chapter 2
CHILD ABUSE—A PROBLEM OF DEFINITION

WHAT IS ABUSE?

Child abuse is often a secret. Since the 1960s, however, Americans have become increasingly aware of the problems of child abuse and neglect (together referred to as child maltreatment). In 1963 some 150,000 young victims of maltreatment were reported to authorities (Juvenile Court Statistics, U.S. Department of Health, Education, and Welfare, Children's Bureau, Washington, DC, 1966). In 2002 state child protective services (CPS) agencies received nearly 2.6 million reports of child maltreatment involving about 4.5 million children (Child Maltreatment 2002, U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, Washington, DC, 2004).

There is still no agreement on what constitutes child abuse. In August 2002 a mother in Brilliant, Ohio, was charged with three counts of felony child endangerment for allegedly allowing her three children to become seriously sunburned. A sheriff's deputy had arrested the woman after noticing that her three young children had sunburned faces while at the county fair in 95°F weather. The woman spent eight days in jail. Authorities later released the mother after determining that the children were not that badly burned. She was charged with a single count of misdemeanor child endangerment, which the prosecutor dismissed two months later.

In September 2002 a surveillance camera in a store in Mishawaka, Indiana, recorded a mother apparently beating and punching her four-year-old daughter inside her car. The videotape, which aired nationally, caused public outrage. The mother was charged with battery to a child, a felony that could bring her a maximum of three years in jail. The child was put in foster care while the case was under investigation. While extreme cases like the Indiana one are easy to label, less severe cases, such as the sunburned children, are viewed differently by different people.

Federal Definition

Official definitions of child abuse and neglect differ among institutions, government bodies, and experts. According to the Child Abuse Prevention and Treatment Act (CAPTA) Amendments of 1996 (Public Law 104-235), which amended the 1974 CAPTA:

The term "child abuse and neglect" means, at a minimum, any recent act or failure to act, on the part of a parent or caretaker [including any employee of a residential facility or any staff person providing out-of-home care who is responsible for the child's welfare], 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 term "child" means a person under the age of eighteen, unless the child protection law of the state in which the child resides specifies a younger age for cases not involving sexual abuse.]

It should be noted that this definition of child abuse and neglect specifies that only parents and caregivers can be considered perpetrators of child maltreatment. Abusive or negligent behavior by other persons—strangers or persons known to the child—is considered child assault. Both forms of abusive behavior are crimes against children.

Based on a concern that severely disabled newborns may be denied medical care, CAPTA also considers as child abuse and neglect the "withholding of medically indicated treatment," including appropriate nutrition, hydration, and medication, which in the treating physician's medical judgment would most likely help, improve, or correct an infant's life-threatening conditions. This definition, however, does not refer to situations where treatment of an infant, in the physician's medical judgment, would prolong dying, be ineffective in improving or correcting all of the infant's life-threatening conditions, or would be futile in helping the infant to survive. In addition, this definition does not include circumstances where the infant is chronically or irreversibly comatose.

State Definitions

CAPTA provides a foundation for states by identifying a minimum set of acts or behaviors that characterize child abuse and neglect. Each state, based on CAPTA guidelines, has formulated its own definitions of the different types of child maltreatment. State definitions, however, may be unclear. For example, states typically define neglect as the failure to provide adequate food, clothing, shelter, or medical care. About one-fifth of states do not have a separate definition for neglect. Moreover, most child protective services agencies consider recent incidences of neglect instead of patterns of behavior that may constitute chronic, or continuing, neglect.

States define child abuse and neglect in three areas in state statutes: reporting laws for child maltreatment, criminal codes, and juvenile court laws. Most state laws also include exceptions, such as religious exemptions, corporal punishment, cultural practices, and poverty.

CAPTA DEFINES FOUR MAIN TYPES OF CHILD MALTREATMENT

Physical Abuse

Physical abuse is the infliction of physical injury through punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. Physical abuse is generally a willful act. There are cases, however, in which the parent or caretaker may not have intended to hurt the child. In such cases, the injury may have resulted from over-discipline or corporal punishment. Nonetheless, if the child is injured, the act is considered abusive.

Sexual Abuse

Sexual abuse includes fondling a child's genitals, intercourse, incest, rape, sodomy, exhibitionism, and commercial exploitation through prostitution or the production of pornographic materials.

