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6
Consequences of
Child Abuse and Neglect

The consequences of maltreatment can be devastating. For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive, and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attentional problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations all the way to extraordinarily violent behaviors. Thus, the consequences of abuse and neglect affect the victims themselves and the society in which they live.

Many complexities challenge our understanding of factors and relationships that exacerbate or mitigate the consequences of abusive experiences. The majority of children who are abused do not show signs of extreme disturbance. Research has suggested a relationship between child maltreatment and a variety of short- and long-term consequences, but considerable uncertainty and debate remain about the effects of child victimization on children, adolescents, and adults. The relationship between the causes and consequences of child maltreatment is particularly problematic, since some factors (such as low intelligence in the child) may help stimulate abusive behavior by the parent or caretaker, but low intelligence can also be a consequence of abusive experiences in early childhood.

The scientific study of child maltreatment and its consequences is in its



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Page 208 6 Consequences of Child Abuse and Neglect The consequences of maltreatment can be devastating. For over 30 years, clinicians have described the effects of child abuse and neglect on the physical, psychological, cognitive, and behavioral development of children. Physical consequences range from minor injuries to severe brain damage and even death. Psychological consequences range from chronic low self-esteem to severe dissociative states. The cognitive effects of abuse range from attentional problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations all the way to extraordinarily violent behaviors. Thus, the consequences of abuse and neglect affect the victims themselves and the society in which they live. Many complexities challenge our understanding of factors and relationships that exacerbate or mitigate the consequences of abusive experiences. The majority of children who are abused do not show signs of extreme disturbance. Research has suggested a relationship between child maltreatment and a variety of short- and long-term consequences, but considerable uncertainty and debate remain about the effects of child victimization on children, adolescents, and adults. The relationship between the causes and consequences of child maltreatment is particularly problematic, since some factors (such as low intelligence in the child) may help stimulate abusive behavior by the parent or caretaker, but low intelligence can also be a consequence of abusive experiences in early childhood. The scientific study of child maltreatment and its consequences is in its

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Page 209 infancy. Until recently, research on the consequences of physical and sexual child abuse and neglect has been based primarily on retrospective studies of adolescents or adults that are subject to clinical bias and inaccurate recall (Aber and Cicchetti, 1984). Research on the consequences of abuse is also challenged by the hidden nature of much abuse and because these experiences may not come to anyone's attention until years after they occur. Maltreatment often occurs in the presence of multiple problems within a family or social environment, including poverty, violence, substance abuse, and unemployment. Distinguishing consequences that are associated directly with the experience of child maltreatment itself rather than other social disorders is a daunting task for the research investigator. Research on the consequences of child maltreatment is also uneven and, as a result, we do not yet understand the consequences on children of particular types or multiple forms of abuse. In recent years, much attention has been focused on the consequences of child sexual abuse, especially the adolescent and adult sexual behavior of the victim. Less attention has been given to the short- and long-term consequences of child neglect and physical abuse. Only recently has public awareness expanded to include recognition of the psychological consequences that stem from even the most subtle forms of emotional maltreatment. Some experts now contend that the psychological or emotional components of abuse and neglect are the factor most responsible for the destructive consequences of all types of maltreatment (Brassard et al., 1987; Erickson and Egeland, in press; Newberger, 1973). Nor do we yet know the importance of the particular timing, intensity, and context of abuse on the outcome. Factors such as the age and developmental status of the child may influence the outcomes of maltreatment experiences. Effects that appear at only one life stage, whether immediately following the maltreatment or later, are often different from those that persist throughout life. What may appear to be adaptive or functional at one point in development (avoiding an abusive parent or desensitizing oneself against feelings) may later compromise the person's ability to draw on and respond to personal relationships in an adaptive and flexible way. Given the wide variations reported in the research literature, certain intrinsic strengths and vulnerabilities within a child and the child's environment may affect the extent to which abuse will have adverse consequences. Disordered patterns of adaptation may lie dormant, only to appear during times of stress or in conjunction with particular circumstances (Sroufe and Rutter, 1984). Little research has focused on gender differences in the consequences of child abuse and neglect. Early clinical reports of violence primarily describe violent male adolescents, although Widom's (1991b) delinquency analysis had higher rates of arrests for violence of abused and neglected

