Child Protection in Families Experiencing Domestic Violence

Child Abuse and Neglect User Manual Series

Author(s):  Office on Child Abuse and Neglect., Caliber Associates. Bragg

Year Published:  2003

Chapter 2
The Overlap Between Child Maltreatment and Domestic Violence
 

Over the past few decades, there has been a growing awareness of the co-occurrence of domestic violence and child maltreatment. Studies report that there are approximately between 750,000 and 2.3 million victims of domestic violence each year. Many of these victims are abused several times, so the number of domestic violence incidents is even greater. According to a national study by the U.S. Department of Health and Human Services, approximately 903,000 children were identified by child protective services (CPS) as victims of abuse or neglect in 2001. Increasingly, service providers and researchers have recognized that some of these adult and child victims are from the same families. Research suggests that in an estimated 30 to 60 percent of the families where either domestic violence or child maltreatment is identified, it is likely that both forms of abuse exist. Studies show that for victims who experience severe forms of domestic violence, their children also are in danger of suffering serious physical harm. In a national survey of over 6,000 American families, researchers found that 50 percent of men who frequently assaulted their wives also abused their children. Other studies demonstrate that perpetrators of domestic violence who were abused as children are more likely to physically harm their children. Rates of Domestic Violence Domestic violence measured by the National Crime Victimization Survey (NCVS) includes rape or sexual assault, robbery, and aggravated and simple assault committed by a current or former spouse, boyfriend, or girlfriend. In 2000, about 1 in every 200 households acknowledged that someone in the household experienced some form of domestic violence. There is no statistically significant difference in this rate over the prior 6 years. As with other crimes measured using the NCVS, a household counted as experiencing domestic violence was counted only once, regardless of the number of times that a victim experienced violence and regardless of the number of victims in the household during the year. The following statistics represent reported cases. Characteristic of the household Percent of households that experienced domestic violence Caucasian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% African-American . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% Hispanic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% blank cell Urban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% Suburban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% Rural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% blank cell Northeast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.3% Midwest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.7% South . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% West . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5%   Household Size blank cell 1 person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% 2 to 3 persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.4% 4 to 5 persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0.5% 6 or more persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.0%   Domestic Violence by Type of Crime and Gender in 2001 blankcell Female Male Total Rape or sexual assault 41,740 blank cell 41,740 Robbery 44,060 16,570 60,630 Aggravated assault 81,140 36,350 117,480 Simple assault 421,550 50,310 471,860 blank cell Overall violent crime 588,490 103,230 691,710   The Co-occurence of Child Maltreatment and Domestic Violence An estimated 3.3 to 10 million children a year are at risk for witnessing or being exposed to domestic violence, which can produce a range of emotional, psychological, and behavioral problems for children. This estimate is derived from an earlier landmark study that found approximately 3 million American households experienced at least one incident of serious violence each year. The broad range of this estimate highlights the fact that the exact number of domestic violence incidents is unknown, and there sometimes is incongruence or a lack of agreement about exactly what constitutes "domestic violence." One study estimates that as many as 10 million teenagers are exposed to parental violence each year. This estimate comes from a survey in which adults were asked "whether, during their teenage years, their father had hit their mother and how often" and vice versa for the mother. The survey found that about one in eight, 12.6 percent of the sample, recalled such an incident. In these cases, 50 percent remembered their father hitting the mother, 19 percent recalled their mother hitting the father, and 31 percent recalled the parents hitting each other. These estimates are based on research that identified maltreated children who accompanied victims of domestic violence to shelters and identified adult victims via CPS caseloads. Additionally, research examining the relationship between victims and their own use of violence indicate that they are more likely to perpetrate physical violence against their children than caretakers who are not abused by a partner or spouse. Children who witness domestic violence and are victimized by abuse exhibit more emotional and psychological problems than children who only witness domestic violence. Current data regarding the co-occurrence between domestic violence and child maltreatment compel child welfare and programs that address domestic violence to re-evaluate their existing philosophies, policies, and practice approaches towards families experiencing both forms of violence. The overlap of these issues may be particularly critical in identifying cases with a high risk of violence, such as the relationship between domestic violence and child fatalities in CPS cases. A review of CPS cases in two States identified domestic violence in approximately 41 to 43 percent of cases resulting in the critical injury or death of a child. A number of protocols and practice guidelines have surfaced over the past decade to provide child welfare and service providers with specific assessment and intervention procedures aimed at enhancing the safety of children and victims of domestic violence. Children's Exposure to Domestic Violence Children who live in homes where a parent or caretaker is experiencing abuse are commonly referred to as "child witnesses" or "children who are witnessing" domestic violence. The term "children's exposure" to domestic violence, however, provides a more inclusive definition because it encompasses the multiple ways children experience domestic abuse. Although caretakers frequently believe they are protecting their children from witnessing their abuse, children living in these homes report differently. Researchers have found that 80 to 90 percent of children in homes where domestic violence occurs can provide detailed accounts of the violence in their homes. Research studies have proliferated regarding children's exposure to domestic violence, the problems associated with witnessing, and the protective factors that influence their responses to the violence. Children's exposure to domestic violence typically falls into three primary categories: Hearing a violent event; Being directly involved as an eyewitness, intervening, or being used as a part of a violent event (e.g., being used as a shield against abusive actions); Experiencing the aftermath of a violent event. Children's exposure to domestic violence also may include being used as a spy to interrogate the adult victim, being forced to watch or participate in the abuse of the victim, and being used as a pawn by the abuser to coerce the victim into returning to the violent relationship. Some children are physically injured as a direct result of the domestic violence. Some perpetrators intentionally physically, emotionally, or sexually abuse their children in an effort to intimidate and control their partner. While this is clearly child maltreatment, other cases may not be so clear. Children often are harmed accidentally during violent attacks on the adult victim. An object thrown or weapon used against the battered partner can hit the child. Assaults on younger children can occur while the adult victim is holding the child, and injury or harm to older children can happen when they intervene in violent episodes. In addition to being exposed to the abusive behavior, many children are further victimized by coercion to remain silent about the abuse, maintaining the "family secret." The Effects of Domestic Violence on Children Children who live with domestic violence face numerous risks, such as the risk of exposure to traumatic events, the risk of neglect, the risk of being directly abused, and the risk of losing one or both of their parents. All of these can lead to negative outcomes for children and clearly have an impact on them. Research studies consistently have found the presence of three categories of childhood problems associated with exposure to domestic violence: Behavioral, social, and emotional problems—higher levels of aggression, anger, hostility, oppositional behavior, and disobedience; fear, anxiety, withdrawal, and depression; poor peer, sibling, and social relationships; low self-esteem. Cognitive and attitudinal problems—lower cognitive functioning, poor school performance, lack of conflict resolution skills, limited problem-solving skills, acceptance of violent behaviors and attitudes, belief in rigid gender stereotypes and male privilege. Long-term problems—higher levels of adult depression and trauma symptoms, increased tolerance for and use of violence in adult relationships. Children also display specific problems unique to their physical, psychological, and social development. For example, infants exposed to violence may have difficulty developing attachments with their caregivers and in extreme cases suffer from "failure to thrive." It should be noted that there also are limitations and uncertainties to the research since some of the children in such studies do not show elevated problem levels even under similar circumstances. Preschool children may regress developmentally or suffer from eating and sleep disturbances. School-aged children may struggle with peer relationships, academic performance, and emotional stability. Adolescents are at a higher risk for either perpetrating or becoming victims of teen dating violence. Reports from adults who repeatedly witnessed domestic violence as children show that many suffer from trauma-related symptoms, depression, and low self-esteem. Possible Symptoms in Children Exposed to Domestic Violence Sleeplessness, fears of going to sleep, nightmares, dreams of danger; Physical symptoms such as headaches or stomachaches; Hypervigilance to danger or being hurt; Fighting with others, hurting other children or animals; Temper tantrums or defiant behavior; Withdrawal from people or typical activities; Listlessness, depression, low energy; Feelings of loneliness and isolation; Current or subsequent substance abuse; Suicide attempts or engaging in dangerous behavior; Poor school performance; Difficulties concentrating and paying attention; Fears of being separated from the nonabusing parent; Feeling that his or her best is not good enough; Taking on adult or parental responsibilities; Excessive worrying; Bed-wetting or regression to earlier developmental stages; Dissociation; Identifying with or mirroring behaviors of the abuser. Children's Protective Factors in Response to Domestic Violence Studies documenting the types of problems associated with children who are exposed to domestic violence reveal a wide variation in their responses to the violence. Children's risk levels and reactions to domestic violence exist on a continuum where some children demonstrate enormous resiliency while others show signs of significant maladaptive adjustment. Protective factors such as social competence, intelligence, high self-esteem, outgoing temperament, strong sibling and peer relationships, and a supportive relationship with an adult, are thought to be important variables that help protect children from the adverse effects of exposure to domestic violence. In addition, research shows that the impact of domestic violence on children can be moderated by certain factors, including: The nature of the violence. Children, who witness frequent and severe forms of violence, perceive the violence as their fault. Because they fail to observe their caretakers resolving conflict, these children may undergo more distress than children who witness fewer incidences of physical violence. The frequency with which they witness positive interactions between their caregivers also affects them. Coping strategies and skills. Children with poor coping skills are more likely to experience problems than children with strong coping skills and supportive social networks. Children who utilize problem-solving strategies targeted directly at the source of disagreement demonstrate fewer maladaptive symptoms. Emotion-focused strategies, however, are less desirable because they often target internal responses to a stressful situation, which can result in less effective coping methods (e.g., children fantasizing that their parent's are "getting along"). The age of the child. Younger children appear to exhibit higher levels of emotional and psychological distress than older children. Age-related differences might result from older children's more fully developed cognitive abilities to understand the violence and select various coping strategies to alleviate upsetting emotions. The time since exposure. Children are observed to have heightened levels of anxiety and fear immediately after a recent violent event. Fewer observable effects are seen in children the longer time has past after they have witnessed the violence. Gender. In general, boys exhibit more "externalized" behaviors (e.g., aggression or acting out) while girls exhibit more "internalized" behaviors (e.g., withdrawal or depression). In addition, boys identify more with the male abuser and girls identify more with the female victim; both may continue these roles throughout life if the issues are not addressed. The presence of child abuse. Children who witness domestic abuse and are physically abused demonstrate increased levels of emotional and psychological maladjustment than children who only witness violence and are not abused. Professionals Responding to Child Maltreatment and Domestic Violence: In Search of Common Ground Although adult and child victims often are found in the same families, child protection and domestic violence programs have historically responded separately to victims. The divergent responses are largely due to the differences in each system's historical development, philosophy, mandate, policies, and practices. As a result, these differences have led to variations in desired outcomes and practice methods for child welfare caseworkers and service providers who lack a mutual understanding of one another's mission and approach when addressing the co-occurrence of child maltreatment and domestic violence. Several key debates stemming from these differences have limited collaboration between the two fields. For CPS caseworkers, whose legal mandate is the protection of the abused child, responding to domestic violence has been widely regarded as a peripheral issue. Alternatively, service providers have primarily focused on pursuing safety and empowerment for adult victims. The differing opinion about whose safety is paramount has led to misconceptions and critical accusations by both systems. Child welfare advocates have charged service providers with discounting the safety needs of children by focusing primarily on the adult victim who also may be neglectful or abusive towards the children. Conversely, some service providers accuse child welfare caseworkers of "revictimizing" victims of domestic violence by placing responsibility and blame on adult victims for the violent behaviors of perpetrators or charging the adult victim with "failing to protect" the child. Furthermore, interactions with the perpetrator are markedly distinct for each system. CPS's growing emphasis on a family-centered approach may sometimes compel caseworkers to engage perpetrators, who are either biological parents or caretakers of the children, in efforts aimed at creating healthy and stable families. In contrast, service providers often view separation from perpetrators as a desirable intervention until the safety of all family members is assured. Despite their differences, child welfare advocates and service providers share areas of common ground that can bridge the gap between them, including: Both want to end domestic violence and child maltreatment; Both want children to be safe; Both want adult victims to be protected—for their own safety and so their children are not harmed by the violence; Both believe in supporting a parent's strengths; Both prefer that children not be involved in CPS, if avoidable. Additionally, men historically have not been actively involved with CPS or domestic violence agencies in working to make the necessary behavior modifications that will facilitate change on these issues. The Different Responses to Families Experiencing Domestic Violence As previously discussed, children respond in varying degrees to domestic violence, and researchers caution against holding a unilateral position that children witnessing domestic abuse constitutes child maltreatment or warrants CPS involvement. However, the complexity of the research regarding the intersection between domestic violence and child maltreatment has led various social service providers and policy-makers to believe that every child exposed to domestic violence is at severe risk for harm and warrants formal or mandatory intervention. Some States are considering legislation that broadens the definition of child neglect to include children who witness domestic violence. Expanding the legal definitions of child maltreatment, however, may not always be the most effective method to address the needs of these children in an already overburdened CPS system. It is an unrealistic expectation that CPS investigate every report of children living in a home where domestic violence occurs. However, CPS should screen every report for domestic violence and refer to specific criteria or agency protocol when determining if the referral warrants further investigation. Furthermore, a CPS investigation is typically labor intensive and invasive in the lives of families. Communities can better serve families by allocating new as well as existing resources that build partnerships between CPS, service providers, and the wide network of informal and formal systems that offer a continuum of services based upon the level of risk present. In fact, a number of national, State, and local initiatives throughout the country are demonstrating that a collective ownership and intolerance for abuse against adults and children can form the foundation of a solid, coordinated, and comprehensive approach to ending child maltreatment and domestic violence in their communities. Chapter 6, "Building a Collaborative Response for Families Experiencing Domestic Violence," provides specific examples of promising practices and programs that have implemented community-wide collaborations to address co-occurring child maltreatment and domestic violence. There are families experiencing domestic violence where CPS involvement is necessary. CPS agencies are required to intervene in cases where child exposure to domestic violence meets the State or local legal definition of child abuse and neglect and in instances where children, in addition to adult victims, are physically or sexually abused. Presenting risk factors associated with potentially dangerous and lethal forms of domestic violence also will require intervention by CPS. Parental substance abuse and mental illness are two examples of risk factors that can increase the threat of harm to children who witness domestic violence. In cases where there are several risks to children's safety, CPS caseworkers should address the multiple needs of these families. Relevant services are discussed later in this manual. There are some situations, however, where child protection efforts to secure the safety of children can and should occur without a formal determination of abuse or neglect. After completing a comprehensive assessment of the nature and severity of the domestic violence and its impact on child safety, CPS may elect to refer a family to community-based services rather than substantiating a CPS case. CPS agencies who adopt this alternative response to domestic violence and child maltreatment may find it to be a more manageable and effective approach in assisting victims of domestic violence who have not maltreated their children, but who need help in securing safety and protection for them. Additionally, both the children and the victim are often better served by voluntary, and therefore less stigmatizing, community-based services. This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.

