatment on General Health Daro (1988) has shown that 30% of abused children have chronic health problems, and 3.2% of abused children require hospitalization for serious injuries secondary to child abuse. In a survey 11
of patients from a pediatric intensive care unit, 1.4% of admissions were due to child abuse, 17% of deaths were due to child abuse, and child abuse patients had the highest "Severity of Illness" scores (Irazuzta, 1997). Felitti et al. (1998) reported that persons who have experienced 4 or more categories of child maltreatment and/or household dysfunction are more likely to engage in health-risk behaviors and have poorer adult health outcomes during adulthood than those reporting fewer of these experiences. The group of people who experienced significant maltreatment showed a 4-12 times greater risk for alcoholism, depression, drug abuse, and suicide attempts, a 2-4 times greater risk for smoking, poor self-rated health, 50 sex partners, and sexually transmitted disease, a 1.4-1.6 times greater risk for physical inactivity and obesity, and a 1.6-2.9 times greater risk for ischemic heart disease, cancer, chronic lung disease, skeletal fractures, hepatitis, stroke, diabetes, and liver disease. Moreover, women with sexual abuse histories compared to those without abuse histories have been shown to be at increased risk for suffering from chronic pelvic pain (Walker et al., 1988), gastrointestinal problems (Drossman, 1992; Drossman et al., 1982, 1990, 1994; Leserman et al. 1996; Scarinci et al., 1995) and neurological complaints, including headaches and backaches (Berkowitz, 1998). Lesserman et al. (1988) also demonstrated that women with severe abuse histories have worse physical health, greater pain, greater number of non-GI somatic symptoms, greater number of days disabled by illness, and greater number of physician visits and greater functional distress. Given the multitude of medical problems associated with child maltreatment, it is not surprising that health service utilization was reported to be 2.5 times greater in college women who reported childhood sexual abuse compared to the control group (Berkowitz, 1998). Moreover, a recent study demonstrated that women who reported sexual abuse had median annual health care costs that were $245 greater than costs among women who did not have a history of abuse (Walker et al., 1999). The authors propose that although the absolute cost differences per year per woman were relatively modest, the large number of women in the population with sexual abuse histories suggests that the total costs to society are substantial. Summary and Conclusions In summary, child abuse and neglect have been serious and costly problems in America for many years. Each year over 3 million children are reported abused and/or neglected. As described in the present paper, childhood trauma has been shown to have serious consequences. It has been demonstrated that a range of psychiatric symptoms and disorders during child- and adulthood, including depression, post-traumatic stress disorder, borderline personality disorder, substance use, suicidality, self-mutilation, somatization, sexual behavior problems, dissociative disorders, and learning disorders are associated with early traumatic experiences. Moreover, criminal behavior, disturbances in learning and occupational functioning, as well as general health difficulties have been shown to be significantly increased in populations that experienced childhood trauma. Given the considerable impact of childhood abuse and neglect on emotional well-being and behavior throughout the life span, it becomes crucial to view the emerging behavioral and psychiatirc problems in the context of the traumatic experience. Only if the emerging symptoms and disorders are treated in the context of the traumatic experience can the dilemmas be treated in an effective and efficient manner. 12
