What is child abuse? It is the physical or emotional abuse of a
child by a parent, guardian, or other person. Reports of child abuse,
including sexual abuse, beating, and murder, have climbed in the United
States and some authorities believe that the number of cases is largely
under reported. Child neglect is sometimes included in legal
definitions of child abuse to cover instances of malnutrition,
desertion, and inadequate care of a child’s safety. When reported,
child abuse cases are complicated by inadequate foster care services
and a legal system that has trouble accommodating the suggestible
nature of children, who are often developmentally unable to distinguish
fact from make-believe (Hay, 1996).
In 1993, the United States Advisory Board on Child Abuse and Neglect
declared a child protection emergency. Between 1985 and 1993, there
was a 50 percent increase in reported cases of child abuse. Three
million cases of child abuse are reported in the United States each
year. Treatment of the abuser has had only limited success and child
protection agencies are overwhelmed (Lewitt, 1997).
Recently, efforts have begun to focus on the primary prevention of
child abuse. Primary prevention of child abuse must be implemented on
many levels before it can be successful. Prevention plans on the
social level include increasing the economic self-sufficiency of
families, discouraging corporal punishment and other forms of violence,
making health care more accessible and affordable, expanding and
improving coordination of social services, improving the identification
and treatment of psychological problems, and alcohol and drug abuse,
providing more affordable child care and preventing the birth of
unwanted children. Prevention plans on the family level include helping
parents meet their basic needs, identifying problems of substance abuse
and spouse abuse, and educating parents about child behavior,
discipline, safety and development. Primary prevention is both the
prevention of disease before it occurs, and the reduction of its
incidence. In the case of child abuse, primary prevention is defined
as any intervention designed for the purpose of preventing child abuse
before it occurs (Hay, 1996).
Between 1985 and 1993, the number of cases of child abuse in the
United States increased by 50 percent. In 1993, three million children
in the United States were reported to have been abused. Thirty-five
percent of these cases of child abuse were confirmed. Data from various
reporting sources, indicates that improved reporting could lead to a
significant increase in the number of cases of child abuse verified by
child protection agencies. The lack of verification does not indicate
that abuse did not occur, only that it could not be verified. The
facts are that each year 160,000 children suffer severe or life-
threatening injury and 1,000 to 2,000 children die as a result of abuse.
Of these deaths, 80 percent involve children younger than five years
of age, and 40 percent involve children younger than one year of age.
One out of every 20 murder victims is a child. Murder is the fourth
leading cause of death in children from one to four years of age and
the third leading cause of death in children from five to fourteen
years of age. Neonaticide, which is the murder of a baby during the
first 24 hours of life, accounts for 45 percent of children killed
during the first year of life (Lewitt, 1997).
As I stated above, deaths from abuse are under reported and some
deaths classified as the result of accident and sudden infant death
syndrome might be reclassified as the result of child abuse if
comprehensive investigations were more routinely done. Most child
abuse takes place in the home and is started by persons are know to and
trusted by the child. Even though it has been widely publicized, abuse
in day-care and foster-care settings accounts for only a small number
of confirmed cases of child abuse. In 1996, only two percent of all
confirmed cases of child abuse occurred in these settings. Child abuse
if fifteen times more likely to occur in families where spousal abuse
occurs. Children are three times more likely to be abused by their
fathers than by their mothers. No differences have been found in the
incidence of child abuse in rural versus urban areas. Following are
the types of abuse and the percentages of the different types.
Neglect – 54%
Physical abuse – 25%
Sexual abuse – 11%
Emotional abuse – 3%
Other – 7%
Not only do children suffer from the physical and mental cruelty of
child abuse, they endure many long-term consequences, including delays
in reaching developmental milestones, refusal to attend school and
separation anxiety disorders. Other consequences include an increased
likelihood of future substance abuse, aggressive behaviors, high-risk
health behaviors, criminal activity, depressive and affective disorders,
personality disorders, post-traumatic stress disorder, panic attacks,
schizophrenia and abuse of their own children and spouse. Research has
shown that a loving, caring and stimulating environment during the
first three years of a child’s life is important for proper brain
development (Davis, 1998).