Updated on July 24, 2006

Third National Incidence Study of Child Abuse and Neglect

This report presents the results of the congressionally mandated Third National Incidence Study of Child Abuse and Neglect (NIS-3). The NIS is the single most comprehensive source of information about the current incidence of child abuse and neglect in the United States. The NIS-3 findings are based on a nationally representative sample of over 5,600 professionals in 842 agencies serving 42 counties. The study used two sets of standardized definitions of abuse and neglect. Under the Harm Standard, children identified to the study were considered to be maltreated only if they had already experienced harm from abuse or neglect. Under the Endangerment Standard, children who experienced abuse or neglect that put them at risk of harm were included in the set of those considered to be maltreated, together with the already-harmed children.

The NIS-3 provides us with important insights about the incidence and distribution of child abuse and neglect and about changes in incidence since the previous studies.

Incidence

• There have been substantial and significant increases in the incidence of child abuse and neglect since the last national incidence study was conducted in 1986.
• Under the Harm Standard definitions, the total number of abused and neglected children was two-thirds higher in the NIS-3 than in the NIS-2. This means that a child's risk of experiencing harm-causing abuse or neglect in 1993 was one and one-half times the child's risk in 1986.
• Under the Endangerment Standard, the number of abused and neglected children nearly doubled from 1986 to 1993. Physical abuse nearly doubled, sexual abuse more than doubled, and emotional abuse, physical neglect, and emotional neglect were all more than two and one-half times their NIS-2 levels.
• The total number of children seriously injured and the total number endangered both quadrupled during this time.

Child Characteristics

• Girls were sexually abused three times more often than boys.
• Boys had a greater risk of emotional neglect and of serious injury than girls.
• Children are consistently vulnerable to sexual abuse from age three on.
• There were no significant race differences in the incidence of maltreatment or maltreatment-related injuries uncovered in either the NIS-2 or the NIS-3.

Family Characteristics

• Children of single parents had a 77% greater risk of being harmed by physical abuse, an 87% greater risk of being harmed by physical neglect, and an 80% greater risk of suffering serious injury or harm from abuse or neglect than children living with both parents.
• Children in the largest families were physically neglected at nearly three times the rate of those who came from single-child families.
• Children from families with annual incomes below $15,000 as compared to children from families with annual incomes above $30,000 per year were over 22 times more likely to experience some form of maltreatment that fit the Harm Standard and over 25 times more likely to suffer some form of maltreatment as defined by the Endangerment Standard.
• Children from the lowest income families were 18 times more likely to be sexually abused, almost 56 times more likely to be educationally neglected, and over 22 times more likely to be seriously injured from maltreatment as defined under the Harm Standard than children from the higher income families.

