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Understanding Child Abuse and Neglect (1993)

Chapter: 6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT

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Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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6
Consequences of
Child Abuse and Neglect

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

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

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

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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infancy. Until recently, research on the consequences of physical and sexual child abuse and neglect has been based primarily on retrospective studies of adolescents or adults that are subject to clinical bias and inaccurate recall (Aber and Cicchetti, 1984). Research on the consequences of abuse is also challenged by the hidden nature of much abuse and because these experiences may not come to anyone's attention until years after they occur. Maltreatment often occurs in the presence of multiple problems within a family or social environment, including poverty, violence, substance abuse, and unemployment. Distinguishing consequences that are associated directly with the experience of child maltreatment itself rather than other social disorders is a daunting task for the research investigator.

Research on the consequences of child maltreatment is also uneven and, as a result, we do not yet understand the consequences on children of particular types or multiple forms of abuse. In recent years, much attention has been focused on the consequences of child sexual abuse, especially the adolescent and adult sexual behavior of the victim. Less attention has been given to the short- and long-term consequences of child neglect and physical abuse. Only recently has public awareness expanded to include recognition of the psychological consequences that stem from even the most subtle forms of emotional maltreatment. Some experts now contend that the psychological or emotional components of abuse and neglect are the factor most responsible for the destructive consequences of all types of maltreatment (Brassard et al., 1987; Erickson and Egeland, in press; Newberger, 1973).

Nor do we yet know the importance of the particular timing, intensity, and context of abuse on the outcome. Factors such as the age and developmental status of the child may influence the outcomes of maltreatment experiences. Effects that appear at only one life stage, whether immediately following the maltreatment or later, are often different from those that persist throughout life. What may appear to be adaptive or functional at one point in development (avoiding an abusive parent or desensitizing oneself against feelings) may later compromise the person's ability to draw on and respond to personal relationships in an adaptive and flexible way. Given the wide variations reported in the research literature, certain intrinsic strengths and vulnerabilities within a child and the child's environment may affect the extent to which abuse will have adverse consequences. Disordered patterns of adaptation may lie dormant, only to appear during times of stress or in conjunction with particular circumstances (Sroufe and Rutter, 1984).

Little research has focused on gender differences in the consequences of child abuse and neglect. Early clinical reports of violence primarily describe violent male adolescents, although Widom's (1991b) delinquency analysis had higher rates of arrests for violence of abused and neglected

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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females, a pattern not evident for males. Studies of sexual promiscuity and teenage pregnancy have primarily included females who were sexually abused. Few studies have found consistent differences in the reaction of boys and girls to molestation, although one popular report found boys to have more externalizing and girls to have more internalizing symptoms (Friedrich et al., 1988). The lack of attention to gender differences may result from the small number of male victims of sexual abuse in most studies and lower rates of reporting of childhood sexual abuse in males.

This chapter is organized in a developmental framework. It begins with a description of what is known about the childhood consequences of child maltreatment, followed by a discussion of what is known about the consequences of abuse and neglect in adolescence and adulthood. A discussion of labeling effects, considering the issues of stigma, bias, and discriminatory treatment, is followed by an examination of a number of potential protective factors. The chapter concludes with recommendations for research.

Childhood

Medical and Physiological Consequences

Physical abuse in infants and young children can lead to brain dysfunction (Dykes, 1986) and sometimes death. Most fatality victims of abuse and neglect are under age 5.1 In 1991, an estimated 1,383 children died from abuse or neglect; 64 percent of these deaths were attributed to abuse and 36 percent to neglect (McCurdy and Daro, 1992). However, the number of child deaths caused by abuse and neglect may actually be much higher, since cause of death is often misclassified in child fatality reports (McClain et al., 1993; Robinson and Stevens, 1992).

A child does not need to be struck on the head to sustain brain injuries. Dykes (1986) has indicated that infants who are shaken vigorously by the extremities or shoulders may sustain intracranial and intraocular bleeding with no sign of external head trauma. Thus early neglectful and physically abusive practices have devastating consequences for their small victims.

Neglect cases may occur at any point of a child's development but are often associated with early childhood, when they are more likely to be discovered by health professionals, educators, and child welfare workers. One form of child neglect is associated with nonorganic failure to thrive infants. The absence of physical growth in these infants can be measured by objective scales of weight and height (Drotar, 1992). Neglect is usually suspected when such infants demonstrate significant weight gain following hospital admission or child removal from the family. Deprivational dwarfism, a medical term applied to children of small stature whose physical

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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growth is impaired by the absence of nutritional requirements, is another type of child neglect associated with some young children. Even after diagnosis and treatment, the psychological consequences of emotional neglect persist. Polansky et al. (1981) found that young adolescents who in their infancy were diagnosed as failure to thrive were defiant and hostile. Drotar (1992) notes that factors that trigger nonorganic failure to thrive and child neglect should be separated from factors that maintain these behaviors. In early periods of neglectful behavior, the child may exhibit stressful behaviors in the forms of feeding problems, irritability, or deficits in social responsiveness that place increased demands on the parent's caretaking duties (Powell and Low, 1983; Powell et al., 1987). In some cases, nutritional deprivation, combined with increased maternal detachment, sets into motion a "vicious cycle of cumulative psychological risk" (Drotar, 1992:121). Eventually, the parent may begin to perceive the child as quiet, sickly, or not very competent, perceptions that may not be shared by others who observe the child (Ayoub and Miler, 1985; Kotelchuck, 1982). In the absence of growth indicators of nonorganic failure to thrive or deprivational dwarfism, clinical diagnosis of child neglect is quite difficult. Oates (1984a,b; 1992) has described some nonspecific behavioral characteristics of nonorganic failure to thrive infants, which include lack of smiling, an expressionless face, gaze aversion, self-stimulating behavior, intolerance of changes in routine, low activity level, and flexed hips.

Abuse and neglect may result in serious health problems that can adversely affect children's development and result in irremediable lasting consequences. Early studies of physically abused children documented significant neuromotor handicaps, including central nervous system damage, physical defects, growth and mental retardation, and serious speech problems (Elmer and Gregg, 1967; Green et al., 1974; Martin et al., 1974; Morse et al., 1970). Physically abused children have been found to have more mild neurologic signs, serious physical injuries, and skin markings and scars than their nonabused peers (Kolko et al., 1990). Children who have been sexually abused, and some children who have been physically neglected, have shown heightened sexuality and signs of genital manipulation. A particularly serious biological consequence of child and adolescent sexual abuse is the risk of sexually transmitted diseases, including human immunodeficiency virus, gonorrhea, and syphilis.

Cognitive and Intellectual Consequences

Cognitive and language deficits in abused children have been noted clinically (Augoustinos, 1987; Azar et al., 1988; Fantuzzo, 1990; Kolko, 1992). Abused and neglected children with no evidence of neurological impairment have also shown delayed intellectual development, particularly

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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in the area of verbal intelligence (Augoustinos, 1987). Some studies have found lowered intellectual functioning and reduced cognitive functioning in abused children (Hoffman-Plotkin and Twentyman, 1984; Perry et al., 1983). However, others have not found differences in intellectual and cognitive functioning, language skills, or verbal ability (Alessandri, 1991; Allen and Oliver, 1982; Elmer, 1977; Lynch and Roberts, 1982).

Problematic school performance (e.g., low grades, poor standardized test scores, and frequent retention in grade) is a fairly consistent finding in studies of physically abused and neglected children (Eckenrode et al., 1991; Salzinger et al., 1984; Wolfe and Mosk, 1983), with neglected children appearing the most adversely affected. The findings for sexually abused children are inconsistent.