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Page 210 females, a pattern not evident for males. Studies of sexual promiscuity and teenage pregnancy have primarily included females who were sexually abused. Few studies have found consistent differences in the reaction of boys and girls to molestation, although one popular report found boys to have more externalizing and girls to have more internalizing symptoms (Friedrich et al., 1988). The lack of attention to gender differences may result from the small number of male victims of sexual abuse in most studies and lower rates of reporting of childhood sexual abuse in males. This chapter is organized in a developmental framework. It begins with a description of what is known about the childhood consequences of child maltreatment, followed by a discussion of what is known about the consequences of abuse and neglect in adolescence and adulthood. A discussion of labeling effects, considering the issues of stigma, bias, and discriminatory treatment, is followed by an examination of a number of potential protective factors. The chapter concludes with recommendations for research. Childhood Medical and Physiological Consequences Physical abuse in infants and young children can lead to brain dysfunction (Dykes, 1986) and sometimes death. Most fatality victims of abuse and neglect are under age 5.1 In 1991, an estimated 1,383 children died from abuse or neglect; 64 percent of these deaths were attributed to abuse and 36 percent to neglect (McCurdy and Daro, 1992). However, the number of child deaths caused by abuse and neglect may actually be much higher, since cause of death is often misclassified in child fatality reports (McClain et al., 1993; Robinson and Stevens, 1992). A child does not need to be struck on the head to sustain brain injuries. Dykes (1986) has indicated that infants who are shaken vigorously by the extremities or shoulders may sustain intracranial and intraocular bleeding with no sign of external head trauma. Thus early neglectful and physically abusive practices have devastating consequences for their small victims. Neglect cases may occur at any point of a child's development but are often associated with early childhood, when they are more likely to be discovered by health professionals, educators, and child welfare workers. One form of child neglect is associated with nonorganic failure to thrive infants. The absence of physical growth in these infants can be measured by objective scales of weight and height (Drotar, 1992). Neglect is usually suspected when such infants demonstrate significant weight gain following hospital admission or child removal from the family. Deprivational dwarfism, a medical term applied to children of small stature whose physical

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Page 211 growth is impaired by the absence of nutritional requirements, is another type of child neglect associated with some young children. Even after diagnosis and treatment, the psychological consequences of emotional neglect persist. Polansky et al. (1981) found that young adolescents who in their infancy were diagnosed as failure to thrive were defiant and hostile. Drotar (1992) notes that factors that trigger nonorganic failure to thrive and child neglect should be separated from factors that maintain these behaviors. In early periods of neglectful behavior, the child may exhibit stressful behaviors in the forms of feeding problems, irritability, or deficits in social responsiveness that place increased demands on the parent's caretaking duties (Powell and Low, 1983; Powell et al., 1987). In some cases, nutritional deprivation, combined with increased maternal detachment, sets into motion a "vicious cycle of cumulative psychological risk" (Drotar, 1992:121). Eventually, the parent may begin to perceive the child as quiet, sickly, or not very competent, perceptions that may not be shared by others who observe the child (Ayoub and Miler, 1985; Kotelchuck, 1982). In the absence of growth indicators of nonorganic failure to thrive or deprivational dwarfism, clinical diagnosis of child neglect is quite difficult. Oates (1984a,b; 1992) has described some nonspecific behavioral characteristics of nonorganic failure to thrive infants, which include lack of smiling, an expressionless face, gaze aversion, self-stimulating behavior, intolerance of changes in routine, low activity level, and flexed hips. Abuse and neglect may result in serious health problems that can adversely affect children's development and result in irremediable lasting consequences. Early studies of physically abused children documented significant neuromotor handicaps, including central nervous system damage, physical defects, growth and mental retardation, and serious speech problems (Elmer and Gregg, 1967; Green et al., 1974; Martin et al., 1974; Morse et al., 1970). Physically abused children have been found to have more mild neurologic signs, serious physical injuries, and skin markings and scars than their nonabused peers (Kolko et al., 1990). Children who have been sexually abused, and some children who have been physically neglected, have shown heightened sexuality and signs of genital manipulation. A particularly serious biological consequence of child and adolescent sexual abuse is the risk of sexually transmitted diseases, including human immunodeficiency virus, gonorrhea, and syphilis. Cognitive and Intellectual Consequences Cognitive and language deficits in abused children have been noted clinically (Augoustinos, 1987; Azar et al., 1988; Fantuzzo, 1990; Kolko, 1992). Abused and neglected children with no evidence of neurological impairment have also shown delayed intellectual development, particularly

