National Academies Press: OpenBook

Understanding Child Abuse and Neglect (1993)

Chapter: SUMMARY

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Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Summary

Child maltreatment is a devastating social problem in American society. In 1990, case reports involving over 2 million children were made to social service agencies. In the period 1979 through 1988, about 2,000 child deaths (ages 0-17) were recorded annually as a result of abuse and neglect (McClain et al., 1993), and an additional 160,000 cases resulted in serious injuries in 1990 alone (Daro and McCurdy, 1991). However tragic and sensational, the counts of deaths and serious injuries provide limited insight into the pervasive dimensions of child abuse and neglect. Reports of child maltreatment reveal little about the interactions among individuals, families, communities, and society that lead to such incidents. The services required for children who have been abused or neglected, including medical care, family counseling, foster care, and specialized education, cost more than $500 million annually, according to estimates by the General Accounting Office (1991).

No specific theories about the causes of child abuse and neglect have been substantially replicated across studies, yet significant progress has been gained in the past few decades in identifying the dimensions of complex phenomena that contribute to the origins of child maltreatment. Furthermore, research in the field of child maltreatment studies is relatively undeveloped when compared with related fields such as child development, social welfare, and criminal violence.

In part, this underdevelopment is influenced by a lack of funds as well as the methodological difficulties of research on topics with a complex

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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etiology. But in part it is underinvestment due to bias, prejudice, and the lack of a clear political constituency for children in general, and disadvantaged children in particular, in the competition for scarce research funds. Substantial efforts are now required to reach beyond the limitations of current knowledge and to gain new insights that can lead to the prevention of maltreatment and also improve the quality of social services and public policy decisions affecting the health and welfare of abused and neglected children and their families. Long-term research and collaborative ventures are necessary to develop knowledge that can improve understanding of, and response to, child maltreatment.

The panel has identified five key reasons why child maltreatment research should be viewed as a central focus of more comprehensive research activity.

1.

Research on child maltreatment can provide scientific information that will help with the solution of a broad range of individual and social disorders. Research in this field is demonstrating that experiences with child abuse and neglect are a major component of many child and adult mental and behavioral disorders, including delayed development, poor academic performance, delinquency, depression, alcoholism, substance abuse, deviant sexual behaviors, and domestic and criminal violence.

2.

Research on child maltreatment can provide insights and knowledge that can directly benefit victims of child abuse and neglect and their families. Individuals who have been victimized as a result of child maltreatment deserve to have research efforts dedicated to their experience, in the same manner as our society invests in scientific research for burn victims, victims of genetic or infectious diseases, or those who are subjected to other forms of trauma.

3.

Research on child maltreatment can reduce long-term economic costs associated with treating the consequences of child maltreatment, in areas such as mental health services, foster care, juvenile delinquency, and family violence. Economic issues must also be considered in evaluating long-term treatment costs and loss of earnings associated with the consequences of child victimization. One analysis cited by the General Accounting Office that used prevalence and treatment rates generated from multiple studies (Daro, 1988) calculated that the future lost productivity of severely abused children is $658-1300 million annually, if their impairments limit their potential earnings by only 5-10 percent.

4.

Research on child maltreatment can provide empirical evidence to improve the quality of many legal and organizational decisions that have broad-based social implications. Government officials, judges, legislators, social service personnel, child welfare advocates, and others make hundreds of crucial decisions each day about the lives and futures of child

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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victims and their offenders. These decisions will benefit from informed guidance on the effectiveness and consequences of various social interventions that address child maltreatment. Such guidance can evolve from research on the outcomes of alternative responses to reports of child abuse and neglect, results of therapeutic and social service interventions, and cost-effectiveness studies.

5.

Research on the etiology of child maltreatment can provide a scientific basis for primary prevention of child abuse—that is, through programs that will counteract etiological factors before they have a chance to produce child abuse in the next generation.

Charge To The Panel

The commissioner of the Administration for Children, Youth, and Families (ACYF) in the U.S. Department of Health and Human Services requested that the National Academy of Sciences convene a study panel to undertake a comprehensive examination of the theoretical and pragmatic research needs in the area of child maltreatment. The Panel on Research on Child Abuse and Neglect was asked specifically to:

Review and assess research on child abuse and neglect, encompassing work funded by ACYF and other known sources under public and private auspices;

Identify research that provides knowledge relevant to the field, and

Recommend research priorities for the next decade, including building blocks for knowledge development, new areas of research that should be funded by public and private agencies, and suggestions regarding fields that are no longer a priority for funding.

The report resulting from this study provides recommendations for allocating existing research funds and also suggests funding mechanisms and topic areas to which new resources could be allocated or enhanced resources could be redirected.

A Developmental And Ecological Perspective

Over the past several decades, a growing number of state and federal funding programs, government reports, specialized journals, and research centers, as well as national and international societies and conferences, have examined various dimensions of the problem of child maltreatment. The results of these efforts have been inconsistent and uneven. In addressing aspects of each new revelation of abuse or each promising new intervention, research efforts often have become diffuse, fragmented, specific, and narrow. What is lacking is a coordinated approach and a general conceptual

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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framework that can add new depth to our understanding of child maltreatment. A coordinated approach can accommodate diverse perspectives while providing direction and guidance in establishing research priorities and synthesizing research knowledge. Collaborative efforts are also needed to facilitate the integration and application of research on child maltreatment with related areas such as child development, spousal violence, substance abuse, and juvenile delinquency.

In contrast to conceptualizing this report in terms of categories of maltreatment or responses of the social system to child maltreatment, the panel presents a child-oriented research agenda that emphasizes the importance of knowing more about the backgrounds and experiences of developing children and their families, within a broader social context that includes their friends, neighborhoods, and communities. This framework stresses the importance of knowing more about the qualitative differences between children who suffer episodic experiences of abuse or neglect and those for whom maltreatment is a chronic part of their lives. And this approach highlights the need to know more about circumstances that affect the consequences, and therefore the treatment, of child maltreatment, especially circumstances that may be affected by family, cultural, or ethnic factors that often remain hidden in small, isolated studies.

The panel has adopted an ecological developmental perspective to examine factors in the child, family, and society that can exacerbate or mitigate the incidence and destructive consequences of child maltreatment. In the panel's view, this perspective reflects the understanding that development is a process involving transactions between the growing child and the social environment or ecology in which development takes place. Positive and negative factors in the cycle of child development merit attention in shaping a research agenda on child maltreatment. The panel's ecological perspective recognizes that dysfunctional families are often part of a dysfunctional environment. This report extends beyond what is—to what could be, if children and families were supported to attain healthy development. We cannot simply build a research agenda for the existing social system; we need to develop one that independently challenges the system to adapt to new perspectives, new insights, and new discoveries.

Identification And Definitions

Four categories of child maltreatment are now generally distinguished: (1) physical abuse, (2) sexual abuse, (3) neglect, and (4) emotional maltreatment. These four categories have become the focus of separate studies of incidence and prevalence, etiology, prevention, consequences, and treatment, with uneven development of research within each area and poor integration of knowledge across areas. Each category has developed its own

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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typology and framework of reference terms. As a result, we know very little about the extent to which different types of child abuse and neglect share common risk factors or the ways in which they respond to different types of interventions.

The co-occurrence of different forms of child maltreatment has been examined only to a limited extent and the specific causes, consequences, prevention, and treatment of selected types of child abuse and neglect is relatively unknown. Inconsistencies in definitions often preclude comparative analyses of clinical studies.

The complexity of studies on child maltreatment also reflects the fragmentation of services and responses by which our society addresses specific cases. Furthermore, the duration, source, intensity, timing, and situational context of incidents of child victimization are important. Yet information about these factors is rarely requested or recorded by social agencies or health professionals in the process of identifying or documenting reports of child maltreatment.

Despite vigorous debate over the last two decades, little progress has been made in constructing clear, reliable, valid, and useful definitions of child abuse and neglect. The difficulties in constructing definitions include such factors as lack of social consensus over what forms of parenting are dangerous or unacceptable; uncertainty about whether to define maltreatment based on adult characteristics, adult behavior, child outcome, environmental context, or some combination; conflict over whether standards of endangerment or harm should be used in constructing definitions; and confusion as to whether similar definitions should be used for scientific, legal, and clinical purposes.

Standardization of definitions is difficult and carries with it dangers of oversimplification. However, consistent definitions are necessary for better measurement and instrumentation in the field. Attempts to reach consensus on clear operational measures must be made to overcome existing limitations and to develop more refined measures. The formulation of research definitions of child maltreatment should be guided by four key principles: consideration of the specific objectives the definition must serve; division into homogeneous subtypes; conceptual clarity; and feasibility in practice.