BIBLIOGRAPHY 1. Ackerman, P.T., Newton, J.E.O., McPherson, W.B., Jones, J.G., and Dykman, R.A. (1998) Prevalence of post traumatic stress disorder and other psychiatric diagnoses in three groups of abused children (sexual, physical, and both). Child Abuse and Neglect. 22 (8):759-774. 2. American Humane Association. (1994). Twenty years after CAPTA: A portrait of the child protective services system. 3. American Humane Society. (1996). Answers to Common Questions about Child Abuse and Neglect Fact Sheet. 4. Anderson, J.C., Williams, S., McGee, R., and Silva, P.A. (1987). DSM-III disorders in preadolescent children: Prevalence in a large sample from the general population. Archives of General Psychiatry. 44:69-76. 5. Azar, S.T. and Siegel, B.R. (1990). Behavioral treatment of child abuse: A developmental perspective. Behavior Modification. 14(3):279-300. 6. Becker, J.V., Alpert, J.L., BigFoot, D.S., Bonner, B.L., Geddie, L.F., Henggeler, S.W., Kaufman, K.L., and Walker, C.E. 1995. Empirical research on child abuse treatment: Report by the child abuse and neglect treatment working group, American Psychological Association. Journal of Clinical Child Psychology. 24 (supp.):23-46. 7. Becker, J.V., Alpert, J.L., BigFoot, D.S., Bonner, B.L., Geddie, L.F., Henggeler, S.W., Kaufman, K.L., and Walker, C.E. (1995). Empirical research on child abuse treatment: Report by the child abuse and neglect treatment working group, American psychological association. Journal of Clinical Child Psychology. 24:23-46. 8. Benjamin, R.S., Costello, E.J., and Warren, M. (1990). Anxiety disorders in a pediatric sample. Journal of Anxiety Disorders. 4:293-316. 9. Berkowitz, C.D. (1998). Medical consequences of child sexual abuse. Child Abuse & Neglect. 22(6):541-550. 10. Berliner, L. and Saunders, B.E. (1996) Treating fear and anxiety in sexually abused children: Results of a controlled 2-year follow-up study. Child Maltreatment. 1(4):294-309. 11. Bernstein, G.A., Borchardt, C.M., and Perwien, A.R.(1996). Anxiety disorders in children and adolescents: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 35:1110-1118. 12. Birmaher, B., Ryan, N.D., Williamson, D.E., Brent, D.A., Kaufman, J., Dahl, R.E., Perel, J., and Nelson, B. (1996). Childhood and adolescent depression: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 35:1427-1437. 13. Borkovec, T.D., and Castonguay, L.G. (1998). What is scientific meaning of empirically supported therapy? Journal of Consulting and Clinical Psychology. 66(1):136-142. 14. Briere, J. (1996). Treatment outcome research with abused children: Methodological considerations in three studies. Child Maltreatment. 1(4):348-352. 15. Brown, T.L., Swenson, C.C., Cunningham, P.B., Henggeler, S.W., Schoenwald, S.K., and Rowland, M.D. 1997. Multisystemic treatment of violent and chronic juvenille offenders: Bridging the gap between research and practice. Administration and Policy in Mental Health. 25(2):221-238. 16. Brunk, M., Henggeler, S.W., and Whelan, J.P. (1987). Comparison of multisystemic therapy and parent training in the brief treatment of child abuse and neglect. Journal of Consulting and Clinical Psychology. 55(2):171-178. 13
17. Caldwell, R.A. (1992). The costs of child abuse vs. child abuse prevention: Michigan's experience. Michigan Children's Trust Fund. 18. Cantwell, D.P. (1996). Attention deficit disorder: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 35:978-988. 19. Center for Mental Health Services, Department of Human Health Services. (1998). Mental, emotional and behavioral disorders in children and adolescents fact sheet. 20. Chadwick, D.L. (1998). Medical consequences of child sexual abuse: Commentary. Child Abuse & Neglect. 22(6):551-552. 21. Chaffin, M., Kelleher, K., and Hollenberg, J. (1996). Onset of physical abuse and neglect: Psychiatric, substance abuse, and social risk factors from prospective community data. Child Abuse & Neglect. 20(3):191-203. 