Child Protective Services (CPS) Investigation

• CPS investigated only 28% of the recognized children who met the Harm Standard. This was a significant decrease from the 44% investigated in 1986.
• Although the percentage of children whose abuse or neglect was investigated declined, the actual number of children investigated remained constant.
• CPS investigated less than one-half of all Harm Standard children recognized by any source and less than one-half of all Endangerment Standard children recognized by any source except police and sheriffs' departments (52%).
• Schools recognized the largest number of children maltreated under the Harm Standard, but only 16% of these children were investigated by CPS.
• CPS investigated only 26% of the seriously injured and 26% of the moderately injured children.

This study would not have been possible without the support of hundreds of agencies and individual caseworkers, teachers, police officers, social workers, probation officers, nurses, and other professionals in the study counties who contributed their enthusiastic support and much of their time in the effort to assess accurately the incidence, nature, and distribution of child abuse and neglect in the United States. I extend my appreciation to these dedicated respondents.

This report summarizes the Third National Incidence Study of Child Abuse and Neglect (NIS-3). It gives a synopsis of the study's background and objectives, its design and methods, and its key findings and implications.

Background and Objectives

The National Incidence Study (NIS) is a congressionally mandated, periodic effort of the National Center on Child Abuse and Neglect (NCCAN). The first NIS (NIS-1), mandated under P.L. 93-247 (1974), was conducted in 1979 and 1980 and published in 1981. The second NIS (NIS-2), mandated under P.L. 98-457 (1984), was conducted in 1986 and 1987 and published in 1988. The third NIS (NIS-3) was mandated under P.L. 100-294 (as amended). The NIS-3 data were collected in 1993 and 1994, analyses conducted in 1995 and 1996, and these results published in 1996. A key objective of the NIS-3 was to provide updated estimates of the incidence of child abuse and neglect in the United States and measure changes in incidence from the earlier studies.

Design and Methods

The NIS-3 offers an important perspective on the scope of child abuse and neglect. The NIS includes children who were investigated by child protective service (CPS) agencies, but it also obtains data on children seen by community professionals who were not reported to CPS or who were screened out by CPS without investigation. This means that the NIS estimates provide a more comprehensive measure of the scope of child abuse and neglect known to community professionals, including both abused and neglected children who are in the official statistics and those who are not. The NIS follows a nationally representative design, which means that the estimates represent the numbers of abused and neglected children in the United States who come to the attention of community professionals. The fact that there have been three similar national incidence studies that have used comparable methods and definitions means that one can compare NIS-3 estimates with those from the earlier studies in order to identify any changes over time in the incidence and distribution of abused and neglected children.

The NIS-3 was conducted in a nationally representative sample of 42 counties. In every county, the CPS agency was a key participant, providing basic demographic data on all the children who were reported and accepted for investigation during the 3-month study data period, September 5 through December 4, 1993. Further details about the child's maltreatment and the outcome of the CPS investigation were obtained for a representative sample of these cases.

Like the NIS-1 and NIS-2 before it, the NIS-3 employed a sentinel survey methodology, in which community professionals serving children and families in various categories of non-CPS agencies were also recruited into the study. In each county, these sentinels were a representative sample of all professional staff who were likely to come into contact with maltreated children in police and sheriffs' departments, public schools, day-care centers, hospitals, voluntary social service agencies, mental health agencies, and the county juvenile probation and public health departments. The participating sentinels in the NIS-3 were 5,612 professionals in 800 non-CPS agencies who remained on the lookout for maltreated children during the study period. They were trained in the standard NIS definitions of abuse and neglect at the outset, and they submitted data forms on any children they encountered who were maltreated during the study data period. The NIS-3 collected a total of 50,729 data forms: 4,711 from non-CPS sentinels; 3,154 on the investigation outcomes and the abuse and neglect involved in cases sampled at participating CPS agencies; and 42,864 capturing the basic demographic data on all cases reported to participating CPS agencies during the study period.

Children who were submitted to the study by non-CPS sentinels and those who were investigated in the CPS sampled cases were evaluated according to standard study definitions of abuse and neglect, and only children who fit the standards were used in generating the national estimates. The definitional standards used in the NIS-3 were identical to those used in the NIS-2. These standards imposed a number of requirements, including the restriction that the abuse or neglect be within the jurisdiction of CPS (i.e., perpetrated or permitted by a parent or caretaker), and they applied uniform classification systems to index the type of maltreatment and the severity and type of injury or harm.

Two sets of definitional standards were applied: the Harm Standard and the Endangerment Standard. The Harm Standard was developed for the NIS-1, and it has been used in all three national incidence studies. It is relatively stringent in that it generally requires that an act or omission result in demonstrable harm in order to be classified as abuse or neglect. Exceptions are made in only a few categories where the nature of the maltreatment itself is so egregious that the standard permits harm to be inferred when direct evidence of it is not available. The chief advantage of the Harm Standard is that it is strongly objective in character. Its principal disadvantage is that it is so stringent that it provides a view of abuse and neglect that is too narrow for many purposes, excluding even many children whose maltreatment is substantiated or indicated as abuse or neglect by CPS.

To meet the need to include the full set of substantiated/indicated children in the incidence statistics, the Endangerment Standard was developed as a definitional standard during the NIS-2 to supplement the perspective provided by the Harm Standard. The Endangerment Standard includes all children who meet the Harm Standard but adds others as well. The central feature of the Endangerment Standard is that it allows children who were not yet harmed by maltreatment to be counted in the abused and neglected estimates if a non-CPS sentinel considered them to be endangered by maltreatment or if their maltreatment was substantiated or indicated in a CPS investigation. In addition, the Endangerment Standard is slightly more lenient than the Harm Standard concerning the identity of allowable perpetrators in that it includes maltreatment by adult caretakers other than parents in certain categories as well as sexual abuse perpetrated by teenage caretakers. The Endangerment Standard was used in both the NIS-2 and the NIS-3.

Duplicate forms about the same child were identified and unduplicated, so that each child was included in the database only once. Finally, the data were weighted to represent the total number of children maltreated in the United States and annualized to transform the information from the 3-month data period into estimates reflecting a full year.

The National Incidence of Child Abuse and Neglect

The findings of the Third National Incidence Study of Child Abuse and Neglect (NIS-3) show a sharp increase in the scope of the problem, whether maltreatment is defined using the Harm Standard or the Endangerment Standard.

Estimated Incidence As Defined by the Harm Standard.

An estimated 1,553,800 children in the United States were abused or neglected under the Harm Standard in 1993. The NIS-3 total reflects a 67% increase since the NIS-2 estimate, which indicated that the total was 93 1,000 children in 1986, and it corresponds to a 149% increase since the NIS-1 estimate for 1980 of 625,100 children. Significant or close-to-significant increases were found in both abuse and neglect. The number of abused children who were countable under the Harm Standard rose by 46% from an estimated 507,700 in the NIS-2 to 743,200 in the NIS-3. The number of neglected children who fit the Harm Standard increased significantly from 474,800 during the NIS-2 data collection in 1986 to 879,000 at the time of the NIS-3 data period in 1993. In the estimates given here and below, children are included in all categories that apply to them (i.e., those who were both abused and neglected are included in both estimates).

Considering specific types of abuse and neglect as defined by the Harm Standard, significant increases since the NIS-2 were found in the incidence of sexual abuse, physical neglect, and emotional neglect, and a close-to-significant (i.e., statistically marginal) increase was observed in the incidence of physical abuse:

• The estimated number of sexually abused children under the Harm Standard rose from II 9,200 in 1986 to 217,700 in 1993 (an 83% increase);
• The number of physically neglected children under the Harm Standard increased from an estimated 167,800 at the time of the NIS-2 to an estimated 338,900 in the NIS-3 (a 102% rise in incidence);
• There was a 333% increase in the estimated number of emotionally neglected children using the Harm Standard, from 49,200 in the NIS-2 to 212,800 in the NIS-3; and
• The estimated number of physically abused children under the Harm Standard was 269,700 at the time of the NIS-2, but it had increased to 381,700 during the NIS-3 (a 42% increase).

When these abused and neglected children were classified according to the injury or harm they suffered from maltreatment that fit the Harm Standard, there was a substantial and significant increase in the incidence of children who were seriously harmed and a statistically marginal increase in the number for whom injury could be infeffed due to the severe nature of their maltreatment. The estimated number of seriously injured children essentially quadrupled from 141,700 to 565,000 in the intervening 7 years between the NIS-2 and the NIS-3 (a 299% increase). The number for whom injury could be infeffed increased from an estimated 105,500 children in the NIS-2 to an estimated 165,300 children in the NIS-3 (a 57% increase).