Psychological Abuse (Emotional Abuse, Verbal Abuse, or Mental Injury)

Psychological abuse includes acts or omissions by the parents or by other caregivers that have caused, or could cause, serious behavioral, cognitive, emotional, or mental disorders. In some cases of emotional abuse, the abuser's act alone, without any harm evident in the child's behavior or condition, is enough cause for intervention by child protective services (CPS) agencies. For example, the parent/caregiver may use extreme or bizarre forms of punishment, such as locking a child in a dark room or closet.

Other forms of psychological abuse may involve more subtle acts, such as habitual scapegoating (erroneously blaming the child for things that go wrong), belittling, or rejection of the child. For CPS to intervene, demonstrable harm to the child is often required. Although any of the types of child maltreatment may be found separately, different types of abuse often occur in combination with one another. Emotional abuse is almost always present when other types are identified.

Child Neglect

Child neglect is an act of omission characterized by failure to provide for the child's basic needs. Neglect can be physical, educational, or emotional. Physical neglect includes failure to provide food, clothing, and shelter; refusal of or delay in seeking health care (medical neglect); abandonment; inadequate supervision; and expulsion from the home or refusal to allow a runaway to return home. Educational neglect includes permitting chronic truancy, failure to enroll a child of mandatory school age in school, and failure to take care of a child's special educational needs. Emotional neglect includes substantial inattention to the child's need for affection, failure to provide needed psychological care, spousal abuse in the child's presence, and allowing drug or alcohol use by the child. It is very important to distinguish between willful neglect and a parent's or a caretaker's failure to provide the necessities of life because of poverty or cultural factors.

A DESCRIPTION OF MALTREATED CHILDREN

Perhaps better than a definition of child abuse is a description of the characteristics likely to be exhibited by abused and/or neglected children. The Department of Health and Human Services indicates that, in general, abused or neglected children are likely to have at least several of the following characteristics:

• They appear to be different from other children in physical or emotional makeup, or their parents inappropriately describe them as being "different" or "bad."
• They seem unduly afraid of their parents.
• They may often bear welts, bruises, untreated sores, or other skin injuries.
• Their injuries seem to be inadequately treated.
• They show evidence of overall poor care.
• They are given inappropriate food, drink, or medication.
• They exhibit behavioral extremes—for example, crying often or crying very little and showing no real expectation of being comforted; being excessively fearful or seemingly fearless of adult authority; being unusually aggressive and destructive or extremely passive and withdrawn.
• Some are wary of physical contact, especially when initiated by an adult. They become fearful when an adult approaches another child, particularly one who is crying. Others are inappropriately hungry for affection, yet may have difficulty relating to children and adults. Based on their past experiences, these children cannot risk getting too close to others.
• They may exhibit a sudden change in behavior—for example, displaying regressive behavior, such as pants wetting, thumb sucking, frequent whining, becoming disruptive, or becoming uncommonly shy and passive.
• They take over the role of the parent, being protective or otherwise attempting to take care of the parent's needs.
• They have learning problems that cannot be diagnosed. If a child's academic intelligence quotient (IQ) is average or better and medical tests indicate no abnormalities, but the child still cannot meet normal expectations, the answer may well be problems in the home—one of which may be abuse or neglect. Particular attention should be given to the child whose attention wanders and who easily becomes self-absorbed.
• They are habitually truant or late for school. Frequent or prolonged absences sometimes result when a parent keeps an injured child at home until the evidence of abuse disappears. In other cases, truancy indicates lack of parental concern or inability to regulate the child's schedule.
• In some cases, they arrive at school too early and remain after classes have ended, rather than go home.
• They are always tired and often sleep in class.
• They are inappropriately dressed for the weather. Children who never have coats or shoes in cold weather are receiving less than minimal care. Those who regularly wear long sleeves or high necklines on hot days, however, may be dressed to hide bruises, burns, or other marks of abuse.

Many of the psychological symptoms of abuse can be contradictory. One child may be excessively aggressive, while another may be too compliant. One child may be extremely independent, while another may exhibit a clinging behavior. A child may be overly mature, attending to the emotional needs of a parent who is incapable of meeting his or her own needs. These different behaviors are possible symptoms of abuse. No one behavior on the part of a child, however, is conclusive evidence of abuse.