Dodge and colleagues (1990) found that physically harmed 4-year-old children showed deviant patterns of processing social information, related to aggressive behavior, at age 5. Physically harmed children (relative to nonphysically harmed children) were significantly less attentive to social cues, more inclined to attribute hostile intent, and less able to manage personal problems. They explain possible cognitive deficits in abused and neglected children by suggesting that physical abuse affects the development of social-information-processing patterns, which in turn lead to chronic aggressive behavior. The experience of severe physical harm is associated with the "acquisition of a set of biased and deficient patterns of processing social provocation information" (p. 1679).

Differences in findings on the cognitive and intellectual consequences of childhood maltreatment may be related to the failure to control for important variables, such as socioeconomic status, and the lack of statistical power of small sample sizes.2 Other possible explanations for the inconsistencies in this literature are the tendency of earlier studies to aggregate different types of maltreatment (which may mask different consequences associated with specific forms of child maltreatment) or the inclusion of children who had neurological dysfunction to begin with (which can dramatically influence cognitive and intellectual performance). More recent studies have excluded children with obvious neurological impairments. Yet maltreatment, especially early maltreatment, can cause injury to the central nervous system that results in future cognitive impairments (Lewis and Shanok, 1977).

Psychosocial Consequences

Some studies suggest that certain signs of severe neglect (such as when a child experiences dehydration, diarrhea, or malnutrition without receiving appropriate care) may lead to developmental delays, attention deficits, poorer social skills, and less emotional stability. Consequences of physical child

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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abuse have included deficiencies in the development of stable attachments to an adult caretaker in infants and very young children (Cicchetti, 1989; Cicchetti and Barnett, 1991; Crittenden and Ainsworth, 1989). Poorly attached children are at risk for diminished self-esteem and thus view themselves more negatively than nonmaltreated children. In several studies, school-age victims of physical abuse showed lower self-esteem on self-report (Allen and Tarnowski, 1989; Kinard, 1982; Oates et al., 1985) and parent-report measures (Kaufman and Cicchetti, 1989), but other studies found no differences (e.g, Stovall and Craig, 1990).

The consequences of neglectful behavior can be especially severe and powerful in early stages of child development. Drotar (1992) notes that maternal detachment and lack of availability may harm the development of bonding and attachment between a child and parent, affecting the neglected child's expectations of adult availability, affect, problem solving, social relationships, and the ability to cope with new or stressful situations (Aber and Allen, 1987; Main et al., 1985). One study by Rohner (1986) has presented impressive cross-cultural evidence of the negative consequences of parental neglect and rejection on children's self-esteem and emotional stability.

In a prospective study of the qualitative range of caregiving in a high-risk sample, Egeland and Sroufe (1981a) identified a group of mothers who were psychologically unavailable to their infants. These mothers were detached and unresponsive to their children's bids for care and attention. Children from this group were compared with physically abused, neglected, verbally rejected, and control groups from the same high-risk sample. Using multiple measures across different situations and outcome measures designed to assess the salient developmental issues of each age, the results indicated that children in all maltreatment groups functioned poorly (Erickson et al., 1989). Over time their functioning deteriorated. There were many similarities in terms of the pattern of development between the maltreatment groups, but there were also a number of interesting differences.

Nearly all the children in this study whose mothers were psychologically unavailable were anxiously attached at 18 months of age, with the majority of these classified as anxious avoidant (86 percent). These children were observed with their mothers in a problem-solving situation at 24 months and a teaching task at 42 months and were found to be angry, noncomplacent, lacking in persistence, and displaying little positive affect. One of the most dramatic findings for these children was the nearly 40 point decline in performance on the Bayley Scales of Infant Development between 9 and 24 months. In the preschool classroom, these children presented varied and serious behavior problems.

Studies have reported evidence of other psychosocial problems in young children. Higher incidence of suicide attempts and self-mutilation have been

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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reported in clinical samples (Green, 1978). Comparison studies with nonphysically abused children indicate heightened levels of depression, hopelessness, and lower self-esteem in physically abused children (Allen and Tarnowski, 1989; Kazdin et al., 1985). Greater emotional difficulties in older physically abused children have also been identified (Kinard, 1980, 1982). In a more recent investigation involving prepubescent (ages 7 to 12) maltreated children, Kaufman (1991) found a disproportionate number of the maltreated children who met the diagnostic criteria for one of the major affective disorders.3

Linkages between parental behaviors that have emotionally or psychologically destructive consequences on children have not been clearly established. While verbally or symbolically abusive acts designed to terrorize or intimidate a child (such as constant belittling or the destruction of a favorite object or pet) are associated with severe long-term consequences (Vissing et al., 1991), the processes by which children interpret aggressive or neglectful actions are poorly understood. The failure to provide age-appropriate care (such as parental availability and nurturance), cognitive stimulation, or achievement expectations also can have profound psychological impact, especially when such omissions occur during critical child and adolescent developmental periods.

Although causal linkages between parental behaviors and the consequences on the child's development have been assumed, pathways that govern or mediate such linkages have not been well documented (Knudsen, 1992).

Inappropriate sexual behavior, such as frequent and overt self-stimulation, inappropriate sexual overtures toward other children and adults, and play and fantasy with sexual content, are commonly cited as symptoms of sexual abuse in studies that compare sexually abused with nonabused or nonclinical children (Kendall-Tackett et al., 1993). Across six studies of sexually abused preschoolers (those most likely to manifest such symptoms), approximately 35 percent of the abused children showed such behaviors. Sexual abuse has also sometimes been associated with the onset of sexual activity in middle childhood. Reported rates vary widely because of differences in samples, measurement instruments, and definitions of the outcome behavior. The lowest estimates (of 7 percent) were based on a large study that included many well-functioning and older children.

While sexualization seems relatively specific to sexual abuse, inappropriate sexual behavior has been noted in nonsexually abused children. Deblinger et al. (1989) compared the reports of inappropriate sexual behaviors across sexually abused, physically abused, and nonabused psychiatrically hospitalized children matched for age, sex, and socioeconomic status. They found that approximately the same percentage of sexually inappropriate behavior in physically abused (17 percent) as in sexually abused chil-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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dren (18 percent). However, early sexual abuse may occur and not be documented until much later in life (Stein and Lewis, 1992).

In a recent review of studies reporting quantitative findings about the impact of sexual abuse of minors, Kendall-Tackett et al. (1993) found that sexually abused children were often more symptomatic than their nonabused counterparts in terms of fear, nightmares, general post-traumatic stress disorder, withdrawn behavior, neurotic mental illness, cruelty, delinquency, sexually inappropriate behavior, regressive behavior, running away, general problem behaviors, and self-injurious behavior. Estimates of sexually abused children diagnosed as meeting the DSM-III-R criteria for post-traumatic stress disorder range from 21 percent (Deblinger et al., 1989) to 48 percent (McLeer et al., 1988).4

Sexually abused children, particularly those abused by a family member, may show high levels of dissociation, a process that produces a disturbance in the normally integrative functions of memory and identity (Trickett and Putnam, in press). Many abused children are able to self-hypnotize themselves, space out, and dissociate themselves from abusive experiences (Kluft, 1985). In some clinical studies, severely abused children appear to be impervious to pain, less empathetic than their nonabused peers, and less able than other children to put their own suffering into words (Barahal et al., 1981, Straker and Jacobson, 1981).

