Effects of child abuse and neglect for children and adolescents
Effects of child abuse and neglect for children and adolescents
Child abuse and neglect is a social and public health problem, as well as a children's rights issue in Australia. Abuse and neglect can lead to a wide range of adverse consequences for children and young people. This paper provides an overview of the possible effects of child abuse and neglect and explores whether different types of maltreatment are associated with specific adverse consequences in childhood and adolescence.
Types of abuse and neglect
Child abuse and neglect refers to any behaviour by parents, caregivers, other adults or older adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Such behaviours may be intentional or unintentional and can include acts of omission (i.e., neglect) and commission (i.e., abuse) (Bromfield, 2005; Cristofel et al., 1992; Gilbert et al., 2009). The five main subtypes of child abuse and neglect are physical abuse, emotional maltreatment, neglect, sexual abuse, and witnessing family violence.
For more information on the definitions of child abuse and neglect see What is Child Abuse and Neglect?
Factors affecting the consequences of child abuse and neglect
Not all children exposed to similar experiences of abuse and neglect are affected in the same way. For some children and young people, the effects of child abuse and neglect may be chronic and debilitating; others may experience less adverse outcomes (Miller-Perrin & Perrin, 2007). A range of other life experiences and family circumstances - both positive and negative - impact on a child's vulnerability or resilience in the face of maltreatment. Resilience refers to the ability of a child to cope and even thrive despite being exposed to negative experiences (Child Welfare Information Gateway, 2008; Hunter, 2012). When a child who has experienced abuse or neglect has few protective factors (such as positive relationships with extended family and friends), the risk of more serious adverse outcomes increases. Risk factors that may contribute to poorer outcomes for children exposed to abuse and neglect include socio-economic disadvantage, social isolation, living in dangerous neighbourhoods, large families, a caregiver with depression or alcohol or drug dependence, and whether the child has a disability (Dubowitz & Bennett, 2007; Jaffee & Maikovich-Fong, 2011). Factors that contribute to a child's resilience include child attributes (e.g., self-esteem and independence), features of the family environment (e.g., parenting quality), and extra-familial and community resources (e.g., high quality peer relationships and school environment) (Haskett et al., 2006; Hunter, 2012).
Critical factors that influence the way child abuse and neglect affects children and young people includethe frequency and duration of maltreatment and the co-occurrence of multiple forms of maltreatment.
Chronic maltreatment defined as "recurrent incidents of maltreatment over a prolonged period of time" (Bromfield & Higgins, 2005, p. 39) has been linked to worse outcomes than transitory or isolated incidents of maltreatment (e.g., Ethier, Lemelin, & Lacharite, 2004; Graham et al., 2010; Johnson-Reid, Kohl, & Brett, 2012).
Research suggests that maltreatment types are interrelated, that is, a large proportion of children and young people who experience childhood abuse or neglect are exposed to more than one type of abuse (known as multi-type maltreatment). Further to this, other forms of victimisation such as bullying or assault by a peer have often been found to co-occur with child maltreatment (known as poly-victimisation) (Finkelhor, Ormrod, & Turner, 2006). Research indicates that those who experience multi-type maltreatment and/or poly-victimisation are more likely to experience high levels of trauma symptoms and worse outcomes than those who are exposed to no maltreatment or only one type (Finkelhor et al., 2006; Higgins & McCabe, 2001).
In attempting to explain some of the adverse outcomes associated with chronic and multi-type maltreatment a concept that is often employed is complex trauma. Complex trauma reflects the multiple and interacting symptoms, disorders, multiple adverse experiences, and the broad range of cognitive, affective and behavioural outcomes associated with prolonged trauma, particularly if occurring early in life and involving an interpersonal element (e.g., sexual abuse) (Price-Robertson, Rush, Wall, & Higgins, 2013). Complex trauma affects the developing brain and may interfere with a child's capacity to integrate sensory, emotional and cognitive information, which may lead to over-reactive responses to subsequent stress and long-term effects such as cognitive, behavioural, physical and mental health problems (National Scientific Council on the Developing Child [NSCDC], 2007; Perry, 2001; Streeck-Fischer & van der Kolk, 2000).