Victims of Physical Abuse

Victims of physical abuse often display bruises, welts, contusions, cuts, burns, fractures, lacerations, strap marks, swellings, and/or lost teeth. While internal injuries are seldom detectable without a hospital examination, anyone in close contact with children should be alert to multiple injuries, a history of repeated injuries, new injuries added to old ones, and untreated injuries, especially in very young children. Older children may attribute an injury to an improbable cause, lying for fear of parental retaliation. Younger children, however, may be unaware that a severe beating is unacceptable and may admit to having been abused.

Physically abused children frequently have behavior problems. Especially among adolescents, chronic and unexplainable misbehavior should be investigated as possible evidence of abuse. Some children come to expect abusive behavior as the only kind of attention they can receive and so act in a way that invites abuse. Others break the law deliberately in order to come under the jurisdiction of the courts to obtain protection from their parents. According to "Recognizing Signs of Child Abuse" (The Nemours Foundation, http://www.kidshealth.org [accessed December 27, 2004]), children who have been abused may display a wide array of behavioral problems including being aggressive or disruptive; displaying intense anger or rage; being self-abusive or self-destructive; feeling suicidal or depressed; using drugs or alcohol; fearing certain adults; and avoiding being at home.

Parents who inflict physical abuse generally provide necessities, such as adequate food and clean clothes. Nevertheless, they get angry quickly, have unrealistic expectations of their children, and are overly critical and rejecting of their children. "Parents who abuse their children may avoid other parents in the neighborhood, may not participate in school activities, and may be uncomfortable talking about their children's injuries or behavioral problems," according to the Nemours Foundation. While many abusive parents have been mistreated as children themselves and are following a learned behavior, an increasing number who physically abuse their own children do so under the influence of alcohol and drugs.

Victims of Physical Neglect

Physically neglected children are often hungry. They may go without breakfast and have neither food nor money for lunch. Some take the lunch money or food of other children and hoard whatever they obtain. They show signs of malnutrition: paleness, low weight relative to height, lack of body tone, fatigue, inability to participate in physical activities, and lack of normal strength and endurance.

These children are usually irritable. They show evidence of inadequate home management and are unclean and unkempt. Their clothes are often torn and dirty. They may lack proper clothing for different weather conditions, and their school attendance may be irregular. In addition, these children may frequently be ill and may exhibit a generally repressed personality, inattentiveness, and withdrawal. They are in obvious need of medical attention for such correctable conditions as poor eyesight, poor dental care, and lack of immunizations.

A child who suffers physical neglect also generally lacks parental supervision at home. The child, for example, may frequently return from school to an empty house. While the need for adult supervision is, of course, relative to both the situation and the maturity of the child, it is generally held that a child younger than twelve should always be supervised by an adult or at least have immediate access to a concerned adult when necessary.

Parents of neglected children are either unable or unwilling to provide appropriate care. Some neglectful parents are mentally deficient. Most lack knowledge of parenting skills and tend to be discouraged, depressed, and frustrated with their role as parents. Alcohol or drug abuse may also be involved.

Physical neglect can be a result of poverty and/or ignorance and may not be intentional. According to the National Clearinghouse on Child Abuse and Neglect Information (Acts of Omission: An Overview of Child Neglect, April 2001), if poor parents fail to feed their children adequately, they would be charged with neglect only if they know of food assistance programs but have failed to use them.

Victims of Emotional Abuse and Neglect

Emotional abuse and neglect are as serious as physical abuse and neglect, although this condition is far more difficult to describe or identify. Emotional maltreatment often involves a parent's lack of love or failure to give direction and encouragement. The parent may either demand far too much from the child in the area of academic, social, or athletic activity or withhold physical or verbal contact, indicating no concern for the child's successes and failures and giving no guidance or praise.

Parents who commit emotional abuse and neglect are often unable to accept their children as fallible human beings. The effects of such abuse can often be far more serious and lasting than those of physical abuse and neglect. Emotionally abused children are often extremely aggressive, disruptive, and demanding in an attempt to gain attention and love. They are rarely able to achieve the success in school that tests indicate they can achieve.

