New Directions in Child Abuse and Neglect Research (2014)

3


Causality

As the field of child abuse and neglect has progressed, theoretical models have become more complex (e.g., Belsky, 1993; Cicchetti and Lynch, 1993; Cicchetti and Toth, 1998; Cicchetti and Valentino, 2006), and the number of studies has increased dramatically. Most have reported an association or correlation between a variety of potential risk factors and child abuse and neglect, contributing to the description of the problem, but few have investigated causes. This chapter reviews the literature on the candidate explanatory factors for child abuse and neglect and considers whether it is appropriate to draw causal inferences regarding these associations. Major challenges to the field are discussed, and the committee suggests that research needs to move beyond correlational designs and analyses to test causal models.

In contrast to other areas covered in the 1993 National Research Council (NRC) report, relatively little progress has been made in understanding the causes of child abuse and neglect. Risk factors for child abuse and neglect, which have been identified by research based on nonexperimental and correlational studies, provide valuable information to practitioners working directly with abused and neglected children, as well as policy makers and researchers seeking to launch inquiries into new areas of investigation. For example, the extensive research on risk factors has been applied in the creation of valuable risk assessment tools used by many child welfare agencies to predict whether children are at low, medium, or high risk for reoccurrence of abuse or neglect based on individual case characteristics (see Chapter 5). Yet while the existing research on risk factors can help in predicting abuse or neglect for the purposes of identifying individuals and

populations in need of prevention and treatment efforts, it cannot explain why these factors result in abuse and neglect in certain situations but not in others. This limits the guidance that the research can provide for the creation and implementation of effective policies and programs. To design more effective prevention and treatment policies and interventions, therefore, a better understanding of the causal mechanisms of child abuse and neglect is required.

ESTABLISHING A CAUSAL CONNECTION

Muehrer and Koretz (1992) argue that a theoretical framework explaining the mechanisms and processes leading to certain outcomes provides the groundwork for the development and implementation of interventions that are preventive in nature. They stress the importance of identifying “factors that may play a causal, not simply correlational, role in the development of targeted outcomes” (p. 10). According to Blalock (1964), the noted methodologist and statistician, “the fact that causal inferences are made with considerable risk of error does not, of course, mean that they should not be made at all” (p. 5). Similarly, the committee believes it is important to advance the field with respect to determining the causes of child abuse and neglect.

According to formal tests of causal models, at least four conditions must be met to support the causal influence of hypothesized risk factors. First, one must demonstrate that a logical relationship exists. Second, one must demonstrate that an empirical association exists. Third, one must demonstrate that the correct temporal sequence exists. And finally, one must demonstrate that the relationship is not spurious, or due to some other characteristic or variable(s) (Hill, 1965; Schuck and Widom, 2001).

The vast majority of the existing literature on risk factors for child abuse and neglect provides a logical justification for the relationship, and numerous studies report an empirical association. Determining whether these studies meet the third criterion—demonstration of the correct temporal sequence—is more difficult and complex. One of the major problems with studies using retrospective measures of child abuse and neglect is that the temporal ordering of risk factors and abuse and neglect cannot be established reliably. Although a few prospective longitudinal studies exist (e.g., Dixon et al., 2005; Pears and Capaldi, 2001), most studies rely on cross-sectional designs, with information being collected at one point in time. Although one might assume that the temporal relationships are correct when asking parents whether they were abused as a child and at the same time asking whether they abuse their own children, memories are faulty, and questions have been raised about the validity and reliability of such measures (Gale et al., 1988; Henry et al., 1994; Ross, 1989; Squire, 1989;

White et al., 2007; Williams, 1994). According to Offer and colleagues (2000, p. 736), what one remembers depends on many factors, including “length of time since the event; frequency of the event; level of emotionality caused by the event; personal interpretation of and value placed on the event; and present expectations, needs, and beliefs” (see also Hardt and Rutter, 2004).

The fourth criterion (lack of spuriousness) has been addressed infrequently. To establish that a relationship is causal rather than spurious, one must control for variables that serve either theoretically or empirically as common covariates. Because many individual, family, and neighborhood risk factors that increase the likelihood of child abuse and neglect are also associated with other outcomes (Korbin, 1980; Leung and Carter, 1983; Widom et al., 1995), a causal relationship between those factors and child abuse and neglect becomes more credible if the relationship persists despite controls for these important covariates. At present, it is difficult to determine the nature of the association between risk factors and the perpetration of child abuse and neglect (Schuck and Widom, 2001).

Prospective longitudinal designs, ideally beginning before the birth of the child, provide an opportunity to determine the correct temporal order of risk factors and child abuse and neglect, to adjust for social and individual confounding factors as they occur, and to minimize reliance on recall and the selection of participants on the basis of outcomes (Gilbert et al., 2009). Animal analogue studies also provide an opportunity to examine these relationships systematically, but questions will remain about the extent to which findings can be generalized and the extent to which the experiences of abuse and neglect in animal models are representative of abuse and neglect in humans. Longitudinal ethnographic study designs may also offer additional perspectives on how certain life-course and everyday experiences shape child abuse and neglect (Burton et al., 2009). Ethnographies may be particularly helpful in discerning the meaning of abuse and neglect in everyday life and how one might characterize them as “normal” attributes in the lives of those mired in social and economic inequalities and uncertainty. The following excerpt from ethnographic fieldwork is illustrative of the more nuanced understanding of child abuse and neglect experiences that such research can provide:

The ten-year-old girl sat on an idle swing, chatting with the caseworker on the swing beside her. “How many times,” the girl asked, “have you been raped?” The question came casually, as if it could merely glide into the conversation. The caseworker, “Barbara,” tried to stay composed. “I said that I hadn’t, and she was surprised,” Barbara recalled. “I thought everybody had been,” she remembered the girl saying. “Her friends talked about it in school,” Barbara observed. “It’s an everyday thing.” (Shipler, 2004, p. 142)

CANDIDATE EXPLANATORY FACTORS FOR
CHILD ABUSE AND NEGLECT

This review is organized into individual-level, family, contextual, and macrosystem factors that have been hypothesized as risk factors for the abuse or neglect of children. The discussion draws on the work of Bronfenbrenner (1979) and Belsky (1980), who identified these interrelated and mutually embedded factors that contribute to child abuse and neglect. Contextual factors represent the broader social systems (e.g., employment, neighborhoods) that influence parental functioning, whereas macrosystem factors represent the social or cultural forces that contribute to and maintain abuse or neglect.

Individual-Level (Parental) Risk Factors

Individual-level (parental) risk factors for child abuse and neglect include a history of child abuse and neglect, or intergenerational transmission; early childbearing; and parental psychopathology.

History of Childhood Abuse and Neglect (Intergenerational Transmission)

The most pervasive assumption on the part of the public and some policy makers is that a parent’s past experience of abuse or neglect during childhood increases the risk for that parent to abuse or neglect his or her own children. This notion of intergenerational transmission was the premier developmental hypothesis in the field of abuse and neglect (Garbarino and Gilliam, 1980); according to these authors, however, the alleged relationship had not really “passed scientific muster” (p. 111).

Since that time, a number of studies have found evidence to support a history of child abuse or neglect as a risk factor for perpetration of abuse or neglect. Estimates are that about one-third of individuals who were abused or neglected will abuse or neglect their own children, with the proportion ranging from 25 to 35 percent (Jackson et al., 1999; Kaufman and Zigler, 1987). These figures suggest that the majority of parents with a history of abuse or neglect do not go on to abuse or neglect their own children.