Estimated Incidence Using the Endangerment Standard.

Between 1986 and 1993, the total estimated number of abused and neglected children in the United States who fit the Endangerment Standard nearly doubled: in 1986, there were an estimated 1,424,400 abused and neglected children in the United States. The NIS-3 estimate of 2,815,600 reflects a 98% increase over the NIS-2 figure. Significant increases were found in both abuse and neglect. The number of abused children more than doubled from an estimated 590,800 to 1,221,800 (a 107% increase), while the estimated number of neglected children also more than doubled from 917,200 to 1,961,300 (a 114% increase).

• The increases were substantial and significant in all types of abuse and neglect except educational neglect;
• The estimated number of physically abused children rose from 311,500 to 614,100 (a 97% increase);
• The estimated number of sexually abused children increased from an estimated 133,600 children to 300,200 (a 125% increase);
• The more recent estimate of the number of emotionally abused children was 183% higher than the previous estimate (188,100 in 1986 versus 532,200 in 1993);
• The estimated number of physically neglected children increased from 507,700 to 1,335, 100 (a 163% increase); and
• The estimated number of emotionally neglected children nearly tripled in the interval between the studies, rising from 203,000 in 1986 to 585,100 in 1993 (a 188% increase).

When the children whose abuse or neglect met the Endangerment Standard were classified according to the injury or harm they suffered, significant increases were evident in two categories. First, the 1993 estimate of the number of children who were endangered by their maltreatment (but not yet harmed) was more than four times the corresponding 1986 estimate. That is, the number of endangered children rose from an estimated 254,000 in 1986 to an estimated 1,032,000 in 1993 (a 306% increase). Second, the number of children who were seriously injured or harmed by abuse or neglect that fit the Endangerment Standard in 1993 was well over one-half million, which is nearly quadruple the 1986 estimate for this category. In 1986, an estimated 143,300 children had been seriously injured by abuse or neglect; in 1993, the figure was 569,900 children (a 298% increase). Note that nearly all (99%) of the children who counted as seriously injured here were also countable under the Harm Standard, so the near-quadrupling of their numbers since 1986 essentially reiterates what was reported above in connection with the Harm Standard.

Distribution of Child Abuse and Neglect by the Child's Characteristics

The child's sex and age were related to the rate of maltreatment, but race was not.

Child's Sex.

Girls were sexually abused about three times more often than boys, under both the Harm Standard and the Endangerment Standard. This finding reiterates the NIS-2 result, so females' disproportionately greater risk of sexual abuse has been stable over time. This sex difference in incidence rates of sexual abuse leads to higher rates of abuse in general among girls. Also, because the definitional guidelines permit the inference that injury or harm occurred in connection with the more extreme forms of sexual abuse, girls' greater risk of sexual abuse also accounts for their higher incidence rates for inferred injury.

At the same time, boys had higher incidence rates than girls in some arenas, and boys' maltreatment risks also demonstrated some increases since the NIS-2. Boys were at somewhat greater risk of serious injury (24% higher than girls' risk under both definitional standards), and boys were significantly more likely to be emotionally neglected (boys' risk was 18% greater than girls'). Also, boys' rates of physical neglect defined by the Harm Standard and of emotional abuse using the Endangerment Standard increased more since the NIS-2 than girls' rates did. Moreover, trends in the incidence of fatal injuries from maltreatment moved in opposite directions for girls and boys-the incidence of fatally injured girls declined slightly since the NIS-2, while the incidence of fatally injured boys rose.

Child's Age.

A consistent feature of the age differences in incidence rates within the NIS-3 was the lower incidence of maltreatment among the younger children under both definitional standards. In most cases, the differentiation was between the 0- to 2-year-olds and older children or between the 0- to 5-year-olds and older children. It is possible that the lower rates at these younger ages reflect undercoverage of these age groups. That is, prior to attaining school age, children are less observable to community professionals.

Another recurring theme in connection with age is that of disproportionate increases in the incidence of maltreatment among the younger children (under 12 years old) and especially among children in their middle-cbildhood years (ages 6 to I 1). Note that as circumstances deteriorate and maltreatment becomes more prevalent and more severe, older children have greater opportunities for escape. Also, older children are more able to defend themselves andIor retaliate. These factors may have moderated the increases in maltreatment that were observed among the older age groups.

The disproportionate increases during the younger and middle-childhood years mean that the overall profiles of age differences in maltreatment were different in the NIS-3 than they had been in the NIS-2. During the NIS-2, the risk of maltreatment generally increased with the age of the child in a close-to-linear fashion. With the lopsided increases among the younger children and among children in their middle-childhood years, the profile has changed toward a curvilinear configuration-where the middle-years of childhood are associated with the maximum risk of maltreatment-and toward a somewhat flatter distribution-where age differences are somewhat attenuated overall compared to their NIS-2 patterns.

One of the most striking findings is the age distribution of sexual abuse, which combined the general flattening of the age differences in incidence rates with a very low age transition in the distribution of incidence rates. The rate of sexual abuse as defined under the Endangerment Standard was very low for 0- to 2-year-olds, but then relatively constant for children ages 3 and older, indicating a very broad age range of vulnerability from preschool age on.

Race.

The NIS-3 found no race differences in maltreatment incidence. The NIS-3 reiterates the findings of the earlier national incidence studies in this regard. That is, the NIS-1 and the NIS-2 also found no significant race differences in the incidence of maltreatment or maltreatment-related injuries.

Service providers may find these results somewhat surprising in view of the disproportionate representation of children of color in the child welfare population and in the clientele of other public agencies. However, it should be recognized that the NIS methodology identifies a much broader range of children than those who come to the attention of any one type of service agency or the even smaller subset who receive child protective and other child welfare services. The NIS findings suggest that the different races receive differential attention somewhere during the process of referral, investigation, and service allocation, and that the differential representation of minorities in the child welfare population does not derive from inherent differences in the rates at which they are abused or neglected. It is also important to recognize that while there are no overall race differences in the incidence of child abuse and neglect in the NIS-3 findings, subsequent analyses that simultaneously consider multiple characteristics may reveal race differences in maltreatment incidence among specific subsets of children (e.g., for children of certain ages, for one sex but not the other, etc.).

Distribution of Child Abuse and Neglect by Family Characteristics

The incidence of child maltreatment varied as a function of family income, family structure, family size, and the metropolitan status of the county.

Family Structure.

Children of single parents were at higher risk of physical abuse and of all types of neglect and were overrepresented among seriously injured, moderately injured, and endangered children. Compared with their counterparts living with both parents, children in single parent families had:

• a 77% greater risk of being harmed by physical abuse (using the stringent Harm Standard) and a 63% greater risk of experiencing any countable physical abuse (using the Endangerment Standard);
• an 87% greater risk of being harmed by physical neglect and a 165% greater risk of experiencing any countable physical neglect;
• a 74% greater risk of being harmed by emotional neglect and a 64% greater risk of experiencing any countable emotional neglect;
• a 220% (or more than three times) greater risk of being educationally neglected;
• an approximately 80% greater risk of suffering serious injury or harm from abuse or neglect;
• an approximately 90% greater risk of receiving moderate injury or harm as a result of child maltreatment; and
• a 120% (or more than two times) greater risk of being endangered by some type of child abuse or neglect.

Among children in single-parent households, those living with only their fathers were approximately one and two-thirds times more likely to be physically abused than those living with only their mothers.

Although parents are not necessarily, nor even most frequently, the perpetrators of maltreatment, the relationship between parent structure and maltreatment incidence is understandable, considering the added responsibilities and stresses of single-parenting together with the likelihood that surrounding social and practical support may be inadequate.

Family Size.

The incidence of maltreatment was related to the number of dependent children in the family, especially in the categories of physical and educational neglect. For educational neglect, and for physical neglect according to the Harm Standard, the pattern was nonlinear: the incidence rates were highest for children in the largest families (those with four or more children), intermediate for "only" children, and lowest for children in families with two to three children. Children in the largest families were almost three times more likely to be educationally neglected, and nearly two and two-fifths times more likely to be physically neglected under the Harm Standard, compared to children in families with two or three children. Under the Endangerment Standard, the pattern was one of increasing incidence of physical neglect with greater numbers of children. Children in the largest families were physically neglected at nearly three times the rate of those who came from "only" child families.

Additional children in a household mean additional tasks and responsibilities, so it is understandable why incidence rates of child abuse and neglect may be higher when there are more children. Accounting for why "only" children have higher rates of educational neglect and of physical neglect under the Harm Standard than children in families with two or three children requires a different explanation. One possibility is that there may be too many expectations focused on "only" children, whereas expectations (and disappointments) are diffused over multiple children in the larger families. Another possibility is that many "only" child households represent the early stages in their families' development, since a number of these families will have additional children, in time. Thus, many "only" children are in families with relatively young and inexperienced parents and caretakers.