Behavioral Consequences

Physical aggression and antisocial behavior are among the most consistently documented childhood outcomes of physical child abuse. Most studies document physical aggression and antisocial behavior using parent or staff ratings (Aber et al., 1990; Hoffman-Plotkin and Twentyman, 1984; Perry et al., 1983; Salzinger et al., 1984); other measures, such as child stories (Dean et al., 1986); or observational measures across a wide variety of situations, including summer camps and day care settings (Alessandri, 1991; Bousha and Twentyman, 1984; Howes and Eldredge, 1985; Howes and Espinosa, 1985; Kaufman and Cicchetti, 1989; Main and George, 1985; Trickett and Kuczynski, 1986; Walker et al., 1989). Some studies indicate that physically abused children show higher levels of aggression than other maltreated children (Hoffman-Plotkin and Twentyman, 1984; Kaufman and Cicchetti, 1989) although other studies indicate that neglected children may be more dysfunctional (Rohrbeck and Twentyman, 1986).

A prospective study comparing preschool children who were classified as physically harmed with those who were unharmed (Dodge et al., 1990) found that children with a history of physical harm were rated six months later as more aggressive by teachers and peers. These differences were not accounted for by the child's demographic or family background. Evidence

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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from other longitudinal studies indicates continued problems of aggression and anger (Egeland and Sroufe, 1981b) and the development of conduct disorder (Rogeness et al., 1986). Children who experienced severe violence were reported (by their parents) in the National Family Violence Survey to have higher rates of conduct problems and rule violating behaviors than those who did not experience severe violence (Straus and Gelles, 1990; Hotaling et al., 1990).

Maltreated children may also be less competent in their social interactions with peers (Straus and Gelles, 1990; Howes and Espinosa, 1985). For some physically abused children, this may manifest in withdrawal or avoidance (Kaufman and Cicchetti, 1989), or fear, anger, and aggression (Main and George, 1985).

Effects of Witnessing Domestic Violence

Not much is known about the psychosocial status of siblings of abused children. Several studies suggest that the child's experience of witnessing violence toward siblings or parents may be as harmful as the experience of victimization itself (Rosenbaum and O'Leary, 1981). Some studies have suggested that children who see violence in their homes may view such behavior as an appropriate means of resolving conflict and also see violence as an integral part of a close relationship (Groves et al., 1993; Jaffe et al., 1988; Straus, 1992). However, research on the effects of a child's witnessing family violence is contradictory and characterized by methodological flaws. In many studies of the effects of observing family violence, for example, the child subjects are often themselves the victims of physical child abuse.

A few studies in the area of physical aggression and violence suggest that siblings of aggressive children exhibit high rates of aggressive/oppositional behavior (Patterson et al., 1989; Patterson, 1982). These findings have been confirmed in observational studies showing that aggressive and hostile behavior is exhibited by various members of families of aggressive children.

Related evidence examining the role of interparental conflict suggests witnessing verbal hostility and physical violence between parents is associated with significantly higher levels of child internalizing and externalizing behavior on parent rating scales, and lower levels of child competence based on direct interviews (Fantuzzo et al., 1991) compared with witnessing verbal hostility alone. The impact of observing parental conflict and violence has been demonstrated on various clinical measures of child functioning (see Fantuzzo and Lindquist, 1986; Jaffe et al., 1990, 1991; Widom, 1989c; Wolfe and Jaffe, 1991). Studies have generally not examined whether the results are due to exposure to parental violence, the effects of confounding variables such as child rejection, limited caretaking skills, and parental in-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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volvement, or other forms of family conflict associated with a dysfunctional home environment.

Adolescence

Research on the developmental consequences of child abuse and neglect is still relatively new. Studies of the consequences of child abuse and neglect that appear in adolescence have generally not differentiated between consequences that are derived from earlier childhood experiences with maltreatment and consequences that are unique to adolescent experiences with abuse and neglect.

Delinquency

An extensive body of work has examined the relationship between childhood victimization and later delinquency (for reviews, see Gray et al, 1986; Garbarino and Plantz, 1986; Widom, 1989c, 1991b). Although the majority of abused children do not become delinquent, and the majority of delinquents are not abused as children, this research indicates that abused and neglected children are at increased risk for juvenile delinquency. Prospective studies estimate the incidence of delinquency in adolescents who have been abused or neglected as children to be about 20 to 30 percent (Widom, 1989c). Retrospective studies, in which delinquents were asked about their early backgrounds, estimated rates from approximately 8 to 26 percent (Widom, 1989c). What is not known is whether specific, or combined, institutional responses to incidents of abuse (such as arrest of the perpetrator, foster care, and the provision of mental health services) influence the probability of delinquent behavior by abused or neglected children.

In one study, childhood abuse or neglect significantly increased a child's risk for an arrest during adolescence by more than 50 percent (26 versus 17 percent) (Widom, 1989b).5 Abused and neglected children began their official criminal activity approximately one year earlier than the control subjects (16.5 versus 17.3 years) and had approximately twice the number of arrests. Early childhood victimization was associated with increased risk of arrest as a juvenile (prior to age 18) compared with controls. When considering delinquency, degrees of aggression must be taken into account. Some clinical studies indicate that violent delinquents are more likely to have suffered severe abuse than nonviolent delinquents (Lewis and Shanok, 1977; Lewis et al., 1979, 1982).

An epidemiological study of medical hospital records of deliquent and nondelinquent adolescents matched for age, sex, race, and socioeconomic status found that the delinquent sample had significantly more accidents, injuries, and illnesses than the nondelinquents (Shanok and Lewis, 1981;

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Lewis et al., 1985). Of note, white delinquents experienced far greater numbers of adverse medical events than white nondelinquents, although the medical histories of black delinquents were only slightly more adverse than their black nondelinquent counterparts.

Violence

Almost 30 years ago, Curtis (1963) suggested that abused and neglected children would ''become tomorrow's murderers and perpetrators of other crimes of violence, if they survive" (p. 386). Subsequently, a number of small-scale clinical reports described prior abuse in the family backgrounds of adolescents who attempted or succeeded in killing their parents (Easson and Steinhilber, 1961; King, 1975; Sendi and Blomgren, 1975). Since then, larger and more systematic studies have explored the relationship between child abuse, neglect, and violent behavior in delinquents (Alfaro, 1981; Geller and Ford-Somma, 1984; Gutierres and Reich, 1981; Hartstone and Hansen, 1984; Kratcoski, 1982).

These studies, which differ in design, scope, and quality, reveal contradictory findings. Some studies provide strong support for the cycle of violence (Geller and Ford-Somma, 1984; Lewis et al., 1979, 1985; Straus et al., 1980; Vissing et al., 1991). In a clinical study of 97 incarcerated male delinquents (Lewis et al., 1979), neuropsychiatric vulnerabilities and histories of abuse and family violence distinguished the more violent subjects from their less violent delinquent counterparts.6 When these 97 delinquents were followed into young adulthood, the abused delinquents who also were most impaired neuropsychiatrically were found to have committed the greatest numbers of crimes as adults (Lewis et al., 1989).

Other studies have not found significant differences between abused and nonabused delinquents (Kratcoski, 1982). In one study, abused delinquents were less likely to engage in later aggressive crimes (Gutierres and Reich, 1981). Fagan et al. (1983) found low incidences of both child abuse and parental violence among violent juvenile offenders. In most studies, the majority of abused children did not become delinquents or violent offenders.

Widom (1989b) did not find that abused and neglected children had significantly higher rates of arrest as juveniles for violent crimes than controls (4 versus 3 percent) although abused or neglected females appeared to be at increased risk of arrest for violent crimes during adolescence (Widom, 1991b).