Emotional maltreatment can be hard to determine. Is the child's abnormal behavior the result of maltreatment on the part of the parents, or is it a result of inborn or internal factors? Stuart N. Hart, Marla R. Brassard, Nelson J. Binggeli, and Howard A. Davidson ("Psychological Maltreatment," The APSAC Handbook on Child Maltreatment, 2nd ed., Thousand Oaks, CA: Sage Publications, Inc., 2002) have listed problems associated with emotional abuse and neglect, including poor appetite, lying, stealing, enuresis (bed-wetting), encopresis (passing of feces in unacceptable places after bowel control has been achieved), low self-esteem, low emotional responsiveness, failure to thrive, inability to be independent, withdrawal, suicide, and homicide.

Victims of Medical Neglect and Abuse

Medical neglect refers to the parents' failure to provide medical treatment for their children, including immunizations, prescribed medications, recommended surgery, and other intervention in cases of serious disease or injury. Some situations involve a parent's inability to care for a child or lack of access to health care. Other situations involve a parent's refusal to seek professional medical care, particularly because of a belief in spiritual healing.

Thorny legal issues have been raised by cases in which parents' freedom of religion clashes with the recommendations of medical professionals. Medical abuse may also involve the Munchausen syndrome by proxy, in which psychologically disturbed parents create illnesses or injuries in children in order to gain sympathy for themselves.

religious beliefs. Religious beliefs sometimes prevent children from getting needed medical care. For example, Christian Scientists believe that God heals the sick and that prayer and perfect faith are the proper responses to illness. Other religions, most notably Jehovah's Witnesses, forbid blood transfusions. Religious exemption laws make it difficult to prosecute parents who do not seek treatment for a sick child because their religion forbids it, although courts generally order the emergency treatment of the children.

Rita Swan, a former Christian Scientist who lost her sixteen-month-old child to untreated meningitis, is the president of Children's Healthcare Is a Legal Duty, Inc. (CHILD, Inc.), an organization that seeks to protect children from abusive cultural and religious practices, especially religion-based medical neglect. CHILD, Inc., reported that as of September 2004, thirty-nine states had religious exemptions from child abuse and neglect charges in the civil code, and thirty-one states had a religious defense to criminal charges. All states except Mississippi and West Virginia had religious exemptions from immunizations.

According to CHILD, Inc., Sec. 113 (42 U.S.C. 5106i) of the CAPTA Amendments of 1996 allows parents to withhold medical care from their children based on religious beliefs. Section 113 states:

Nothing in this Act shall be construed:

1. as establishing a Federal requirement that a parent or legal guardian provide a child any medical service or treatment against the religious beliefs of the parent or legal guardian; and
2. to require that a State find, or to prohibit a State from finding, abuse or neglect in cases in which a parent or legal guardian relies solely or partially upon spiritual means rather than medical treatment, in accordance with the religious beliefs of the parent or legal guardian.

munchausen syndrome by proxy. Munchausen syndrome is a psychiatric disorder in which patients fake illness or make themselves sick in order to get medical attention. In 1977 British physician Roy Meadow wrote a paper describing a condition he called Munchausen syndrome by proxy (MSBP) in which parents, usually mothers, call attention to themselves by inducing illnesses in their children or by hurting them ("Munchausen Syndrome by Proxy: The Hinterland of Child Abuse," The Lancet, vol. 310, issue 8033). As a result of Meadow's article, authorities have concluded that some incidents of sudden infant death syndrome (SIDS), or the unexplained death of an infant, are murders attributable to parents, especially mothers, suffering from MSBP. Meadow became an expert witness for prosecutors and child protective services. As a result of his testimony, many parents lost their children to the state, had their parental rights terminated, or were charged with murder.

In MSBP situations, children are usually subjected to endless and often painful diagnostic tests, medications, and even surgery. The abuse is most often perpetrated against infants and toddlers before they can talk. Some older children who have been abused in this way do not reveal the deception, however, because they fear they will be abandoned by their parents if they are no longer sick. Others come to believe that they must truly be ill. According to Dr. Guy E. Brannon in "Munchausen Syndrome by Proxy" (http://www.emedicine.com/med/topic3544.htm [accessed January 6, 2005]), in about 10% of cases, MSBP has led to children's deaths.

Dr. Brannon reported that about six hundred cases of MSBP occur each year. He also noted that mothers are the perpetrators in 95% of the cases. Although there are no specific numbers, some experts believe that many of these mothers themselves have been abused as children. A mother with MSBP may think that by devoting her life to "helping" her sick child, she could be a nurturing parent, unlike her own abusive mother. She not only gets the attention that she craves but also the sympathy of those involved in her child's care.