Scope Of The Problem

From 1976, when the first national figures for child maltreatment were generated, to 1990, the most recent year covered by the National Child Abuse and Neglect Data System, reports of maltreatment have grown from 416,033 per year (affecting 669,000 children) to 1,700,000 per year (affecting 2,712,917 children). This alarming rise in the number of reported cases

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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of child maltreatment has promoted the view that there is an epidemic of child maltreatment in the United States.

The panel's review of national prevalence and incidence child maltreatment studies has revealed important methodological problems that greatly affect the usefulness of these data for drawing conclusions about both the scope and origins of the problem. These methodological problems include definitional issues, confusion of prevalence and incidence, the source of maltreatment data, sampling and design considerations, a paucity of reliable and valid measurement instruments, the problem of retrospective bias, the impact of mandatory reporting requirements on the reliability of survey respondents' reports, and scarce funding for methodological work (specifically instrument development). The paucity of rigorous epidemiological investigations has retarded progress in this field. However, the available evidence suggests that child abuse and neglect is an important, prevalent problem in the United States, with conservative estimates placing the annual number of children affected by this problem at more than 1 million, following an analysis of substantiated rates of reported cases. Child abuse and neglect are particularly important compared with other critical childhood problems because they are often directly associated with adverse physical and mental health consequences in children and families. Furthermore, given the prevalence of childhood maltreatment, the level of federal funds expended in this research area is extremely small when compared with the resources allocated for less prevalent childhood mental disorders, such as autism and childhood schizophrenia.

Specifically, the panel concludes:

Much of the tremendous increase in maltreatment is probably the result of increased reporting, although significant increases in the occurrence rate itself may have occurred as well.

Neglect is more common than any individual type of child maltreatment and has consistently accounted for approximately half of the cases of maltreatment. The chronic nature of child neglect cases needs to be considered in discussions of incidence and prevalence.

Total reports of physical abuse increased significantly between 1980 and 1986, although severe forms of physical abuse may actually have decreased.

Sexual abuse reported to child protective services has shown the largest reported increase of any form of abuse or neglect.

Emotional abuse is the least studied of all the types of abuse.

Overview Of Etiological Models

Most forms of maltreatment are part of a pattern of maladaptive behavior that emerges over time, but research evidence regarding the origins and

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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maintenance of this pattern is not clear. Investigators disagree about whether child maltreatment is a continuum of behaviors (ranging from mild physical discipline to severe forms of physical or sexual abuse) or a set of unique behavioral problems with distinctive etiologies.

Since no single risk factor has been identified that provides a necessary or sufficient cause of child maltreatment, etiological models of child maltreatment have evolved from isolated cause-and-effect models to approaches that consider the combination of individual, familial, environmental, and social or cultural risk factors that may contribute to child maltreatment. The phenomenon of child abuse and neglect has thus been moved away from a theoretical framework of an individual disorder or psychological disturbance, toward a focus on extreme disturbances of childrearing, often part of a context of other serious family problems, such as substance abuse or mental illness.

Interactive models suggest that child maltreatment occurs when multiple risk factors outweigh protective, compensatory, and buffering factors. The role of particular risk or protective factors may increase or decrease during different developmental and historical periods, as individuals, their life circumstances, and the society in which they live change. These models show promise and suggest issues that need to be addressed in research on the etiology of child maltreatment.

Individual Ontogenic Factors

A parent's personality influences child development primarily through the interactive process of parenting. Disrupted parenting can occur in a variety of ways, especially when a parent's personality attributes (such as anger or anxiety) are compounded by additional stresses such as marital conflict, absence of the spouse, poverty, unemployment, and having a difficult child. Individual factors that have sometimes been associated with child maltreatment include adult attitudes, attributions, and cognitive factors; the intergenerational transmission of abusive parenting; the use of alcohol and drugs; characteristics of the child (such as temperament); and demographic factors such as maternal age, marital status, and household density. Research on the role of these individual factors in stimulating or maintaining neglectful or abusive behaviors has been contradictory and inconclusive, suggesting that no single factor, in isolation, can explain with satisfaction the origins of child maltreatment. For example, although alcohol often is cited as a principal risk factor in the etiology of child maltreatment, its relationship to child abuse and neglect remains uncertain. More needs to be known about the unique and immediate effects of alcohol, its co-occurrence with other problem behaviors such as antisocial personality disorder and substance abuse, the circumstances under which different types

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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of drinking situations lead to or sustain violence against children, and cultural factors that mitigate or exacerbate connections between substance use or abuse and aggression.

Family Factors

Dysfunctions in all aspects of family relations, not just parent-child interactions, are often present in the families of maltreated children, and research is needed to examine whether such dysfunctions contribute to or are consequences of child maltreatment. Anger, conflict, and social isolation are pervasive features of maltreating families. In many cases of maltreatment, there often is not a single maltreated child, but multiple victims. Thus, maltreated children may be exposed to considerable violence involving other family members as well as violence directed toward themselves.

A distinctive feature associated with chronically neglecting families is the chaotic and unpredictable character of the family system. The effect on children of repeated acts of violence or constant fluctuations in the makeup of their household, in addition to child neglect, has not been examined in the research literature, although such factors may contribute to unrelatedness and detachment.

An important gap in the literature on child maltreatment is the lack of comparative analysis of the effects of parenting styles and dysfunctional parenting patterns (including abuse and neglect) on children in different social, ethnic, and cultural groups. The relationships among physical discipline, stress, and parental and family dysfunctions that give rise to the emergence of child maltreatment also need to be clarified.

Although a parent's own history of victimization during childhood is thought to predict child maltreatment, this association is based on retrospective studies that are sometimes methodologically suspect. The relationship between physical discipline and child maltreatment is also largely unknown, particularly in the context of cultural differences and practices. Finally, stressful life events are thought to play an important role on parental abilities, but relations between stress and poor parenting are complex and poorly understood at this time.

Environmental and Community Factors

Family functioning occurs within the context of various social institutions and external forces that influence family and parent-child behaviors. Research on environmental factors has concentrated on neighborhood and community environments, but other factors may affect individual and family functioning as well, including the workplace, the media, the school, church, and peer groups.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Discussion of the relationship of poverty to child maltreatment has persisted since publications of the early professional papers on child abuse in the 1960s. Although child maltreatment is reported across the socioeconomic spectrum, it is disproportionately reported among poor families. Furthermore, child maltreatment—especially child neglect—is not simply concentrated among the poor, but among the poorest of the poor. Whether this association results from greater stress due to poverty-related conditions that precipitate abuse, or from greater scrutiny by public agencies that results in overreporting, or whether maltreatment is but one characteristic of the pattern of disruption among the poorest of the poor continues to be debated. The link between unemployment and maltreatment is significant in understanding the relationship between poverty and maltreatment. Families reported for abuse often have multiple problems, and the abuse may simply be a part—or a consequence—of a broader continuum of social dysfunctions.

Although it occurs in all social levels, violent behavior toward children, particularly severe violence, is more likely in poor families. Despite the fact that the evidence on maternal age as a risk factor for child maltreatment is mixed, mothers with young children living below the poverty line have the greatest risk of behaving violently toward children.

Although neighborhoods are recognized as important in the ecology of child maltreatment, more insight is needed into the processes by which neighborhood conditions and factors affect maltreatment. Poor neighborhoods differ in their social and physical conditions and in their ability to influence specific risks posed to children by poverty, unemployment, and community violence. Socioeconomic conditions have predictive value for explaining child maltreatment rates, yet some neighborhoods have higher or lower child abuse rates than would be expected based on socioeconomic conditions alone.

Social isolation has been identified as an important etiological risk factor in child maltreatment, but its role as a consequence or cause of maltreatment is uncertain. The influence of family ties and organizational affiliations (including employment and education) are poorly understood but increasingly recognized as powerful forces in shaping parenting styles and family functioning. Financial stability, employment, and neighborhoods can create a context that either supports a family during periods of stress or enhances the potential for abuse.

Social and Cultural Factors

Family practices and policies that reflect social and cultural values can foster or mitigate stress in family life. Although the relationship of cultural factors is not well understood, some American societal values may contribute to child maltreatment and they have achieved new importance in emerg-

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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ing theoretical models of child maltreatment. Racism, for example, can lead to an inequitable distribution of resources, education, and employment that undermine many ethnic minority families' abilities to support their children (financially and emotionally) and to provide parental care. The term societal neglect has been suggested to characterize American tolerance for a situation in which one-fifth of all preschool children live below the poverty line, with a substantially higher rate among ethnic minorities. Societal fascination with violence, including violence toward children, has been suggested as a risk factor for child maltreatment, as has the lack of coherent family leave and family support policies, particularly the absence of preventive health care for infants, children, and adolescents at risk for maltreatment.