22. Chambless, D.L., and Hollon, S.D. (1998). Defining empirically supported theories. Journal of Consulting and Clinical Psychology. 66(1):7-18. 23. Chemtob, C.M., Nakashima, J., Hamada, R.S., and Carlson, J.G. Brief treatment for Elementary School children with disaster related post traumatic stress disorder: A field study. Manuscript submitted. 24. Child Maltreatement 1995: Reports from the States to the National Child Abuse and Neglect Data System (1995). 25. Children's Defense Fund. (1998). Children in the States: 1998 United States Profile. 26. Children's Welfare League of America. (1997). Child Abuse and Neglect: A Look at the Fifty States (1997). 27. Cicchetti, D. (1995). A developmental psychopathology perspective on child abuse and neglect. J Am Acad Child Adolesc Psychiatry. 34(5):541-65. 28. Clark, D.B., Lesnick, L., and Hegedus, A.M. (1997). Traumas and other adverse life events in adolescents with alcohol abuse and dependence. Journal of the American Academy of Child Adolescent Psychiatry. 36(12):1744-1751. 29. Cohen, J.A. and Mannarino, A.P. (1996). Treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child Adolescent Psychiatry. 35(1):42-50. 30. Culp, R.E., Little, V., Letts,D., and Lawrence, H. (1991). Maltreated children's self-concept: effects of a comprehensive treatment program. American Journal of Orthopsychiatry. 61(1):114-121. 31. Daro, D. (1998). Public Opinion and Behaviors Regarding Child Abuse Prevention 1998 Survey. Center on Child Abuse and Prevention Research, National Committee to Prevent Child Abuse. 32. Davis, S.P., and Fantuzzo, J.W. (1989). The effects of adult and peer social initiations on the social behavior of withdrawn and aggressive maltreated preschool children. Journal of Family Violence. 4(3):227-248. 33. De Bellis, M.D., and Putnam, F.W. 1994. The psychobiology of childhood maltreatment. Child and Adolescent Psychiatric Clinics of North America. 3(4):663-678. 34. Deblinger, E., Lippmann, J., and Steer, R. (1996). Sexually abused children suffering posttraumatic stress symptoms: Initial treatment outcome findings. Child Maltreatment. 1(4):310-321. 35. Deblinger, E., McLeer, S.V., and Henry, D. (1990). Cognitive behavioral treatment for sexually abused children suffering post-traumatic stress: Preliminary findings. Journal of the American Academy of Child Adolescent Psychiatry. 29(5):747-752. 14
36. Deykin, E.Y., and Buka, S.L. (1997). Prevalence and risk factors for posttraumatic stress disorder among clinically dependant adolescents. American Journal of Psychiatry. 154(6):752-757. 37. Eber, L., and Nelson, C.M. (1997). School-based wraparound planning: Integrating services for students with emotional and behavioral needs. American Journal of Orthopsychiatry. 67(3):385-395. 38. Egan, K.J. (1983). stress management and child management with abusive parents. Journal of Clinical Child Psychology. 12(3):292-299. 39. Eisen, S.A., Neuman, R., Goldberg, J., True, W.R., Rice, J., Scherrer, J.F., and Lyons, M.J. (1998). Contribution of emotionally traumatic events and inheritance to the report of current physical health problems in 4042 Vietnam era veteran twin pairs. Psychosomatic Medicine. 60:533-539. 40. Elmer, E. (1986). Outcome of residential treatment for abused and high-risk infants. Child Abuse & Neglect. 10(3):351-360. 41. Fantuzzo, J.W. (1990). Behavioral treatment of the victims of child abuse and neglect. Behavior Modification. 14(3):316-339. 42. Fantuzzo, J.W., Jurecic, L., Stovall, A., Hightower, A.D., Goins, C., and Schachtel, D. (1988). Effects of adult and peer social initiations on the social behavior of withdrawn, maltreated preschool children. Journal of Consulting and Clinical Psychology. 56(1):34-39. 43. Farber, S.K. (1991). A response to "The emotional consequenes of physical child abuse" By Annaclare Van Dalen. Clinical Social Work Journal. 19(1):95-98. 