There have been some recent changes in regards to the causes of child
abuse. The results of research initiated by the National Research
Council’s Panel on Research on Child Abuse and Neglect showed the first
important step away from the simple cause and effect patterns. The
panel stated that the simple cause and effect patterns have certain
limitations, mostly related to their narrow focus on the parents.
These patterns are limited by asking only about the isolated set of
personal characteristics that might cause parents to abuse their
children. These patterns failed to account for the occurrence of
different forms of abuse in one child. These patterns had very little
explanatory power in weighing the value of various risk factors
involved in child abuse. As a result, they were not very accurate in
predicting future cases of child abuse. To replace the old static
pattern, the panel has substituted what it calls an ecologic model.
This model considers the origin of all forms of child abuse to be a
complex interactive process. This ecologic model views child abuse
within a system of risk and protective factors interacting across four
levels: (1) the individual, (2) the family, (3) the community and (4)
the society. Some factors are more closely linked with some forms of
abuse than others. The following are factors thought to contribute to
the development of physical and emotional abuse and neglect of children:
High crime rate Personal history of physical or sexual abuse
Lack of or few social services Teenage parents
High poverty rate Lack of parenting skills
High unemployment rate Unwanted pregnancy
Child-related Poor coping skills
Prematurity Low self-esteem
Low birth weight Personal history of substance abuse
Handicap Known history of child abuse
Lack of preparation for extreme stress of having a new infant
(Understanding Child Abuse and Neglect,1996).
Many people would argue that our society does not really value its
children. This argument is highlighted by the fact that one in four
children in the United States lives in poverty, and many children do
not have any form of health insurance. The presence of high levels of
violence in our society is also thought to contribute to child abuse.
Deadly violence is more common in the United States than in seventeen
other developed countries. Seventy-five percent of violence occurring
in this country is domestic violence. The United States leads
developed countries in homicide rates for females older than 14 years
and for children from five to fourteen years of age. Other factors
that may contribute to high rates of violence include exposure to
television violence and reliance on corporal punishment (McKay, 1997).
Poverty is the most frequently and persistently noted risk factor for
child abuse. Physical abuse and neglect are more common among the
people who are the poorest. Whether this is brought on by the stress
of poverty-related conditions or results from greater scrutiny by
public agencies, resulting in over reporting, is debated. Other
factors include inaccessible and unaffordable health care, fragmented
social services and lack of support from extended families and
communities (Besharov, 1990).
Parents who were abused as children are more likely than other parents
to abuse their own children. Lack of parenting skills, unrealistic
expectations about a child’s capabilities, ignorance of ways to manage
a child’s behavior and of normal child development may further
contribute to child abuse. It is estimated that forty percent of
confirmed cases of child abuse are related to substance abuse. It is
also estimated that eleven percent of pregnant women are substance
abusers, and that 300,000 infants are born each year to mothers who
abuse crack cocaine. Domestic violence also increases the risk of
child abuse (Helfer, 1998).
Other factors that increase the risk of child abuse include emotional
immaturity of the parents, which is often highly correlated to actual
age, as in the case of teenage parents, poor coping skills, often
related to age but also occurring in older parents, poor self-esteem
and other psychologic problems experienced by either one or both
parents, single parenthood and the many burdens and hardships of
parenting that must be borne without the help of a partner, social
isolation of the parent or parents from family and friends and the
resulting lack of support that their absence implies, any situation
involving a handicapped child or one that is born prematurely or at a
low birth weight, any situation where a sibling younger than 18 months
of age is already present in the home, any situation in which the child
is the result of an unwanted pregnancy or a pregnancy that the mother
denies, any situation where one sibling has been reported to the child
protective services for suspected abuse, and finally, the general
inherent stress of parenting which, when combined with the pressure of
anyone or a combination of the factors previously mentioned, may
exacerbate any difficult situation (Besharov, 1990).