Inconsistencies in studies of the relationship between early childhood maltreatment and subsequent violent behaviors may be attributed to various factors, including study designs, reliance on reports of maltreatment, and the use of arrests for violence as the only measure of violent behavior.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Becoming a Runaway

In national surveys in which runaways were asked about their early childhood histories, most runaways do not report having been sexually or physically abused prior to their leaving home. However, abusive experiences in the home may increase the chances of an adolescent's becoming a runaway. Pagelow (1984) noted that "many runaway children are not running toward something, but rather are running away from something—a home life in which they were subject to abuse, particularly sexual abuse" (p. 49). Only a handful of studies have attempted to describe the extent to which adolescents who run away report experiences with abuse. In two studies, sexual abuse victims were found to have run away from home more often during adolescence than clinical controls (Herman, 1981; Meiselman, 1978). In the 1988 National Survey of Missing, Abducted, Runaway, and Thrownaway Children in America, approximately 3 percent of the runaways reported having been sexually abused and 1 percent physically harmed (Finkelhor et al., 1990). In contrast, in a runaway shelter in Ohio, 75 percent of the youths reported having experienced physical maltreatment (McCord, 1983). One prospective study traced official criminal histories for a large sample of abused and neglected children and matched controls and found direct support for a relationship between early childhood victimization and adolescent running away (Widom, 1991b).7

The results of these studies suggest that there may be a link between childhood victimization and running away. The hypothesized linkage between maltreatment experiences and running away warrants further examination, since it may shed light on at least one pathway to problem behaviors and on possible intervention points. In the case of children who run away, delinquent behavior during adolescence may represent an adaptive response to the immediate situation of an abusive home, although such a response may be dangerous and ultimately harmful to the child. For these children, one might speculate that the long-term consequences may be different for abused children who do not manifest this type of acting out during adolescence. At the same time, the effects of early abusive experiences may be manifest in ways not related to delinquency or running away, but may lie in more subtle manifestations of emotional damage such as low self-esteem, depression, withdrawal, or, in the extreme, suicide.

Intimacy, Sexual Problems, and Teenage Pregnancy

Briere (1992a,b) has suggested that abuse-related symptomatology can wax and wane across the life span (Friedrich and Reams, 1987). This variability may reflect developmental issues. For example, intimacy and sexual problems may first appear in adolescence when the individual con-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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fronts these issues. Other effects, such as revictimization or substance abuse, may also occur in young adulthood.8

Many clinicians and researchers have described a relationship between childhood sexual abuse and sexually promiscuous or dysfunctional behavior (e.g., sexual offenses, prostitution) in adolescence (Allen, 1980; Becker et al., 1986; Burgess et al., 1987; Courtois, 1979; DeYoung, 1982; Fehrenbach et al., 1986; Finkelhor, 1979; Finkelhor et al., 1989; Groth, 1979; Greenwald, 1970; Herman and Hirschman, 1977; James and Meyerding, 1977; Seghorn et al., 1987; Silbert and Pines, 1981; Wyatt, 1988). However, the methodological weaknesses of these studies do not provide empirical support for a causal relationship between sexual abuse, sexual dysfunction, and promiscuity. Indeed, in a review of research on the impact of child sexual abuse, Browne and Finkelhor (1986:66) cautioned that "although clinical literature suggests that sexual abuse during childhood plays a role in the development of other problems ranging from anorexia nervosa to prostitution, empirical evidence about its actual effects is sparse."

Female victims of child sexual abuse are often though to be at increased risk of becoming pregnant as teenagers, an important outcome of child sexual abuse because of the theoretical link between early parenting and inadequate childrearing practices. In a review of this literature, Bohigan (1989) concluded that existing research had not yet clearly established a relationship between child sexual abuse and adolescent pregnancy, but that abusive mothers do have more children at younger ages (Zuravin, 1988).9 One difficulty in interpreting this literature is that a teenager's pregnancy may result from a variety of factors, including forced sexual intercourse, promiscuity, and inadequate contraceptive protection following a history of sexual abuse (Gershenson et al., 1989).

Although victims of childhood abuse may be increasingly vulnerable to sexual promiscuity and at increased risk for teenage pregnancy, solid empirical evidence does not yet exist. Research is needed to clarify and extend our knowledge about possible causal relationships between different forms of childhood victimization and adolescent pregnancy, taking into account relevant demographic variables and confounding factors such as socioeconomic status (Brooks-Gunn and Furstenberg, 1989; Chase-Landale et al., 1991).

Alcohol Problems

Recent research has called attention to alcohol problems that may be a consequence of child maltreatment. Researchers have hypothesized that for abused and neglected children, alcohol use may serve a number of possible functions: (1) to provide psychological escape from an abusive and aversive environment; (2) to serve as a form of self-medication in which the child tries to gain control over his or her negative life experiences; (3) to act as a

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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form of self-enhancement to improve the child's self-esteem (Miller et al., 1989); or (4) to reduce feelings of isolation and loneliness (for a review, see Ireland and Widom, in press). Similar to escaping from an abusive home environment by running away, alcohol use may serve as a coping strategy adopted by abused and neglected children.

Despite the hypothesized association, evidence supporting this relationship is sketchy. Relatively few studies have examined alcohol problems in adolescents who were abused or neglected in childhood, and even fewer have looked at these connections in nonclinical samples. One study found that physical abuse was significantly related to alcohol use in a cohort of high-risk youth prior to the initial interview, but not during the follow-up period about one year later (Dembo et al., 1990).

In addition, parental alcohol problems may be antecedent to child maltreatment and may have an important role in influencing the parent's maltreating behavior. Since most child abuse is committed by biological parents, familial factors may contribute to a relationship between childhood victimization and a child's subsequent risk for alcohol problems. Children of parents with alcohol problems are generally at increased risk for the development of alcohol problems (Goodwin et al., 1973, 1977; Russell et al., 1985; Schuckit, 1986). If parents with alcohol problems are more likely to abuse or neglect their children, then multiple reasons might support hypotheses that their offspring will be at increased risk for the development of alcohol problems. Research is needed to disentangle the effects of an abusive or neglectful home environment on alcoholism from family history of alcoholism, multiple problems commonly facing abusive families, and other predispositions for alcohol problems.

Illicit Drug Use or Abuse

Illicit drug use or abuse in adolescence has sometimes been viewed as a form of psychological escape or as a form of self-medication to control negative sensations (Cavaiola and Schiff, 1989; Harrison et al., 1989a,b; Singer et al., 1989). Illicit drug use may also result from a need for self-enhancement and improved self-esteem (Dembo et al., 1987, 1989). Drugs may be used to reduce feelings of isolation and loneliness, by providing the adolescent with a peer group, as he or she becomes part of the drug culture (Singer et al., 1989).

In contrast to the sparse literature on adolescent alcohol problems and childhood victimization, several studies suggest a relationship between childhood victimization and adolescent substance abuse, although the results of this research are sometimes inconsistent (Benward and Densen-Gerber, 1975; Cavaiola and Schiff, 1989; Dembo et al., 1987, 1989; Gomes-Schwartz et al., 1985; Harrison et al., 1989; Lindberg and Distad, 1985a; Runtz and

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Briere, 1986; Sansonnet-Hayden et al., 1987; Singer et al., 1989). One study by Harrison et al. (1989b) of adolescent males in a chemical dependency treatment program found that male victims of sexual abuse used a wider variety of drugs than nonvictims and used more drugs to self-medicate but did not report an earlier onset of drug use. In contrast, Goldston et al. (1989) found that drug abuse was more common among a control group of girls than sexually abused girls. A study of 444 adolescent girls admitted to chemical dependency treatment programs found that sexually abused girls did not differ in the overall prevalence or frequency of substance use from nonvictims, although the victims were more likely to report regular use of particular drugs and to report an earlier age of onset of drug use (Harrison et al., 1989a). These findings of earlier onset of substance use by female sexual abuse victims support the self-medication hypothesis, rather than motivations associated with peer pressure. Sex differences in the use of illicit drugs may be related to differences in socialization experiences, to age-related patterns of drug use, or to actual gender differences in age of onset of drug behavior (Colten and Marsh, 1984).