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Page 212 in the area of verbal intelligence (Augoustinos, 1987). Some studies have found lowered intellectual functioning and reduced cognitive functioning in abused children (Hoffman-Plotkin and Twentyman, 1984; Perry et al., 1983). However, others have not found differences in intellectual and cognitive functioning, language skills, or verbal ability (Alessandri, 1991; Allen and Oliver, 1982; Elmer, 1977; Lynch and Roberts, 1982). Problematic school performance (e.g., low grades, poor standardized test scores, and frequent retention in grade) is a fairly consistent finding in studies of physically abused and neglected children (Eckenrode et al., 1991; Salzinger et al., 1984; Wolfe and Mosk, 1983), with neglected children appearing the most adversely affected. The findings for sexually abused children are inconsistent. Dodge and colleagues (1990) found that physically harmed 4-year-old children showed deviant patterns of processing social information, related to aggressive behavior, at age 5. Physically harmed children (relative to nonphysically harmed children) were significantly less attentive to social cues, more inclined to attribute hostile intent, and less able to manage personal problems. They explain possible cognitive deficits in abused and neglected children by suggesting that physical abuse affects the development of social-information-processing patterns, which in turn lead to chronic aggressive behavior. The experience of severe physical harm is associated with the "acquisition of a set of biased and deficient patterns of processing social provocation information" (p. 1679). Differences in findings on the cognitive and intellectual consequences of childhood maltreatment may be related to the failure to control for important variables, such as socioeconomic status, and the lack of statistical power of small sample sizes.2 Other possible explanations for the inconsistencies in this literature are the tendency of earlier studies to aggregate different types of maltreatment (which may mask different consequences associated with specific forms of child maltreatment) or the inclusion of children who had neurological dysfunction to begin with (which can dramatically influence cognitive and intellectual performance). More recent studies have excluded children with obvious neurological impairments. Yet maltreatment, especially early maltreatment, can cause injury to the central nervous system that results in future cognitive impairments (Lewis and Shanok, 1977). Psychosocial Consequences Some studies suggest that certain signs of severe neglect (such as when a child experiences dehydration, diarrhea, or malnutrition without receiving appropriate care) may lead to developmental delays, attention deficits, poorer social skills, and less emotional stability. Consequences of physical child