The United States Advisory Board on Child Abuse and Neglect has stated
that only a universal system of early intervention, grounded in the
creation of caring communities, could provide an effective foundation
for confronting the child abuse crisis. It is believed that successful
strategies for preventing child abuse require intervention at all
levels of society. No agreement has been formed concerning which
programs or services should be offered to prevent child abuse. This is
because research on the prevention of child abuse is limited by the
complexity of the problem, the difficulty in measuring and interpreting
the outcomes, and the lack of attention to the interaction among
variables in determining risk status for subsequent abuse. A broad
range of programs has been developed and implemented by public and
private agencies at many levels, little evidence supports the
effectiveness of these programs (Rushton, 1997).
As 1994 look back on a review of 1,526 studies on the primary
prevention of child abuse found that only thirty studies were
methodologically sound. Of the eleven studies dealing primarily with
physical abuse and neglect, only two showed a decrease in child abuse
as measured by a reduction in hospital admissions, emergency department
visits or reports to child protective services. Although there is a
need for better designed research to evaluate the effectiveness of
prevention strategies, recommendations for preventive interventions are
based on what we currently know about causes of child abuse (Hay, 1996).
Primary prevention strategies based on risk factors that have a low
predictive value are not as likely to be effective as more broadly
based social programs. In addition, programs focused on a society level
rather than on the individual level prevent the stigmatization of a
group or an individual. Society strategies for preventing child abuse
that are proposed but unproven include increasing the value society
places on children, increasing the economic self-sufficiency of
families, enhancing communities and their resources, discouraging
excessive use of corporal punishment and other forms of violence,
making health care more accessible and affordable, expanding and
improving treatment for alcohol and drug abuse, improving the
identification and treatment of mental health problems, increasing the
availability of affordable child care and preventing the births of
unwanted children through sex education, family planning, abortion,
anonymous delivery and adoption (Rushton, 1997).
Common Features of Successful Child Abuse Prevention Programs
Strengthen family and community connections and support.
Treat parents as vital contributors to their children’s growth and
Create opportunities for parents to feel empowered to act on their own
Respect the integrity of the family.
Enhance parents’ capability to foster the optimal development of their
children and themselves.
Establish links with community support systems.
Provide settings where parents and children can gather, interact,
support, learn from each other.
Enhance coordination and integration of services needed by families.
Enhance community awareness of the importance of healthy parenting
Provide emergency support for parents 24 hours a day. (Rushton, 1997).
Plans aimed at helping the individual can also be considered strategies
for helping the family. In the list of features of successful child
abuse prevention programs listed above, the idea is to support parents
in their role of parenting. Until parents’ basic needs are met, they
may find it difficult to meet the needs of their children. The first
thing parents need is assistance in meeting their basic requirements
for food, shelter, clothing, safety and medical care. Only when these
needs are met can higher needs be addressed (Rushton, 1997).
The next step should be to identify and treat parents who abuse
alcohol or drugs, and identify and counsel parents who suffer from
spousal abuse. Identifying and treating parents with psychologic
problems is also important. Other issues that need attention include
financial concerns, and employment and legal problems. Providing an
empathetic ear and being a source of referral for help with these
issues may take physicians a long way toward nurturing needy parents.
The next higher level of need includes education about time management
and budgeting skills, stress management, coping and parenting skills
such as appropriate discipline, knowledge of child development,
nutrition and feeding problems, and safety issues (Rushton, 1997).
In the United States, some of the specific methods of delivering
services to families include long-term home visitation, short-term home
visitation, early and extended postpartum mother/child contact, rooming
in, intensive physician contact, drop-in centers, child classroom
education, parent training and free access to health care.