Conclusions

Many factors have been identified as contributing to the occurrence of child maltreatment, but single-factor theories of child maltreatment have not been able to identify specific mechanisms that influence the etiology of child maltreatment. Such environmental factors as poverty and unemployment and such individual characteristics as a prior history of abuse, social isolation, and low self-esteem have been significantly associated with child maltreatment offenders, but the relationships among such factors are not well understood in determining the origins of child maltreatment. The panel believes that the etiology of maltreatment involves complex clusters of variables that interact along various dimensions of a child's ecological/transactional system. Factors that increase risk for maltreatment and factors that decrease the likelihood for maltreatment are found at all ecological levels and interact to produce child maltreatment. Although theoretical models that describe the etiological complexity of maltreatment have been developed, they have not been subjected to testing and adequate research. Our recommendations seek to address these limitations.

Prevention

In the past, the risk factor literature for child maltreatment has been dominated by an orientation that emphasizes correction of perceived weaknesses or problem behaviors and ignores protective factors that may influence outcomes. In recent years, some researchers have begun to examine variables that foster healthy relationships and reduce risk for child maltreatment. The reduction of multiple vulnerabilities as well as the development of compensatory behaviors should be a goal for future prevention research.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Risk Factors and Pathways to Prevention

Until recently, the primary focus in designing preventive interventions was the identification and modification of problematic or damaging parental practices associated with child maltreatment, such as physical discipline, failure to provide children with basic necessities and care, and mismatches between a parent's expectations and a child's ability.

This singular focus on parental roles was altered with the recognition of the prevalence of sexual abuse in the late 1970s. Research on victims of child sexual abuse suggested that risk factors with respect to perpetrator characteristics, victim characteristics, and sociodemographic variables are far more heterogeneous than they are for physical abuse or neglect victims. As a result, prevention advocates focused on ways to strengthen potential victims of sexual abuse through classroom-based instruction for children of all ages.

In recent years, schools have placed a new emphasis on violence prevention programs, designed to equip students to develop nonviolent methods of conflict resolution. Although the generalizability of these programs to the field of child maltreatment has not been systematically assessed, such programs represent a promising direction for future research.

Parental Enhancement Programs

Parental practices in families with young children are a major focus of research on prevention strategies for child maltreatment. Prevention strategies have built on individual, familial, and community-level risk and protective factors that contribute directly to both parental practices and to child well-being. This research foundation has provided the basis for identifying vulnerable families that are at high risk for maladaptive parental practices. Increasingly, at-risk communities are becoming the target of early intervention programs.

Four major types of prevention strategies have been developed for families with young children (defined as the prenatal period through age 8): (1) comprehensive programs, often including home visitor services that vary widely in both scope and content, (2) center-based programs that include a family support component, parent information services, and early childhood education services, (3) community-based interventions that offer a range of family support services, and (4) hospital-based interventions.

Although some well-designed, randomized control, clinical trials exist (such as the Olds study [1986a,b] in upstate New York), many early intervention services lack a theoretical framework and their mission is not always well defined. Some interventions demonstrate that knowledge about child development can be transferred to parents in a relatively brief period of time (i.e., 6-12 weeks), but a time commitment of six months or more is

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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needed to change attitudes and strengthen parenting and interpersonal skills. Prevention programs need to focus directly on families at most risk for maltreatment, to accommodate families with differing needs and experiences, and to adapt to changing family situations.

Community-Based Prevention Programs

The large majority of existing community-based programs focus on prevention of physical and sexual abuse. Child maltreatment prevention programs that are found in the schools are primarily child sexual abuse prevention programs designed for children in elementary and high schools. In addition to major efforts in child sexual abuse prevention, the panel reviewed two other efforts that may have implications for the prevention of child abuse and neglect. These are community-based antipoverty programs, some of which involve vocational or educational assistance, and the violence prevention programs in the schools designed to educate children, primarily adolescents, about conflict resolution skills. Such programs may be important in helping improve the welfare of many families and peer relations, but they have not been systematically evaluated in terms of their outcomes for child abuse and neglect.

Although sexual abuse prevention education programs have generally achieved the goals of teaching prevention knowledge and skill acquisition, it is not clear that these gains are retained over time or are useful to a child under assault, especially if the offender is a relative or trusted adult. Less is known about the efficacy of child sexual abuse prevention programs compared with prevention efforts directed primarily at the physical abuse and neglect of children. There is disagreement in the child safety field about the theories that should guide child sexual abuse prevention programs. At this juncture, it seems critical for child sexual assault prevention programs to evaluate the contributions of extensive parent and teacher training components. Research efforts should be expanded to include extended after-school programs and in-depth discussion programs for certain high-risk groups (e.g., former victims, teen-age parents).

Since poverty has consistently been associated with child maltreatment, particularly child neglect, programs designed to improve the income of poor families could become a major source of prevention of child neglect. At a time when education has become an important requirement for better-paying jobs, programs designed to increase the career options of young parents through educational and vocational training efforts are commonly viewed as part of the preventive spectrum for child maltreatment.

Day care providers, teachers, principals, and others who have ongoing and long-term contact with children are in a position to identify suspected victims of maltreatment and report them to child protective services. Such

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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interventions can be a source of reduced incidence for the recurrence or the prevention of child maltreatment. However, the low percentage of suspected cases identified by educators and other personnel in the school system that are eventually reported to child protection agencies may be a cause for concern. Day care providers, educators, and other youth service personnel require training in the identification of child abuse and neglect, guidance in reporting suspected cases, and methods for supporting maltreatment victims and their families, including referrals to relevant treatment services and peer support groups for victims.

Since many families who are reported for child maltreatment are characterized by other forms of violence (including spouse abuse and involvement in criminal assaults), interrupting the cycle of violence in one area of life may have spillover effects on others, but this assumption needs to be tested empirically. School-based interventions have several advantages, including accessibility to a broad youth population, mandated attendance, ease in scheduling, and cost effectiveness. Although school-based violence prevention programs are a promising development, no firm conclusions can be drawn at this time regarding their effectiveness or generalizability for the prevention of child abuse, and it is not known if participants will be less likely to be perpetrators of family violence.

Media representatives can become important participants in public education about prevention in child abuse and neglect. Media efforts to prevent child maltreatment may benefit from lessons derived from the role of the media in addressing public health issues. Similarly, media programs could be developed to promote community support for appropriate parental practices, especially in the use of physical discipline, and to improve the response of bystanders who witness acts of child maltreatment in public places.

Community-based prevention efforts show promise, especially in the design of multisystem approaches that can build on family-school-media-community approaches. Many avenues can be considered in designing prevention programs, but well-designed program evaluations are critical for developing a knowledge base to guide future efforts. The community mental health approach and community-based interventions designed to reduce smoking and heart disease represent much promise, but such efforts have not yet been developed or tested in the area of child maltreatment.

The Role of Cultural and Social Values in Prevention

Prevention programs increasingly focus on ways to foster cultural changes that could lead to regulatory and voluntary approaches to reinforce health messages at other system levels. Several areas that have relevance for prevention research on child maltreatment include attitudes toward the use

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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of corporal punishment, the effects of criminal sanctions on the maltreatment of children, and the use of violence as a means of resolving conflict. Reliance on corporal punishment by parents has been identified by some researchers as an important risk factor for physical abuse, but corporal punishment is usually not dealt with in programs to prevent physical abuse. Research is needed on whether the inclusion of alternatives to spanking in such programs reduces physical abuse.

In considering the effectiveness of criminal sanctions in the area of child maltreatment, associated problems of abusive and neglectful families need to be recognized. Many of these families are already involved with the legal system because of other behaviors, including substance abuse, juvenile delinquency, and other crimes. Assessment of the impact of criminal sanctions solely in the area of child maltreatment is challenging, since the perpetrators may be removed from the home in a variety of other ways involving the court system.

Conclusions

Evaluations of home visitation programs, school-based programs for the prevention of sexual abuse and violence, and other community-based child maltreatment prevention programs are quite limited. Many evaluations are compromised by serious methodological problems, and many promising preventive interventions do not systematically include child maltreatment as a program outcome. Children and families who are most at risk for child maltreatment may not participate in the interventions, and those that do may not be sufficiently motivated to change or will have difficulty in implementing skills in their social context, especially if they live in violent neighborhoods.