County Metropolitan Status.

The incidence of children who had been moderately harmed by maltreatment was significantly lower among children in large urban counties than among children who lived in other urban counties. This was interpreted as reflecting a general under-coverage of moderately injured maltreated children in the large urban counties. It was not clear whether this was because the moderately injured children are less likely to be encountered by community professionals in the large urban centers, because community professionals in these locales are less likely to identify these children as maltreated, or because the NIS information sources in these counties are less likely to submit data about these maltreated children.

Family Income.

Despite the fact that only a rather gross index of family income was available, and despite a substantial percentage of cases with missing data on this factor, family income was significantly related to incidence rates in nearly every category of maltreatment. Compared to children whose families earned $30,000 per year or more, those in families with annual incomes below $15,000 per year were:

• more than 22 times more likely to experience some form of maltreatment under the Harm Standard and over 25 times more likely to suffer maltreatment of some type using the Endangerment Standard;
• almost 14 times more likely to be harmed by some variety of abuse and nearly 15 times more likely to be abused using the Endangerment Standard criteria;
• more than 44 times more likely to be neglected, by either definitional standard;
• almost 16 times more likely to be a victim of physical abuse under the Harm Standard and nearly 12 times more likely to be a victim of physical abuse using the Endangerment Standard;
• almost 18 times more likely to be sexually abused by either definitional standard;
• thirteen times more likely to be emotionally abused under the Harm Standard criteria and more than 18 times more likely to be emotionally abused in a manner that fit Endangerment Standard requirements;
• forty times more likely to experience physical neglect under the Harm Standard and over 48 times more likely to be a victim of physical neglect using the Endangerment Standard;
• over 29 times more likely to be emotionally neglected under the Harm Standard definitions and over 27 times more likely to be emotionally neglected by Endangerment Standard criteria;
• nearly 56 times more likely to be educationally neglected, by either definitional standard;
• sixty times more likely to die from maltreatment of some type under the Harm Standard and over 22 times more likely to die from abuse or neglect using the Endangerment Standard;
• over 22 times more likely to be seriously injured by maltreatment under the Harm Standard and almost 22 times more likely to be seriously injured by maltreatment that fit the Endangerment Standard requirements;
• about 18 times more likely to be moderately injured by abuse or neglect under the Harm Standard and nearly 20 times more likely to have a moderate injury from maltreatment as defined by the Endangerment Standard;
• fifty-seven times more likely to be classified as having an inferred injury under the Harm Standard and 39 times more likely to meet the criteria for inferred injury as defined by the Endangerment Standard; and
• over 31 times more likely to be considered endangered, although not yet injured, by some type of abusive or neglectful treatment.

The NIS-3 findings on the correlation between family income and child maltreatment are entirely consistent with the earlier findings of the NIS-2. Moreover, they cannot be plausibly explained on the basis of the higher visibility of lower-income families to community professionals.

On the one hand, the NIS sentinels observe substantial numbers of children and families at the middle- and upper-income levels. The large majority of maltreated children were recognized by professionals likely to encounter children and fan-filies at all Income levels, such as sentinels in hospitals, schools, day-care centers, mental health agencies, voluntary social service agencies; by professionals not represented by NIS sentinel categories; and by the general public. Sentinels in schools alone recognized the majority of the maltreated children. Although the NIS design includes only public schools, approximately 89% of the U.S. population of school-age children attend public schools, so children attending the public schools represent a broad spectrum of family income levels. Moreover, the private schools not reflected in the NIS include religiously affiliated schools, which have sliding scales for poorer children, so children who attend private schools are not necessarily from better economic circumstances than children enrolled in public schools.

On the other hand, if the income finding is interpreted as an artifact of selective observation of low-income families, then it would mean that there have to be enough undetected abused and neglected children in the middle- and upper-income brackets used here to equalize the incidence rates across different income categories. That would require an astounding number of still-undetected children in the nation who experience countable maltreatment. Specifically, it would mean that an additional 2,138,700 children suffered maltreatment according to the Harm Standard yet remained hidden to the NIS. Similarly, it would mean there were an additional 4,500,700 children in 1993 who experienced maltreatment under the Endangerment Standard but who escaped observation by community professionals. To add some perspective as to what this would entail, consider that almost seven% of the total U.S. child population would be maltreated in countable ways yet entirely escape the attention of the spectrum of community professionals who serve as NIS sentinels, and all of these additional children would have to be in families with incomes of $15,000 per year or more.

Considering the implications of the alternative, it appears more plausible to assume that the income-related differences in incidence found in the NIS reflect real differences in the extent to which children in different income levels are being abused or neglected. Note that. there are a number of problems associated with poverty that may contribute to child maltreatment: more transient residence, poorer education, and higher rates of substance abuse and emotional disorders. Moreover, families at the lower socioecononu'c levels have less adequate social support systems to assist parents in their child care responsibilities.

Distribution of Child Abuse and Neglect by Perpetrator Characteristics

Children who had been maltreated as defined by the Harm Standard were categorized according to their relationship to the most closely related perpetrator and according to this perpetrator's sex, age, and employment status; these categorizations were examined in relation to the type of maltreatment and the severity of the child's injury or harm. Perpetrators' relationships to the children also were examined in relation to the children's race. The findings represent only a preliminary exploration of perpetrator characteristics in the NIS-3 data, since they lack significance tests concerning potential relationships and substantial percentages of the children were missing information concerning certain of the perpetrator characteristics.

Perpetrator's Relationship to the Child.

The majority of all children countable under the Harm Standard (78%) were maltreated by their birth parents, and this held true both for children who were abused (62% were maltreated by birth parents) and for those who were neglected (91 % experienced neglect by birth parents).

Birth parents were the most closely related perpetrators for 72% of the physically abused children and for 81% of the emotionally abused children. The pattern was dis tinctly different for sexual abuse. Nearly one-half of the sexually abused children were sexually abused by someone other than a parent or parent-substitute, while just over one-fourth were sexually abused by a birth parent, and one-fourth were sexually abused by other than a birth parent or parent-substitute. In addition, a sexually abused child was most likely to sustain a serious injury or impairment when a birth parent was the perpetrator.

Perpetrator's Sex.

Children were somewhat more likely to be maltreated by female perpetrators than by males: 65% of the maltreated children had been maltreated by a female, whereas 54% had been maltreated by a male. Of children who were maltreated by their birth parents, the majority (75%) were maltreated by their mothers and a sizable minority (46%) were maltreated by their fathers (some children were maltreated by both parents). In contrast, children who were maltreated by other parents or parent-substitutes, or by other persons, were more likely to have been maltreated by a male than by a female (80 to 85% were maltreated by males; 14 to 41 % by females).

Abused children presented a different pattern in connection with the sex of their perpetrators than did the neglected children. Children were more often neglected by female perpetrators (87% by females versus 43% by males). This finding is congruent with the fact that mothers and mother substitutes tend to be the primary caretakers and are the primary persons held accountable for any omissions and/or failings in caretaking. In contrast, children were more often abused by males (67% were abused by males versus 40% by females). The prevalence of male perpetrators was strongest in the category of sexual abuse, where 89% of the children were abused by a male compared to only 12% by a female.

Among all abused children, those abused by their birth parents were about equally likely to have been abused by mothers as by fathers (50% and 58%, respectively), but those abused by other parents, parent-substitutes, or other, nonparental perpetrators were much more likely to be abused by males (80 to 90% by males versus 14 to 15% by females). This general pattern held for emotional abuse, but was slightly different in the area of physical abuse. Children who had been physically abused by their birth parents were more likely to have suffered at the hands of their mothers than their fathers (60% versus 48%), while those who had been physically abused by other parents or parent-substitutes were much more likely to have been abused by their fathers or father-substitutes (90% by their fathers versus 19% by their mothers). For sexual abuse, the child's relationship to the perpetrator made very little difference, since males clearly predominated as perpetrators, whatever their relationship to the child. Moreover, the severity of the injury or impairment that the child experienced as a result of maltreatment did not appear to bear any relationship to the sex of the perpetrator.

Perpetrator's Age.

The perpetrator's age was entirely unknown for one-third of the children who were countable under the Harm Standard. Given the prevalence of children maltreated by perpetrators of unknown age, the findings here are tentative, since they could easily be eradicated if all perpetrators' ages were known.

Among all maltreated children, only a small percentage (13%) had been maltreated by a perpetrator in the youngest age bracket (under 26 years of age). However, younger perpetrators were slightly more predominant among children who had been sexually abused (where 22% had been sexually abused by a perpetrator under 26 years of age) and among children who had been maltreated in any way by someone who was not their parent or parent-substitute (among whom 40% had been maltreated by a perpetrator in the youngest age bracket).