Kaufman and Zigler (1987) critically reviewed the literature related to the hypothesis of intergenerational transmission of child abuse and neglect, concluding that many studies lacked the evidence needed to support the hypothesis because of weaknesses in the representative samples, in methodology, in formal definitions, and in descriptive statistics (Kim, 2009). More than 10 years later, Ertem and colleagues (2000) systematically reviewed studies of the intergenerational transmission of child physical abuse that

met two criteria: the study used information about physical abuse in two consecutive generations, and it included a comparison or nonabused group. The authors developed a scale of eight methodological standards derived from a hypothetical experimental design to examine the validity of the studies they included in their review. Among the 10 studies they reviewed, only 1 met all eight standards, 3 met more than four, and 2 met only one. Ertem and colleagues (2000) also calculated the relative risk of child abuse between the abused and nonabused parents, and found that it varied from 1.05 to 37.80 (Ertem et al., 2000; Kim, 2009).

Stith and colleagues (2009) conducted a meta-analysis of 155 studies published between 1975 and 2000 in which parents’ prior experience of abuse was included. Collectively, these studies examined 39 different risk factors for child physical abuse and 22 for neglect. Stith and colleagues found that parents’ experience of childhood abuse had a moderate effect size in predicting subsequent acts of physical abuse (d = 0.44) and a smaller, but significant, effect size in predicting neglect (d = 0.31). As Stith and colleagues (2009) note, the meta-analysis cannot make any claims about the causal relationship between the risk factors examined and child abuse and neglect outcomes because their review encompasses studies that explore causality among indicators in different directions, as well as studies with both cross-sectional and longitudinal designs.

Thornberry and colleagues (2012) also examined the strength of the evidence base for the intergenerational transmission of child abuse and neglect, including in their review studies of child neglect and sexual abuse in addition to child physical abuse. They identified 47 studies that they evaluated against 11 methodological criteria. While most of the studies reported support for the hypothesis that a parental history of child abuse and neglect is a risk factor for perpetration of abuse and neglect, the authors express concern about the predictive value of many of these studies because of methodological limitations. Most of the studies met fewer than half of the methodological criteria. Among the 9 studies deemed most methodologically sound, the results were mixed with regard to the intergenerational transmission hypothesis. Four of the studies generally supported the theory (Dixon et al., 2005; Egeland et al., 1988; Pears and Capaldi, 2001; Thompson, 2006), 3 provided very limited support for only one type of abuse or neglect (Berlin et al., 2011; Renner and Slack, 2006; Sidebotham et al., 2001), and 2 found no evidence of transmission of abusive or neglectful behavior (Altemeier et al., 1984; Widom, 1989). The authors conclude that the widespread acceptance of the theory of intergenerational transmission of abuse and neglect is unsupported by these studies given their substantial methodological limitations.

Despite the broad acceptance of parental experience of abuse and neglect as a risk factor for perpetration of abuse and neglect and despite

some progress in research on this hypothesis, the extent to which this risk factor explains the perpetration of child abuse and neglect remains unclear. Concerns remain as to the methodological validity of the evidence on this subject. A particular challenge to this body of research is the fact that experiences of child abuse and neglect need to be measured across two generations. Yet in much of the existing literature, a history of parental abuse and neglect often is measured by asking parents to recount memories across long periods of time, lessening the validity of the results. Also, a single reporter sometimes is called upon to assess a history of abuse and neglect for both generations (parent and child) (Thornberry et al., 2012; Widom, 1989). Problematic as well is when the sample is involved in parent training programs, institutionalized, or in some other specialized setting. Given society’s disapproval of various forms of family violence, this issue is of particular concern because much of the child abuse literature is based on self-reports by parents (often mothers) who are typically participants, either voluntarily or involuntarily, in groups for abusing parents (Widom, 1989).

A related issue is whether researchers should focus not on whether parents with a history of abuse directly abuse their children but on whether they consistently put them in harm’s way at the hands of others. Burton and colleagues (2009), reporting findings for the Three-City Study ethnography, indicate that many of the mothers in their sample who had suffered abuse as children serially entered and exited short-term relationships with romantic partners and often “unsuspectingly” invited abusive men into their homes and the lives of their children. In this way, mothers consistently increased the risk for abuse and neglect of their children by others, as had been done to many of them as children.

Similarly, Renner and Slack (2006) examined the relationship between mothers’ childhood experiences of family violence—including physical abuse, sexual abuse, neglect, and witnessing domestic violence—and child abuse and neglect reports to child protective services regarding their children. They found that women with a history of sexual or physical abuse in childhood were three times more likely to have both experiences of adulthood intimate partner violence and allegations of child abuse and neglect toward their own children than (compared with) women with no history of childhood sexual or physical abuse. In contrast, the study found no association between any form of victimization during childhood and perpetration of child abuse or neglect in adulthood in the absence of experiences of intimate partner violence. Renner and Slack (2006) conclude that the complex relationship among childhood experiences of abuse and neglect, adulthood experiences of intimate partner violence, and adulthood perpetration of child abuse and neglect warrants further study and may shed light on the mixed findings on intergenerational transmission.

Early Childbearing

Early childbearing has been linked to an increased risk for child abuse (Connelly and Straus, 1992). Compared with older mothers, for example, younger mothers are more likely to have children referred to child protective services for abuse and neglect or circumstances suggestive of child abuse and neglect (Parrish et al., 2011; Putnam-Hornstein and Needell, 2011). Brown and colleagues (1998) found that the relative youth of a mother at childbirth was a significant risk factor for physical abuse, sexual abuse, and neglect.

Using data from two waves of the National Institute of Mental Health’s Epidemiologic Catchment Area Study, Chaffin and colleagues (1996) separately assessed the relative impact of potential risk factors for child physical abuse and neglect in a representative community sample. To assess risk factors for their impact on the initiation of abuse and neglect, the analysis focused on parents who did not report any abuse or neglect in the first wave of the study but reported either physical abuse or neglect in the second wave. Parental age (mothers younger than 18 at the birth of their first child) was one of only two social or demographic factors shown to have a significant effect on the onset of both physical abuse and neglect, with younger parents showing a higher likelihood to commit both.

On the other hand, Klerman (1993) notes that the increased risk of child abuse and neglect for young compared with older mothers may be due in part to socioeconomic factors, such as income, education, family size, mobility, and stress. Using demographic data on parents with indicated abuse and neglect reports in 1988 and parents with children in out-of-home care in Illinois in 1990, Massat (1995) found that adolescent parents were not overrepresented among abusing and neglecting parents or among parents with children in out-of-home care, although low maternal age was associated with a number of negative outcomes for children. As Simkins (1984, p. 45) notes: “Age happens to be correlated with a large array of other variables such as the quality of prenatal and postnatal care, the socioeconomic status of the mother, and whether there are other caretakers in addition to the teenage mother.” Thus, low socioeconomic status is a risk factor for early childbearing as well as for child abuse and neglect.

Using data from the Fragile Families and Child Wellbeing Study, Lee (2009) examined the relationship between harsh parenting behaviors (self-reports that included maternal spanking) by mothers who were aged 19 or younger compared with mothers who were 26 or older at the birth of the target child. Adolescent motherhood was significantly related to harsh parenting behavior, even after controlling for demographic and maternal characteristics. It is unclear why Lee omitted mothers who were aged 20-25 at the birth of the target child and whether the study controlled for the

number of other children the mother had at the time of the birth of the target child.