The panel's primary conclusion is that comprehensive and intensive prevention programs that incorporate a theoretical framework, identifying critical pathways to child maltreatment, offer the greatest potential for future programmatic efforts. New theoretical models that incorporate ecological and developmental perspectives have complicated the development of prevention research, but these models hold much promise, for they suggest multiple opportunities for prevention. Prevention research needs to be guided by rigorous evaluation that can provide knowledge about the importance of different combinations of risk and protective factors, the developmental course of various forms of maltreatment, and the importance of replacing or supplementing risk behaviors with compensatory skills. In the face of uncertainty as to whether etiologies of the various forms of child maltreatment are similar or different, a diverse range of approaches to prevention research should be encouraged.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Consequences

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 attention problems and learning disorders to severe organic brain syndromes. Behaviorally, the consequences of abuse range from poor peer relations to extraordinarily violent behaviors. Thus, the victims of abusive treatment and the society in which they live pay an enormous price for the results of child maltreatment.

Yet empirical studies of child maltreatment have identified important complexities that challenge our understanding of factors and relationships that exacerbate or modify 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 scientific study of child maltreatment and its consequences is in its infancy. Until recently, research on the consequences of physical and sexual child abuse and neglect has been limited by delays between the child's experience and official identification of maltreatment. 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 problems is a daunting task for the research investigator.

As a result, we do not yet understand the consequences on children of particular types or multiple forms of abuse. Nor do we yet know the importance of the particular timing, intensity, and context of abuse on the outcome. Factors such as age, gender, developmental status, family relationships, and placement experiences of the child may influence the outcomes of maltreatment experiences. Disordered patterns of adaptation may lie dormant, only to appear during times of stress or in conjunction with particular circumstances. Furthermore, certain intrinsic strengths and vulnerabilities within a child and the child's environment may affect the extent to which abuse will have adverse consequences.

Victims of child abuse and neglect are at increased risk for delinquency and running away, but the majority of childhood victims do not manifest these problem behaviors. Significantly less is known about connections between childhood victimization and other problem behaviors, such as teen-

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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age pregnancy, use of alcohol and illicit drugs, and self-destructive behavior. Alcohol and illicit drug use are both illegal for teenagers, creating a natural confounding of alcohol and substance use with delinquency. Diagnoses of alcoholism are complicated by the presence of antisocial personality disorder, which in turn may include components of criminal behavior and sexual promiscuity. Engaging in any one of these behaviors, then, might increase the likelihood of involvement in other high-risk behaviors.

Issues of Stigma, Bias, and Discrimination

Problem behaviors may result from the chain of events occurring subsequent to the victimization rather then the victimization experience per se. For example, being separated from one's biological parents, subsequent to the abuse and neglect incident(s), and placed in foster care can be associated with deleterious effects. Furthermore, children can encounter discrimination against their race, color, language, life and family styles, and religious and cultural beliefs that affect their self-esteem and magnify the initial and lasting effects of both types of victimization. The observed relationship between early childhood victimization and later problem behaviors may also be affected by practices of the juvenile justice system that disproportionately label and treat maltreatment victims as juvenile offenders.

Protective Factors

Not all abused and neglected children grow up to become dysfunctional adults. A broad range of protective factors, such as temperamental attributes, environmental conditions, and positive events, can mitigate the effects of early negative experiences. The consequences of childhood maltreatment vary by demographic, background, and clinical variables—such as the child's gender, the family's socioeconomic status, and the level of marital and family violence.

Individual characteristics, such as high intelligence, certain kinds of temperament, the cognitive appraisal of victimization experiences, a relationship with a significant person, and out-of-home placement experiences protect some childhood victims. But conflicting or indirect evidence about most of these characteristics and experiences results in a major gap in knowledge about what factors make a difference in the lives of abused and neglected children. Research is needed to determine the role of protective factors and mediating individual characteristics, particularly how they operate to increase or decrease vulnerability for problem behaviors.

Placement outside the home may act to protect abused and neglected children from serious long-term consequences, but such an action is controversial. Foster care placements may pose additional risks for the abused or

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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neglected child, and the trauma of separation from one's biological family can also be damaging. Although some out-of-home placements may exacerbate stress in children from abusive and neglectful households, such placements may not always be deterimental. However, abused and neglected children in foster care and other out-of-home placement experiences, who typically come from multi-problem families, are a particularly vulnerable group because they have experienced both a disturbed family situation and separation from their natural parents.

Conclusions

Knowledge of the long-term consequences of childhood maltreatment into adulthood is extremely limited, with sparse information on intellectual and academic outcomes and medical and physiological consequences. Some research has addressed parenting behaviors (particularly the intergenerational effects of abuse), but the vast majority of existing research has focused on psychosocial outcomes and, in particular, psychopathology.

Childhood victimization often occurs in the context of multiproblem homes. Other family variables, such as poverty, unemployment, parental alcoholism or drug problems, and other factors that affect social and family functioning, need to be disentangled from the specific effects of childhood abuse and neglect. Few studies have assessed the long-term consequences on the development of abused and neglected children, beyond adolescence and into adulthood. Control groups matched on socioeconomic status and other relevant variables become necessary and vital components of this research, in order to determine the effect of childhood victimization on later behavior, in the context of family and demographic characteristics.

Interventions And Treatment

Research on interventions in child maltreatment is complicated by ethical, legal, and logistical problems, as well as difficulties in isolating factors specifically associated with child abuse and neglect in programs that often include families with multiple problems. Interventions include the assessment and investigation of child abuse reports by state child protection agencies, clinical treatment of physical injuries, legal action against the perpetrator, family and individual counseling, self-help services, and informal provision of goods and services (e.g., homemaker and respite care). Multiple agencies determine policies that guide interventions in child abuse and neglect and coordinate human and financial resources to fulfill these objectives. Researchers in this area have limited resources to collect compatible data, the results of project evaluations are rarely published in the profes-

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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sional literature, and issues of service delivery and accessibility are difficult to document.

The fragmentary nature of research in this area inhibited the panel's ability to evaluate the strengths and limitations of the intervention process. Furthermore, we did not have sufficient time to evaluate the full spectrum of administrative and legal procedures associated with reports of child maltreatment. The panel has thus focused its attention on those areas in which significant theory and empirical evidence exist.

Treatment of Child Victims

Despite the large literature on the detrimental effects of child maltreatment, the majority of treatment programs do not provide services directed at the psychosocial problems of the abused child. Children's involvement in treatment programs has generally occurred in the context of family-based services in which some children have received direct programmatic attention but others have not. Treatment interventions for child victims of abuse and neglect draw extensively from approaches for treating other childhood and adolescent problems with similar symptom profiles, but the psychological effects of abuse have not been well formulated in terms of theoretical constructs that can provide a basis for intervention.

Treatment of Adult Survivors

The treatment of adult survivors of childhood sexual victimization is a newly emerging field; the first programs appeared in the late 1970s. Many adult survivors of child abuse do not identify themselves as such, and most treatment programs or studies for adult survivors focus on child sexual abuse rather than other forms of child maltreatment. Research on the treatment of adult survivors is submerged in the literature on adult psychological disorders such as addiction, eating disorders, borderline personality disorders, and sexual dysfunction.

Treatment for Adult and Adolescent Sex Offenders

The treatment of child molesters is a controversial issue. Treatment programs are frequently offered to adult and adolescent offenders as part of plea bargaining negotiations in criminal prosecutions. The traditional assumption has been that children and society are better protected by offender treatment than by traditional prosecution and incarceration if the treatment service is effective. However, there is currently considerable debate about whether child molesters can be effectively treated. Until recently, adolescent sexual offenders have been neglected in clinical and research literature.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Empirically tested models to explain why adolescents commit sexual crimes or develop deviant sexual interest patterns are lacking.

The most common approaches to treating child molesters are comprehensive treatment programs aimed at simultaneously treating multiple aspects of deviant sexual behavior. Although many different approaches to the treatment of sexual offenders have been tried (including group therapy, family systems treatment, chemical interventions, and relapse prevention), scientific data indicating sustained reductions in recidivism are not available. Most studies follow offenders for only one year after treatment, and the effectiveness of the treatments in eliminating molestation behavior beyond that period is not known. Preliminary outcome data on the treatment of juvenile sex offenders show positive outcomes, although there is a lack of substantive research in the field and a lack of consensus regarding basic principles of treatment.