A child's severity of injury or harm from maltreatment appeared not to be associated with the age of the perpetrator.

Perpetrator's Employment Status. 

Perpetrator's employment status was unknown for more than one-third of the maltreated children, limiting the value of the findings on this issue. Nearly one-half of all maltreated children were abused by a perpetrator who was employed, and this held true for both abuse and neglect. Of the children who sustained serious injury, the majority were maltreated by an employed perpetrator. In no category were the majority of children maltreated by a perpetrator who was unemployed.

Child's Race and Relationship to the Perpetrator. 

Because the perpetrator's race was not known for children submitted to the study solely through non-CPS sources, the child's race was examined in connection with the relationship to the perpetrator and with the nature and severity of the maltreatment.

For overall abuse, child's race reflected no notable connection to the relationship with the perpetrator. However, among sexually abused children, white children constituted a greater proportion of children who were sexually abused by their birth parents than of those sexually abused by other parents and parent-substitutes, and by others. Among physically abused children, white children were more prevalent among those who were physically abused by other parents and parent-substitutes than among those who were physically abused by their birth parents or among those physically abused by other types of perpetrators. Although non-white children were the minority of victims in all categories, they were more prevalent among children who were physically or sexually abused by perpetrators other than parents or parent-substitutes.

White children are a larger majority of those who suffered serious injury, whereas nonwhite children's representation was strongest among those who experienced moderate injury and among those for whom injury could be infeffed based on the severity of their maltreatment.

Sources of Recognition for Maltreated Children

School staff predominated as a source of recognition for maltreated children. School sentinels recognized 59% of the children who suffered maltreatment as defined by the Harm Standard and 54% of the Endangerment Standard total. Other important sources of abused and neglected children were hospitals, police departments, social service agencies, and the general public. For maltreatment defined under the Endangerment Standard, day-care centers also joined in the group of agency categories that encountered more than 100,000 abused and neglected children.

Since the NIS-2, hospitals more than tripled the rate at which they recognized maltreated children; mental health agencies nearly quadrupled their rate of recognition of children who met the Harm Standard and increased their recognition fivefold of children who met the Endangerment Standard; schools more than doubled their rate of recognition of children who met the Endangerment Standard, which included a 70% increase in their recognition rate for the Harm Standard sector. Endangerment Standard recognition more than doubled in law enforcement agencies. Interestingly, there were no changes in the contributions of sources that are tapped in the NIS only through their reports to CPS (e.g., private physicians and the general public). This last finding probably reflects the relatively stable level of CPS involvement with the abused and neglected children countable in the NIS over the time period, as noted below.

Official Reporting of Maltreated Children and Their Investigation by Child Protective Services

The NIS methodology provides information that speaks only to the end result of several processes, indicating whether or not a given maltreated child was or was not among the children whose maltreatment was investigated by CPS. Children who do not receive CPS investigation of their maltreatment represent an enigma to the study, as it cannot be determined whether this was because they were not reported to CPS or because CPS screened their reports out without an investigation.

Despite that limitation, the NIS-3 findings concerning the percentages of abused and neglected children whose maltreatment received CPS investigation are cause for serious concern. Only a minority of the children who were abused or neglected, by either definitional standard, received CPS attention for their maltreatment. CPS investigated the maltreatment of only 28% of children who were countable under the Harm Standard and of only 33% of those whose maltreatment fit the Endangerment Standard. Moreover, the percentages of those who received CPS investigation represented less than one-half of the maltreated children in all categories of maltreatment except fatalities, and across nearly all recognition sources. Especially remarkable was the finding that CPS investigation extended to only slightly more than one-fourth of the children who were seriously harmed or injured by abuse or neglect.

Another important finding was that the percentages of maltreated children who receive CPS investigation have decreased significantly since the NIS-2. The percentage of children receiving investigation among those who met the Harm Standard dropped from 44% to 28%, while the percentage of CPS investigation of children who met the Endangerment Standard fell from 51% to 33%. Although the decline was significant only among children recognized in law enforcement agencies and hospitals, it nevertheless cut across every type of recognition source. The decline in rates of CPS investigation affected abuse under the Harm Standard, all categories of maltreatment under the Endangerment Standard, and all levels of outcomes except fatalities.

At the same time, the actual numbers of countable children investigated by CPS remained stable (when considering Harm Standard totals) or even slightly increased (considering the Endangerment Standard totals). Thus, as the total number of maltreated children has risen, it means that a larger percentage of them have not had access to CPS investigation of their maltreatment. This picture suggests that the CPS system has reached its capacity to respond to the maltreated child population.

Implications

Are the observed increases in the incidence of child abuse and neglect, especially the quadrupling of the numbers of children who were seriously injured or endangered by maltreatment, real increases in the scope of the problem, or do they instead reflect improved recognition on the part of sentinels and other reporters to CPS? The fact that the increases occurred where they did-among children who were seriously injured and among children who were endangered-suggests that both of these dynamics contributed to the observed increases, each dynamic affecting a different sector of the abused and neglected population.

More Children Are Now Being Abused and Neglected Than in 1986, and Their Injuries Are More Serious.

The rise in the number of seriously injured children probably reflects a real increase in child abuse and neglect, because it cannot plausibly be explained on the basis of heightened sensitivity. It is unreasonable to suppose that quadruple the number of seriously injured victims of abuse and neglect existed at the time of the NIS-2 and somehow escaped notice by community professionals. The fact that the seriously injured group has quadrupled during the 7 years since the NIS-2, and now comprises more than one-half million children, appears to herald a true rise in the scope and severity of child abuse and neglect in the United States.

Although the NIS does not address the causes of abuse and neglect, it was striking how often illicit drug use was noted in the narrative descriptions on the NIS data forms. The increase in illicit drug use since the fall of 1986 when the NIS-2 data were collected may have contributed to the rise in incidence observed in the NIS-3. Economics is another factor that may have enlarged the problem. Family income is the strongest correlate of incidence in nearly all categories of abuse and neglect, with the lowest income families evidencing the highest rates of maltreatment. Increases in incidence since 1986 may partially derive from decreased economic resources among the poorer families and the increase in the number of children living in poverty.

Community Professionals Are Better at Recognizing Abused and Neglected Children, Especially Those Endangered but Not Yet Harmed by Maltreatment. The rise in the number of endangered children probably stems from improved recognition of more subtle cues-those that indicate abusive and neglectful behaviors that have not yet resulted in harm or injury. It is quite plausible to suppose that some (even sizable) portion of the endangered children escaped attention in the NIS-2, but that by the time of the NIS-3, community professionals had learned to pay better attention to information that might indicate endangering maltreatment. Note that this explanation also completes an account of consistent progression in recognition across the three national incidence studies. The NIS-2 demonstrated an increase in the number of moderately injured children. In interpreting that finding, it was considered likely to have derived from improved attentiveness to moderate-injury indicators of abuse and neglect. The NIS-3 found no statistical change in the numbers of moderately injured children, which suggests that professionals had reached close-to-maximum recognition rates for this category of children at the time of the NIS-2. The fourfold increase in the number of endangered children in the NIS-3 implies that the subsequent further improvements in recognition have now shifted toward even subtler cues:those associated with not-yet-injurious abusive actions and neglectful omissions.

Better Targeting Is Needed To Ensure CPS Investigation for the Children Who Most Need It.

The number of NIS-countable children who are investigated by CPS has remained fairly stable, or risen slightly, since the last national incidence study in 1986. As a result, CPS investigation has not kept up with the dramatic rise in the incidence of these children, so the percentages who receive CPS investigation of their maltreatment have fallen significantly. The low rates of CPS investigation of the maltreated children, especially of those already seriously injured by maltreatment, warrant immediate attention.

These findings emphasize the need for better targeting, whether by reporters in referring children to CPS, by CPS screening practices in connection with reports, or by both. One possibility is that, although reporters now demonstrate considerable perceptiveness in identifying maltreated children, they have not reliably translated this into reports to CPS, or are unclear as to how to do so. Another possibility is that CPS, which has increasingly turned to screening cases in order to keep its workload manageably within the range of its resources, has not been using effective screening criteria or has been unclear or inconsistent about the criteria to be applied. Note that these are not independent dynamics, because the response of CPS to a report provides feedback that has consequences for future reporting behaviors. Information bearing on these issues is provided by reports on two of the NIS-3 special substudies: the Sentinel Questionnaire Follow-up Study, which asked school sentinels about their decisions to report cases to CPS, and the CPS Screening Policy and Recordkeeping Study, which examined the screening policies and practices of CPS agencies that participated in the NIS-3.