For further details on chronic maltreatment, the interrelatedness of sub-types of child abuse and neglect, and complex trauma, see Rarely An Isolated Incident: Acknowledging the Interrelatedness of Child Maltreatment, Victimisation and Trauma (Price-Robertson et al., 2013).
Other factors that can affect the consequences of child abuse and neglect on children and adolescents include:
- the age and developmental stage at which maltreatment occurred: some evidence suggests that the younger the child was at the time of the onset of the maltreatment, the more likely they are to experience problems later in life;
- the severity of maltreatment: the greater the severity of abuse or neglect, the higher the likelihood of negative outcomes;
- the type/s of abuse and/or neglect: different sub-types of maltreatment may be related to different negative outcomes;
- the child or young person's perceptions of the abuse: worse outcomes are likely if the victim/survivor experiences feelings of self-blame, shame or stigmatisation; and
- the relationship the child or young person had (or has) with the perpetrator: for example, in child sexual abuse increased negative affects tend to be associated with the perpetrator being a father, father-figure or someone with whom the child has an intense, emotional relationship (Bromfield & Higgins, 2005; Miller-Perrin & Perrin, 2007; Price-Robertson et al., 2013).
Trauma, stress and the developing brain
Trauma caused by experiences of child abuse and neglect appears to have serious effects on the developing brain (McCrory, De Brito, & Viding, 2010; Streeck-Fischer & van der Kolk, 2000). The Center of the Developing Child at Harvard University has released a range of working papers that critically review the literature on brain development (NSCDC, 2007; 2010; 2012). They have noted several key messages:
- Brains develop over time and through interaction with the environment.
- Chronic, toxic stress of the sort experienced by maltreated children, and particularly in the absence of consistent, supportive and interactive relationships with adult caregivers, has been found to have an especially deleterious effect on young children's growing brains (NSCDC, 2007; 2012).
- Exposure to complex and chronic trauma can result in persistent psychological problems.
- The interaction between genes and environment also plays a role in how the brain develops, particularly during the early developmental period (NSCDC, 2007; 2010).
Consequences of child abuse and neglect
Child abuse and neglect can affect all domains of development - physical, psychological, emotional, behavioural, and social - all of which are interrelated. The remainder of this paper discusses the possible consequences of child abuse and neglect identified in the research literature. The research reviewed included high-quality systematic reviews and primary studies with large representative samples in English-speaking countries. Adverse consequences are broadly linked to all abuse types; however, where appropriate, associations are made between specific types of maltreatment and negative outcomes.
Attachment and interpersonal relationship problems
Babies and young infants exposed to abuse and neglect are more likely to experience insecure or disorganised attachment problems with their primary caregiver (Baer & Martinez, 2006; Cyr, Euser, Bakermans-Kranenburg, & Van Ijzendoorn, 2010; Jordan & Sketchley, 2009; Meadows, Tunstill, George, Dhudwar, & Kurtz, 2011; Schore, 2002; Streeck-Fischer & van der Kolk, 2000). Patterns of child-caregiver attachment are extremely important for a child's early emotional and social development. For children with an insecure attachment, the parent/caregiver, who should be the primary source of safety, protection and comfort, becomes a source of danger or harm (Cyr et al., 2010; Hildyard & Wolf, 2002). Without the security and support from a primary caregiver, babies and infants may find it difficult to trust others when in distress, which may lead to persistent experiences of anxiety or anger (Streeck-Fischer & van der Kolk, 2000).
Insecure attachments alter the normal developmental process for children, which can severely affect a child's ability to communicate and interact with others and form healthy relationships throughout their life (Bacon & Richardson, 2001). Reviews of the literature have reported that child maltreatment is associated with problematic peer relationships in childhood and adolescence (Meadows et al., 2011; Trickett, Negriff, Ji, & Peckins, 2011). Further to this, difficulties in peer relations may be a precursor to difficulties in romantic relations (Trickett et al., 2011).