Family-Oriented Interventions

Most treatment interventions for physical abuse, child neglect, and emotional abuse seek to change parenting practices or the home environment. Only recently have treatment services incorporated empirical findings that examine the interactions of family members, abusive parents' perceptions of their children, behavioral characteristics that may restrict parenting abilities, and emotional reactions to stressful childrearing situations.

A lack of consensus exists regarding the effectiveness of a wide range of treatment services for maltreating families, including parental enhancement programs, family systems treatment, home-based services, and family support programs. Outcome studies have indicated positive behavioral and attitudinal changes as a result of family or parent treatment, but few studies have examined the effects of such interventions on subsequent reports of child abuse and neglect beyond one year. Definitive conclusions about the generalizability of the findings from studies of family-oriented programs in reducing subsequent child maltreatment are difficult to develop because the participants in these programs often present varied types of parental dysfunction.

Family Income and Supplemental Benefits

Government programs designed to alleviate or mitigate the effects of poverty on children are often part of a comprehensive set of services for low-income, maltreating families. Such programs include Social Security supplemental income programs, Aid to Families with Dependent Children, Women with Infants and Children food supplement program, Head Start, rent-subsidy programs, and school lunch programs, among others. While

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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national and local child welfare programs designed to improve the well-being of all poor families may provide food, shelter, and other necessary resources for children in households characterized by neglect or abuse, the relationship between income support, material assistance, and the subsequent reduction of maltreatment has not been systematically addressed.

Community-Based Interventions

Family-oriented interventions often exist within a context of a broad range of diverse services provided by community agencies. Understanding these responses to child maltreatment is important in understanding the experiences of children and families following reports of maltreatment. Yet little is known about the efficacy of these community-based interventions.

A few treatment programs have been developed at the community level to provide services to families, such as counseling and educational services for the parents, supervised day care, and specialized referrals for community services, including mental health care, housing, and substance addiction treatment. Although such neighborhood-focused programs may assist children who are victims of abuse or neglect, program evaluations usually do not consider outcomes in terms of maltreatment subpopulations.

Medical Treatment of Child Abuse

Health professionals in private practice, community health clinics, and hospitals are often the first point of contact for abused children and their families when physical injuries are sustained. Little is known about treatments recommended for abused children in medical settings, and even less is known about specific treatment outcomes. Studies suggest, however, that many health professionals may not be sufficiently trained to detect or validate signs of abuse or to deal with the emotional, technical, and legal aspects of evaluating maltreated children, particularly sexually abused children.

Child Protective Services

Child protection agencies receive and screen initial reports of child abuse and neglect from educators, health personnel, police, members of the public (e.g., neighbors, family friends), relatives (including siblings and parents), and others to determine whether investigation is required. The processes that determine their responses to children and families have not attracted much research attention, although a few studies have attempted to document and characterize various stages of the process and their effects on children and families. Evaluations of operations of child protective services

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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are complicated by the emergency situation in which most investigations occur, the confidential nature of the process, limited budgets, staff turnover, variations in definitions of child maltreatment and the absence of clear objectives, procedures, and standards of evaluation. The lack of systematic record-keeping and compatible data, and political sensitivity also inhibit the observation and analysis of decisions made by child protective services workers.

Research on the nature and effectiveness of risk assessment and referral decisions involving maltreating families is difficult, and we know little about factors that influence the assessment, investigation, and substantiation of specific cases; the operation of the referral system and follow-up services; the character of cases that are likely to receive services; the nature, intensity, and length of the services provided; and outcomes resulting from intervention services for different types of child maltreatment. Many factors can affect referral decisions, including availability of services, costs to clients and sponsors, ease of access, client attitudes, perceived need, and organizational relations. Recent clinical reports of child abuse cases suggest that many cases are closed immediately after services have been initiated and, in some instances, even prior to actual service delivery.

Child Welfare Services

The decision to allow a maltreated child to remain with family members or relatives during treatment is a critical and controversial aspect of the case management process. In some cases, temporary or permanent foster care is provided to children on the premise that protection of the child from physical harm is paramount.

Research on services provided to children in foster or kinship care is difficult. Information about children in foster care is often dispersed among biological parents, foster parents, relatives, and caseworkers, and cooperation among agencies providing services is frequently hampered by issues of confidentiality, funding and eligibility requirements, budgetary restrictions, and the specialized nature of professional services, that tend to focus on isolated problems.

Legal Intervention in Child Maltreatment

A small proportion of child maltreatment cases that are reported to child protection agencies become involved with juvenile courts, family courts, and criminal courts. Areas of convergence and conflict between the goals of service providers and the legal system in the treatment of child abuse and neglect have been documented, but much uncertainty remains in this area. Legal interventions in child maltreatment are complicated by many factors,

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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such as the absence of physical evidence, difficulties in obtaining consistent and reliable testimony from children, emotional trauma that might be incurred in forcing a child victim to testify against a parent or other adult who may have harmed him or her, and inconclusive scientific evidence regarding the effectiveness of treatment in halting abusive and neglectful behavior. Even though relatively low numbers of sexually abused children are involved in court proceedings, the legal treatment of child sexual abuse cases has attracted significant research attention. Almost nothing is known about the quality of court experiences for children or adults who are affected by physical abuse, neglect, and emotional maltreatment.

Social and Cultural Interventions

National policies, professional services, and institutional programs sometimes reveal inconsistent policies and fundamental value conflicts. Values that strongly influence the current American social context for responding to reported or suspected child maltreatment include respect for child safety and family preservation. The rights of individual privacy, confidentiality, and other liberties that are often constitutionally guaranteed also influence both the provision of social and professional interventions as well as evaluations of their effectiveness.

The conditions under which child, parental, or community rights should supersede all other rights and obligations, and the criteria that should be considered in balancing long-term dangers against immediate threats, are unclear. Research defining the ''best interests of the child" is becoming a significant issue in determining the outcomes of assignment of visitation and custodial rights in court decisions.

Conclusions

Medical, psychological, social, and legal interventions in child maltreatment cases seek to reduce the negative physical, behavioral, and emotional consequences of child abuse and neglect, foster attitudes and behaviors that improve the quality of parent-child interactions, and limit or eradicate recurrences of maltreatment. Interventions have been developed in response to public, professional, legal, and budgetary pressures that often have competing and sometimes contradictory policies and objectives. Some interventions focus on protecting the child or protecting the community; others focus on providing individual treatment for the child or the offender; others emphasize developing family coping strategies and improving skills in parent-child interactions. Assumptions about the severity of selected risk factors, the adequacy of caretaking behaviors, the impact of abuse, and the steps necessary to prevent abuse or neglect from recurring may vary.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Little is known about the quality of existing interventions in treating different forms of child maltreatment. No comprehensive inventory of treatment interventions currently exists, and we lack basic descriptive and evaluative information regarding key factors that influence the delivery and results of treatment for victims and offenders at different developmental stages and in different environmental contexts. A coherent base of research information on the nature and the effectiveness of treatment is not available at this time to guide the decisions of case workers, probation officers, health professionals, family counselors, and judges.

Investigations of child maltreatment reports often influence the development and availability of other professional services, including medical examinations, counseling, evaluation of risk factors, and substantiation of complaints. Research on various federal, state, and private agency involvement and interactions in treatment interventions has not been systematically organized. Although the panel acknowledges the challenges of performing research in this area, future study designs require adequate sample sizes, well-characterized and well-designed samples, and validated and comparable measures.

Human Resources, Instrumentation,
And Research Infrastructure

Child maltreatment research in the 1990s will require a diverse mix of professional skills and collaborative efforts. The development of human resources, measurement tools, and research infrastructure in this field is complicated by the absence of support for problem-oriented research efforts in academic centers; the legal and ethical complexities associated with this kind of research; the lack of a shared research paradigm that can integrate interdisciplinary efforts across types of maltreatment; problems in gaining access to relevant data and study populations; the absence of data and report archives; and funding inconsistencies associated with shifting research priorities.

The Research Community

A variety of disciplines and subject areas contributes to studies of child maltreatment, including medicine (especially pediatrics and psychiatry), psychology, social work, criminal justice, law, sociology, public health, nursing, anthropology, demography, statistics, and education. Few systematic efforts have been made to integrate research on child maltreatment with the knowledge that has evolved from recent studies of normal child development, family systems, adult and child sexual behavior, family violence, community violence, substance abuse, poverty, and injuries.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Academic training for professionals who must work in the area of child maltreatment has not kept pace with the demands for expertise. About a dozen child maltreatment research programs exist at various universities, medical centers, and child advocacy organizations, but the depth and quality of these centers as well as the skills and affiliations of their research staff are generally unknown. Consequently, considerable effort is needed to deepen and broaden the human resources, instrumentation, and research infrastructure available for addressing the key research questions.