Most studies of the association between illicit drug use and childhood victimization have focused on sexually abused children in clinical settings or in detention facilities. With some exceptions, these studies are cross-sectional designs, include information about childhood abuse experiences based on retrospective self-reports, and do not utilize control groups. These methodological limitations suggest that a causal connection between childhood victimization and adolescent substance use or abuse has not been established.

Self-Destructive Behavior, Depression, and Suicide Attempts

Several writers have suggested that severe childhood maltreatment also is related to later self-destructive behavior (Gutierres and Reich, 1981), withdrawal (George and Main, 1979; Kagan, 1977; Martin and Beezley, 1977), and depression (Allen and Tarnowski, 1989; Kazdin et al., 1985). Although this body of work is not extensive, some abused and neglected children appear to engage in self-abusive and self-destructive behavior in adolescence. Lindberg and Distad's (1985a) small study of 27 adolescents with incest histories found that one-third had attempted suicide. Sansonnet-Hayden et al. (1987) found that depressive symptoms and schizoid/psychotic symptoms (hallucinations) significantly differentiated adolescent inpatients with a history of sexual abuse from those with no history of sexual abuse, although it was not clear whether these behaviors came before or after the abusive experiences. Prospective and longitudinal research appears warranted to assess the extent to which this self-destructive and negative life trajectory characterizes abused and neglected children.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Summary

Victims of child abuse and neglect are at increased risk for delinquency and running away. However, existing research indicates that the majority of childhood victims do not manifest these behaviors. Significantly less is known about connections between childhood victimization and other problem behaviors, such as teenage pregnancy, alcohol and illicit drug use and abuse, self-destructive behavior, and suicide. Alcohol and illicit drug use are both illegal for teenagers, creating a natural confounding of alcohol or substance use with delinquency. For example, alcoholics often attempt other destructive behaviors, including suicide attempts (Schuckit, 1986). 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 at-risk behaviors.

A variety of adolescent problems may be related to early childhood victimization. Current knowledge about these outcomes is still uncertain. Research is needed to document the increased risk, scope, and magnitude of adolescent problem behaviors among maltreated children compared with children and adolescents in control groups.

Adulthood

Our 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 sequelae. 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.

Intergenerational Cycles of Abuse

A popular belief in both the scholarly and popular literature is that adults who were abused as children are more likely to abuse their own children. As noted in Chapter 4, Kaufman and Zigler (1987) estimated the rate of intergenerational transmission of abuse to be 30 percent (with a 5 percent margin of error). This means that about one-third of the individuals who were abused or neglected as children will abuse their own children and that two-thirds will not. "Being maltreated as a child puts one at risk for becoming abusive but the path between these two points is far from direct or inevitable" (Kaufman and Zigler, 1987:190).

Kalmuss (1984) used data from the National Family Violence Survey to

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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explore the relationship between family aggression and severe marital aggression in the next generation. She found that children who observed hitting between their parents were more likely to be involved in severe marital aggression than children who were hit as teenagers. However, the probability of marital aggression increased dramatically when respondents had experienced both types of family aggression.

Studies addressing sexual maladjustment and/or problems in intimate relationships among adults with a history of sexual abuse show little consistency. Studies that find no differences in marital and sexual adjustment often use college student samples, which may reflect less severe abuse or less severe consequences (Trickett, 1992).

Recent studies have indicated that women with histories of sexual abuse before age 18 (especially incest survivors) are more likely to be poor contraceptors, to have multiple sexual partners, and to have short-term intimate relationships than women with no abuse histories. They were also at increased risk for unintended and terminated pregnancies and for sexually transmitted diseases (Wyatt et al., in press).

Long-term Consequences of Child Maltreatment

Over the last decade, there has been a dramatic recent increase in the number of clinical and research reports retrospectively linking childhood sexual abuse to specific forms of adult psychopathology. In adults, short- and long-term psychosocial problems have been noted (Gil, 1988): (1) cognitive distortions, such as guilt, shame, and self-blame (Gold, 1986; Jehu et al., 1984/85); (2) mood disturbance, such as anxiety or depression (Peters, 1984, 1988; Stein et al., 1988); (3) posttraumatic stress (Craine et al., 1988; Lindberg and Distad, 1985b; Wyatt et al., 1992); (4) interpersonal problems, such as isolation, fear of intimacy, and revictimization (Briere and Zaidi, 1989; Harter et al., 1988); (5) self-injurious behavior (suicide attempts or self-mutilation (DeWilde et al., 1992; Walsh and Rosen, 1988); (6) substance abuse (Ladwig and Anderson, 1989; Root, 1989); (7) borderline personality disorder (Stone, 1990); (8) somatization and somatoform disorders, particularly chronic pelvic pain (Loewenstein, 1990; Greenwald, 1990); (9) eating disorders (Demitrack et al., 1990, 1991); (10) some forms of chronic psychosis (Beck and van der Kolk, 1987; Bryer et al., 1987); and (11) multiple personality disorder (Putnam, 1989; Ross et al., 1989).

These studies' reliance on retrospective self-reported information to determine a history of childhood victimization can be problematic (Briere, 1992a; Widom, 1988; Wolfe and Mosk, 1983). Recollection of a history of childhood victimization can be influenced by what Cicchetti and Rizley (1981:40) called "the influence of contemporary adaptation on recall." The passage of time may also work against accurate or complete recall of child-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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hood traumas. One example of the potential impact of time on recollection of childhood victimization may be found in Russell's (1984) research, in which she found that older women reported less sexual abuse than younger women. Although one might conclude from this that the incidence of sexual abuse had increased over the years, other possible explanations are that the passage of time leads to forgetfulness about these experiences or that older women may simply be more embarrassed about revealing this information. Memories of abusive experiences change during one's lifetime, and thus retrospective studies cannot guarantee the validity of information about childhood victimization. Briere (1992a) suggests that future studies might include additional variables relevant to report bias, such as social desirability, tendency toward repression, and attitudes toward abuse disclosure.

Several recent studies, producing inconsistent results, have examined the sequelae of physical child abuse. At present, these have focused primarily on interpersonal aggression (McCord, 1983; Pollock et al., 1990; Widom, 1989a).

An even smaller number of studies have examined problems associated with psychological maltreatment (Briere and Runtz, 1988a; Garbarino et al., 1986; Brassard et al., 1987; Vissing et al., 1991). With few exceptions (McCord, 1983; Widom, 1989b), there is virtually no information about the adult status of neglected children.

Furthermore, childhood victimization often occurs in the context of multiproblem homes, in which child abuse and/or neglect may be only one of the family's problems. 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 or neglect. 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. This is particularly true of consequences such as aggression, delinquency and other problem behaviors (Widom, 1989c) that are correlated with demographic characteristics. For example, in one 8-year follow-up study of incarcerated delinquent boys (Lewis et al., 1989), almost all were known to the criminal justice system as adults. The constellation of violent abusive upbringing and neuropsychiatric and cognitive vulnerabilities was associated with adult violent crime. Beitchman et al., (1991) recently concluded that the child sexual abuse literature "has been vague in separating effects directly attributable to sexual abuse from effects that may be due to preexisting psychopathology in the child, family dysfunction, or to the stress associated with disclosure" (p. 538).

