Psychiatric Correlates and Consequences of Abuse and Neglect

Key Points

Every state in the US has passed legislation that makes physicians and other health professionals mandatory reporters for child and elder abuse and neglect.
Abused children are at serious risk for behavioral, emotional, and learning disorders. Mental injury to a child can have pervasive and long-term effects on a child's development.
Neglect is the most common form of child maltreatment reported to state protective services.
The National Research Council has estimated that 1 to 2 million Americans age 65 years or older have been the victim of abuse or neglect.
It is estimated that the majority of elder abuse and neglect cases are never reported to a protective agency.
The legal definition of elder abuse may vary from state to state. However, most states include five elements: infliction of pain or injury; infliction of emotional or psychological harm; sexual assault; material or financial exploitation; and neglect.

Overview

Children and the elderly are particularly vulnerable to abuse and to neglect because of special needs that often require them to be dependent on others. This dependence may render them vulnerable to mistreatment by caregivers of all types. Psychiatrists need to understand how to diagnose and to respond to abuse and to neglect, both in the interest of providing sound clinical treatment to their patients and because of specific legal and ethical obligations that physicians have in the setting of abuse and neglect. Although the rates of childhood victimization declined between 2005 and 2009, an alarming number of children—almost 763,000—were victims of abuse in 2009. Furthermore, as the birth rate and average life expectancy continue to increase in the US, the safety and welfare of both children and the elderly will increasingly pose major health, economic, and societal concerns. According to the United States Census Bureau, our nation's youth will increase 10.9% between 2015 and 2040. As of 2010, individuals under age 18 made up approximately one-fourth of the US population, or approximately 74.2 million children, an increase in the child population of more than 50% since 1950. Similarly, but to an even greater degree, in 2010 the number of persons over the age of 65 was 40.4 million, and this is estimated to almost double to 80.4 million by 2040.

Both federal and state laws address the abuse and neglect of children and the elderly. In 1974, Congress passed landmark legislation to provide federal support to aid in the battle against child mistreatment. In the federal Child Abuse Prevention and Treatment Act (CAPTA), the federal government provided states with federal funding for the prevention and treatment of child abuse. This funding was conditional on the states adopting mandatory reporting laws. Currently, all states have mandatory reporting statutes for child abuse and neglect that require certain groups of professionals (such as physicians, day care providers, and teachers) to notify authorities when they become aware that a child may be the victim of abuse or neglect. However, each state provides its own definition of child abuse and neglect, and states have differences as to who must report and the circumstances under which the report must be made.

By comparison, legislation to protect the elderly from mistreatment grew from the child protection system. Federal interest to protect this population first appeared in the 1960s when legislation was created to protect those adults seen as defenseless and susceptible to being harmed by others. In 1962, bearing some similarity to the earlier parens patriae (or state as parent ) authority of the state to protect helpless citizens, Congress passed Public Welfare Amendments to the Social Security Act. These amendments authorized payments to the states to establish protective services for “persons with physical and/or mental limitations, who were unable to manage their own affairs. … or who were neglected or exploited.”

Twelve years later, in 1974, the Title XX amendment to the Social Security Act established Adult Protective Services (APS) as a state-mandated program with umbrella coverage for all adults age 18 years and older. The funding for these protective services was earmarked from social services block grants (SSBGs) given by the federal government to the states, which had been used exclusively for child social protective services. This legal change marked the beginning of heightened focus on elder care and protection.

In the 1970s a series of major scandals about nursing home quality gave rise to both congressional and state investigations and further focused attention on the protection of the elderly. Legislative changes at the state level ensued. By 1985, 46 states designated a responsible agency for elder protective services. In 1998, the current National Center on Elder Abuse (NCEA) was established. State agencies and national professional organizations have established numerous guidelines and reference sources to assist in the detection, intervention, monitoring, and treatment of both child and elder abuse and neglect. The American Psychiatric Association (APA), American Medical Association (AMA), National Center on Child Abuse and Neglect (NCCAN), National Center on Elder Abuse (NCEA), and state social service agencies are some of the groups that have provided extensive information to address abuse and neglect in these populations. Every state, every US territory, and the District of Columbia now have laws governing child and elder abuse and neglect. While the minimum standards for defining abuse and neglect are federally mandated, individual states may develop their definitions and standards regarding abuse and neglect, so long as they exceed the federal standard. For example, in some states, voluntary reporting is permitted for some entities. However, in every state, reporting is mandatory for professional caregivers (including doctors, nurses, therapists, and social workers). Every state has laws that require physicians to report suspected abuse or neglect, and in some states suspicion of abuse or neglect alone, or “reasonable grounds,” is sufficient to trigger the duty to report. It is critical that physicians and other mental health providers familiarize themselves with the specific standards and requirements for mandated reporting in every jurisdiction in which they practice. For example, some physicians and mental health clinicians may feel that reporting a caregiver or a child's parents might pose difficulties in terms of the therapeutic alliance. These professionals may be tempted to try to work with these families before notifying state social services. It is important to note that doing so can leave mandated reporters vulnerable to legal prosecution for failure to file a timely report and to civil liability for failure to protect a patient from harm by delaying a mandated report. Finally, many state laws grant immunity to physicians who report in good faith, thereby minimizing exposure to liability for reporting abuse and neglect.