The main NIS-3 data can offer some guidance in targeting. Neglect warrants more attention. It affects the greatest number of maltreated children, and their injuries are often serious. Children from the poorest families are at the greatest risk of maltreatment, so these children may warrant increased CPS attention as well. Children in single-parent families also experienced higher rates of maltreatment. A number of characteristics explored here are not unrelated to each other-for instance, single-parent families often have lower incomes. Further analyses of the NIS-3 data can address the independent contributions of different characteristics to better clarify risk factors that can guide CPS screening activities. Narratives on the NIS data forms can also be more systematically explored. The narratives often included spontaneous comments about illegal drug use, indicated whether the perpetrator had a history (sometimes a criminal record) of sexually or physically abusing/assaulting other children or adults, or noted that the incident described was not the first time the child had been abused or neglected.

As part of improving CPS targeting of the more serious cases, efforts should also focus on achieving better consensus about what types of cases should not receive CPS investigation. Very few of the educationally neglected children currently have their maltreatment investigated by CPS, and those who do may have been maltreated in multiple ways, with the CPS investigation focusing on abuse or other types of neglect. The current role of CPS in relation to educational neglect might be the centerpiece of an emerging consensus on what specific forms of abuse or neglect should not receive CPS investigation.

Forging Working Relationships Between CPS Agencies and Schools.

The NIS has consistently demonstrated that professionals in schools play a central and critical role in identifying children who are abused and neglected. As policies are developed to address the burgeoning problem of child abuse and neglect, they should capitalize on the unique role of school professionals as front-line observers.

Information provided by the DHHS.

For more information, contact the National Clearinghouse on Child Abuse and Neglect Information at nccanch@calib.com.

Updated on April 6, 2001

Bonding and Attachment in Maltreated Children: Consequences of Emotional Neglect of a Child

By Bruce D. Perry, M.D., Ph.D.

Introduction

The most important property of humankind is the capacity to form and maintain relationships. These relationships are absolutely necessary for any of us to survive, learn, work, love, and procreate. Human relationships take many forms but the most intense, most pleasurable and most painful are those relationships with family, friends and loved ones. Within this inner circle of intimate relationships, we are bonded to each other with "emotional glue" — bonded with love.

Each individual's ability to form and maintain relationships using this "emotional glue" is different. Some people seem "naturally" capable of loving. They form numerous intimate and caring relationships and, in doing so, get pleasure. Others are not so lucky. They feel no "pull" to form intimate relationships, find little pleasure in being with or close to others. They have few, if any, friends, and more distant, less emotional glue with family. In extreme cases an individual may have no intact emotional bond to any other person. They are self-absorbed, aloof, or may even present with classic neuropsychiatric signs of being schizoid or autistic.
The capacity and desire to form emotional relationships is related to the organization and functioning of specific parts of the human brain. Just as the brain allows us to see, smell, taste, think, talk, and move, it is the organ that allows us to love — or not. The systems in the human brain that allow us to form and maintain emotional relationships develop during infancy and the first years of life. Experiences during this early vulnerable period of life are critical to shaping the capacity to form intimate and emotionally healthy relationships. Empathy, caring, sharing, inhibition of aggression, capacity to love, and a host of other characteristics of a healthy, happy, and productive person are related to the core attachment capabilities which are formed in infancy and early childhood.

Frequently Asked Questions

What is attachment?

Well, it depends. The word "attachment" is used frequently by mental health, child development, and child protection workers but it has slightly different meanings in these different contexts. The first thing to know is that we humans create many kinds of "bonds." A bond is a connection between one person and another. In the field of infant development, attachment refers to a special bond characterized by the unique qualities of maternal-infant or primary caregiver-infant relationships. The attachment bond has several key elements: (1) an attachment bond is an enduring emotional relationship with a specific person; (2) the relationship brings safety, comfort, and pleasure; (3) loss or threat of loss of the person evokes intense distress. This special form of relationship is best characterized by the maternal-child relationship. As we study the nature of these special relationships, we are finding out about how important they can be for the future development of the child. Indeed, many researchers and clinicians feel that the maternal-child attachment provides the working framework for all subsequent relationships that the child will develop. A solid and healthy attachment with a primary caregiver appears to be associated with a high probability of healthy relationships with others, while poor attachment with the mother or primary caregiver appears to be associated with a host of emotional and behavioral problems later in life.

In the mental health field, attachment has come to reflect the global capacity to form relationships. For the purposes of this paper, attachment capabilities refers to the capacity to form and maintain an emotional relationship while attachment refers to the nature and quality of the actual relationship. A child, for example, may have an "insecure" attachment or "secure" attachment.

What is bonding?

Simply stated, bonding is the process of forming an attachment. Just as bonding is the term used when gluing one object to another, bonding is using our "emotional glue" to become connected to another. Bonding, therefore, involves a set of behaviors that will help lead to an emotional connection (attachment).

Are bonding and attachment genetic?

The biological capacity to bond and form attachments is most certainly genetically determined. The drive to survive is basic in all species. Infants are defenseless and must depend upon a caregiving adult for survival. It is in the context of this primary dependence, and the maternal response to this dependence, that a relationship develops. This attachment is crucial for survival.

An emotionally and physically healthy mother will be drawn to her infant — she will feel a physical longing to smell, cuddle, rock, coo, and gaze at her infant. In turn the infant will respond with snuggling, babbling, smiling, sucking, and clinging. In most cases, the mother's behaviors bring pleasure and nourishment to the infant, and the infant's behaviors bring pleasure and satisfaction to the mother. This reciprocal positive feedback loop, this maternal-infant dance, is where attachment develops.

Therefore, despite the genetic potential for bonding and attachment, it is the nature, quantity, pattern, and intensity of early life experiences that express that genetic potential. Without predictable, responsive, nurturing, and sensory-enriched caregiving, the infant's potential for normal bonding and attachments will be unrealized. The brain systems responsible for healthy emotional relationships will not develop in an optimal way without the right kinds of experiences at the right times in life.

What are bonding experiences?

The acts of holding, rocking, singing, feeding, gazing, kissing, and other nurturing behaviors involved in caring for infants and young children are bonding experiences. Factors crucial to bonding include time together (in childhood, quantity does matter!), face-to-face interactions, eye contact, physical proximity, touch, and other primary sensory experiences such as smell, sound, and taste. Scientists believe the most important factor in creating attachment is positive physical contact (e.g., hugging, holding, and rocking). It should be no surprise that holding, gazing, smiling, kissing, singing, and laughing all cause specific neurochemical activities in the brain. These neurochemical activities lead to normal organization of brain systems that are responsible for attachment.

The most important relationship in a child's life is the attachment to his or her primary caregiver — optimally, the mother. This is due to the fact that this first relationship determines the biological and emotional 'template' for all future relationships. Healthy attachment to the mother built by repetitive bonding experiences during infancy provides the solid foundation for future healthy relationships. In contrast, problems with bonding and attachment can lead to a fragile biological and emotional foundation for future relationships.

When are these windows of opportunity?

Timing is everything. Bonding experiences lead to healthy attachments and healthy attachment capabilities when they are provided in the earliest years of life. During the first three years of life, the human brain develops to 90 percent of adult size and puts in place the majority of systems and structures that will be responsible for all future emotional, behavioral, social, and physiological functioning during the rest of life. There are critical periods during which bonding experiences must be present for the brain systems responsible for attachment to develop normally. These critical periods appear to be in the first year of life, and are related to the capacity of the infant and caregiver to develop a positive interactive relationship.

What happens if this window of opportunity is missed?

The impact of impaired bonding in early childhood varies. With severe emotional neglect in early childhood the impact can be devastating. Children without touch, stimulation, and nurturing can literally lose the capacity to form any meaningful relationships for the rest of their lives. Fortunately, most children do not suffer this degree of severe neglect. There are, however, many millions of children who have some degree of impaired bonding and attachment during early childhood. The problems that result from this can range from mild interpersonal discomfort to profound social and emotional problems. In general, the severity of problems is related to how early in life, how prolonged, and how severe the emotional neglect has been.
This does not mean that children with these experiences have no hope to develop normal relationships. Very little is known about the ability of replacement experiences later in life to "replace" or repair the undeveloped or poorly organized bonding and attachment capabilities. Clinical experiences and a number of studies suggest that improvement can take place, but it is a long, difficult, and frustrating process for families and children. It may take many years of hard work to help repair the damage from only a few months of neglect in infancy.

Are there ways to classify attachment?

Like traits such as height or weight, individual attachment capabilities are continuous. In an attempt to study this range of attachments, however, researchers have clustered the continuum into four categories of attachment: secure, insecure-resistant, insecure-avoidant, and insecure-disorganized/disoriented. Securely attached children feel a consistent, responsive, and supportive relation to their mothers even during times of significant stress. Insecurely attached children feel inconsistent, punishing, unresponsive emotions from their caregivers, and feel threatened during times of stress.