Few studies have assessed the long-term consequences on the development of abused and neglected children, beyond adolescence and into adult-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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hood. Research is needed on the long-term physical, psychological, and social consequences of child maltreatment to address the methodological deficiencies currently associated with retrospective studies.

Issues Of Stigma, Bias, And Discrimination

Problem behaviors may result from the chain of events occurring subsequent to the victimization rather than the victimization experience per se. For example, a child's removal from family members following maltreatment and foster care placement can be associated with deleterious effects (Bohman and Sigvardsson, 1980; Bryce and Ehlert, 1977; Canning, 1974; Frank, 1980; Littner, 1974).

Furthermore, racial and ethnic minority children can encounter discrimination against their race, color, language, life and family styles, and religious and cultural beliefs that affect their self-esteem and exacerbate the initial and lasting effects of both types of victimization (Wyatt, 1990).

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 adjudicate maltreatment victims as juvenile offenders because of survey bias (Smith et al., 1980). In reviewing the literature on the relationship between child maltreatment and delinquency, Garbarino and Plantz (1986) suggested that behavioral responses to maltreatment may ultimately lead to delinquency as a consequence of maltreatment. For example, a child who becomes estranged from his or her parents or from prosocial peers may develop friendships with antisocial friends. In turn, this association with delinquent friends leads to the adoption of a highly visible delinquent lifestyle.

Interaction Of Risk And Protective Factors

Abused and neglected children appear to be at risk of a variety of negative outcomes, yet many studies show that not all abused and neglected children grow up to become dysfunctional adults. For example, a number of studies of sexual abuse victims have found a surprising proportion of them to be asymptomatic (Caffaro-Rouget et al., 1989; Conte and Schuerman, 1987; Kendall-Tackett et al., 1993; Mannarino and Cohen, 1986; Tong et al., 1987). Similar findings have been reported for the intergenerational transmission of abuse from abused child to abusive parent (Kaufman and Zigler, 1987) and the transmission of violence from abused child to perpetrator of violence (Widom, 1989b,c).

Garmezy (1981) has called attention to the role of protective factors described as dispositional attributes, environmental conditions, and positive events that can mitigate the effects of early negative experiences. Various

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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demographic, background, and clinical variables that may influence the consequences of childhood maltreatment include the child's sex (Dean et al., 1986; Mangold and Koski, 1990; Walker et al., 1989), and family socioeconomic status (Margolin, 1990; Vondra et al., 1990; Walker et al., 1989). The level of marital and family violence (Cappell and Heiner, 1990; Trickett and Kuczynski, 1986) also deserves attention as a protective factor, one that may have a number of interactive effects on the consequences of child maltreatment.

Intelligence

Although high intelligence (including good cognitive abilities, social competence, and creativity) and good scholastic attainment may exert a protective effect in the context of an abusive environment, the role of intelligence as a mediator between childhood victimization and later problem behaviors is poorly understood. Intelligence may play a direct role or it may act as a mediator between childhood victimization and other factors as school performance and problem-solving skills.10

Frodi and Smetana (1984) found that controlling for IQ eliminates differences between maltreated and nonmaltreated children in their ability to identify emotional behaviors. Furthermore, high-IQ children have been found to maintain good achievement test performance at both low and high levels of stress, whereas low-IQ children show a drop in performance under high stress (Garmezy et al., 1984). Lower levels of intelligence appear to be related to higher rates of delinquency (Werner, 1983; Werner and Smith, 1982; Wilson and Herrnstein, 1985). However, Moffit, Gabrielli, Mednick, and Schulsinger (1981) found a negative relationship between IQ and delinquency (high IQ—less likelihood of becoming delinquent), while controlling for socioeconomic status.

Temperament

As noted in Chapter 4, conflicting evidence exists as to whether some infants and young children with difficult temperaments elicit abusive behaviors by their parents or caretakers (Petit and Bates, 1989). Although some have found that children with difficult temperaments may be singled out for abuse (Friedrich and Boriskin, 1976; Herrenkohl and Herrenkohl, 1981), other researchers have not found this to be the case (Dodge et al., 1990; Silver et al., 1969). As noted in Chapter 4, child factors are generally viewed as contributory, not causal or predictive factors, in a transactional model because they influence behavior only in the presence of other risk factors (Starr, 1992). Temperament is most likely to interact with early

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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childhood experiences to exacerbate in some cases, or to minimize in other cases, a child's level of risk for the development of later problem behaviors.

Cognitive Appraisal of Events

Research suggests that a person's cognitive appraisal of life events strongly influences individual responses to particular events (Lazarus and Launier, 1978). The same event may be perceived by different individuals as irrelevant, benign, positive, or threatening and harmful. In considering the effects of childhood victimization, the child's cognitive appraisal of events will determine at least in part whether they are experienced as neutral, negative, or harmful. Abuse perceived as parental rejection may have more harmful effects than abuse perceived as arising from the parent's externally imposed frustrations. Research on perceptions of children may contribute to understanding the long-term consequences of abuse (Herzberger et al., 1981).

Research on the extent to which abused and neglected children's cognitive appraisal of events mediates the subsequent development of dysfunctional behaviors has been studied as part of a 14-year longitudinal study of 2,000 families (Zimrin, 1986). In this study, 35 families with abused children were identified, including a small group of abused children (n = 9) who had survived the trauma of their childhood and became well-adjusted adults. Variables that appeared to distinguish the survivors from the other children were: fatalism, self-esteem, cognitive abilities, hope and fantasy, behavior patterns, and external support. Zimrin's interpretation of these results was that the child's cognitive appraisal or perception of their good personal resources, intellectual potential, good self-image, and hope, coupled with relatively sound external resources, enhanced the lives of the survivor children.

In women who were sexually abused as children, Wyatt and Newcomb (1990) found that attributions of self-blame for the abuse were related to the severity of negative outcomes. Self-esteem and internal locus of control were found to mediate depression in a mixed group of maltreated adolescents (Moran and Eckenrode, in press).

Feelings of hopelessness, of loss of control of one's life course, may decrease a person's ability to deal with stressful life events. The acquisition of certain negative attributional styles or maladaptive coping strategies might serve as an important mechanism linking childhood victimization to later dysfunctional behavior. However, different attributional styles and coping strategies may also lead to more positive outcomes. Future research should investigate the extent to which individual perceptive and cognitive styles mediate children's responses to abuse and neglect.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Relationship with a Significant Person

Clinicians and child protection service workers have recognized the importance of significant persons in the lives of abused and neglected children, yet the role of such individuals in protecting victimized children from long-term negative consequences is poorly documented. In the literature on children's responses to the stress of hospital admissions, for example, a supportive relationship with a nurse reduced emotional disturbance during hospitalization (Visintainer and Wolfe, 1975). For individuals with a history of childhood victimization, the experience of having one biological parent, or foster parent, who provided support and love while growing up was associated with better outcomes in adulthood (Egeland and Jacobvitz, 1984; Egeland et al., 1984). Despite the fact that few competent ''survivors" are found among longitudinal samples of physically or emotionally neglected children (Farber and Egeland, 1987), competent children were more likely to be those children whose mothers showed some interest in them and were able to respond to them emotionally.