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Page 213 abuse have included deficiencies in the development of stable attachments to an adult caretaker in infants and very young children (Cicchetti, 1989; Cicchetti and Barnett, 1991; Crittenden and Ainsworth, 1989). Poorly attached children are at risk for diminished self-esteem and thus view themselves more negatively than nonmaltreated children. In several studies, school-age victims of physical abuse showed lower self-esteem on self-report (Allen and Tarnowski, 1989; Kinard, 1982; Oates et al., 1985) and parent-report measures (Kaufman and Cicchetti, 1989), but other studies found no differences (e.g, Stovall and Craig, 1990). The consequences of neglectful behavior can be especially severe and powerful in early stages of child development. Drotar (1992) notes that maternal detachment and lack of availability may harm the development of bonding and attachment between a child and parent, affecting the neglected child's expectations of adult availability, affect, problem solving, social relationships, and the ability to cope with new or stressful situations (Aber and Allen, 1987; Main et al., 1985). One study by Rohner (1986) has presented impressive cross-cultural evidence of the negative consequences of parental neglect and rejection on children's self-esteem and emotional stability. In a prospective study of the qualitative range of caregiving in a high-risk sample, Egeland and Sroufe (1981a) identified a group of mothers who were psychologically unavailable to their infants. These mothers were detached and unresponsive to their children's bids for care and attention. Children from this group were compared with physically abused, neglected, verbally rejected, and control groups from the same high-risk sample. Using multiple measures across different situations and outcome measures designed to assess the salient developmental issues of each age, the results indicated that children in all maltreatment groups functioned poorly (Erickson et al., 1989). Over time their functioning deteriorated. There were many similarities in terms of the pattern of development between the maltreatment groups, but there were also a number of interesting differences. Nearly all the children in this study whose mothers were psychologically unavailable were anxiously attached at 18 months of age, with the majority of these classified as anxious avoidant (86 percent). These children were observed with their mothers in a problem-solving situation at 24 months and a teaching task at 42 months and were found to be angry, noncomplacent, lacking in persistence, and displaying little positive affect. One of the most dramatic findings for these children was the nearly 40 point decline in performance on the Bayley Scales of Infant Development between 9 and 24 months. In the preschool classroom, these children presented varied and serious behavior problems. Studies have reported evidence of other psychosocial problems in young children. Higher incidence of suicide attempts and self-mutilation have been

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Page 214 reported in clinical samples (Green, 1978). Comparison studies with nonphysically abused children indicate heightened levels of depression, hopelessness, and lower self-esteem in physically abused children (Allen and Tarnowski, 1989; Kazdin et al., 1985). Greater emotional difficulties in older physically abused children have also been identified (Kinard, 1980, 1982). In a more recent investigation involving prepubescent (ages 7 to 12) maltreated children, Kaufman (1991) found a disproportionate number of the maltreated children who met the diagnostic criteria for one of the major affective disorders.3 Linkages between parental behaviors that have emotionally or psychologically destructive consequences on children have not been clearly established. While verbally or symbolically abusive acts designed to terrorize or intimidate a child (such as constant belittling or the destruction of a favorite object or pet) are associated with severe long-term consequences (Vissing et al., 1991), the processes by which children interpret aggressive or neglectful actions are poorly understood. The failure to provide age-appropriate care (such as parental availability and nurturance), cognitive stimulation, or achievement expectations also can have profound psychological impact, especially when such omissions occur during critical child and adolescent developmental periods. Although causal linkages between parental behaviors and the consequences on the child's development have been assumed, pathways that govern or mediate such linkages have not been well documented (Knudsen, 1992). Inappropriate sexual behavior, such as frequent and overt self-stimulation, inappropriate sexual overtures toward other children and adults, and play and fantasy with sexual content, are commonly cited as symptoms of sexual abuse in studies that compare sexually abused with nonabused or nonclinical children (Kendall-Tackett et al., 1993). Across six studies of sexually abused preschoolers (those most likely to manifest such symptoms), approximately 35 percent of the abused children showed such behaviors. Sexual abuse has also sometimes been associated with the onset of sexual activity in middle childhood. Reported rates vary widely because of differences in samples, measurement instruments, and definitions of the outcome behavior. The lowest estimates (of 7 percent) were based on a large study that included many well-functioning and older children. While sexualization seems relatively specific to sexual abuse, inappropriate sexual behavior has been noted in nonsexually abused children. Deblinger et al. (1989) compared the reports of inappropriate sexual behaviors across sexually abused, physically abused, and nonabused psychiatrically hospitalized children matched for age, sex, and socioeconomic status. They found that approximately the same percentage of sexually inappropriate behavior in physically abused (17 percent) as in sexually abused chil-