Dr. Mary Ainsworth developed a simple process to examine the nature of a child's attachment. This is called the Strange Situation procedure. Simply stated, the mother and infant are observed in a sequence of "situations": parent-child alone in a playroom; stranger entering room; parent leaving while the stranger stays and tries to comfort the baby; parent returns and comforts infant; stranger leaves; mother leaves infant all alone; stranger enters to comfort infant; parent returns and tries to comfort and engage the infant. The behaviors during each of these situations is observed and "rated." The behaviors of children in this testing paradigm is observed and categorized based upon both the child's willingness to re-engage with the parent, and the child's emotional state during the reunion.

Classification of Attachment: Securely Attached
Percentage at One Year:  60-70 %
Response in Strange Situation:  Explores with M in room; upset with separation; warm greeting upon return; seeks physical touch and comfort upon reunion.
Classification of Attachment:  Insecure: Avoidant
Percentage at One Year: 15-20 %
Response in Strange Situation:  Ignores M when present; little distress on separation; actively turns away from M upon reunion
Classification of Attachment: Insecure: Resistant
Percentage at One Year: 10-15 %
Response in Strange Situation:  Little exploration with M in room, stays close to M; very distressed upon separation; ambivalent or angry and resists physical contact upon reunion with M
Classification of Attachment: 
Percentage at One Year:  5-10 %
Response in Strange Situation:  Confusion about approaching or avoiding M; most distressed by separation; upon reunion acts confused and dazed — similar to approach-avoidance confusion in animal model

What other factors influence bonding and attachment?

Any factors that interfere with bonding experiences can interfere with the development of attachment capabilities. When the interactive, reciprocal "dance" between the caregiver and infant is disrupted or difficult, bonding experiences are difficult to maintain. Disruptions can occur because of primary problems with the infant, the caregiver, the environment, or the "fit" between the infant and caregiver.

Infant: The child's "personality" or temperament influences bonding. If an infant is difficult to comfort, irritable, or unresponsive compared to a calm, self-comforting child, he or she will have more difficulty developing a secure attachment. The infant's ability to participate in the maternal-infant interaction may be compromised due to a medical condition, such as prematurity, birth defect, or illness.

Caregiver: The caregiver's behaviors can also impair bonding. Critical, rejecting, and interfering parents tend to have children that avoid emotional intimacy. Abusive parents tend to have children who become uncomfortable with intimacy, and withdraw. The child's mother may be unresponsive to the child due to maternal depression, substance abuse, overwhelming personal problems, or other factors that interfere with her ability to be consistent and nurturing for the child.

Environment: A major impediment to healthy attachment is fear. If an infant is distressed due to pain, pervasive threat, or a chaotic environment, they will have a difficult time participating in even a supportive caregiving relationship. Infants or children in domestic violence, refugee situations, community violence, or war zone environments are vulnerable to developing attachment problems.

Fit: The "fit" between the temperament and capabilities of the infant and those of the mother is crucial. Some caregivers can be just fine with a calm infant, but are overwhelmed by an irritable infant. The process of reading each other's non-verbal cues and responding appropriately is essential to maintain the bonding experiences that build in healthy attachments. Sometimes a style of communication and response familiar to a mother from one of her other children may not fit her new infant. The mutual frustration of being "out of sync" can impair bonding.

How does abuse and neglect influence attachment?

There are three primary themes that have been observed in abusive and neglectful families. The most common effect is that maltreated children are, essentially, rejected. Children who are rejected by their parents will have a host of problems including difficulty developing emotional intimacy; some of these are listed below. In abusive families, it is common for this rejection and abuse to be transgenerational. The neglectful parent was neglected as a child; they in turn pass on the way they were parented. Another theme is "parentification" of the child. This takes many forms. One common form is when an immature young woman becomes a single parent. The infant is treated like a playmate and very early in life like a friend. It is common to hear these young mothers talk about their four-year-old as "my best friend" or "my little man." In other cases, the adults are so immature and uninformed about children that they treat their children like adults — or even like another parent. As a result, their children may participate in fewer activities with other children who are "immature." This false sense of maturity in children often interferes with the development of same-aged friendships. The third common theme is the transgenerational nature of attachment problems — they pass from generation to generation.

It is important to note that previously secure attachments can change suddenly following abuse and neglect. The child's perception of a consistent and nurturing world may no longer "fit" with their reality. For example, a child's positive views of adults may change following physical abuse by a baby-sitter.

Are attachment problems always from abuse?

No, in fact the majority of attachment problems are likely due to parental ignorance about development rather than abuse. Many parents have not been educated about the critical nature of the experiences of the first three years of life. With more public education and policy support for these areas, this will improve. Currently, this ignorance is so widespread that it is estimated that one in three people has an avoidant, ambivalent, or resistant attachment with their caregiver. Despite this insecure attachment, these individuals can form and maintain relationships — yet not with the ease that others can.

What specific problems can I expect to see in maltreated children with attachment problems?

The specific problems that you may see will vary depending upon the nature, intensity, duration, and timing of the neglect and abuse. Some children will have profound and obvious problems, while some will have very subtle problems that you may not realize are related to early life neglect. Sometimes these children do not appear to have been affected by their experiences. However, it is important to remember why you are working with the children and that they have been exposed to terrible things. There are some clues that experienced clinicians consider when working with such children; these are listed below.

Developmental delays: Children experiencing emotional neglect in early childhood often have developmental delay in other domains. The bond between the young child and her caregivers provides the major vehicle for developing physically, emotionally, and cognitively. It is in this primary context that children learn language, social behaviors, and a host of other key behaviors required for healthy development. Lack of consistent and enriched experiences in early childhood can result in delays in motor, language, social, and cognitive development.

Eating: Odd eating behaviors are common, especially in children with severe neglect and attachment problems. They will hoard food, hide food in their rooms, or eat as if there will be no more meals even if they have had years of consistent available foods. They may have failure to thrive, rumination (throwing up food), swallowing problems and, later in life, odd eating behaviors that are often misdiagnosed as anorexia nervosa.

Soothing behavior: These children will use very primitive, immature and bizarre soothing behaviors. They may bite themselves, head bang, rock, chant, scratch, or cut themselves. These symptoms will increase during times of distress or threat.

Emotional functioning: A range of emotional problems is common in maltreated children, including depressive and anxiety symptoms. One common behavior is "indiscriminant" attachment. All children seek safety. Keeping in mind that attachment is important for survival, children may seek attachments — any attachments — for their safety. Non-clinicians may notice abused and neglected children are "loving" and hug virtual strangers. Children do not develop a deep emotional bond with relatively unknown people; rather, these "affectionate" behaviors are actually safety-seeking behaviors. Clinicians are concerned because these behaviors contribute to the abused child's confusion about intimacy, and are not consistent with normal social interactions.

Inappropriate modeling: Children model adult behavior — even if it is abusive. Maltreated children learn that abusive behavior is the "right" way to interact with others. As you can see, this potentially causes problems in their social interactions with adults and other children. For children who have been sexually abused, they may become more at-risk for future victimization. Boys who have been sexually abused may become sexual offenders.

Aggression: One of the major problems with these children is aggression and cruelty. This is related to two primary problems in neglected children: (1) lack of empathy and (2) poor impulse control. The ability to emotionally "understand" the impact of your behavior on others is impaired in these children. They really do not understand or feel what it is like for others when they do or say something hurtful. Indeed, these children often feel compelled to lash out and hurt others — most typically something less powerful than they are. They will hurt animals, smaller children, peers and siblings. One of the most disturbing elements of this aggression is that it is often accompanied by a detached, cold lack of empathy. They may show regret (an intellectual response) but not remorse (an emotional response) when confronted about their aggressive or cruel behaviors.

Responsive adults, such as parents, teachers, and other caregivers make all the difference in the lives of maltreated children. The next article in this series, "Bonding and Attachment in Maltreated Children: How You Can Help," suggests some strategies to use to make a difference in a child's life.

*Adapted in part from: "Maltreated Children: Experience, Brain Development and the Next Generation" (W.W. Norton & Company, New York, in preparation)

SIDEBAR:

Dr. Bruce D. Perry, M.D., Ph.D., is an internationally recognized authority on brain development and children in crisis. Dr. Perry leads the ChildTrauma Academy, a pioneering center providing service, research and training in the area of child maltreatment (www.ChildTrauma.org). In addition he is the Medical Director for Provincial Programs in Children's Mental Health for Alberta, Canada. Dr. Perry served as consultant on many high-profile incidents involving traumatized children, including the Columbine High School shootings in Littleton, Colorado; the Oklahoma City Bombing; and the Branch Davidian siege. His clinical research and practice focuses on traumatized children-examining the long-term effects of trauma in children, adolescents and adults. Dr. Perry's work has been instrumental in describing how traumatic events in childhood change the biology of the brain. The author of more than 200 journal articles, book chapters, and scientific proceedings and is the recipient of a variety of professional awards.

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