44. Felitti, V.J., Anda, R.F., Nordernberg, D., Willimason, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S. (1998). Relationship of childhood abuse to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. Am J Prev Med. 14 (4):245258. 45. Fergusson, D.M., and Lynskey, M.T. (1997). Physical punishment/maltreatment during childhood and adjustment in young adulthood. Child Abuse & Neglect. 21(7):617-630. 46. Finkelhor, D. and Berliner, L. (1995). Research on the treatment of sexually abused children: a review and recommendations. Journal of American Child Adolescent Psychiatry. 34(11):1408-1423. 47. Flament, M.F., Whitaker, A. Rapoport, J.L. et al. (1998). Obsessive compulsive disorder in adolescence: an epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry. 27:764-771. 48. Friedrich, W.M. (1996). Clinical considerations of empirical treatment studies of abused children. Child Maltreatment. 1(4):345-347. 49. Friedrich, W.M., Luecke, W.J., Beilke, R.L., and Place, V. (1992). Psychotherapy outcome of sexually abused boys. Journal of Interpersonal Violence. 7(3):396-409. 50. Gabel, S., Swanson, A.J., and Shindledecker, R. (1990). Aggressive children in a day treatment program: Changed outcome and possible explanations. Child Abuse & Neglect. 14(4):515-523. 51. Garbarino, J., and Gilliam, G. 1980. Understanding Abusive Families. Lexington, Massachusetts: D.C. Heath and Company. 52. Garfield, S.L. (1998). Some comments on empirically supported treatments. Journal of Consulting and Clinical Psychology. 66(1):121-125. 53. Gianconia, R.M., Reiherz, H.Z., Silverman, A.B., Pakiz, B., Frost, A.K., and Cohen, E. (1995). Traumas and posttraumatic stress disorder in a community population of older 15
adolescents. Journal of American Academy of Child and Adolescent Psychiatry. 34:13691380. 54. Goldfried, M.R., and Wolfe. B.E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology. 66(1):143-150. 55. Greenwalt, B.C., Sklare, G., and Portes, P. 1998. The theraputic treatment provided in cases involving physical child abuse: A description of current practices. Child Abuse & Neglect. 22(1):71-78. 56. Healy,K., Kennedy, R., and Sinclair, J. (1991). Child physical abuse observed. Comparison of families without history of child abuse treated in an in-patient family unit. British Journal of Psychiatry, 158:234-237. 57. Henggeler, S.W., Cunningham, P.B., Pickrel, S.G., Schoenwald, S.K., and Brondino, M.J. 1996. Multisystemic therapy: An effective violence prevention approach for serious juvenille offenders. Journal of Adolescence. 19:47-61. 58. Henggeler, S.W., Cunningham, P.B., Pickrel, S.G., Schoenwald, S.K., and Brondino, M.J. (1996). Multisystemic therapy: An effective violence prevention approach for serious juvenile offenders. Journal of Adolescence. 19:47-61. 59. Henggeler, S.W., Schoenwald, S.K., and Munger, R.L. 1996. Families and therapies achieve clinical outcomes, systems of care mediate the process. Journal of Child and Family Studies. 5(2):177-183. 60. Henggeler, S.W., Schoenwald, S.K., and Pickrel, S.G. 1995. Multisystemic therapy: Bridging the gap between university- and community-based treatment. Journal of Consulting and Clinical Psychology. 63(5):709-717. 61. Henggeler, S.W., Schoenwald, S.K., and Pickrel, S.G. (1995). Multisystemic therapy: Bridging the gap between university- and community-based treatment. Journal of Consulting and Clinical Psychology. 63:709-717. 62. Hollon, S.D. (1996). The efficacy and effectiveness of psychotherapy relative to medications. American Psychologist. 51(10):1025-1030. 63. Holman, E.A., and Stokels, D. (1994). The environmental psychology of child sexual abuse. journal of experimental psychology. 14:237-252. 64. Hornick, J.P., and Clarke, M.E. 1986. A cost/effectiveness evaluation of lay therapy treatment for child abuseing and high risk parents. Child Abuse & Neglect. 10(3):309-318. 65. Irazuzta, J.E., McJunkin, J.E., Danadian, K., Arnold, F., and Zhang, J. 1997. Outcome and cost of child abuse. Child Abuse & Neglect. 