Types of Abuse and Neglect

Federal and state laws describe various types of abuse and neglect for both children and the elderly. For both groups these subcategories of abuse and neglect include physical abuse, emotional (psychological) abuse, sexual abuse, and neglect. This chapter will focus on physical and emotional abuse and on neglect. The topic of sexual abuse is beyond the scope of this chapter.

Child Abuse and Neglect

Types of Maltreatment

The federal Child Abuse Prevention and Treatment Act (CAPTA) provides minimum standards for the definition of child abuse and neglect. Under CAPTA, which was recently amended by the federal CAPTA Reauthorization Act of 2010, child abuse and neglect is defined as “any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.” The federal definition in CAPTA has been the subject of many different interpretations. Specifically, there are many competing approaches to how this legislation should be applied and incorporated into state law. For example, certain states define child abuse and neglect as a single concept whereas others consider abuse and neglect as different entities that require separate definitions. In addition, the standard for what constitutes abuse can also vary among states. Despite these jurisdictional differences, abuse is most often defined by states as “harm or substantial risk of harm” or “serious threat or serious harm” to a child. For example, the state of Massachusetts defines child abuse as “the non-accidental commission of any act by a caretaker upon a child under age 18 which causes, or creates a substantial risk of physical or emotional injury, or constitutes a sexual offense under the laws of the Commonwealth or any sexual contact between a caretaker and a child under the care of that individual.” As mentioned previously, each state can determine the grounds for intervention to protect a child, but there are common trends among states. For example, a “child” is generally defined as a person who is under age 18 and not an emancipated minor. Emancipation status is not available in every state, but, in the majority of states in which it is, emancipation is a legal status that allows minors to attain the rights of legal adulthood, provided certain criteria are met, before the age at which they would normally be considered adults. For example, in some states a child who is married, a parent, or in the armed forces can be considered emancipated. It is important to review the relevant statutes specific to each state of practice to know which criteria apply.

Physical Abuse

Worldwide, definitions of what constitutes physical abuse vary among (1) individual country, state, or jurisdiction; (2) cultural norms; and (3) biological predispositions. When physical abuse is suspected, it is important to consider the cultural and ethnic influences that may validate different interpretations of abuse.

In the US, Dr. C. Henry Kempe's landmark 1962 publication coined the term battered child syndrome. Kempe described findings consistent with a pattern of abuse that included the existence of multiple bone fractures in different stages of healing that were suggestive of child maltreatment. Since that time, the types of physical findings linked to non-accidental injuries have grown dramatically in scope and the methods of detection have become increasingly sophisticated. Even with increased knowledge and diagnostic abilities, one of the most common methods used to screen for the presence of physical abuse remains a discrepancy between the physical findings and the parent's or caregiver's explanation of the mechanism of injury. The identification of inconsistencies between the report provided and the objective data on physical examination are important as evidence that the stories given do not reflect reality and that injuries may be sustained as the result of intentional infliction rather than by accidental means.

Emotional Abuse

Mental injury to a child can have pervasive and long-term effects on a child's development. It is important to recognize that emotional abuse may accompany physical abuse, sexual abuse, or neglect, but may also occur entirely independent of other forms of maltreatment. To date, 48 states include emotional maltreatment within their definition of child abuse. (Georgia and Washington do not include emotional abuse in their statutory definitions.) Emotional abuse has been defined by a number of national organizations, including the AMA, the American Academy of Pediatrics, the United States Department of Health and Human Services, and the National Center on Child Abuse and Neglect. According to the American Academy of Pediatrics Committee on Child Abuse and Neglect, emotional abuse is defined as “psychological maltreatment. … [from] a repeated pattern of damaging interactions between parent(s) and child that becomes typical of the relationship.” In some situations the pattern is chronic and pervasive, whereas in others these damaging interactions occur only in the setting of specific triggers or “potentiating factors.” Overall, emotional maltreatment “is a pattern of behavior that impairs a child's emotional development or sense of self-worth, [which] may include constant criticism, threats, or rejection, as well as withholding love, support or guidance.” Psychological maltreatment assaults a child's emotional, social, and basic human development. Gabarino and others have described forms of psychically-destructive behavior inflicted by an adult on a child and the ways these types of emotional abuses may manifest from a developmental perspective.