A different picture emerges from an inspection of national statistics on child abuse and neglect. Table 3-1 summarizes the age of the perpetrators identified in child abuse and neglect reports by state and overall. Overall, only 6 percent of substantiated cases involve perpetrators under age 20; in contrast, 18 percent of all first-time births are to women (girls) under 20. The percentage has dropped dramatically since the 1970s, when 35 percent of all first-time births were to teens. This discrepancy between research findings and national statistics suggests a need for further exploration of the complex relationship between early childbearing and perpetration of child abuse and neglect. One question is whether a substantial proportion of teen parents who are reported/confirmed for child abuse were themselves foster children. This group of teen parents might be a good target for and benefit substantially from preventive services. Nonetheless, this body of research suggests that early childbearing may be implicated as a risk factor for child abuse and neglect, but not necessarily a causal factor.

Parental Psychopathology

Early writings reflected a belief that parental psychopathology was one of the causes of child abuse and neglect (Baumrind, 1993, 1995). While maternal mental health problems have been linked to an increased risk of child abuse and neglect (Brown et al., 1998), Wolfe (1999) found that fewer than 10 percent of abusing parents had a primary psychiatric disorder that was linked to their abusive behavior. Reviewed below is the literature on several psychiatric disorders that have been implicated in the etiology of child abuse and neglect, although few of these studies meet the criteria for drawing conclusions about causality. At present, the existing evidence suggests that specific forms of psychopathology may play a role in a parent’s abuse or neglect of a child.

In one of the rare longitudinal studies of risk for child abuse and neglect beginning in infancy, Kotch and colleagues (1995) recruited mothers of newborn infants with biomedical and sociodemographic risk factors from community and regional hospitals and local health departments in 42 counties of North and South Carolina. The study considers maternal psychopathology, along with other risk factors for child abuse and neglect. For every four at-risk mother and infant pairs, the next mother to deliver a normal newborn was recruited to serve as part of a comparison group, and both groups were interviewed shortly after giving birth. State central registries of child abuse and neglect were reviewed when each infant was 1 year old. Kotch and colleagues found that several characteristics of the mothers (education, depression, and whether the mother lived with her own

mother at age 14) were the best predictors of an abuse or neglect report. However, they also found that the number of other dependent children in the home and receipt of Medicaid were significant predictors of abuse and neglect reports, suggesting that multiple factors must be considered in thinking about causality.

Depression Several prospective studies have reported high rates of depression in abusing and neglecting parents (Kotch et al., 1999); thus, these findings meet at least one of the important criteria (correct temporal sequence) for establishing causality. Mothers who are depressed and/or anxious are at higher risk for physically abusing their children (Brown et al., 1998). Maternal depression also has been associated with childhood neglect (Bishop and Leadbeater, 1999; Brown et al., 1998; Éthier et al., 1995). Studies have shown that mothers who experience depression may be more disparaging, pessimistic, and ill tempered and less responsive to their children’s needs relative to mothers without depression (Downey and Coyne, 1990; Nolen-Hoeksema et al., 1995). Pears and Capaldi (2001) found that, in addition to a history of abuse reported by parents, disciplinary inconsistency, depression, and posttraumatic stress disorder among parents were predictive of their abuse of their male children.

In a review of the literature on this topic, Knutson and Schartz (1997) conclude that about half of the studies examined failed to support the relationship between depression and child abuse. They suggest that unexamined moderators or confounders may play a role. In addition, since most of the research on this topic is based on cross-sectional studies, the temporal order of these relationships is unknown. The link between maternal depression and child abuse may be a consequence of having engaged in abusive behavior toward a child, or depression may play a causal role in the perpetration of child abuse because depressed parents may be more likely to react to their child’s misbehavior with abuse or other forms of harsh or neglectful parenting (Belsky, 1993). The findings of the few existing prospective studies provide some evidence that maternal depression may play a causal role, but further research clearly is needed.

Substance abuse Substance (alcohol and drug) abuse is thought to be a major risk factor for the perpetration (Dubowitz et al., 2011; Ondersma, 2002) and recurrence (Jonson-Reid et al., 2010) of child abuse and neglect. Chaffin and colleagues (1996) found that parents who had a substance abuse disorder at the onset of their study were more than four times as likely as parents without such a disorder to commit physical abuse and more than 2.5 times as likely to have an episode of neglect. In an analysis of administrative data on a large sample of abused and neglected children in Florida, Yampolskaya and Banks (2006) found that caregiver alcohol and

TABLE 3-1 Perpetrators Identified in Child Abuse and Neglect Reports by Age, 2010 (Unique Count)

NOTE: Fifty states reported case-level data about perpetrators. One state did not report perpetrator data in the Child File and one state submitted an SDC file, which does not have fields for perpetrator data.
SOURCE: ACF, 2011.

substance use was related to neglect but not abuse. Using data from a longitudinal study of 224 children (selected from pediatric clinics that served primarily low-income urban families) who were followed over a 10-year period, Dubowitz and colleagues (2011) found that maternal drug use was one of five risk factors that significantly predicted a subsequent report to child protective services for abuse and neglect. Mothers who indicated they had ever used drugs were 1.7 times more likely to have a child reported to child protective services for abuse and neglect than mothers who had never used drugs.

The association between substance use disorders and deviant parenting is likely complex, encompassing both short- and long-term effects of substances used in addition to the context and characteristics of parents (Moss and Tarter, 1993). Moreover, a parent with a substance use disorder can cause parenting difficulties for the other parent (Ammerman et al., 1999). It is also likely that caseworkers’ perceptions of caregivers’ substance abuse influence their perceptions of neglect and its severity (Berger et al., 2010). Studies have found as well that parental drinking or a family history of alcoholism is a risk factor for childhood sexual and physical abuse (Miller et al., 1997; Vogeltanz et al., 1999).

Kelleher and colleagues (1994) studied the association between alcohol and drug disorders and child abuse and neglect using a sample drawn from the National Institute of Mental Health’s Epidemiologic Catchment Area Study, a representative, community-based survey. The prevalence of substance use disorders was much higher among the group of adults who reported either physical abuse or neglect of a child than among those who did not report abuse and neglect (40 percent and 16 percent, respectively), after controlling for potential confounding variables.

In sum, a number of studies have described an elevated rate of substance abuse problems in parents who abuse or neglect their children, controlling for at least some moderating factors.

Antisocial personality disorder Antisocial personality disorder (ASPD) in parents has been implicated as another risk factor for child abuse or neglect (Belsky and Vondra, 1989). As suggested by Capaldi (Capaldi, 1992; Capaldi and Stoolmiller, 1999), antisocial behavior interferes with the development of social competence, causing a chain reaction of developmental failures in young adulthood. In the longitudinal study described earlier, Brown and colleagues (1998) examined a number of parental mental health factors to determine whether they predicted child abuse and neglect. They found that maternal sociopathy (similar to ASPD) was a significant risk factor for physical abuse, neglect, and child sexual abuse, whereas paternal psychopathology and sociopathy predicted child neglect.

Summary Several types of parental psychopathology have been examined as risk factors for child abuse and neglect. Of the forms of parental psychopathology (primarily maternal) considered thus far, the strongest evidence suggests that maternal depression and substance abuse play an important role in the perpetration of child abuse and neglect by parents. Further research is needed, however, to begin to establish whether that role is causal.