Among sexually abused children, the presence of a supportive, positive relationship with a nonabusive parent or sibling has been considered a positive mediating variable (Conte and Schuerman, 1988). In her review of research on the effects of sexual abuse in childhood, Berliner (1991) noted that the level of impact of child sexual abuse was related to whether the child was believed and supported by his or her nonabusive family members (Everson et al., 1989; Gomes-Schwartz et al., 1990; Morrow and Sorell, 1989). Furthermore, in an examination of the prevalence of depressive disorder among a sample of 56 maltreated children, Kaufman (1991) found that the quality of social support affected the likelihood of abused children's developing depressive disorder.11

Developing a relationship with a significant person in one's life sometimes occurs naturally, but children who are severely abused or neglected may experience significant barriers in this area. Research is needed to assess the extent to which the lives of abused and neglected children are characterized by a relationship with a significant person and the extent to which a significant personal relationship mitigates long-term negative consequences.

Placement Experiences and Foster Care

Although placement outside the home may be a potentially protective factor affecting the long-term consequences of abused and neglected children, the role of placement and foster care remains controversial in studies of child maltreatment (Runyan et al., 1982). Methodological problems in the research literature on the impact of placement experiences on abused

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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and neglected children weaken its scientific validity; improved research is needed to be relevant to public policy (Wald et al., 1988; Widom, 1991a).

Studies have suggested that under certain conditions foster care placement experiments may protect abused and neglected children. Although some children are injured by foster parents, the rate of reported abuse by foster parents is reported to be lower than that of the general population, and far lower than the rate of re-abuse by abusive parents (Bolton et al., 1981). Some studies suggest that foster care improves on the relatively poor results of parent treatment programs (Cohn and Collignon, 1979; Herrenkohl et al., 1980; Magura, 1981). Studies of adults who grew up in foster homes found no evidence of more problems such as delinquency, criminality, mental illness, and marital failure than in the general population (see Widom, 1991a). Other studies found that children who had been in foster care at least a year were rated by their social workers as being better off (physically and socially) than at the time they entered foster care (Kent, 1976) and that the well-being of the majority of the children had improved in terms of physical development, IQ, and school performance after six months in foster care (Fanshel and Shinn, 1978).

Critics of foster care stress the need to maintain biological family ties, the desire to minimize government interference in family life, the financial cost of placement, and the concern that foster care may actually be worse for children than leaving them in the home (Hubbell, 1981; Wald, 1976; Wald et al., 1988). Examinations of foster care experiences have described the inadequacy, failures, and high costs of the system (Gruber, 1978; Schorr, 1982), the high rate of behavior problems (Bohman and Sigvardsson, 1980; Bryce and Ehlert, 1977; Frank, 1980; Littner, 1974), and school problems (Canning, 1974) among foster children. However, these studies did not compare rates of such behaviors in nonfoster care children or present information about these children prior to their placement.

Out-of-home placements may pose additional risks for the abused or 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 detrimental. Using a matched historical cohort design with children who had been maltreated, Runyan and Gould (1985) found no support for the idea that foster care is responsible for the subsequent problems of delinquency among victims of maltreatment.

Widom (1991a) also examined the role of placement experiences in relation to delinquency and violence. Abused and neglected children in foster care and other out-of-home residential experiences, who typically come from multiproblem families, are a particularly vulnerable group because they have experienced both a disturbed family situation and separation from their natural parents. In this research, under certain circum-

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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stances, out-of-home placements did not necessarily lead to higher risk of arrest for delinquency and violence, especially if the child spent a significant amount of time in the first placement, in which the child would have the opportunity to develop attachments (and thus a stronger sense of self and self-esteem). Children who spent more than 10 years in their first placement had the lowest overall rates of arrests as an adolescent for delinquency and for violence.

In speculating about the effects of foster care on behavioral consequences, the developmental literature on children's responses to other forms of stressful life events should be considered. For example, children's responses to parental divorce (Wallerstein and Kelly, 1980; Wallerstein, 1983) and bereavement (Rutter, 1966) vary by age and level of development. Yarrow and Goodwin (1973) found that a child who moved from a foster home to a permanent adoptive home before the age of 6 months tended to show only transitory distress. By contrast, in somewhat older children (between age 7-12 months), such a change involved more pervasive disturbances. Similarly, according to Rutter (1966), the age period of greatest risk for the stress of hospital admission is between 6 months and 4 years of age. Children below the age of 6-7 months may be relatively immune because they have not yet developed selective attachments and therefore do not experience separation anxiety. Children above the age of 4 years are also less vulnerable, probably because they have the cognitive skills necessary to understand the situation.

Research on the impact of placement decisions is needed to help social workers and therapists identify the different needs of abused and neglected children and their families and to design programs to facilitate a positive outcome. In particular, research is needed on the role of family strengths or weaknesses as well as child characteristics that may influence the success or lack of success of placement experiences. Children who experience multiple placement experiences may require special services, and research is needed to identify particular resources for this subgroup of abused and neglected children.

Summary

Individual characteristics, such as high intelligence, certain kinds of temperament, the cognitive appraisal of victimization experiences, a relationship with a significant person, and some out-of-home placement experiences may serve as buffers for childhood victims. But conflicting or indirect evidence about most of these characteristics and experiences results in a major gap in our 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 influence a child's vulnerability for problem behaviors.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Research Recommendations

Research on the consequences of child abuse and neglect can offer significant insights in the development of interventions. In particular, research on consequences can help improve our understanding of the nature, magnitude, and significance of abusive and neglectful experiences in childhood. Such experiences appear to result in tragic and costly outcomes for children, their families, and society as a whole. Knowing more about the nature of the consequences of child abuse and neglect will help justify preventive interventions. Such knowledge will also help improve treatment programs designed to expand the role of protective factors that may mitigate destructive consequences of maltreatment experiences.

Recommendation 6-1: Research that simultaneously assesses consequences across multiple outcomes for multiple types of maltreatment should be supported.

Research is needed that assesses direct and subtle consequences across a broad range of domains (cognitive and intellectual, medical and physiological, psychosocial, behavioral, and psychiatric). The effects of different and multiple types of child maltreatment in a variety of cultural contexts should also be considered in future research programs. The common practice of treating abused and neglected children together, or eliminating one type of maltreatment from study, may reveal only a partial portrait of childhood victims' risk for later consequences. Existing research has focused on physical and sexual abuse, with relatively little attention to neglect or emotional maltreatment, yet the accumulation of stress associated with chronic neglect may produce consequences for young children similar to those produced through physical abuse. This would seem particularly important given that the number of reported cases of child neglect far surpasses those of physical abuse in national statistics.

In particular, research on emotional maltreatment deserves to be expanded as a significant gateway in understanding its consequences and its role in stimulating other forms of child maltreatment. Emotional maltreatment studies deserve support because they could provide insight into the development of severe forms of behavior disorders and developmental delays in children.

Recommendation 6-2: The consequences of child abuse and neglect should be examined in a longitudinal developmental framework that examines the timing, duration, severity, and nature of effects over the life course in a variety of cultural environments.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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One of the most promising developments in the field of child maltreatment studies has been the appearance of longitudinal studies. In the case of child sexual abuse, most follow-up studies have been for approximately 12 to 18 months. While some relationships have extensive correlational support, relatively little is known about the temporal sequencing of outcomes such as low self-esteem or the use of alcohol or illicit drugs. Further research to clarify the directionality of these potential linkages should be encouraged.

It would be especially informative to know how the consequences of abuse differ depending on the developmental stage and cultural environment of the individual. A few studies suggest the promise of an approach that can analyze specific age differences in the expression and nature of outcomes. For example, if victims are assessed as children, the full extent of the consequences may not be manifest. As children grow and develop, new symptoms associated with their abuse may emerge that can be examined in prospective longitudinal studies. Much can be learned from research on the processes by which other forms of parental unavailability and apparent rejection or neglect (resulting from actions such as divorce, death, or chronic injury) have psychological influences on the child.