Of all these methods, only long-term home visitation, up to two years,
has been found to be effective in reducing the incidence of child abuse
as measured by hospital admissions, emergency department visits and
reports to child protective services. Man organizations are now
embracing the concept of home visitation as a method of preventing
child abuse by identifying family needs and providing the appropriate
services. Results of one study on home visitation showed benefits or
improvements in several areas: parents’ attitudes toward their children,
interactions between parents and children, and reduction in the
incidence of child abuse. Without a basic framework of support
services such as health care, social services and child care, home
visitors will be unable to deliver needed services (Rushton, 1997).
Strategies for Preventing Child Abuse
Diagnose pregnancy in unmarried mothers and explore its impact with
Assess the number of stressors on new parents, including:
Level of education
Number of children
Identify families with problems of:
Offer new parents:
Services of a social worker
Long-term home visitation
Educate new parents regarding:
Developmental tasks of childhood
Age-appropriate anticipatory guidance
Nutrition and feeding problems
Discourage corporal punishment
Survey parents to identify health issues that are of interest to them
Support universal health care for children
Advocate for quality, affordable and universally available child care
Advocate for community respite care for parents
Advocate for community alcohol and drug treatment, mental health, and
spouse and child abuse centers
Many of the causes of child abuse center on the needs and problems of
the parents. In order to prevent child abuse, we must first help and
support the parents. Parents with multiple emotional, medical,
financial and social needs find it difficult to meet the needs of their
children. It is imperative that physicians develop a supportive
attitude toward parents to ultimately help the children.
Effective prevention of child abuse and neglect can best be achieved
using strategies designed to help parents protect and nurture their
children. These strategies including giving parents the necessary
support, resources and skills. The physician should obtain help from
social workers, home health agencies, financial counselors,
psychologist, local mental health facilities, alcohol and drug
treatment centers and parenting centers, as appropriate. The National
Committee to Prevent Child Abuse has a nationwide network of fifty-two
chapters that provide leadership in prevention of child abuse
(Understanding Child Abuse and Neglect, 1996).
One source I read suggested setting up group parenting classes to
discuss issues such as: safety issues, nutrition and feeding concerns,
discipline and normal child development. Classes should be divided
into two groups: one for the parents of infants and one for the parents
of toddlers, since these two groups will require a different focus.
Providing child care during these classes may be necessary to ensure
Other suggestions are for a physician to help to try prevent child
abuse. Spending less time examining an obviously well child and more
time discussing psycho social issues with that child’s parent is one
suggestion. The following is a list of questions a physician can ask
parents that might help assess the risk of child abuse.
What is it like for you taking care of this baby?
Who helps you with your children?
Do you get time to yourself?
What do you do when the child’s behavior drives you crazy?
Do you have trouble with your child at mealtime or bedtime?
Are your children in day care?
How are things between you and your partner?
If psycho social problems are uncovered, the physician might schedule
more frequent visits to allow for further discussions. Other
strategies include inviting fathers for an office visit and encouraging
the parents to rely on the support of families and friends. It is
important to address issues that are of concern to the parents. It is
also important to try to give very specific and concrete suggestions to
parents instead of talking in broad generalities. Physicians could
suggest that parents use an egg timer to help children anticipate and
be more compliant with bedtime or use time-out as an alternative to
spanking a child for bad behavior. Parents should be reminded of and
taught to distinguish between childish behavior and willful
disobedience, and to discipline only those actions that are in the
child’s control according to his or her stage of development (Rushton,
Many things need to happen at international, national, state and
community levels to prevent child abuse. Studies have shown that
countries with the most generous social services have the lowest rate
of child homicide. People should lobby for greater availability of
drug and alcohol treatment programs, more shelters for the homeless,
more accessible mental health care and more shelters for abused women
and children. These programs and those that provide parenting skills,
support groups and respite care for parents and care givers should be
available in every community.
Child abuse is a complex problem with many causes, it is important
that people not take a defeatist attitude toward its prevention.
Despite the absence of strong evidence to guide preventive efforts,
society can do things to try to prevent abuse. Showing increased
concern for the parents or care givers and increasing attempts to
enhance their skills as parents or care givers may help save the most
vulnerable people, our children, from the nightmare of abuse and