Individual-Level (Child) Characteristics

Although the potential link is controversial and difficult to assess in methodologically rigorous ways, some research has suggested that children can be at greater risk of abuse and neglect if they have a physical and/or mental disability (e.g., mental retardation, physical impairments such as deafness and blindness, serious emotional disturbance). Using data from 35 child protective services agencies selected to be representative of U.S. counties, Westat, Inc., estimated that children with disabilities were 1.7 times more likely to experience child abuse and neglect than children without disabilities (Crosse et al., 1993; Sullivan and Knutson, 2000). However, the authors point out that child protective services agencies rarely recorded disability status in a systematic manner, and agency workers’ opinions, rather than diagnoses by medical or other trained professionals, were relied upon in determining the presence or absence of disabilities. In addition, because this work combined different types of disabilities (physical and mental), it is difficult to determine whether each of these characteristics increases risk.

In terms of national statistics, the National Incidence Study (NIS)-4 is the first cycle of this study to examine the relationship between the incidence of abuse and neglect and a child’s disability status (ACF, 2012). The findings are complex. Under the harm standard, children with documented disabilities had significantly lower rates of physical abuse and moderate harm from abuse and neglect compared with children without disabilities, but significantly higher rates of emotional neglect and serious injury or harm. Under the endangerment standard, children with disabilities had lower rates of abuse overall and of sexual abuse, neglect, physical neglect, and emotional neglect. However, children with disabilities were more likely to be seriously injured or harmed when they experienced abuse or neglect.

Empirical studies show an association between child abuse and neglect and disabilities (Algood et al., 2011; Govindshenoy and Spencer, 2007; Jonson-Reid et al., 2004; Sullivan and Knutson, 1998, 2000; Turner et al., 2011). In an epidemiological study involving a hospital-based sample with medical record information on diagnoses, for example, Sullivan and Knutson (1998) used records from child protective services, foster care, and law enforcement to assess evidence of child abuse and neglect. Based on this large sample of maltreated and nonmaltreated children, they found

that disabilities were a risk factor for maltreatment, although they also found evidence that maltreatment could be relevant in the development of some disabilities (specifically, conduct disorder). Because there were questions about the generalizability of the hospital-based sample, the authors conducted a second study to examine this issue. In this study, Sullivan and Knutson (2000) used an entire school-based population drawn from the same geographic region as the first study and used a school-based disability criterion to reflect inclusion of a broad range of disabilities (not limited to hospital definitions as in the earlier study). The authors found a strong association between disabilities and child abuse and neglect. Among children with disabilities, the abuse and neglect rate was 31 percent, compared with 9 percent among children without disabilities. Specifically, the former children were 3.76 times more likely to be victims of neglect, 3.79 times more likely to be physically abused, and 3.14 times more likely to be sexually abused than children without disabilities. Unfortunately, no data were available on the age at first diagnosis of disability, making it impossible to determine whether the disabilities occurred before or after the child abuse and neglect. Thus the authors conclude: “Because the present data do not really address questions regarding cause and effect, future maltreatment research should consider the role of disabilities as either a risk factor or an outcome” (p. 1271).

Govindshenoy and Spencer (2007) conducted a systematic review of articles published between 1966 and 2006 in the Medline, Embase, Cinahl, Cochrane Library, National Research Register, Social Sciences, and PsychInfo databases. They included articles on population-based cohort, case-control, and cross-sectional studies of children less than 18 years of age and articles describing the results of an empirical analysis of the association between child abuse and neglect and disability. Meta-analysis was not possible because of the heterogeneity of the studies and the small number of studies that met their inclusion criterion. Of the studies reviewed, two were longitudinal, one was a retrospective birth cohort study, and the others were cross-sectional surveys. Methods of ascertaining abuse and neglect and the types of disability studied varied widely. Only two studies described analyses that included potential confounders. Considering these limitations, Govindshenoy and Spencer conclude that “the evidence base for an association of disability with abuse and neglect is weak. Psychological and emotional problems, and learning difficulties appear to be associated with abuse but this association might arise because these conditions share a common aetiological pathway with abuse. There is limited evidence that physical disability predisposes to abuse” (p. 552).

Family Characteristics

Studies have examined several family characteristics as risk factors for child abuse and neglect, including family structure, deficient parenting skills, intimate partner violence, and social isolation.

Family Structure

Over the past several decades, America’s families have become increasingly complex, creating a multiplicity of contexts in which child abuse and neglect may occur. Of special note is the rise in nonmarital cohabitation among romantic partners and multiple-partner fertility (Cherlin, 2010). Multiple-partner fertility involves individuals having biological children with more than one partner, frequently in the context of nonmarital romantic relationships (Burton and Hardaway, 2012; Cancian et al., 2011; Carlson and Furstenberg, 2006). These unions often are characterized by “contentious relations among adults and serial childbearing through serial repartnering, which ultimately produces fairly broad, fluid, and complex networks of multiple biological parents, ‘potential’ coparents, half-siblings, and kin” (Burton and Hardaway, 2012, p. 344; Harknett and Knab, 2007; Sweeney, 2010). Such networks can create considerable inequality and uncertainty in the lives of children that can result in increased risk for child abuse and neglect. For example, ethnographic studies have noted that biological parents in new relationships can divert resources meant for their biological children from previous romantic unions to the children of their new partners, essentially taking the food out of one child’s mouth to give to another (Meyer and Cancian, 2011; Tach et al., 2010). Moreover, as Hall (2010) and others have suggested, such complex families with variable biological parents may open the door for the emergence of inequalities that potentially put children at risk for abuse and neglect. It also has been suggested that colorism, or discrimination based on the lightness or darkness of one’s skin color, may put darker-skinned children in these networks at greater risk for abuse and neglect compared with those with fairer skin (Glenn, 2009; Herring et al., 2004; Hunter, 2007).

Other literature documents the risk of abuse and neglect for children living in single-parent households, households with nonbiological parents, and chaotic families. Several studies have found that single parents are overrepresented among perpetrators of child abuse and neglect (Brown et al., 1998; Dufour et al., 2008; Gillham et al., 1998; Sedlak et al., 2010). Using data from the National Longitudinal Survey of Youth, Berger (2004) found that families with a biological mother and nonbiological father scored poorly on the Emotional Support subscale of the Home Observation for Measurement of the Environment, indicating that such parents may invest

less than biological mother and father pairs in creating sufficient caregiving environments. Furthermore, using data from the Fragile Families and Child Wellbeing Study, Berger and colleagues (2009) found that children living in single-mother families and families with a nonbiological cohabitating father had higher rates of involvement with child protective services than children in families with biological father and mother pairs.

According to the most recent statistics from the NIS-4 (Sedlak et al., 2010), children living with their married biological parents had the lowest rates of abuse and neglect, whereas children living with a single parent who had a cohabiting partner in the household had the highest rates of abuse and neglect in all categories. “Compared to children living with married biological parents, those whose single parent had a live-in partner had more than 8 times the rate of abuse and neglect overall, over 10 times the rate of abuse, and nearly 8 times the rate of neglect” (p. 12). According to National Child Abuse and Neglect Data System (NCANDS) data, the highest rates of child sexual abuse occurred among single parents who had a cohabiting partner; children living in these households had a rate of abuse 10 times higher than that of children living with married biological parents (Sedlak et al., 2010). Finally, families in which children are abused or neglected move twice as often as nonmaltreating families from similar socioeconomic backgrounds (Eckenrode et al., 1995). In sum, although there is fairly consistent evidence that the rates of child abuse and neglect are higher in families without two biological parents, it is not clear how these alternative family structures or complex families act as causal factors in abuse and neglect.

