Child Maltreatment is a Sensitive

Child maltreatment is a sensitive and emotional topic when discussed in public and even more so in private. The consequences linked to child maltreatment have a high likelihood to reverberate later in life in the form of numerous, high risk behaviors that incite high social costs and negative personal health and wellness. However, the sensitivity of the subject matter means child maltreatment is not prioritized in government and public health initiatives despite the burdens associated.

These burdens include a spectrum of high-risk behaviors related to the chronic illnesses and mortality rates that plague society.

Despite limited funding, there are prevention strategies that are effective in reducing the incidence of child maltreatment with many other studies demonstrating effectiveness but in need of evaluation.

The aim of this paper is to peer at the cause and effects of child maltreatment in order to promote the increased use and creation of public health prevention programming for child abuse prevention and treatment. With the current endeavors minimal, every small success in preventing and treating child abuse and effects has profound effects on the vulnerable populations at risk. With enough traction, the epidemiology used to halt child maltreatment incidence may even find use in the prevention of other chronic behaviors such as HIV/AIDS, smoking, and obesity, and the conditions associated.

Defining Child Maltreatment

Child maltreatment is a dynamic and complex issues that differs cases to case, depending on the victim's age, demographic, culture, and relationship with the offender. Child maltreatment includes any and all forms of abuse and exploitation related to the negligent care of a child or children (Mayo Clinic, 2018).

Maltreatment can occur from any number of sources: parents, siblings, caretakers, guardians, close friends, associates, strangers, authority figures such as police or military, employers, health care workers and even other children (Norman et al., 2012; Butchart, Harvey, Mian, & Furniss, 2006). Child maltreatment is distinguished by four types of abuse: physical, sexual, emotional and psychological, and neglect.

Child physical abuse is the intentional use of force with the purpose of harming the child. Most often seen as a form of punishment, distinguishing physical abuse from punishment, particularly from a caretaker or family member, is difficult when they are involved in the nurturing of the child. Physical abuse includes hitting, beating, kicking, strangulation, scalding, burning, poisoning, asphyxiating, or any other form of physical force or factor (Norman et al., 2012; Butchart, Harvey, Mian, & Furniss, 2006).

Child sexual abuse is the exploitation of any sexual act that the child is unable to provide informed consent, developmentally unprepared, or that violates the laws of society (Mayo Clinic Staff, 2018). Sexual abuse is a notable risk factor for mental health disorders and risky behavior and can occur at any age for children or minors (Andrews, Corry, Slade, Issakidis, & Swanston, 2004). Adults and other children can inflict sexual abuse and is normally seen from those who hold a position of power, responsibility, or trust over the child.

Emotional and psychological abuse is considered both the act of emotional degradation and the failure to provide a supporting, developmental environment. The most common forms of emotional abuse involve prolonged patterns of threatening, belittling, discriminating, ridiculing, or any other form of non-physical, hostile behavior. Emotional and psychological abuse carry a high risk of damaging the mental development of a child, resulting in equally poor moral and social integration in their adult years (Norman et al., 2012).

Neglect, similar to emotional abuse, is both the instantaneous hostile treatment and continued failure to provide a proper, healthy developmental environment for the child's health and wellbeing (Mayo Clinic Staff, 2018). Neglect is not a form of abuse reserved for the fiscally misfortunate, as the restrictive behavior may occur in affluent communities too (Widom, Browne, Webb, Fergusson & Lancet, 2009). Neglect usually involves the purposeful removal of life factors such as education, housing, nutrition, overall health, and emotional support.

Patterns of Abuse

Child abuse finds majority of the perpetrators as authority figures, particularly adults that the child knows such as a guardian or close relative in fact, nearly 80% of the perpetrators identified are the parents, with women slightly more likely to abuse than male figures (United States Department of Health and Human Services [USDHHS], 2009). The most common pattern found in child maltreatment studies were single, female parents as the perpetrator in nearly 64% of cases (USDHHS, 2008; Berkel, Tucker, & Finkelhor, 2018).

Children are also known to abuse other children the most common form found in bullying with males generally experiencing more abuse than their female counterparts. Within the family unit, sibling abuse is particularly high and has shown to result in increased aggression and delinquency (Berkel, Tucker, & Finkelhor, 2018). Although sibling and parental abuse are not correlated, when found in conjunction, sibling assault and abuse exacerbates the negative impact of parental or guardian maltreatment.