21(8):751-757. 66. Jacobson, N.S., and Traux, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 39(1):12-19. 67. Jellinek, N.S., Little, M., Benedict, K., Murphy, J.M., Pagano, M., Poitrast, F., Quinn, D. (1995). Placement outcomes of 206 severely maltreated children in the boston juvenile court system: A 7.5-year follow-up study. Child Abuse & Neglect. 19(9): 1051-1064. 68. Johnston-Brooks, C.H., Lewis, M.A., Evans, G.W., and Whalenn, C.K. (1998). Chronic stress and illness in children: The role of allostatic load. Psychosomatic Medicine. 60:597603. 69. Jones, D.P. (1995). The outcome of intervention. Child Abuse & Neglect. 19(11):1361-1362. 70. Keller, R.A., Cicchinelli, L.F., and Gardner, D.M. 1989. Characteristics of child sexual abuse treatment programs. Child Abuse & Neglect. 13:361-368. 16
71. Kerns, D.L. (1998). Establishing a medical research agenda for child sexual abuse: historical perspective and executive summary. Child Abuse & Neglect. 22(6):453-465. 72. Kilpatrick, K.L., and Williams, L.M. (1998). Potential mediators of post-traumatic stress disorder in child witnesses to domestic violence. Child Abuse & Neglect. 22(4):319-330. 73. Kolko, D. (1987). Treatment of child sexual abuse: Programs, Progress and Prospects. Journal of Family Violence. 2(4):303-318. 74. Kolko, D.J. (1996). Clinical monitering of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse & Neglect. 20(1):2343. 75. Kolko, D.J. (1996). Clinical monitoring of treatment course in child physical abuse: Psychometric characteristics and treatment comparisons. Child Abuse & Neglect. 20(1):2343. 76. Kolko, D.J. (1996). Individual cognitive behavioral treatment and family therapy for physically abused children and their offending parents: A comparison of clinical outcomes. Child Maltreatment. 1(4):322-342. 77. Krugman, R.D. (1998). Keynote address: It's time to broaden the agenda. Child Abuse & Neglect. 22(6):475-479. 78. Kurtz, P.D., Gaudin, J.M. Jr., Wodarski, J.S., and Howing, P.T. (1993). Maltreatment and the school-aged child: School performance consequences. Child Abuse & Neglect. 17(5):581-589. 79. Lally, R. et al. (1992) More pride, less delinquency: Findings from ten-year follow up study of the Syracuse University Family Developmental Research Program. In The Zero to Three Child Care Anthology, 1984-1992. Pgs. 95-103. 80. Lanktree, C,B, and Briere, J. (1995), Outcome of therapy for sexually abused children: A repeated measures study. Child Abuse & Neglect. 19(9):1145-1155. 81. Lanktree, C.B. and Briere, J. (1995). Outcome of therapy for sexually abused children: A repeated measures study. Child Abuse & Neglect. 19(9):1145-1155. 82. Lesserman, J., Zhiming, L., Yuming, J.B.H., and Drossman, D.A. (1998). How multiple types of stressors impact on health. Psychosomatic Medicine. 60:175-181. 83. Lewinsohn, P.M., Klein, D.N., Seeley, J.R. (1995). "Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenolgy, comorbidity, and course" 84. MacMillan, H.L., MacMillan, J.H., Offord, D.R., Griffith, L. and MacMillan, A. (1994). Primary prevention of child sexual abuse: A critical review. Part II. Journal of Child Psychology and Psychiatry. 35(5):857-876. 85. MacMillian, H.L., MacMillian, J.H., Offird, D.R., Griffith, L., MacMillian, A. (1994). Primary prevention of child physical abuse and neglect: A critical review. Part I. Journal of Child Psychology and Psychiatry. 35(5):835-856. 86. Malinosky-Rummell, R., and Hansen, D.J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin. 114(1):68-79. 87. March, J.S., and Leonard, H.L. (1996). Obsessive-compulsive disorder in children and adolescents: A review of the past 10 years. Journal of Child and Adolescent Psychiatry. 34:1265-1273. 88. McGain, B. and McKinzey, R.K. (1995). The efficacy of group treatment in sexually abused girls. Child Abuse & Neglect. 19(9):1157-1169. 89. Melton, G.B., and F.D. Barry, Protecting Children from Abuse and Neglect. Guilford: New York, 1994. 17