Deficient Parenting Skills

A growing body of research explores the relationship between deficiencies in specific parenting skills and perpetration of child abuse and neglect. A number of studies have characterized parents who abuse or neglect their children as engaging in less interaction with them (Azar, 2002; Thomas and Zimmer-Gembeck, 2011; Timmer et al., 2005), being hyperresponsive to child-related stimuli (Chen et al., 2010; McCormack et al., 2009), engaging in harsher discipline (Koenig et al., 2000), having unrealistic expectations of their children (Reid et al., 1987), knowing less about child development (Burke et al., 1998; Dore and Lee, 1999), and overreporting their children’s negative behaviors (Haskett et al., 1995). Compared with nonneglecting parents, neglecting parents have been shown to exhibit less empathy toward their children (Shahar, 2001) and less proficient caretaking skills (e.g., preparing food, keeping a clean home), poorer stress management, and less maternal motivation (Coohey, 1998).

Many of these studies examine differences in parental behaviors between abusing and neglecting parents and a comparison group of nonabusing and nonneglecting parents. Therefore, to be judged abusive and to be involved in these studies, these individuals had to have shown parenting behaviors that met some criteria or exceeded community standards of acceptable behavior. Thus, these descriptive findings are not surprising, but do not permit conclusions about causality. In general, these parental characteristics have been used to design interventions and treatment programs for abusing and neglecting parents on the assumption that changing these deficient parenting qualities will lead to lower rates of recurrence of child abuse and neglect. Overall, more research is needed in this area to identify the specific constructs of parenting that are most relevant to child abuse and neglect for the purposes of understanding the phenomenon, identifying at-risk families, and designing and implementing effective prevention and treatment efforts. Still, while these characteristics may be markers or risk factors for child abuse and neglect, further research is needed to determine causality.

Intimate Partner Violence

Numerous studies have reported that interparental violence and child abuse co-occur in families at a high rate (Capaldi et al., 2009; Rumm et al., 2000; Shipman et al., 1999), although studies vary on the extent of the co-occurrence reported, ranging from 18 to 67 percent (Appel and Holden, 1998; Edleson, 1999; Jouriles et al., 2008). Compared with nonabusive mothers, mothers who physically abuse their children report higher rates of victimization by intimate partner violence (Coohey and Braun, 1997). In one study of 1,232 partnered women, Zolotor and colleagues (2007) found the following odds ratios of child abuse in homes experiencing versus those not experiencing domestic violence: physical abuse, 2.7; neglect, 2.04; psychological abuse, 9.8; and sexual abuse, 4.90. As noted, Renner and Slack (2006) found no evidence for the intergenerational transmission of child abuse and neglect in the absence of adulthood experiences of intimate partner violence. Using NCANDS data in an analysis of children reported for neglect, Fox (2004) found that American Indian children were more likely than white children to come from homes where there was violence among caretakers. In another study, using National Survey of Child and Adolescent Well-Being (NSCAW) data, Dettlaff and colleagues (2009) compared Latino children of immigrants and children in native-born families in the child welfare system and found few significant differences in terms of use of excessive discipline, domestic violence, low social support, and difficulty meeting basic needs. Although both of these studies were limited to children

already identified by the system, these findings suggest that further research might investigate the role of ethnic differences in the role of family violence and risk for child abuse and neglect.

Social Isolation

Social isolation has been associated with risk for abusing or neglecting children (Connelly and Straus, 1992; Coohey and Braun, 1997; Kelley et al., 1992; Kotch et al., 1997), although the evidence base on this association varies widely. Studies have reported that abusing and neglecting families lack significant social connections with their extended families, neighborhoods, and communities (Coohey, 1996, 2001; Coohey and Braun, 1997; Coulton et al., 2007). In particular, neglectful parents have been characterized as having no social networks, poor-quality marriages, and briefer relationships with their partners (Brown et al., 1998; Coohey, 1996; DePanfilis, 1996; Dubowitz, 1999). Compared with nonneglectful mothers, neglectful mothers have been found to perceive their own mothers more negatively, to have poorer relationships with their own mothers, and not to perceive their mothers as a source of emotional support (even when relying on them for money and help with child care) (Coohey, 1995).

While most of the studies reported thus far are focused on American families, Gracia and Musitu (2003) examined these issues using abusive and nonabusive families from Spanish and Colombian cultural backgrounds. In both cultures, the abusive parents reported “lower levels of community integration, participation in community social activities, and use of formal and informal organizations” compared with the nonabusive parents (p. 153). However, the families from the two cultures did not differ in the relationship between community social support and child abuse and neglect. Thus, these findings from studies in different cultural contexts regarding the role of community isolation in relation to child abuse and neglect suggest similarities to the earlier findings from studies with Anglo-Saxon families and perhaps generalizability of the phenomenon.

Summary

In sum, several characteristics of complex families, as well as deficient parenting in general, intimate partner violence, and social isolation, are associated with risk for child abuse and neglect. However, the evidence base thus far does not permit a determination of whether these factors or mechanisms play a causal role in the abuse and neglect of children.

Contextual Factors

The ecological model described earlier emphasizes that the social context within which the family lives may influence the likelihood of abuse or neglect. Several studies have examined the extent to which aspects of the broader social system (e.g., employment, neighborhood characteristics) are related to a parent’s risk for becoming abusive or neglectful. The following discussion highlights studies in which the evidence is relatively strong, and also describes characteristics that place children at risk for abuse and neglect.

Poverty, Unemployment, and Low Socioeconomic Status

Poverty, unemployment, and low socioeconomic status have been reported as risk factors for child abuse and neglect (Berger, 2004; Chaffin et al., 1996; Fryer and Miyoshi, 1996; Kotch et al., 1997; Slack et al., 2003, 2004). Among all types of abuse and neglect, neglect is most strongly associated with poverty and low socioeconomic status (Brown et al., 1998; Chaffin et al., 1996; Drake and Pandey, 1996; Jones and McCurdy, 1992; Korbin et al., 1998), although there is evidence that poverty also is associated with physical abuse (Chaffin et al., 1996; Pears and Capaldi, 2001). Poverty may reduce a parent’s capacity to nurture, monitor, and provide consistent parenting by contributing to the number of stressful life events experienced while also limiting available material and emotional resources. On the other hand, the potential role of poverty as a risk factor for abuse or neglect is complicated by the transmission of poverty, as a household characteristic, from one generation to the next (Behrman et al., 1990; Duncan et al., 1998; Mayer and Lopoo, 2001). Longitudinal designs that might be able to tease out the role of poverty and the associated stressors in influencing the risk for child abuse and neglect would be a worthwhile focus for future work. In addition, experimental studies evaluating the impact on child abuse and neglect of providing economic assistance to impoverished families could inform understanding of the causal role of poverty.

Neighborhood Characteristics

Characteristics of neighborhoods in which children and their families live have been associated with differences in the likelihood of child abuse and neglect (Coulton et al., 1999; Freisthler et al., 2006; Garbarino and Kostelny, 1992). For example, rates of child abuse and neglect have been associated with structural aspects of the neighborhood and community (poverty, large number of children per adult resident, population turnover, and high concentrations of single-parent families) (Coulton et al., 2007;

Drake and Pandey, 1996; Korbin et al., 1998, 2000). Lynch and Cicchetti (1998) found that rates of child abuse and neglect (particularly physical abuse) were related to levels of child-reported violence in the community and to the severity of child neglect.