In June 2000 David E. Hall et al. reported the diagnosis of MSBP in twenty-three out of forty-one suspected cases at Children's Healthcare of Atlanta at Scottish Rite, Atlanta, Georgia ("Evaluation of Covert Video Surveillance in the Diagnosis of Munchausen Syndrome by Proxy: Lessons from 41 Cases," Pediatrics, vol. 105, no. 6). For four years the researchers, after notifying law enforcement, monitored the children through hidden video cameras to determine the reasons for their inexplicable illnesses. The video surveillance showed the mothers abusing their children, from suffocation to injection with chemicals. Critics charged that the families' right to privacy had been invaded, but the researchers argued that abused children cannot speak up for themselves and need others to protect them.

false allegations of munchausen syndrome by proxy. In 2003 a British high court overturned the conviction of three mothers who had been found guilty of murdering their children based on Meadow's expert testimony. In one case, Meadow testified that the chances of two SIDS deaths in a family were one in seventy-three million. In another case, a jury convicted a mother of murder based on the pediatrician's sole testimony that three SIDS must be murder. Meadow based his testimony on his own theory, Meadow's law, which states that in a single family "one sudden infant death is a tragedy, two is suspicious, and three is murder until proved otherwise." Since then, Meadow's theories have been proven wrong. It was also discovered that Meadow could not produce any peer-reviewed research that would have supported his MSBP findings in 1977. Critics say that Meadow's discovery of the new illness resulted from just two of his cases and that he had not produced any records of his research on these cases. In 2004 British authorities continued to review child abuse cases that used Meadow's expert testimony. The British Medical Council also began an investigation of Meadow.

Physicians and child abuse experts are more cautious in labeling parents who harm their children as suffering from MSBP. Despite the controversies concerning MSBP, many physicians believe that there is such a condition, although it is said to be rare. In 2004 the British Medical Journal reported that just a minority of parents who intentionally hurt their children have shown Munchausen syndrome characteristics (Alan W. Craft and David M. B. Hall, "Munchausen Syndrome by Proxy and Sudden Infant Death," vol. 328, May 29, 2004). According to the authors, because "there is no single psychological profile in Munchausen syndrome by proxy," pediatricians replaced the term with Fabricated and/or Induced Illness in Children (FII). They noted, however, that research has shown that some cases of SIDS were later shown to be FII. They added that the occurrence of more than one infant death in a family is more likely to be due to homicide or inherited conditions.

A FAMILY AT RISK FOR MALTREATMENT

While it is impossible to determine whether child maltreatment will occur, generally a family may be at risk if the parent is young, has little education, has had several children born within a few years, and is highly dependent on social welfare. According to the Field Guide to Child Welfare (Judith S. Rycus and Ronald C. Hughes, Washington, DC: Child Welfare League of America, 1998), a family at high to moderate risk includes parents who do not understand basic child development and who may discipline inappropriately for the child's age; those who lack the necessary skills for caring for and managing a child; those who use physical punishment harshly and excessively; and those who do not appropriately supervise their children.

Furthermore, families under stress are more likely to produce abusive parents and abused or neglected children, such as during divorce or other problems with adult relationships, death, illness, disability, incarceration, or loss of a job, according to Rycus and Hughes. Small stresses can have a cumulative effect and become explosive with a relatively minor event. For potentially abusive parents, high levels of ongoing stress, coupled with inadequate coping strategies and limited resources, produces an extremely high-risk situation for children involved.

According to the Department of Health and Human Services, a family may also be at risk if the parent:

• is a "loner"—feels isolated with no family to depend on, has no real friends, or does not get along well with the neighbors
• has a poor self-image and feels worthless, with a pervading sense of failure
• feels unloved, unappreciated, and unwanted, with a great fear of rejection
• has severe personal problems, such as ill health, alcoholism, or drug dependency
• feels that violence can often be the solution to life's problems or has not learned to "blow off steam" in a socially acceptable manner
• was abused or neglected as a child

A family may also be at risk if the child:

• is "different"—smaller than average, more sickly, disabled, considered unattractive, or was premature
• resembles or reminds the parent of someone the parent hates, or if the child "takes after" a disappointing spouse or former loved one
• is more demanding or otherwise has more problems than do other children in the family
• is unwanted—seen as a "mistake" or burden, having "ruined things" for the parent