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Page 215 dren (18 percent). However, early sexual abuse may occur and not be documented until much later in life (Stein and Lewis, 1992). In a recent review of studies reporting quantitative findings about the impact of sexual abuse of minors, Kendall-Tackett et al. (1993) found that sexually abused children were often more symptomatic than their nonabused counterparts in terms of fear, nightmares, general post-traumatic stress disorder, withdrawn behavior, neurotic mental illness, cruelty, delinquency, sexually inappropriate behavior, regressive behavior, running away, general problem behaviors, and self-injurious behavior. Estimates of sexually abused children diagnosed as meeting the DSM-III-R criteria for post-traumatic stress disorder range from 21 percent (Deblinger et al., 1989) to 48 percent (McLeer et al., 1988).4 Sexually abused children, particularly those abused by a family member, may show high levels of dissociation, a process that produces a disturbance in the normally integrative functions of memory and identity (Trickett and Putnam, in press). Many abused children are able to self-hypnotize themselves, space out, and dissociate themselves from abusive experiences (Kluft, 1985). In some clinical studies, severely abused children appear to be impervious to pain, less empathetic than their nonabused peers, and less able than other children to put their own suffering into words (Barahal et al., 1981, Straker and Jacobson, 1981). Behavioral Consequences Physical aggression and antisocial behavior are among the most consistently documented childhood outcomes of physical child abuse. Most studies document physical aggression and antisocial behavior using parent or staff ratings (Aber et al., 1990; Hoffman-Plotkin and Twentyman, 1984; Perry et al., 1983; Salzinger et al., 1984); other measures, such as child stories (Dean et al., 1986); or observational measures across a wide variety of situations, including summer camps and day care settings (Alessandri, 1991; Bousha and Twentyman, 1984; Howes and Eldredge, 1985; Howes and Espinosa, 1985; Kaufman and Cicchetti, 1989; Main and George, 1985; Trickett and Kuczynski, 1986; Walker et al., 1989). Some studies indicate that physically abused children show higher levels of aggression than other maltreated children (Hoffman-Plotkin and Twentyman, 1984; Kaufman and Cicchetti, 1989) although other studies indicate that neglected children may be more dysfunctional (Rohrbeck and Twentyman, 1986). A prospective study comparing preschool children who were classified as physically harmed with those who were unharmed (Dodge et al., 1990) found that children with a history of physical harm were rated six months later as more aggressive by teachers and peers. These differences were not accounted for by the child's demographic or family background. Evidence

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Page 216 from other longitudinal studies indicates continued problems of aggression and anger (Egeland and Sroufe, 1981b) and the development of conduct disorder (Rogeness et al., 1986). Children who experienced severe violence were reported (by their parents) in the National Family Violence Survey to have higher rates of conduct problems and rule violating behaviors than those who did not experience severe violence (Straus and Gelles, 1990; Hotaling et al., 1990). Maltreated children may also be less competent in their social interactions with peers (Straus and Gelles, 1990; Howes and Espinosa, 1985). For some physically abused children, this may manifest in withdrawal or avoidance (Kaufman and Cicchetti, 1989), or fear, anger, and aggression (Main and George, 1985). Effects of Witnessing Domestic Violence Not much is known about the psychosocial status of siblings of abused children. Several studies suggest that the child's experience of witnessing violence toward siblings or parents may be as harmful as the experience of victimization itself (Rosenbaum and O'Leary, 1981). Some studies have suggested that children who see violence in their homes may view such behavior as an appropriate means of resolving conflict and also see violence as an integral part of a close relationship (Groves et al., 1993; Jaffe et al., 1988; Straus, 1992). However, research on the effects of a child's witnessing family violence is contradictory and characterized by methodological flaws. In many studies of the effects of observing family violence, for example, the child subjects are often themselves the victims of physical child abuse. A few studies in the area of physical aggression and violence suggest that siblings of aggressive children exhibit high rates of aggressive/oppositional behavior (Patterson et al., 1989; Patterson, 1982). These findings have been confirmed in observational studies showing that aggressive and hostile behavior is exhibited by various members of families of aggressive children. Related evidence examining the role of interparental conflict suggests witnessing verbal hostility and physical violence between parents is associated with significantly higher levels of child internalizing and externalizing behavior on parent rating scales, and lower levels of child competence based on direct interviews (Fantuzzo et al., 1991) compared with witnessing verbal hostility alone. The impact of observing parental conflict and violence has been demonstrated on various clinical measures of child functioning (see Fantuzzo and Lindquist, 1986; Jaffe et al., 1990, 1991; Widom, 1989c; Wolfe and Jaffe, 1991). Studies have generally not examined whether the results are due to exposure to parental violence, the effects of confounding variables such as child rejection, limited caretaking skills, and parental in-