Using an ecological framework and multilevel modeling, Coulton and colleagues (1999, p. 1019) examined the impact of “neighborhood structural conditions and individual risk factors for child abuse and neglect. Parents of children under the age of 18 were selected systematically from 20 randomly selected census-defined block groups with different risk profiles for child maltreatment report rates” and were administered a variety of questionnaires designed to assess characteristics of the environment and the potential for child abuse. The authors found that neighborhood poverty and child care burden affected the potential for child abuse after controlling for individual risk factors. However, they also found that the effects of neighborhood characteristics were weaker than has been reported in studies of official child abuse and neglect reports, and that there was greater variation in the potential for child abuse within than among neighborhoods.

In a subsequent paper, Coulton and colleagues (2007) review the existing literature and conclude that “only a few studies examine direct measures of parenting behaviors associated with maltreatment, and these show a weaker relationship with neighborhood disadvantage. Moreover, the processes that link neighborhood conditions to either maltreatment reports or parenting behaviors are not yet confirmed by the research literature” (p. 1117). The authors note problems with selection bias, variations in neighborhood definitions, and the failure to control for spatial influences in the existing research.

Based on concerns about the disproportionate number of racial and ethnic minority children in the child welfare system, Freisthler and colleagues (2007) examined how rates of child abuse and neglect for black, Hispanic, and white children might vary by neighborhood characteristics. Using data from 940 census tracts in California, they found that for black children, higher rates of poverty and higher density of alcohol outlets were positively associated with abuse and neglect rates, but other characteristics (population changes, population mobility, and higher percentage of black residents) were associated with lower rates. For Hispanic children, poverty, unemployment, and percentage of female-headed families were associated with increased risk for abuse and neglect. For white children, the percentages of poverty, elderly people, and Hispanic residents and the ratio of children to adults were positively associated with neighborhood rates of abuse and neglect. These findings suggest that the role of these contextual factors varies with the demographic characteristics of children and families and needs to be taken into account in future studies aimed at understanding causality.

Guterman and colleagues (2009) studied whether mothers’ individual perceptions of their neighborhood social processes are related to self-reported predicted risk for physical child abuse and neglect. They examined this question using cross-sectional data from a national birth cohort sample of 3,356 mothers across 20 U.S. cities when the index child was 3 years of age. The authors used multiple-group structural equation modeling to test for differences across African American, Hispanic, and white mothers and found that perceived negative neighborhood processes had an indirect effect on the risk for physical abuse through parenting stress and personal control pathways. In contrast, however, they found that their predictor models did not differ significantly across ethnic groups. Unfortunately, because this is a cross-sectional study, the temporal relationship of these variables is unclear.

The vast majority of the literature examining the associations of neighborhood characteristics with rates and risks of child abuse and neglect has focused on national and urban samples. In contrast, Weissman and colleagues (2003, p. 1145) studied these relationships in one rural area of the United States. They analyzed “county-level data from Iowa between 1984 and 1993 for associations between county characteristics and rates of child abuse. Rates of single-parent families, divorce, and elder abuse were significantly associated with reported and substantiated child abuse … while economic factors were not.” Thus, these authors conclude that family structure is more strongly related to rates of child abuse reports and substantiation than are socioeconomic factors in this rural area.

Although limited, the findings of this body of research suggest that the role of contextual factors (as highlighted in the more complex ecological models) is important in understanding the risk for child abuse and neglect.

Macrosystem Factors

Social attitudes, such as attitudes toward violence or beliefs about discipline and corporal punishment, have been examined as risk factors for child abuse and neglect (Bower-Russa et al., 2001). One of the assumptions of an ecological perspective on child abuse and neglect is that a society’s willingness to accept elevated levels of violence establishes precedence for family violence, such as physical child abuse (Belsky, 1980; Gelles, 1997). Norms within an individual’s peer group and community can contribute to the likelihood that violence will be viewed as an acceptable solution to difficulties within the family (Straus et al., 1980).

In the United States, physical punishment is widely practiced and accepted, and these attitudes create an environment in which abuse and neglect may occur (Cicchetti and Lynch, 1993). However, the rate of corporal punishment has been declining since the mid-1980s (Straus and Stewart, 1999; Zolotor et al., 2011). Most schools have banned the use of physical

punishment, foster care parents are not allowed to use physical discipline/corporal punishment, and physical abuse is illegal in all 50 states (Center for Effective Discipline, 2013). On the other hand, all states allow parents to discipline their children physically (Davidson, 1997). On some level, therefore, there is a sense that physical punishment is tolerated when it is committed by a parent, but not by another person.

Coohey (2001) examined whether differences exist in the extent of familism (defined as attitudes, behaviors, and family structures operating within an extended family system) and child abuse and neglect in Latino and Anglo families. The author reports that both Latina and Anglo mothers who did not abuse or neglect their children appeared to have a higher level of familism than the abusive and neglectful mothers in both groups.

Recent work by Dunlap and colleagues (2009) uses ethnographic data to examine the “normalization of violence” that appears to characterize the childhood experiences of inner-city crack users. About half of them recalled being physically abused by their mothers or their mothers’ various male partners. Those who did not report being beaten in childhood typically reported various types of physical attacks that they “deserved.” Physical abuse, especially by mothers, frequently was seen as an expression of love. The authors suggest that these crack users viewed this type of abuse as a normal occurrence during their childhood and adolescence. They suggest that this type of physical discipline socialized and prepared them for the violence that would likely take place as they grew up in the inner-city environment. These findings suggest the importance of social context and, in some instances, “how much not being abused may serve as a protective factor among poor inner-city populations” (p. 16).

Complex Interaction of Multiple Risk Factors

The sections above have reviewed a large body of research focused on the impact of individual risk factors on the likelihood of perpetrating or experiencing child abuse and neglect. However, many of the risk factors that have been identified are interrelated and seldom are present in isolation from other risk factors. Some studies have shown that the presence of multiple risk factors can dramatically increase the likelihood of child abuse and neglect. In one longitudinal analysis of potential risk factors for child physical abuse, sexual abuse, and neglect, for example, Brown and colleagues (1998) collected data on abuse and neglect from both retrospective self-report surveys and official New York state records and considered a broad array of demographic, familial, child, and parenting factors as predictors of risk for child abuse and neglect. These authors found a substantial increase in the likelihood of child abuse and neglect when four or more risk factors were present. Their results also showed that the incidence

of physical abuse, sexual abuse, or neglect increased from 3 percent among families with no risk factors present to 24 percent among families subject to four or more risk factors, and similar increases for each specific type of abuse or neglect. In their 18-year longitudinal study of a New Zealand birth cohort, Woodward and Fergusson (2002) found that young people reared by mothers with both alcohol/drug problems and depression tended to report higher levels of their mother’s use of physical punishment and child abuse and neglect during childhood (birth to age 16).

Another example of the complex interaction of risk factors for child abuse and neglect is based on the proposition that dissociation may act as a mediator of child abuse and neglect across generations (Egeland and Susman-Stillman, 1996). 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. 826). In one longitudinal study of severely sexually abused girls followed into parenthood, Kim and colleagues (2010) found that increased dissociation, together with a history of experiencing self-reported punitive parenting as a child, predicted whether a mother would parent her own children in a harsh and punitive manner. Thus, these authors hypothesize a tentative generational loop in which harsh and abusive parenting increases the risk for higher child- and adolescent-level dissociation, which in turn increases the risk for impulsive behavior and harsh parenting of offspring.

Together, these findings suggest that children being raised in families with multiple risk factors are at considerably higher risk for abuse and neglect than children not raised in such families. However, the complex interaction of multiple risk factors is not clearly understood, especially in conjunction with protective factors and resilience (discussed on p. 95), nor is it understood with respect to how children from different backgrounds in terms of culture, race, ethnicity, socioeconomic status, immigrant status, or geographic region of the country are at risk for child abuse and neglect.