Learning and developmental problems
Strong associations have been made between child maltreatment and learning difficulties and/or poor academic achievement (Gilbert et al., 2009; Mills, 2004; Veltman & Browne, 2001). Abuse and neglect in the early years of life can seriously affect the developmental capacities of infants, especially in the critical areas of speech and language (Wolfe, 1999).
Prospective research studies have consistently shown that maltreated children have lower educational achievement than other groups of children (Gilbert et al., 2009). In a meta-analysis by Veltman and Browne (2001), 31 of 34 studies (91%) indicated that abuse and neglect was related to poor school achievement and 36 of 42 (86%) indicated delays in language development. However, the authors acknowledged that studies associating child abuse and neglect with learning problems are problematic in that most studies do not know the intellectual status of children before maltreatment. A more recent longitudinal study of maltreated children in the United States found that chronicity of maltreatment affected maths scores negatively and type of maltreatment affected reading scores negatively but higher intelligence and daily living skills (e.g., ability to dress oneself, ability to perform household tasks) were protective factors against poor math and reading performance (Coohey, Renner, Hua, Zhang, & Whitney, 2011).
Mental health problems
Extensive research has identified a strong relationship between child maltreatment and a range of mental health problems, with post-traumatic stress disorder (PTSD) often reported (Gilbert et al., 2009; Greeson et al., 2011; Kearney, Wechsler, Kaur, & Lemos-Miller, 2010; Schore, 2002; Streeck-Fischer & van der Kolk, 2000). Recent research suggests that diagnosing children with PTSD does not capture the full developmental effects of chronic child abuse and neglect and as noted previously, many researchers now prefer the term "complex trauma" (Cook et al., 2005; Price-Robertson et al., 2013). Maltreated children experiencing PTSD symptoms are also often found to be experiencing other disorders such as attention deficit hyperactivity disorder, oppositional defiant and conduct disorders, substance abuse, and anxiety, mood, psychotic, and adjustment disorders (Kearney, Wechsler, Kaur, & Lemos-Miller, 2010).
Mental health problems, such as depression and anxiety disorders, have consistently been linked with child abuse and neglect, particularly for adolescents (Brown, Cohen, Johnson, & Smailes, 1999; Gilbert et al., 2009; Harkness & Lumley, 2008; Kaufman, 1991). In a review of seven large-scale studies, all studies showed a high association between child maltreatment and depression in adolescence (Harkness & Lumley, 2008). For example, the authors cited a longitudinal study by Brown and colleagues which found that children and adolescents who reported a history of abuse or neglect were three times more likely to exhibit a depressive disorder than non-maltreated children. Similarly, in a Victorian study of characteristics of children referred to a therapeutic health service for children who had been abused or neglected (the Take Two Program), 62% of children met the criteria for at least one mental health diagnosis (Frederico, Jackson, & Black, 2008).
Eating disorders, including anorexia and binge-purge behaviour (bulimia), may also be associated with child abuse and neglect (Brewerton, 2007). Sexual abuse has been widely linked to eating disorders in children and adolescents; however, experiencing other maltreatment types or multiple forms of abuse and neglect have also been shown to increase the risk of developing an eating disorder (Brewerton, 2007).
Research suggests that abuse and neglect significantly increases the risk of suicidal ideation and attempted suicide for young people (Brodsky & Stanley, 2008; Evans, Hawton, & Rodham, 2005; Miller, Esposito-Smythers, Weismoore, & Renshaw, 2013; Thompson et al., 2012). A systematic review by Evans and colleagues (2005) found a strong link between physical and sexual abuse and attempted suicide/suicidal thoughts occurring during adolescence. Similarly, in a systematic review of the literature, Miller and colleagues (2013) found that although all forms of maltreatment were associated with adolescent suicidal ideation and suicide attempts, child sexual abuse and emotional abuse might be more important than physical abuse or neglect. Supporting this, Brodksy and Stanley (2008) found that risks of repeated suicide attempts were eight times greater for youths with a sexual abuse history. The authors suggested that sexual abuse could be specifically related to suicidal behaviour because it is closely associated with feelings of shame and internal attributions of blame (Brodsky & Stanley, 2008).