Child neglect is the most common form of abuse found in substantiated cases (Pillado, Kim & Dierkhising, 2010). In 2007, 59% of the cases reported to child protective services were child neglect, and 34% of child abuse deaths were due to neglect (USDHHS, 2009). Neglect differs in regard to the transmission from one generation to the next due to the wide variability of the definition of neglect. Child neglect is present though in those who had experienced neglect before (Berzenski, Yates & Egeland, 2018). Some studies demonstrate that the likelihood of a child's neglect is significantly correlated with the parents' neglect that neglect taking form in one of the other methods of maltreatment (Berlin, Appleyard & Dodge, 2012).

Physical abuse is the second most common form of maltreatment due to the fact that physical mistreatment can include both intent driven and accidental instances (National Child Traumatic Stress Network, 2009). Similar to neglect, there is a likelihood of re-victimization in the child of the parent who had experienced childhood physical abuse. Studies demonstrate that a reason for the increased likelihood is due to learnt behavior from their own childhood and the normalization of physical abuse as a form of discipline (Hunter, 2014).

Sexual abuse is the third most common form of abuse, with research showing that nearly 25% of girls and 16% of boys are at risk for sexual abuse before the age of 18 (Finkelhor, Hotaling, Lewis & Smith, 1990; Centers for Disease Control and Prevention, 2005). Although the rates of sexual abuse are higher in females, social stigma and perceived loss of masculinity are associated with lower rates of disclosure in male victims (Johnson et al., 2006). Interestingly, sexual abuse does not transmit generationally, with the rate of sexual abuse significantly lower in families where the parent had been abused in their youth (Ney, 1998).

Emotional abuse is the least common form of abuse, mostly due to the wide spectrum of variability and lack of physical identifiers bruises, abrasions, bites, et cetera. Despite the lack of reporting, German studies have shown that emotional abuse leads to more severe forms of mental disorders and substance dependency (Schilling et al., 2016), which in turn, puts their own children at a greater risk for abuse than non-abusing families (American Society for Positive Care of Children, 2018).

When observing cross-sectional studies over the past decade, researchers found that transmissible forms of maltreatment neglect, physical, and emotional are more homotypic than heterotypic, meaning that female guardians afflict female children and male guardians abuse male children more often when peering at sexual abuse patterns (Berzenski, Yates & Egeland, 2018). It is important to note that the abuse in a parent does not imply that the child will have the same fate; merely, there is an increased likelihood when peering at intergenerational maltreatment.

The Effects of Maltreatment

Child abuse and neglect demonstrate a number of serious, negative, socio-emotional effects on children and as they age, resulting in conditions such as post-traumatic stress disorder, elevated anxiety, self-harming, suicide, educational underachievement, aggression, risky sexual activity, and depression (Norman et al., 2012; Turner et al., 2017). Additionally, research on socio-development in abused individuals shows less ambition, lower self-esteem, and overall less social success than their counterparts (Moylan et al., 2010).

Child maltreatment, first and foremost, results in physical injury and acute emotional trauma which later manifests in the more destructive substance abuse, outward aggression or violence to strangers and loved ones (Lansford et al., 2007; Widom, Czaja, & Dutton, 2008), as well as the co-existing mental health diagnoses (Widom, DuMont, & Czaja, 2007) mentioned earlier. Studies also demonstrate that children who experience numerous forms of maltreatment, or that have dual exposure to abuse, from either the same or numerous sources such as sibling victimization have an even greater likelihood for poor and risky behavior (Moylan et al., 2010; Tucker et al., 2015).

In more extreme forms of neglect and abuse, child maltreatment is associated with stunted growth, abnormal physical depravities, and even dysfunctional motor development(Petersen, Joseph, & Feit, 2014). Considering that maltreatment also consists of withholding vital care factors such as nutrition, social environments, and positive external factors, these findings are foreseeable. In studies peering at the health of children adopted from foster care, those who had suffered extreme maltreatment had poorer health screenings compared to their counterparts (Petersen, Joseph, & Feit, 2014).

As stated previously, child maltreatment is correlated with the significance of violent or disruptive social behavior, substance abuse and addiction, risky sexual activity and mental health disorders with many prospective and retrospective studies over two decades presenting the associations (Petersen, Joseph, & Feit, 2014).

Child Maltreatment and Public Health

Child maltreatment a major, preventable public health dilemma across the nation (Shaw & De Jong 2012; WHO, 2016). Each year, about 1% of children are found to have identifiable and affirmed abuse cases; however, studies and surveys provided by child protective services demonstrate much greater proportions of child abuse. According to 2017 national statistics, nearly 7.4 million children were found in child abuse reports.

Of those cases, the highest rate of child abuse was found in children under the age of one year at 25% per 1,000 children. In 2016 1,750 children died due to abuse and neglect, meaning that five children died from abuse every day in that year (American Society for the Positive Care of Children, 2018). From the data, researchers concluded that maltreatment cases were up by 4% and fatalities 6% as compared to previous years (HHS, ACF, Children's Bureau, 2017).