Finding: Despite the broad acceptance of parental experience of abuse and neglect as a risk factor for perpetration of abuse and neglect, the extent to which this risk factor explains the perpetration of child abuse and neglect remains unclear. Major methodological concerns with the existing body of evidence on intergenerational transmission include reliance on parents’ recounting of memories over a long period of time, reliance on parents’ reports of abuse and neglect for both themselves and their children, and samples being drawn from specialized abuse-and neglect-related settings. Emerging research on more complex questions about intergenerational transmission may reconcile the mixed evidence on this topic.

Finding: Early childbearing has been linked to an increased risk for child abuse and neglect, although national statistics on child abuse and neglect do not reflect this relationship, suggesting that further research to understand this discrepancy is warranted. Some research suggests that low socioeconomic status is a risk factor for both early childbearing and child abuse and neglect, while other research finds early childbearing to be significantly related to harsh parenting behavior after controlling for demographic and maternal characteristics.

Finding: Of the forms of parental (primarily maternal) psychopathology examined as risk factors for child abuse and neglect, the strongest evidence suggests that substance abuse and maternal depression play an important role in the perpetration of child abuse and neglect by parents. Further research is needed to establish whether parental depression and substance abuse play a causal role.

Finding: Research suggests that children can be at greater risk of abuse and neglect if they have a physical and/or mental disability, although this relationship is complicated and requires further research. Methodological concerns within this body of research include inconsistent definitions and procedures for establishing disability status, failure to distinguish among types of disabilities, limited knowledge about the temporal relationship between abuse and neglect and disability diagnosis, and insufficient attention to confounders.

Finding: There is fairly consistent evidence that the rates of child abuse and neglect are higher in families without two biological parents. Data from NCANDS and the NIS-4 show that children living in households with a single parent and cohabitating partner were at the highest risk of abuse and neglect compared with children in other arrangements. In addition, complex networks arising from multiple-partner fertility can create considerable inequality and uncertainty in the lives of children that can result in increased risk for abuse and neglect.

Finding: Some research suggests that deficiencies in parenting behaviors may indicate an increased risk for or serve as a marker for child abuse and neglect. More research is required to understand the relationship between specific parenting practices and child abuse and neglect.

Finding: Numerous studies have reported that interparental violence and child abuse co-occur in families at a high rate, suggesting a strong relationship between intimate partner violence and child abuse and neglect.

Finding: Findings from numerous studies, including some in diverse cultural contexts, identify social isolation as a risk factor for child abuse and neglect.

Finding: Poverty, unemployment, and low socioeconomic status have been reported as risk factors for child abuse and neglect, with neglect being most strongly associated with poverty and low socioeconomic status, followed by physical abuse.

Finding: Some structural aspects of neighborhoods and communities have been associated with rates of child abuse and neglect. Additional findings suggest that the role of contextual factors varies with the demographic characteristics of children and families, as well as with the community’s location on the urban-rural continuum. Some research indicates that mothers’ perceived negative neighborhood processes have an indirect effect on the risk for physical abuse through parenting stress and personal control pathways.

Finding: Important macrosystem factors that have been associated with child abuse and neglect include social attitudes about physical punishment and violence and the extent of familism among mothers.

Finding: Research suggests that children being raised in families with multiple risk factors are at considerably higher risk for abuse and neglect than children not raised in such families. However, the complex interaction of multiple risk factors is not clearly understood, especially in conjunction with protective factors and with demographic characteristics.

PROTECTIVE FACTORS

The importance of protective factors—dispositional attributes, environmental conditions, biological predispositions, and positive events that can act to mitigate risk factors (Garmezy, 1991; Masten, 2001, 2011; Masten et al., 1990)—is increasingly being recognized. Most of this research has focused on factors that enable children exposed to severe stressors to overcome the negative consequences of these experiences; relatively little is known about factors that protect at-risk children from being abused or neglected. In one of the most frequently cited studies on “breaking the cycle of abuse,” Egeland and colleagues (1988) found that abused mothers who did not repeat the cycle of abuse were more likely than those who did repeat the cycle to have received emotional support from a nonabusive adult during childhood; to have participated in therapy during any period

of their lives; and to have had a nonabusive and more stable, emotionally supportive, and satisfying relationship with a mate. More recently, Kotch and colleagues (1995, 1997) found that social support modified the negative impact of stressful life events on families at risk for child abuse and neglect. As Thompson (1995, p. 170) notes: “one secure, supportive social relationship may be all that is necessary to promote more adequate functioning in troubled parents.” Clearly, more research is needed on protective factors that may act to prevent abuse and neglect in families at risk.

Finding: Relatively little is known about factors that protect at-risk children from being abused or neglected. Some research suggests that social support, in the form of secure, supportive relationships, may play a significant role in protecting against the risk factors for child abuse and neglect. Clearly, more research is needed on protective factors that may act to prevent abuse and neglect in families at risk.

METHODOLOGICAL CHALLENGES

Since the 1993 National Research Council (NRC) report was issued, researchers in the field of child abuse and neglect have continued to face considerable methodological challenges. This chapter has reviewed several papers that identify methodological limitations of existing studies. Much of that research involves retrospective cross-sectional designs and is based on specialized, nonrepresentative samples. Method bias may arise if the same respondents, usually parents, provide information about both the parenting they received in their own childhood (or their own characteristics) and the parenting practices they use with their children. A related concern is parents’ potential unwillingness to admit to engaging in poor parenting practices with their children because of social desirability issues or fear of outside intervention mandated by reporting laws. Conducting research with abused and neglected children in general is a challenging process because of difficulties in recruiting samples and in navigating ethical and legal reporting requirements. Finally, studies vary widely in the definitions and measures of child abuse and neglect used, hindering comparisons across studies. In the few studies that include “neglect,” for example, definitions range from “lack of supervision” to a broader conceptualization of parental omissions, including extreme failure to provide necessary food, clothing, medical attention, and shelter.

Finding: Studies of risk and protective factors for as well as causes of child abuse and neglect are limited by significant methodological challenges, including a reliance on data from retrospective cross-sectional designs with nonrepresentative samples, reports from a single responder

about two generations’ experiences of abuse and neglect, responses potentially compromised by concerns about social desirability and legal reporting requirements, and a lack of consistency and clarity regarding definitions of abuse and neglect.

CONCLUSIONS

The review of the empirical literature on the causes of child abuse and neglect presented in this chapter provides some clues as to likely candidate risk factors. As risk factors, parental substance abuse, a history of child abuse and neglect, and depression appear to have the strongest support in the literature. However, it is important to acknowledge that all of these factors simply describe elevated risk, and none of them has been shown to “cause” child abuse and neglect. Indeed, the best estimates suggest that a minority of abused children will repeat the cycle with their own children. The studies reviewed also address the role of stressful environments and the impact of poverty, but it likewise is unclear whether these contextual factors “cause” child abuse and neglect. What is clear from this review is that there are a number of candidate risk factors for child abuse and neglect, but insufficient evidence to conclude that they are causal factors.

Since the 1993 NRC report was published, minimal progress has been made in understanding the causes of child abuse and neglect, particularly compared with the substantial progress made in understanding the nature of the problem and its consequences (discussed in the next chapter). Determining causality remains one of the most difficult challenges in the field. Research in the field needs to move beyond correlational designs and analyses to test causal models. Knowledge of the causes of child abuse and neglect has direct implications for the design and targeting of prevention efforts.