90. Miller, T.R., Cohen, M.A., and Wiersema. Victim costs and consequences: A new look. Research report for the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. February 1996. 91. Moeller, T.P., Bachmann, G.A., and Moeller, J.R. (1993). The combined effects of physical, sexual, and emotional abuse during childhood: Long-term health consequences for women. Child Abuse & Neglect. 17:623-640. 92. National Committee on Child Abuse and Neglect Clearinghouse. (1996). National child abuse and neglect statistical fact sheet. 93. National Committee to Prevent Child Abuse. (1998). Child Abuse and Neglect Statistics. 94. Nelki, J.S. and Watters, J. (1989). A group for sexually abused young children : Unravelling the web. Child Abuse & Neglect. 13:369-377. 95. Nicol, A.R., Smith, J., Kay, B., Hall, D., Barlow, J., and Williams, B. (1988). A focused casework approach to the treatment of child abuse: A controlled comparison. Journal of Child Psychology and Psychiatry. 29(5):703-711. 96. Oates, R.K. and Bross, D.C. (1995). What have we learned about treating child physical abuse? A literature review of the last decade. Child Abuse & Neglect. 19(4):463-473. 97. Office of Juvenile Justice (OJJDP). Breaking the cycle of violence by addressing youth victimization, abuse and neglect. 98. Pelcovitz, D., and Kaplan, S. (1996). Post-traumatic stress disorder in children and adolescents. Child and Adolescent Psychiatry Clinics of North America. 3(2):449-469. 99. Perry, B.D. (1997) "Incubated in terror: Neurodevelopmental factors in the `Cycle of Violence'". In: Children, Youth and Violence: The Search for Solutions. Ed: Orlofsky, J. Guilford: New York, Pgs. 124-148. 100. Persons, J.B., and Silberschatz, G. (1998). Are results of randomized controlled trials useful to psychotherapists. Journal of Consulting and Clinical Psychology. 66(1):126-135. 101. Pfefferbaum, B.(1997). Posttraumatic stress disorder in children: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 26:1503-1511. 102. Putnam, F. (1998). Trauma models of the effects of childhood maltreatment. Journal of Aggression, Maltreatment and Trauma. 2(1,3):51-66. 103. Reams, R. and Freidrich, W. (1994). The efficacy of time-limited play therapy with maltreated preschoolers, Journal of Clinical Psychology. 50(6):889-899. 104. Roberts, R.E., Attkisson, C.C., Rosenblatt, A. (1998). Prevalence of Psychopathology among children and adolescents. American Journal of Psychiatry. 155:715-725. 105. Romano, E., and De Luca, R.V. (1997). Exploring the relationship between childhood sexual abuse and adult sexual perpetration. Journal of Family Violence. 12(1):85-98. 106. Santos, A.B., Henggeler, S.W.., Burns, B.J., Arana, G.W., and Meisler, N. 1995. Research on the field-based services: Models for reform in the delivery of mental health care to populations with complex clinical problems. American Journal of Psychiatry. 152(8):1111-1123. 107. Saunders, B.E. and Williams, L.M. (1996). 108. Schamess, G., Streider, F.H. and Connors, K.M. (1997). Supervision and staff training for children's group psychotherapy: general principles and applications with cumulatively traumatized inner-city children. International Journal of Group Psychotherapy. 47(4):399425. 109. Schoenwald, S.K., Borduin, C.M., and Henggeler, S.W. (1998) Multisystemic therapy: Changing the natural and service ecologies of adolescents and families. In M.H. Eprtein, K. 18