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Page 217 volvement, or other forms of family conflict associated with a dysfunctional home environment. Adolescence Research on the developmental consequences of child abuse and neglect is still relatively new. Studies of the consequences of child abuse and neglect that appear in adolescence have generally not differentiated between consequences that are derived from earlier childhood experiences with maltreatment and consequences that are unique to adolescent experiences with abuse and neglect. Delinquency An extensive body of work has examined the relationship between childhood victimization and later delinquency (for reviews, see Gray et al, 1986; Garbarino and Plantz, 1986; Widom, 1989c, 1991b). Although the majority of abused children do not become delinquent, and the majority of delinquents are not abused as children, this research indicates that abused and neglected children are at increased risk for juvenile delinquency. Prospective studies estimate the incidence of delinquency in adolescents who have been abused or neglected as children to be about 20 to 30 percent (Widom, 1989c). Retrospective studies, in which delinquents were asked about their early backgrounds, estimated rates from approximately 8 to 26 percent (Widom, 1989c). What is not known is whether specific, or combined, institutional responses to incidents of abuse (such as arrest of the perpetrator, foster care, and the provision of mental health services) influence the probability of delinquent behavior by abused or neglected children. In one study, childhood abuse or neglect significantly increased a child's risk for an arrest during adolescence by more than 50 percent (26 versus 17 percent) (Widom, 1989b).5 Abused and neglected children began their official criminal activity approximately one year earlier than the control subjects (16.5 versus 17.3 years) and had approximately twice the number of arrests. Early childhood victimization was associated with increased risk of arrest as a juvenile (prior to age 18) compared with controls. When considering delinquency, degrees of aggression must be taken into account. Some clinical studies indicate that violent delinquents are more likely to have suffered severe abuse than nonviolent delinquents (Lewis and Shanok, 1977; Lewis et al., 1979, 1982). An epidemiological study of medical hospital records of deliquent and nondelinquent adolescents matched for age, sex, race, and socioeconomic status found that the delinquent sample had significantly more accidents, injuries, and illnesses than the nondelinquents (Shanok and Lewis, 1981;

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Page 218 Lewis et al., 1985). Of note, white delinquents experienced far greater numbers of adverse medical events than white nondelinquents, although the medical histories of black delinquents were only slightly more adverse than their black nondelinquent counterparts. Violence Almost 30 years ago, Curtis (1963) suggested that abused and neglected children would ''become tomorrow's murderers and perpetrators of other crimes of violence, if they survive" (p. 386). Subsequently, a number of small-scale clinical reports described prior abuse in the family backgrounds of adolescents who attempted or succeeded in killing their parents (Easson and Steinhilber, 1961; King, 1975; Sendi and Blomgren, 1975). Since then, larger and more systematic studies have explored the relationship between child abuse, neglect, and violent behavior in delinquents (Alfaro, 1981; Geller and Ford-Somma, 1984; Gutierres and Reich, 1981; Hartstone and Hansen, 1984; Kratcoski, 1982). These studies, which differ in design, scope, and quality, reveal contradictory findings. Some studies provide strong support for the cycle of violence (Geller and Ford-Somma, 1984; Lewis et al., 1979, 1985; Straus et al., 1980; Vissing et al., 1991). In a clinical study of 97 incarcerated male delinquents (Lewis et al., 1979), neuropsychiatric vulnerabilities and histories of abuse and family violence distinguished the more violent subjects from their less violent delinquent counterparts.6 When these 97 delinquents were followed into young adulthood, the abused delinquents who also were most impaired neuropsychiatrically were found to have committed the greatest numbers of crimes as adults (Lewis et al., 1989). Other studies have not found significant differences between abused and nonabused delinquents (Kratcoski, 1982). In one study, abused delinquents were less likely to engage in later aggressive crimes (Gutierres and Reich, 1981). Fagan et al. (1983) found low incidences of both child abuse and parental violence among violent juvenile offenders. In most studies, the majority of abused children did not become delinquents or violent offenders. Widom (1989b) did not find that abused and neglected children had significantly higher rates of arrest as juveniles for violent crimes than controls (4 versus 3 percent) although abused or neglected females appeared to be at increased risk of arrest for violent crimes during adolescence (Widom, 1991b). Inconsistencies in studies of the relationship between early childhood maltreatment and subsequent violent behaviors may be attributed to various factors, including study designs, reliance on reports of maltreatment, and the use of arrests for violence as the only measure of violent behavior.