How do researchers investigate what causes parents or other caretakers to abuse or neglect the children in their care? In a paper on the causes of behavior, Killeen (2001) argues that understanding a phenomenon involves identifying its origin, structure, substrate, and function and representing these factors in some formal system. He cites the work of Aristotle, who described these types of explanations, referring to them as “efficient causes (triggers), formal causes (models), material causes (substrates or mechanisms), and final causes (functions).” Scholars in the field of child abuse and neglect have provided formal models of its causes (Cicchetti and Toth, 1998), and these models have been helpful in framing the prevention response. Because of the methodological challenges outlined in this chapter, however, understanding of the causes of child abuse and neglect is limited.

This chapter began with a brief discussion of four factors that are needed to establish causality. This review of the existing literature has shown that most published research makes a case for a logical relation-

ship between a particular risk factor and the occurrence of child abuse and neglect. Risk factor studies have produced some evidence of an empirical association. Longitudinal studies would provide evidence of correct temporality, and the lack of spuriousness can be established by experimental controls. Indeed, more researchers have begun to question the strength of the evidence for some risk factors and to examine directly the role of potentially confounding factors. In some cases, these analyses have led to the conclusion that results are explained largely by the psychosocial context within which these children and families are living (Fergusson et al., 2006).

Studies of risk factors for child abuse and neglect have been conducted with methodologies heavily reliant on cross-sectional designs and retrospective self-reports, although there are some notable exceptions. The committee recognizes that not every study can be prospective and longitudinal. Correlational studies can be informative regarding causes, for example, if they use statistical controls to examine spuriousness, particularly when they show that two variables thought to be related are no longer related once one controls for a third variable. A good example is a paper that looks at the effect of male height on wages (Persico et al., 2004). No one knew why male adult height was associated with higher wages, but when the researchers controlled for height in adolescence (age 16), male adult height had no effect on wages. Thus, this was a correlational study, but it made an important contribution because it provided a better understanding of this relationship. Similar studies might be undertaken in the field of child abuse and neglect.

Nonetheless, longitudinal designs starting before the birth of the target children permit better controlled studies of who does and does not harm their children under what cultural, social, and individual circumstances. Such designs are rare in this field because they take time and are expensive. The best designs will take multiple factors into account, such as the candidate risk factors described here, and will involve large enough sample sizes to make it possible to determine what predicts abusive and neglectful behavior, under what conditions, and with which children. The work of Kotch and colleagues (1997, 1999) is an excellent example of such an approach. These designs can provide the strongest evidence for the causes of child abuse and neglect. What the field no longer needs are large population studies of “social addresses” that identify risk but not cause. There have now been many studies of this kind, and future correlational studies need to be clear about what new descriptive questions they can address or how they will analyze the data to examine whether hypothesized effects are in fact due to third variables.

The National Children’s Study (NCS) provides an opportunity to engage in rigorous research to answer questions of causality. The NCS was authorized by the Children’s Health Act of 2000 and is sponsored by a

collaboration among four federal agencies: the National Institute of Child Health and Human Development, the National Institute of Environmental Health Sciences, the Centers for Disease Control and Prevention, and the Environmental Protection Agency. The study’s objective is to recruit and follow a nationally representative sample of 100,000 children from before birth until age 21, examining the effects of the physical, chemical, and social environments on the growth, development, and health of children across the United States. The study includes attention to family dynamics, community and cultural influences, and genetics.

Ten years ago, in 2003, Barry Zuckerman, John Lutzker, and Ruth Brenner testified before the NCS steering committee to argue for the inclusion of child abuse and neglect in the study (IOM and NRC, 2012):

To document the “natural history” of child maltreatment and to understand how environmental, child, and parent characteristics influence occurrences of child maltreatment and subsequent child development, large-scale prospective longitudinal research, such as the NCS, is required…. The ability to identify early markers of problematic parent-child interactions and factors that contribute to the likelihood of child maltreatment across different stages in children’s and families’ lives will provide invaluable information for the timing and delivery of cost-effective services to prevent child maltreatment…. The NCS also can provide information about the timing, dosage, and content of interventions necessary to address the consequences of child maltreatment and facilitate healthy child development through the study of interventions occurring within the sample and through using the NCS cohort as a control group in prevention and intervention research involving independent samples.

The committee urges the leadership of the NCS to include child abuse and neglect as one of its focal topics.

Studies of early neglect and deprivation with animal models, particularly rats and mice, may also offer opportunities to understand the causes of child abuse and neglect, including transgenerational processes that affect behavior (Champagne and Meaney, 2001; Champagne et al., 2003; Kaufman et al., 2000; Maestripieri, 2005; Maestripieri et al., 2006; Suomi, 1997) and the influence of substance abuse (Johns et al., 2005, 2010). No good primate analogue exists for neglect, except in the extreme case of infant abandonment. However, emerging research focused on infant physical abuse among nonhuman primates provides an opportunity not only to observe behavior and obtain biological data but also to experiment with parenting through cross-fostering (Sanchez and Pollak, 2009; Sanchez et al., 2010). Nonhuman primates also afford the advantage of a life span about one-fourth that of humans, making longitudinal studies across generations more feasible. Physical abuse of infants by mothers occurs annually at

rates of 2-15 percent at the Yerkes Primate Research Center (Sanchez et al., 2010). The behaviors constituting physical abuse occur in short bouts amid otherwise more normal parenting, but when infant abuse occurs, it is severe and results in infant distress, serious injury, and occasionally death. Thus, animal analogue studies provide a way to manipulate characteristics of parents to determine whether some of the candidate risk factors identified by research in humans lead to animal versions of abuse and neglect. The findings from these animal studies will likely provide important hypotheses for processes to investigate among humans.

Research needs to examine whether there are common underlying factors that result in child abuse and neglect, or discrete behaviors have different etiologies. Are there differences or similarities in the causes of child abuse and neglect by the cultural context, sex, race, and ethnicity of parents? Some of the research described here suggests that candidate risk factors are similar across different contexts. However, relatively little attention has been paid to this issue.

Although children often experience multiple forms of abuse and/or neglect over their lifetimes, little is known about risk factors for specific types of abuse or neglect. That is, are the causes of physical abuse similar to the causes of neglect? Are the causes of sexual abuse different from those of physical abuse and neglect? Research addressing these questions will have direct implications for interventions and prevention programs. Are the causes of child abuse and neglect different in the context of multiple-problem families and communities compared with more cohesive and nonproblematic families and communities? This issue is related to the concern described by Damashek and Chaffin (2012) as the “bundling” of child abuse and neglect with other life adversities. They argue that this bundling results in the inclusion of other risk factors—unmeasured or unaccountable for in research designs—that make it difficult to attribute effects to particular risk factors. This bundling also ignores one of the recommendations of the 1993 NRC report that identifies as essential “research that clarifies the common and divergent pathways in etiologies of different forms of child maltreatment for diverse populations” (p. 32).

Finally, in this chapter, the term “parental” has been used to refer to characteristics of the individual at risk for becoming abusive or neglectful. Because of the nature of laws determining who is reported and defined as an abusing and neglecting parent, however, it is the biological mother (or substitute mother) who is most often the caretaker and whose characteristics have been examined. Fortunately, recent research has begun to address the role of fathers as perpetrators of child abuse and neglect (Lee et al., 2008, 2011). In the future, particularly with the increase in fathers who remain at home, more attention should be paid to paternal characteristics that place children at risk for abuse and neglect.

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