The number of doctorates and other advanced degrees that involve dissertations on child maltreatment studies has been increasing over the past decade, reflecting a growing interest in research in this field. Although many universities offer graduate courses in child abuse and neglect, less than half a dozen universities now sponsor graduate or postgraduate training programs in this field. Graduate training programs have achieved consensus regarding the general body of information necessary in the field of child maltreatment, but considerable variability exists in the length of the programs, student eligibility requirements, time requirements for classroom instruction and practical experience, and the availability of financial support.

Methodological Issues

The absence of support for methodological research has impeded scientific progress in child maltreatment studies. The development of adequate research tools is essential to move a research field beyond theoretical or design problems toward the collection and analysis of empirical data.

Methodology and instrumentation issues present one of the most significant barriers to the development of child maltreatment research. A number of issues deserve particular attention:

Uncertainties about the nature and significance of the phenomena to be measured.

Absence of empirical data and inconsistencies in the type of data collected.

Absence of documentation of the reliability and validity of measures used in child maltreatment research.

In many cases research instruments may simply be unavailable. Measures have been developed to assess "normal" child behavior or other problems in samples of unabused children, but they may not be adequate to assess child maltreatment issues and they may not be standardized on diverse cultural or ethnic populations. Furthermore, available research instruments adapted from other fields may not provide significant information for the practitioner. Difficulties in the use of instruments may result from training—researchers have often come from disciplines that give inadequate

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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attention to the importance of valid and reliable measures and empirical results. Overall, the use of standard measures of family characteristics and social environmental characteristics seems to be less frequent in child maltreatment research than in child development and family research in general.

The development and use of standardized measures in child maltreatment research is complicated by an additional set of pragmatic and professional factors, including the lack of budgetary support for instrumentation research projects, publication policies that discourage discussions of psychometric work in reporting research results, and research sponsors' preference for substantive rather than methodological topics.

Although some useful resources can be identified, the field of child maltreatment studies has not successfully developed a comprehensive information service designed to integrate research publications from diverse professional and private sources in an easily accessible format. In contrast to effective dissemination programs focused on criminal justice research, limited efforts exist to summarize and disseminate maltreatment research findings from the fields of psychology, social work, medicine, and other relevant disciplines.

Federal Funding for Research

Federal support for child maltreatment research is currently divided among 28 separate offices in 5 federal departments—the departments of Health and Human Services, Justice, Education, Defense, and Transportation. The forms of federal research support are diverse, including large research center program awards, individual research awards, data collection efforts, individual training grants, and evaluations of demonstration projects. With the exception of the National Center for Child Abuse and Neglect, which has a research program focused explicitly on studies of child maltreatment, most federal agencies support child maltreatment research in the context of other scientific objectives and program responsibilities, such as research on violence, maternal and child health care, family support, mental health, and criminal justice. As a result, federally supported research activities that may advance scientific knowledge of the identification, causes, consequences, treatment, and prevention of child abuse and neglect are often embedded within other research studies that have multiple objectives. No central repository exists to maintain an ongoing index of federally supported research on child maltreatment.

A 1992 forum sponsored by the Federal Interagency Task Force on Child Abuse and Neglect indicated that the total federal research budget for studies directly related to child maltreatment research is in the $15-20 million range. It is important to note that these figures reflect only research that is "primarily relevant" to child abuse and neglect studies. Additional

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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research efforts related to child maltreatment are also sponsored by federal agencies, although the level of investment in these secondary research efforts depends on the perceived significance of studies about parent-child interactions, substance abuse, family violence, and juvenile delinquency to child maltreatment.

The relevance of child maltreatment research to the central mission of each federal department appears to be idiosyncratic and uneven. Adopting a comprehensive view of research on child maltreatment presents certain difficulties of identification, organization, and taxonomy. Efforts to prevent child abuse and neglect and improve child welfare are dispersed among a wide range of federal programs within the U.S. Department of Health and Human Services alone. However, most of these efforts are not "child abuse" in name, and no systematic effort has been made to evaluate the lessons for child maltreatment learned from them. Various direct services for abused children and their families, demonstration projects, and educational and information dissemination activities are scattered throughout other federal program efforts as well.

Clearly, not all research on children, families, poverty, and violence is relevant to studies of child maltreatment. However, the fragmented and specialized character of the current federal research portfolio in these issues can hamper systematic efforts to organize and build on advances in research. The specialized roles of federal programs that have relevance for studies of child maltreatment continue to inhibit the development of this field. Research investigators and program officers in separate agencies are often unaware of previous studies or active projects related to their research interests. Researchers funded by separate agencies to conduct studies on aspects of child maltreatment often work with separate theoretical paradigms, use different sample populations, develop project-specific methodologies, draw on separate research databases, and present their results in a wide variety of journals and professional meetings. The absence of a central tracking and documentation resource center and the diffuse organization of the federal research portfolio, as well as the fragmented bureaucratic and legislative requirements that are associated with child maltreatment, inhibit the development of a dynamic and interdisciplinary research field.

State Roles in Research on Child Maltreatment

No comprehensive inventory of state research programs exists for studies on child maltreatment issues, but it is unlikely that the total amount of research funds available from individual state agencies is significant (i.e., greater than $1 million per year). However, individual scientists reported to the panel that they have received occasional research support from various state agencies, including the maternal and child health departments and

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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family services offices in the states of Hawaii, Illinois, and Minnesota, the children's trust funds administered by the states, and other offices. The decentralized and sporadic nature of state-funded research efforts discourages efforts to build collaborative interdisciplinary research teams or long-term studies focused on complex research topics.

States are a potential source of future support for specific training and data collection programs in areas such as the criminal justice, education, and public health systems that need to be integrated into comprehensive studies of outcomes and consequences of child abuse and neglect. It is useful to think of the state agencies as important partners in building an expanded research base for studies of child maltreatment.

State science programs are expected to assume a larger role in sponsoring and using research related to domestic health, social, and environmental issues in the decades ahead. The 1992 report of the Carnegie Commission on Science, Technology and Government, for example, concluded that new scientific and technological advisory organizations will be needed to foster better communication between and within the states. These organizations will need to improve the gathering of scientific knowledge, of identifying best practices, and of suggesting research priorities in national science and technology forums. Studies on child maltreatment should be viewed as an important opportunity for building collaborative state and federal research organizations directed toward long-term improvements in social service programs in areas such as child protection, child welfare, family counseling, and foster care.

Private Foundations

In addition to research funding from governmental agencies, at least eight private foundations have selected child abuse and neglect as a priority funding area. Despite this interest, the amount of funds provided by private foundations for studies on child maltreatment is quite limited.

The nongovernmental sector may be an important source of potential funding for dissertation and graduate student support in funding studies on the relationships among child maltreatment, child development, family welfare, poverty, and others. It is most important, therefore, to see the private sector as a collaborator in strengthening the research foundation for studies on child maltreatment.

Conclusions

Support for child maltreatment research has developed in a haphazard, piecemeal fashion, reflecting the absence of a national plan for providing research, educational, and professional support for studies of child abuse and neglect. Governmental roles in this area have been complicated by

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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poor leadership, the absence of sufficient funds to support a robust research program, uncertainties about the most promising research directions to pursue, tensions between the role of the federal and state governments in sponsoring projects in such areas as child maltreatment and child and family welfare, and conflicting social values about the proper interventions to develop in response to child maltreatment incidents. Tensions also exist in the allocation of funds between professional and social services for maltreated children and their families and research projects that seem to provide no immediate benefits for these groups.

Given the current status and evolution of child maltreatment studies, a broad diversity of parallel efforts should be maintained. Top-down or centralized approaches should be avoided that may discourage or fail to recognize the significance of emerging theoretical paradigms, instrumentation research, and other approaches that seek to extend the boundaries of current knowledge about the origins, scope, and consequences of child abuse and neglect. In particular, attention to cultural and ethnic issues that affect our understanding of childhood needs, child development, and family life require a breadth of effort that currently does not exist in the research community.

While diversity of effort is important to maintain, the panel concludes that better national leadership is needed to organize the research base. Such leadership requires more informed documentation of research efforts so that scientific findings, instrumentation, theory, and data can be better recorded, integrated, and disseminated to researchers and practitioners. There is also a pressing need to connect education, research, and practice so that individuals who become caseworkers, family counselors, administrators, legal officials, and future scientists have a richer understanding of the complexities of child maltreatment. Finally, the development of both young and mature scientists needs attention to build a foundation for future explorations of the intricate scientific questions that lie ahead.