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Page 242 Friedrich, W.M., and R.A. Reams 1987 Course of psychological symptoms in sexually abused young children. Psychotherapy 24:160-170. Friedrich, W.N., R.L. Beilke, and A.J. Urquiza 1988 Behavior problems in young sexually abused boys. Journal of Interpersonal Violence 3(1):21-28. Frodi, A., and J. Smetana 1984 Abused, neglected, and nonmaltreated preschoolers' ability to discriminate emotions in others: The effects of IQ. Child Abuse and Neglect 8:459-465. Garbarino, J., E. Guttman, and J.W. Seeley 1986 What is psychological maltreatment? Pp. 1-21 in J. Garbarino, E. Guttman, and J. Seeley, eds., The Psychologically Battered Child. San Francisco: Jossey-Bass. Garbarino, J., and M.C. Plantz 1986 Child abuse and juvenile delinquency: what are the links? Pp. 27-39 in J. Garbarino, C.J. Schellenback, J.M. Sebes, eds. Troubled Youth, Troubled Families: Understanding Families At-Risk for Adolescent Maltreatment. New York: Aldine Publishing Co. Garmezy, N. 1981 Children under stress: Perspectives on antecedents and correlates of vulnerability and resistance to psychopathology. In A.I. Rabin, J. Arnoff, A.M. Barclay, and R.A. Zucker, eds., Further Explorations in Personality. New York: John Wiley. Garmezy, N., A. Masten, and A. Tellegen 1984 The study of stress and comptence in children. A building block for developmental psychopathology. Child Development 55:97-111. Geller, M., and L. Ford-Somma 1984 Violent Homes, Violent Children. A Study of Violence in the Families of Juvenile Offenders. February. New Jersey State Department of Corrections, Trenton, Division of Juvenile Services. Prepared for the National Center on Child Abuse and Neglect. Washington, DC. George, C., and M. Main 1979 Social interactions of young abused children: Approach, avoidance, and aggession. Child Development 35:306-318. Gershenson, H.P., J.S. Musick, H.S. Ruch-Ross, V. Magee, K.K. Rubino, and D. Rosenberg 1989 The prevalence of coercive sexual experience among teenage mothers. Journal of Interpersonal Violence 4:204-219. Gil, E. 1988 Treatment of Adult Survivors of Childhood Abuse. Walnut Creek, CA: Launch Press. Gold, E.R. 1986 Long-term effects of sexual victimization in childhood: An attributional approach. Journal of Consulting and Clinical Psychology 54:471-475. Goldston, D.B., D.C. Turnquist, and J.F. Knutson 1989 Presenting symptoms of sexually abused girls receiving psychiatric services. Journal of Abnormal Psychology 98:314-317. Gomes-Schwartz, B., J.M. Horowitz, and M. Sauzier 1985 Severity of emotional distress among sexually abused preschool, school-age, and adolescent children. Hospital and Community Psychiatry 28:238-243. Gomes-Schwartz, B., J.M. Horowitz, and A. Cardarelli 1990 Child Sexual Abuse: The Initial Effects. Newbury Park, CA: Sage.

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