Kutash, & A, Duchnowski (eds.), Outcomes for children and youth with emotional and behavioral disorders and their families: Programs & evaluation best practices. Pgs.485511). 110. Schoenwald, S.K., Ward, D.M., Henggleler, S.W., Pickrel, S.G., and Patel, H. 1996. Multisystemic therapy treatment of substance abusing or dependant adolescent offenders: Costs of reducing incarceration, inpatient, and residential placement. Journal of Child and Family Studies. 5(4):431-444. 111. Sedlack, A.J. & Broadhurst, D.D. (1996). Executive summary of the third national incidence study of child abuse and neglect (NIS-3). U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth, and Families, National Center on Child Abuse and Neglect. 112. Shaffer, D., Fisher, P., Dulcan, M., Davies, M., Piacentini, J., Schwab-Stone, M.E., Lahey, B.B., Bourdon, K., Jensen, P.J., Bird, H.R., Canino, G., Reiger, D.A. (1996). The NIMH diagnositic interview schedule for children version 2.3 (DISC-2.3): Description, acceptability, prevalence rates, and performance in the MECA study. Journal of the American Academy of Child and Adolescent Psychiatry. 35:865-877. 113. Sinclair, J.J., Larzelere, R.E., Paine, M., Jones, P., Graham, K., and Jones, M. (1995). Outcome of group treatment for sexually abused females living in a group home setting. Journal of Interpersonal Violence. 10(4):533-542. 114. Stauffer, L.B. and Deblinger, E. (1996). Cognitive behavioral groups for nonoffending mothers and their sexually abused children: A preliminary treatment outcome study. Child Maltreatment. 1(1):65-76. 115. Sullivan, P.M., and Knutson, J.F. (1998). The association between child Maltreatment and disabilities in a hospital-based epidemiological study. Child Abuse & Neglect. 22(4):271-288. 116. Szykula, S.A. and Fleischman, M.J. (1985). Reducing out-of-home placements of abused children: Two controlled field studies. Child Abuse & Neglect. 9:277-283. 117. van der Kolk, B. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Rev Psychiatry. 1:253-65. 118. van der Kolk, B., Perry C., and Herman, J.L. (1991). Childhood origins of selfdestructive behavior. Am J Psychiatry. 148:1665-71. 119. Volkmar, F.R. (1996). Childhood and Adolescent Psychosis: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry. 35:843-851. 120. Volpe, R. (1984). A psychoeducational program dealing with child abuse for elementary school children. Child Abuse & Neglect. 8(4):511-517. 121. Wang, C.T., and Daro, D.(1997). Current trends in child abuse reporting and fatalities: The results of the 1997 annual fifty state survey. Center on Child Abuse Prevention Research, National Committee to Prevent Child Abuse. 122. Whiteman, M., Fanshel, D., and Grundy, J.F. (1987). Cognitive-behavioral interventions aimed at anger of parents at risk of child abuse. Social Work. 123. Widom, C.S. and Ames, M.A (1994). Criminal consequences of childhood sexual abuse. Child Abuse & Neglect. 18: 303-318. 124. Widom, C.S., and Maxfield, M.G. (1996). A prospective examination of risk for violence among abused and neglected children. Annals New York Academy of Science. :224237. 19
125. Widom, C.S., and Weeks, R.(1998) Self-reports of early childhood victimization among incarcerated adult male felons. Journal of Interpersonal Violence, June. 126. Wolfe, D.A, Edwards, B., Manion, I., and Koverola, C. (1988). Early intervention for parents at risk of child abuse and neglect: A preliminary investigation. Journal of Consulting and Clinical Psychology. 56(1):40-47. 127. Wolfe, D.A. , The role of intervention and treatment services in the prevention of child abuse and neglect. In Protecting Children from Abuse and Neglect. Eds. Melton, G. and Barry, F. Guilford: New York, 1994. 128. Wolfe, D.A. and Wekerle, C. (1993). Treatment strategies for child physical abuse and neglect: A critical progress report. Clinical Psychology Review. 13:473-500. 129. Wolfe, D.A., Sandler, J., and Kaufman, K. (1981). A competency-based parent training program for child abusers. Journal of Consulting and Clinical Psychology. 49(5):633-640. 20

File: child-abuse-in-america-prevalence-and-consequences.pdf
Title: CHILD ABUSE IN AMERICA:
Author: Research
Published: Wed Mar 5 10:31:23 2003
Pages: 20
File size: 0.47 Mb


Spirit world, 29 pages, 0.28 Mb

, pages, 0 Mb

Authors/Autores, 7 pages, 0.27 Mb
Copyright © 2018 doc.uments.com