Alcohol and other drug use
The psychological effects of child abuse and neglect may lead to alcohol and drug abuse problems in adolescence and adulthood (Fergusson & Lynskey, 1997; Harrison, Fulkerson, & Beebe, 1997; Perkins & Jones, 2004). Evidence suggests that all types of child maltreatment are significantly related to higher levels of substance use (tobacco, alcohol and illicit drugs) (Moran, Vuchinich, & Hall, 2004). It is less clear if particular types of maltreatment are more closely linked to substance misuse and what factors, if any, may mediate the relationship although physical abuse and combinations of abuse do appear to be associated with increased substance abuse (Trickett et al., 2011). In surveying public school students in Grades 6, 9 and 12 in the United States, Harrison and colleagues (1997) found that experiences of physical or sexual abuse increased the likelihood of students using alcohol, marijuana and other drugs. A further study in the United States found that 28% of physically abused adolescents used drugs compared to 14% of non-abused adolescents (Perkins & Jones, 2004). Compared to 22% of the non-abused group, 36% of physically abused adolescents also had high levels of alcohol use.
Researchers have found that child abuse and neglect is associated with behaviour problems in childhood and adolescence (Ethier et al., 2004; Mills, 2004; Shaffer, Huston, & Egeland, 2008). The earlier children are maltreated the more likely they are to develop behaviour problems in adolescence (Frederico et al., 2008). Researchers have often associated maltreatment with internalising behaviours (being withdrawn, sad, isolated and depressed) and externalising behaviours (being aggressive or hyperactive) throughout childhood (Mills, 2004). Longitudinal studies have shown that exposure to a single type of maltreatment as well as multiple types is related to increased internalising and externalising behaviours in childhood and adolescence (Moylan et al., 2009). A large, nationally representative study in the United States reported that children who were maltreated in multiple developmental periods (infancy, toddlerhood, preschool years and early school years) displayed more problem behaviours than children maltreated in only one developmental period and children who were chronically maltreated tended to display more problem behaviours than children suffering situational maltreatment, although this was mediated by a range of family variables such as caregivers having alcohol or drug dependence, lower levels of education or diagnoses of depression (Jaffee & Maikovich-Fong, 2011).
Aggression, violence and criminal activity
In addition to feeling pain and suffering themselves, children exposed to abuse and neglect are at increased risk of inflicting pain on others and developing aggressive and violent behaviours in adolescence (Gilbert et al., 2009; Haapasalo & Pokela, 1999; Maas, Herrenkohl, & Sousa, 2008; Trickett et al., 2011). Research suggests that physical abuse and exposure to family violence are the most consistent predictors of youth violence (Gilbert et al., 2009; Maas et al., 2008). In a meta-analysis by Gilbert and colleagues, both prospective and retrospective studies indicated strong associations between child abuse and neglect and criminal behaviour. A National Institute of Justice study in the United States predicted that abused and neglected children were 11 times more likely to be arrested for criminal behaviour in adolescence (English, Widom, & Brandford, 2004). Eighty three per cent of children in the Take Two program in Victoria demonstrated repeated and severe violence towards others (Frederico et al., 2008).
Physical health problems
Research investigating the effect child abuse and neglect has on overall physical health has largely focused on outcomes in adulthood. However, data from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) in the United States has indicated strong associations between abuse/neglect and health problems in children/adolescents (Flaherty et al., 2006, 2009). Flaherty et al. (2006) found that exposure to one adverse experience doubled the odds of children having overall poor physical health at the age of 6 years, and tripled them if children had experienced four or more adverse experiences. A further study by Hussey, Chang, and Kotch (2006) found that all types of abuse and neglect were associated with 8 of 10 major adolescent health risks.
A common form of abuse affecting the health of babies is shaken baby syndrome. Health problems resulting from shaken baby syndrome may include brain damage, spinal cord injuries, hearing loss, speech difficulties and even death (Child Welfare Information Gateway, 2008).