Although the rates among race are not largely different, African-American children experience the highest rates of maltreatment at 14.5 per 1,000 children almost 5 per 1000 children higher than their white counterparts. Amongst all races, the largest affected age group are infants under the age of 1 at an alarming 24.2 per 1,000 children (American Society for Positive Care of Children, 2018).

The Economic Burden

Child maltreatment is correlated with a multitude of conditions that range from acute injury to chronic illness. Due to this spectrum, the true cost associated with child abuse is difficult to guage costs related to not only medical expense, but also unnecessary societal resource utilization. These factors are considered cost of illness/injury analyses by economic analyst, containing the data of both direct (non)medical expenses and indirect productivity losses for the community (Petersen, Joseph, & Feit, 2014).

Direct medical expenditures include the services found in standard in(out)patient services such as overnight hospitl stays, medication, use of medical devices and potentially medical transportation. On the other hand, direct non medical costs are more related to civil services such as law enforcement, social workers, child protection services, lower educational achievement, incarceration costs, and welfare programming.

There are many studies that detail these costs but in total, the average cost per child is roughly $210,012-$43,178 in childhood and adult medical costs and $166,834, in non medical costs including the aforementioned (Centers for Disease Control and Prevention, 2012; Fang et al., 2012). According to 2012 estimatees, the total cost of all forms of child maltreatment is $124 billion with an average lifetime cost per death resulting from maltreament roughly $1,272,900 (Centers for Disease Control and Prevention, 2012), largely due to the productivity loss.

Prevention and Treatment

The costs associated with child maltreatment are more related to psychiatric disability and morbidity on the suffering population hence the loss of productivity, special education needs, and civil services typically utilized. The absolute burden to the economy of the nation caused the federal government to create The Child Abuse and Treatment Act which allows government intervention when the parents of a child fail to uphold their duty as a guardian. Since the enactment in 1974, it has been amended eight times to include and expand upon the new definitions, factors, and findings related to child maltreatment (USDHHS, 2015).

These amendments have sparked new funding and abuse prevention programming in each state. Although the programming methods are different, their goals are inherently the same, with trajectories focusing on improving screening in primary care providers and pediatric specialists, improving reporting mechanisms, promoting family advocacy, and developing the professional and workforce infrastructure to better collaborate on tackling the needs of families with young children (Florida Department of Children and Families, 2015).

The major blockade to addressing the psychological impact of child abuse and the overall behavior itself is stigma and lack of reporting (Pillado, Kim, & Dierkhisig, 2010). Studies have shown that the two key elements in preventing child abuse is by increasing programs such as the Nurse-Family Partnership, which provides home visiting, and developing population specific programming for the societal factors a family happens to face such as poverty, marginalized, or inaccessibility to resources (Berlin, Appleyard, Dodge, 2011). This method of improving social support in order to change the consequences derive from several studies over the past decades (Hunter & Kilstrom, 1979; Thompson & Ontai, 2000).

Identifying the needs of the family with services that reach out to those whom otherwise cannot find or understand the resources available, while tailoring the care and treatment to specifically nurture the malfunctioned relationship between perpetrator and victim, are promising methods to reducing the prevalence of child abuse. Essentially, creating intervention programming that uses evidence-based practices is the best route to not only ensure the best outcome for the youth of the nation, but also to provide the highest return on public investment. An example of a quality prevention program is the Triple P Program that provides the family system a method of preventing and treating childhood behavioral and emotional problems (Children's Bureau, 2017).

Conclusion and Future Direction

The many studies that peer at child maltreatment demonstrate numerous methods of abusing and neglecting a child and just how negatively abuse impacts both the child and community. Over the past 50 years, child abuse has grown into a nation-wide, if not global public health matter, with worsening numbers.

The largest challenge for any child abuse prevention action is reporting. More than 4.1 million child maltreatment referrals were made in 2016, but many estimate that the actual number of cases is much greater. In that case, programming provided by either government entities, non-profits, health care providers, or any of the like, must turn to outreach methods to reduce the prevalence of the behavior. By using evidence-based programming, interventions are able to adapt and effectively treat numerous family dynamics based on their specific barriers to treatment or child's conditions.

Public Health specialists also play an important role in facilitating the reporting mechanism in communities by making the system more accessible and by reducing the stigma associated with child maltreatment. Together, prevention and treatment, based on the evidence of fore-studies and collaborative data, have an even greater chance of improving the livelihood of millions of children across the United States and hopefully the world.

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