Ethical And Legal Issues

Ethical and legal issues for studies of child maltreatment will gain increasing prominence with the growth of research activities on child maltreatment, especially as researchers acquire the ability and resources to conduct long-term prospective studies of nonclinical samples involving large numbers of children and families.

Human Subjects Research Issues

Many ethical issues arise in the course of human subjects research, some of which have special relevance for studies of child maltreatment.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Five issues that deserve special attention are: (1) the recruitment of research subjects; (2) informed consent and deception; (3) assignment of subjects to experimental or control programs; (4) issues of privacy, confidentiality, and autonomy; and (5) debriefing or desensitizing of research subjects following research on matters that may involve deception or significant stress.

Issues Derived from Research on Children and Families

The validity of scientific research takes on special relevance in studies of children and other vulnerable populations, when research results are likely to influence social policy and public perceptions of the problem under study. Information that scientists disseminate about child victimization is often socially and politically sensitive and can affect both parental and professional behavior as well as public policy. Scientific information, communicated through the popular media, can influence the manner in which abusive parents view abuse, and the ways in which victims view themselves. High-quality research is needed to provide information that has a factual, scientific basis, rather than information based on conjecture or opinion.

Because validity is so important but hard to achieve in research on children and families, factors that affect validity are receiving increased attention. These factors include the definitions of child maltreatment, instrumentation and research methods, selection of subject samples, collection of data, interpretation of findings, and safeguards for ensuring privacy, confidentiality, and reliability in the research study.

Research on Socially Sensitive Topics

Scientific studies of child maltreatment require extraordinary care and confidentiality in eliciting, safeguarding, and disclosing information from respondents because of the socially sensitive nature of the research subject. Family disciplinary practices, the use of violence between family members, and expressions of anger or rage are difficult to detect, observe, and record. Research on children's sexual development is one of the most unexamined areas in all of social science, impeded by a variety of social taboos, political sensitivities, and ethical ambiguities in general and discussions of sexual behavior with children in particular.

Conclusions

Researchers who seek to foster valid and creative research projects must address fundamental ethical issues in the recruitment of research subjects; the process of obtaining informed consent; the assignment of subjects; debriefing, dehoaxing, and desensitizing subjects when deception or stress-

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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ful research is involved; and in providing referrals for children and family members in distress.

Research Priorities

Despite the clear significance of child maltreatment, the panel concludes that research in this area is in an early stage of development. Although much insight has been gained over the past three decades, the field has not yet developed an integrated and organized base of knowledge or ongoing data collection efforts that can inform practice, guide the development of programs and policies relevant to child maltreatment, and shape the formation and testing of major hypotheses in this field. As a result, research is needed in diverse areas to explore promising directions. At the same time, research on child maltreatment requires guidance, coordination, and leadership to organize the research base and cultivate future generations of researchers who are well trained and informed about the complex research questions in this field.

The panel concludes that a research agenda for child maltreatment studies should address four separate objectives. We need knowledge that can:

(1)

Clarify the nature and scope of child maltreatment, guided by well-developed research definitions and instrumentation.

(2)

Provide an understanding of the origins and consequences of child maltreatment in order to better inform theories regarding its etiology and to establish a foundation for improving the quality of future policy and program efforts to address this problem.

(3)

Determine the strengths and limitations of existing approaches and interventions in preventing and treating child maltreatment to guide the development of new and more effective interventions; and

(4)

Develop a science policy for child maltreatment research that recognizes the importance of developing national leadership, human resources, instrumentation, financial resources, and appropriate institutional arrangements for child maltreatment research.

Each chapter in this report includes key research recommendations within the topic under review. In the final chapter of the report (Chapter 10) the panel uses the four headings listed above as a framework for organizing the research priorities that it selected as the most important to address in the decade ahead. Details regarding each priority area appear in the individual chapters of the report.

Under each general heading below, the panel has organized the research priorities in order of their importance, with the most important recommendation listed first within each section.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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The Nature and Scope of Child Maltreatment

Research definitions of child maltreatment are inconsistent, and the breadth and quality of instrumentation for child maltreatment studies are seriously incomplete. The variation in existing definitions and inadequate instrumentation impedes high-quality research, inhibits the comparison of studies of related phenomena, and restrains the development of good evaluations of intervention efforts. Improved definitions and instrumentation will facilitate the development of small- and large-scale epidemiologic investigations. These investigations would provide solid information on the occurrence of these important problems as well as on key etiologic agents.

Research Priority 1. A consensus on research definitions needs to be established for each form of child abuse and neglect. The development of consensus requires a major federal and professional commitment to a dynamic, evolutionary process, guided by a series of expert multidisciplinary panels and developed in conjunction with existing agencies, that could review existing work on research definitions.

Research Priority 2: Reliable and valid clinical-diagnostic and research instruments for the measurement of child maltreatment are needed to operationalize the definitions discussed under Research Priority 1. The absence of appropriate instrumentation and methodology is a second serious barrier to the development of good child maltreatment research. The reliability and validity of these instruments must be established by sound methodology, including testing their relevance and usefulness for economically and culturally diverse populations.

Research Priority 3: Epidemiologic studies on the incidence and prevalence of child abuse and neglect should be encouraged, as well as the inclusion of research questions about child maltreatment in other national surveys. After considerable work on instrumentation, including investigations into effective questioning strategies, the panel recommends funding several epidemiologic studies of different size and scope (including different age groups and ethnic groups) to address several different questions relating to child maltreatment (for example, the extent of the hidden nature of abuse).

Understanding the Origins and Consequences of Child Maltreatment

Research Priority 4: Research that examines the processes by which individual, family, community, and social factors interact will improve understanding of the causes of child maltreatment and should be supported. Theoretical models that integrate a variety of risk and protective factors are a promising development in research on the origins of child maltreatment and deserve further research attention. Rather than endorsing

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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a single approach, the panel recommends that diverse models be tested using a variety of research strategies so that researchers can test theory and generate hypotheses about mechanisms that activate or protect against individual child maltreatment.

Research Priority 5: Research that clarifies the common and divergent pathways in the etiologies of different forms of child maltreatment for diverse populations is essential to improve the quality of future prevention and intervention efforts. Studies that compare the etiologies of different types of maltreatment, and the patterns of risk and protective factors among populations that vary by ethnicity, cultural, and economic status, should be supported. It is particularly important at this time to uncover key pathways for child victimization that may be amenable to prevention or other forms of intervention.

Research Priority 6: Research that assesses the outcomes of specific and combined types of maltreatment should be supported. Research is needed that assesses direct and indirect consequences of child maltreatment across different domains of life, such as health, cognitive and intellectual skills, and social behavior in a variety of cultural contexts.

Research Priority 7: Research is needed to clarify the effects of multiple forms of child victimization that often occur in the social context of child maltreatment. The consequences of child maltreatment may be significantly influenced by a combination of risk factors that have not been well described or understood. The presence or absence of certain characteristics and other adverse events may influence a child's response to childhood victimization, and in some cases the combined effects of two stresses (such as family environment and poor caretaking) may be greater than the sum of the two considered separately. The social context is particularly important, since the effects of abuse or neglect often cannot be separated from other problems confronting families experiencing a variety of problems. It is not yet known whether a syndrome of problem behaviors or combined risks have common origins or whether discrete behaviors have different etiologies. These contrasting pathways have different implications for intervention strategies.

Research Priority 8: Studies of similarities and differences in the etiologies and consequences of various forms of maltreatment across various cultural and ethnic groups are necessary. The effects of risk potentiating and protective factors on child maltreatment in diverse cultural and ethnic groups have not been adequately explored.

Improving Treatment and Preventive Interventions

At present, we have limited knowledge about the range or nature of treatment and preventive services for child maltreatment or the context in

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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which these services are available to children and their families. Research evaluations in this area therefore must seek to broaden understanding of what currently exists as well as documenting what services appear to work for which individuals or groups, under what circumstances. Research on service interventions must also seek to identify factors and mechanisms that facilitate, or impede, the transfer of knowledge between researchers who study the origins, nature, scope, and outcomes of child maltreatment and those who develop and implement policies and programs for child and family services in the public sector.