Adverse consequences of teenage pregnancy and risky sexual activity may also be associated with experiences of abuse and neglect (Fergusson, Horwood, & Lynskey, 1997; Gilbert et al., 2009; Hillis et al., 2004; Mendes & Moslehuddin, 2006; Noell, Rohde, Seeley, & Ochs, 2001). Research has consistently linked teenage pregnancy with experiences of sexual abuse (Hillis et al., 2004; Paolucci, Genuis, & Violato, 2001). Meta-analyses of 21 studies of child sexual abuse reported that this form of abuse more than doubled the risk of adolescent pregnancy (i.e., prior to age 20 years) (Noll, Shenk, & Putnam, 2009). Further to this, a study by Fergusson and colleagues (1997) found that young women (18 years of age) exposed to child sexual abuse had significantly higher rates of teenage pregnancy, increased rates of sexually transmitted diseases, and higher rates of multiple sexual partnerships and appeared to be more vulnerable to further sexual assault and rape.
Research suggests that children and young people may encounter homelessness or housing instability as a result of abuse and neglect (Edidin, Ganim, Hunter, & Karnik, 2012). Homelessness is more likely to eventuate in adulthood however, the Australian Bureau of Statistics (ABS) estimated that approximately 25,503 children were homeless on Census night in 2011 (29% of the homeless population) (ABS, 2012). The Australian Institute of Health and Welfare (AIHW) indicated that 56,559 children aged up to 15 years accompanied their parents into Specialist Homelessness services in 2011-12. The main reason for accompanied children to seek support was domestic and family violence (33%) (AIHW, 2012).
Young people who are removed from the care of their parents because of abuse or neglect may also face homelessness and unemployment soon after leaving out-of-home care (e.g., when they turn 18). A lack of social support networks and poor academic achievement often contribute to the difficulties young people face in finding adequate housing and employment after care.
For a more detailed discussion on the relationship between child abuse/neglect and adverse consequences of unemployment/homelessness in adulthood, see Effects of Child Abuse and Neglect for Adult Survivors.
The most tragic and extreme consequence of child abuse and neglect is abuse that results in death. The World Health Organization (WHO) estimated 31,000 homicide deaths of children aged 15 or younger around the world occur every year (WHO, 2010). This is considered an underestimation as a large number of deaths caused by abuse and neglect go unreported due to being misattributed to other causes such as falls or insufficient investigations and a failure to run post-mortem examinations (Gilbert et al., 2009; WHO, 2010).
In Australia, all deaths are registered at a state level by the Registrar for Births, Deaths and Marriages. Statistics are compiled and reported by the ABS, and include assault. No national data collection exists to describe deaths of Australian children due to abuse and/or neglect. For further information on child deaths from maltreatment by state in Australia, see Child Deaths from Abuse and Neglect.
Research investigating the effects of child abuse and neglect is extensive. However, in most research studies, due to several limitations, it is difficult to make causal links between abuse/neglect and adverse consequences. Additionally, many research studies are unable to control for other environmental and social factors, which makes it difficult to rule out influences such as socio-economic disadvantage, disability and social isolation when associating maltreatment with negative consequences for children and young people. Other research limitations include problems with definitions (for example, type or severity of abuse), recruiting a representative sample, and obtaining accurate recollections of past events by participants (Gilbert et al., 2009; Maas et al., 2008). In spite of the various limitations, research in the area consistently identifies strong links between child abuse and neglect and adverse consequences for children and adolescents.
Child abuse and neglect may lead to a wide range of adverse consequences for children and adolescents. Research suggests that specific types of abuse are more closely related to some adverse outcomes than others, for example, the links between physical abuse and violent or aggressive behaviour. However, experiencing chronic and multiple forms of abuse increase the risk of more damaging and severe consequences for children and young people.
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Authors and Acknowledgements
This paper was prepared by Cathryn Hunter, Senior Research Officer with the Child Family Community Australia information exchange at the Australian Institute of Family Studies.
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