Emotional abuse can be manifest in a variety of ways ( Box 84-1 ). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the first to include a comparable diagnosis, “childhood psychological abuse,” defined as “nonaccidental verbal or symbolic acts by a child's parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child. … Examples. … include berating, disparaging, or humiliating the child; threatening the child; harming/abandoning—or indicating that the alleged offender will harm/abandon—people or things the child cares about; confining the child. … egregious scapegoating of the child; coercing the child to inflict pain on himself or herself; and disciplining the child excessively.” Another DSM-5 diagnosis that may be encountered when dealing with children who are victims of abuse and neglect is “Reactive Attachment Disorder.” According to the DSM-5, this is defined as “a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. … a persistent social and emotional disturbance. … experienced a pattern of extremes of insufficient care as evidenced by. … social neglect or deprivation. … repeated changes of primary caregivers. … rearing in unusual settings that severely limit opportunities to form selective attachments.” (see Box 84-2 for full DSM-5 Diagnostic Criteria). Despite the fact that emotional abuse can lead to long-term harm, it is often difficult to substantiate suspicions or allegations of emotional abuse. Specifically, the damage suffered by the child may not be as apparent as can the outwardly visible signs of physical abuse. Some states therefore require that a psychiatric or psychological diagnosis be linked to the alleged emotional abuse in order to establish a causal connection between the child's disorder and the wrongful behavior by the parent or the caregiver.

Box 84-1

Manifestations of Emotional Abuse

Corrupting

A form of exploitation that encourages the development of inappropriate behaviors (e.g., aggressive, criminal, sexual, or substance-abusing behaviors).

Degrading

Disdainful rejection, spurning, humiliation, ridicule, or criticism that can include being shamefully singled out in public.

Ignoring

Failure to provide emotional responsiveness, or an interest or display of affect toward the child.

Inconsistent Parenting

Ambivalent, contradictory, or unreliable behavior toward the child.

Isolating

Confining or withholding of interactions with other caregiver or peers, unreasonable limits on social interactions.

Rejecting

Avoiding the child, refusing to acknowledge or allow inclusion in activities with family or others.

Terrorizing

Intimidating, threatening, or exposing the child to acts that make the child feel unsafe.

Witnessing Violence or Cruelty

Exposure to domestic violence or destructive physical behavior by caregivers.

Box 84-2

Full DSM-5 Diagnostic Criteria

Reactive Attachment Disorder (313.89 (F94.1))

A.
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
- 1.
  The child rarely or minimally seeks comfort when distressed.
- 2.
  The child rarely or minimally responds to comfort when distressed.
B.
A persistent social and emotional disturbance characterized by at least two of the following:
- 1.
  Minimal social and emotional responsiveness to others.
- 2.
  Limited positive affect.
- 3.
  Episodes of unexplained irritability, sadness, or fearfulness that are evident even during non-threatening interactions with adult caregivers.
C.
The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- 1.
  Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
- 2.
  Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
- 3.
  Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
D.
The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E.
The criteria are not met for autism spectrum disorder.
F.
The disturbance is evident before age 5 years.
G.
The child has a developmental age of at least 9 months.

Specify if:

Persistent : The disorder has been present for more than 12 months.

Specify current severity:

Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Neglect

According to the most recent data report from the National Child Abuse and Neglect Data System (NCANDS), neglect is the most common form of child maltreatment reported to state protective services. More children suffer from neglect than from physical and sexual abuse combined. Despite the fact that neglect makes up almost four-fifths of all reported cases of child mistreatment in the US, it receives less consideration in the literature and the media as compared to physical and sexual abuse. Part of the reason that child neglect receives disproportionately less attention than abuse may be related to difficulties in defining what constitutes neglect. In the Keeping Children and Families Safe Act of 2003, an update of CAPTA, neglect is defined as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure which presents an imminent risk of physical harm.” Although the federal government, through CAPTA, provides minimum standards for child neglect, as in the case of child abuse, states have operationalized the federal standard by implementing definitions that vary widely. That being said, neglect is generally considered as an act of omission rather than one of commission and most definitions incorporate the concept of non-provision of, or inability to provide, adequate care.

Other generalizations may be drawn from state laws about neglect. For example, neglect is typically broken down into five main categories: emotional neglect, physical neglect, medical neglect, failure to thrive (FTT), and educational neglect. Like emotional abuse, neglect is more difficult to identify than is physical abuse, because the more easily identified stigmata of scars, marks, or bruises are often not present. In the absence of demonstrable evidence of harm in settings of neglect, it is often difficult for child protective services to intervene since intervention requires such evidence.

Emotional Neglect.

This form of neglect shares some similarities with emotional abuse insofar as the child's emotional requirements for development and growth are not met. A lack of affection, love, and nurturance can have devastating and lasting effects on a child's health and emotional maturation. This type of emotional deprivation can lead to a host of long-term mental health issues that include attachment disorders, behavior difficulties, emotional instability, low self-esteem, and poor social skills.

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