Research Priority 9: High-quality evaluation studies of existing program and service interventions are needed to develop criteria and instrumentation that can help identify promising developments in the delivery of treatment and prevention services. Independent scientific evaluations are needed to clarify the outcomes to be assessed for service delivery programs in the area of child maltreatment. Such evaluations should identify the outcomes to be assessed, clarify the instrumentation and measures that can provide effective indicators of child and family well-being or dysfunction, and develop the criteria that should be considered in evaluating the effectiveness of a specific program or service. Evaluation studies currently rely heavily on reported incidents of child maltreatment as a measure of program effectiveness. Given the uncertainties associated with official detection of child maltreatment, such outcomes may have limited value in measuring the achievements or limitations of a selected program intervention.

Rigorous evaluation studies should be an essential part of all major demonstration projects in the area of child maltreatment, and funds should also be available for investigator-initiated evaluation studies of smaller program efforts. Smaller programs should be encouraged to use similar assessment instruments, so that results can be compared across studies. Scientific program evaluations, published in the professional literature, are an important means of transferring the knowledge and experience gained in the service sector into the research community. Such information exchange can improve the quality of studies on the origins, consequences, and other aspects of child maltreatment, ultimately leading to improved services and programs.

Evaluation research is particularly important in the following areas:

Evaluation studies of specific program interventions, such as foster care, family preservation services, and self-help programs that examine the conditions and circumstances under which selected programs are beneficial or detrimental to the child are needed.

Empirical research is also needed to determine the degrees to which criminal sanctions deter child abuse and the degree to which removal of offenders or children from the home protects the child from abuse.

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Rigorous scientific evaluations of home visiting programs, focused on the prenatal, postnatal, and toddler periods, are necessary prior to the development of nationwide home visiting programs.

Evaluations of treatments for specific forms of child maltreatment are needed to identify criteria that promote recovery and to identify treatments that are appropriate for children and offenders depending on their sex, age, social class, spoken language or culture, and type of abuse.

Research evaluations of sexual abuse prevention programs are necessary, particularly to determine the outcomes of personal reports of sexual abuse that are often disclosed as a result of such programs.

Research is needed on the extent to which community-based prevention and intervention programs (such as school-based and domestic violence prevention programs, Head Start) focused on families at risk of multiple problems may affect the likelihood of child maltreatment.

Research Priority 10: Research on the operation of the existing child protection and child welfare systems is urgently needed. Factors that influence different aspects of case handling decisions and the delivery and use of individual and family services require attention. The strengths and limitations of alternatives to existing institutional arrangements need to be described and evaluated. We have very poor information about the methods and mechanisms used to identify and confirm cases of child maltreatment, to evaluate the severity of child and family dysfunction, to assess personal and social resources, family strengths, and extrafamilial influences, and to match clients to appropriate treatments based on these formulations. An analysis is needed of interactions among different agencies involved in intervention and treatment and the degree to which decisions made by one agency affect outcomes in others. A research framework that provides standardized classifications and descriptions of child maltreatment investigations, adjudications, and treatment services should be developed. Comparative studies are needed to describe the agencies involved in the system, the types of interventions available for selected forms of maltreatment, the costs of investigating and responding to reports of child maltreatment, and the outcomes of case reports. Such studies should also consider the development of alternatives to existing institutional arrangements to improve the quality of service delivery systems.

Research Priority 11: Service system research on existing state data systems should be conducted to improve the quality of child maltreatment research information as well as to foster improved service interventions. Variations in state definitions of child abuse and neglect as well as differences in verification procedures result in significant unevenness in the quality of research data on child maltreatment reports.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Research Priority 12: The role of the media in reinforcing or questioning social norms relevant to child maltreatment needs further study. Important lessons can be learned from the role of the media in fostering healthy or unhealthy behaviors in areas such as the use of alcohol, smoking, drug use, and condom use. Research is needed that can identify the significant pathways by which key factors and behaviors affect child maltreatment, such as parenting styles, the use of corporal punishment, the use of violence and time-out periods in stress management and conflict resolution, and young children's relationships with strangers and abusive caretakers.

A Science Policy for Research on Child Maltreatment

The complexity of the problem of child maltreatment requires a sustained commitment to high-quality research, national leadership, human resources, and adequate funds. Scientific knowledge can contribute to our understanding of the nature, scope, origins, and consequences of child maltreatment, but such knowledge cannot be developed in a haphazard manner. Thus the panel has formulated priorities for science policy and the research infrastructure that supports child maltreatment studies in order to highlight key strengths and existing deficiencies in the research system.

Research Priority 13: Federal agencies concerned with child maltreatment research need to formulate a national research plan and provide leadership for child maltreatment research. Existing fragmentation in the federal research effort focused on child maltreatment requires immediate attention. National leadership is necessary to develop a long-term plan that would implement the child maltreatment research priorities identified by the panel, help coordinate the field, and focus it on key research questions. The panel believes that Congress, federal agency directors, and the research community should weigh the strengths and limitations of alternative federal research management approaches presented in this report in considering how to implement a national research plan for child maltreatment. Once a course of action has been formulated, current and proposed agency research activities need to be examined so that areas of strength, duplication of effort, and gaps in current efforts can be identified.

Research Priority 14: Governmental leadership is needed to sustain and improve the capabilities of the available pool of researchers who can contribute to studies of child maltreatment. National leadership is also required to foster the integration of research from related fields that offer significant insights into the causes, consequences, treatment, and prevention of child maltreatment.

Research Priority 15: Recognizing that fiscal pressures and budgetary deficits diminish prospects for significant increases in research budgets generally, special efforts are required to find new funds for

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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research on child abuse and neglect and to encourage research collaboration and data collection in related fields. The federal government spent about $15 million in fiscal year 1992 on research directly related to child maltreatment. As a first step in strengthening the research portfolio, the panel recommends that the research budgets of the National Center on Child Abuse and Neglect, the National Institute of Mental Health, the National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, and the Department of Justice that are relevant to child maltreatment studies be doubled over the next three years. Second, the panel recommends that the National Center on Child Abuse and Neglect convene a consortium of government agencies, private foundations, and research scientists to develop a task force to identify ways in which research on programs relevant to child maltreatment (such as substance abuse, spousal violence and child abuse, child homicides, juvenile delinquency, and so forth) can be more systematically integrated into the research infrastructure for child abuse and neglect.

Research Priority 16: Research is needed to identify organizational innovations that can improve the process by which child maltreatment findings are disseminated to practitioners and policy makers. The role of state agencies in supporting, disseminating, and utilizing empirical research deserves particular attention. Research on the information dissemination process can strengthen the ways in which science is used to inform and advise legislative and judicial decision makers. Such research can also contribute to the effective partnerships among scientists, practitioners, clinicians, and governmental officials to encourage the use of sound research results in formulating policies, programs, and services that affect the lives of thousands of children and their families.

State agencies have an important role in developing and disseminating knowledge about factors that affect the identification, treatment, and prevention of child maltreatment. The National Center on Child Abuse and Neglect should encourage the development of a state consortium that can serve as a documentation and research support center, allowing the states to collaborate in sponsoring child maltreatment studies and facilitating the dissemination of significant research findings to state officials.

Research Priority 17: Researchers should design methods, procedures, and resources that can resolve ethical problems associated with recruitment of research subjects; informed consent; privacy, confidentiality, and autonomy; assignment of experimental and control research participants; and debriefings. Research is needed to clarify the nature of individual and group interests in the course of research, to develop clinical advice and experience that can resolve such conflicts among such interests, and to identify methods by which such guidance could be communicated to researchers, institutional review boards, research administrators, research subjects, and others.

Suggested Citation:"SUMMARY." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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References

Daro, D.
1988 Confronting Child Abuse: Research for Effective Program Design. New York: The Free Press, Macmillan.

Daro, D., and K. McCurdy
1991 Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1990 Annual Fifty State Survey. Chicago: National Committee for Prevention of Child Abuse.

General Accounting Office
1991 Child Abuse Prevention: Status of the Challenge Grant Program. May. GAO:HRD91-95. Washington, DC.

McClain, P.W., J.J. Sacks, R.G. Froehlke, and B.G. Ewigman
1993 Estimates of fatal child abuse and neglect, United States, 1979 through 1988. Pediatrics 91(2):338-343.

Olds, D.L., C.R. Henderson, R. Chamberlin, and R. Tatelbaum
1986a Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics 78:65-78.

Olds, D.L., C.R. Henderson, R. Tatelbaum, and R. Chamberlin
1986b Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics 77:16-28.

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Next: 1 INTRODUCTION »
Understanding Child Abuse and Neglect Get This Book
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The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

oDefinitions and scope--exploring standardized classifications, analysis of incidence and prevalence trends, and more.

oEtiology, consequences, treatment, and prevention--analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.

oInfrastructure and ethics--including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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