The identification of specific effects of child maltreatment at certain ages may be an artifact of the existing state of knowledge. At present, there has not yet been sufficient research on the relationship between the age of onset of child abuse and subsequent symptomatology.

Longitudinal studies of the consequences of maltreatment are complicated by a variety of factors in the developmental process. Certain problem behaviors manifest at one age may change as an individual ages. Adults may perceive their victimization as a child differently from earlier points in their lives.

In the absence of longitudinal research, well-designed, cross-sectional retrospective designs may be the most effective, immediate means of identifying the prevalence and effects of maltreatment in adults. Cross-sectional studies conducted with techniques to minimize memory performance error (using anchoring and boundary techniques), can provide retrospective information which can be verified in prospective longitudinal studies.

Recommendation 6-3: Intergenerational studies require support to identify relevant cycles and key factors that affect intergenerational transmission of child maltreatment.

Generational studies of child abuse and neglect are needed to help identify the familial or cultural patterns passed on from generation to generation that society defines as abusive. In addition, future research needs to: (1) emphasize family dynamics that serve as protective factors versus those that

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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exacerbate the effects of abuse; (2) assess and evaluate the parameters of abusive experiences (e.g., frequency, severity, method) and the relationship of the characteristics of abuse experiences with symptom severity; and (3) develop methods and measures for quantifying family processes that may be psychologically harsh or abusive, especially in the area of emotional maltreatment.

Recommendation 6-4: Research needs to consider the co-occurrence of multiple forms of child victimization in the social context of child maltreatment behaviors.

The assessment of consequences for abused and neglected children is complicated by the co-occurrence of other problems (or co-morbidity) in the children and their parents. Certain forms of childhood victimization constitute acute stressors, and child maltreatment often occurs against a background of chronic adversity. The presence or absence of certain characteristics or other adverse events may influence a child's response to childhood victimization, and in some cases the combined effects of two stressors (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—poverty, unemployment, stress, alcohol and drug problems, and violence in the community.

Research in the area of childhood victimization has generally not examined interrelationships among problem behaviors and symptoms of dysfunction in other spheres of living. Since childhood victims may be at risk for the development of multiple problem behaviors, an examination of the co-occurrence of problems should provide a fruitful direction for future research.12

Research on complicated problem behaviors or multiple-risk environments is especially important at this time to identify whether clusters of problem behaviors or combined risks have common origins. Research is also needed to determine whether certain types of problem behaviors represent discrete behaviors with different etiologies. These contrasting models have different implications for intervention strategies. Researchers who emphasize syndromes believe that reducing problem behaviors depends on identifying and modifying a common underlying trait. However, if specific problem behaviors represent specific etiologies, then a single general intervention strategy might fail to reduce the problems of most individuals.

Recommendation 6-5: Research on the role of protective factors, including gender differences in vulnerability and manifestations of subsequent problem behaviors, needs further examination.

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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In many different studies of various types of maltreatment, researchers have identified a small but significant group who have few or no problems. These "protected" children should be targeted for future study. What protective factors or interventions occur in the lives of the abused or neglected children that appear to lead to more positive outcomes? Studies are needed with sample sizes and diverse cultures large enough to examine multiple outcomes, while simultaneously adjusting for relevant demographic characteristics.

For example, we have little evidence about similarities or differences in gender responses to experiences of early abuse and neglect. In studies of violence and sexuality, research on the nonsterotypic relationship (violence: female and sexuality:male) may yield important insights. Large-scale studies assessing the consequences of child abuse and neglect for boys and girls are necessary to compare outcomes for different types of maltreatment.

Recommendation 6-6: Research is needed to improve the methodological soundness of child maltreatment studies, to test hypotheses, and to develop relevant theories of the consequences of childhood victimization.

In the short term, research efforts to describe, document, and evaluate relationships suggested by the clinical literature are necessary. However, in the long term, the field must develop and test hypotheses and build theory. For example, researchers might design research to test specific theories of the effects of child abuse (physical and sexual) against effects expected using a generalized stress model.

Studies also need to determine the influence of sample selection criteria on patterns of consequences. The absence of appropriate comparison groups is a severe methodological flaw in many studies of child maltreatment consequences. Furthermore, a major controversy in the field concerns the extent to which researchers study different types of maltreated subjects. Existing research on the short-term effects of child maltreatment is often based on cases that have been reported to child protection services or law enforcement agencies. Researchers need to select samples from nontraditional populations, such as community and pediatric samples, to improve generalizability of their findings and to avoid the biases inherent in the child protective services reporting system.

Notes

1. In 1991, 79 percent of the children who died were under age 5, and 54 percent were under age 1 (McCurdy and Daro, 1992).

2. A recent study of cognitive abilities found that physically abused children showed lower receptive language scores than nonabused children (Vondra et al., 1990). However,

Suggested Citation:"6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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these children did not differ from children in families with low socioeconomic status. This indicates that the children's cognitive deficits were related to their family backgrounds and living environments, rather than specifically to the abuse experience.

3. Overall, 18 percent of the sample met the criteria for major depression, and 25 percent met the criteria for dysthymia.

4. It is not clear whether there is a specific relationship between child sexual abuse and post-traumatic stress disorder because many other children have related symptoms such as fears, nightmares, somatic complaints, autonomic arousal, and guilt feelings (Kendall-Tackett et al., 1993).

5. In research using a cohorts design study, children who were abused and neglected approximately 20 years ago were followed up through an examination of official criminal records and compared with a matched control group of children with no official record of abuse or neglect (Widom, 1989b).

6. When a subsample of incarcerated delinquents was compared with a matched sample of nondelinquents, neuropsychiatric vulnerabilities and histories of abuse distinguished the delinquents from the nondelinquents (Lewis and Shanok, 1977). Within the comparison group, neuropsychiatric problems and abuse distinguished the more aggressive nondelinquents from their less aggressive nondelinquent peers.

In Lewis's original study (Lewis et al., 1979), abuse and other family violence were examined separately. Data in the later follow-up study (Lewis et al., 1989) suggested that the two phenomena were almost always present in households of seriously delinquent children. These findings complicate the task of identifying the relative importance of different experiential variables.

7. Specifically, as adolescents (before age 18), abused and neglected children were significantly more likely to have an arrest as a runaway than controls (5.8 versus 2.4 percent). Interestingly, the percentage of these abused and/or neglected children who had official contact with the system (as in arrests) was still small, and similar to the percentages in the studies of runaways who reported a history of childhood victimization.

8. Examinations of these potentially stage-specific effects (Kagan, 1977) are difficult in research based on one-shot retrospective reports.

9. In a review of 29 studies that gathered data on fertility outcomes of maltreating families, Zuravin and Taylor (1987) concluded that neglectful families had more children than abusive families and began bearing children at an earlier age. Zuravin (1988), however, found that "abusive and neglectful mothers compared to control mothers space their first two children closer in years, have their first child at a younger age, and have more live births, more unplanned live births, and more children by different fathers" (p. 988).

10. The assessment of high intelligence and scholastic achievement should not be limited to the use of standardized measures of IQ, but should include a variety of other measures that comprehensively assess the child's ability to process information and to adapt to the world.

11. Abused children with more positive supports and fewer conflictual relationships were less likely to be depressed than the other maltreated children in the study. The nondepressed maltreated children were also more likely to report that they felt more cared about by their supports than the depressed children.

12. For example, the co-occurrence of alcoholism, antisocial personality disorder, and substance use has been noted among male jail detainees (Abram, 1990).

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Next: 7 INTERVENTIONS AND TREATMENT »
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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