Physical Abuse of Children

David Mann, Ph.D.*
Ann Palker Corell, M.A.**
Christine Ludy-Dobson, Ph.D.***
Bruce D. Perry, M.D., Ph.D.****

For:
Encyclopedia of Crime & Punishment

Berkshire Publishing Group
Great Barrington, MA
In Press: 2001

This is a ChildTrauma Academy version of a chapter to be published in Encyclopedia of Crime & Punishment, 2001.

Official Citation:

Perry, B.D., Mann, D., Palker-Corell, A. and Ludy-Dobson, C. and Schick, S  Child Physical Abuse  in: Encyclopedia of Crime and Punishment Vol 1.(David Levinson, Ed.) Sage Publications, Thousand Oaks pp 197-202, 2002

* ChildTrauma Academy, Houston, TX and Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX
** ChildTrauma Academy, Houston, TX and Sam Houston State, Huntsville, TX
*** ChildTrauma Academy, Houston, TX
**** ChildTrauma Academy, Houston, TX and Children’s Mental Health Programs, Alberta Mental Health Board, Calgary, CA

Definition

Physical abuse is a form of child maltreatment (a broad category of behavior that also includes sexual abuse, emotional abuse, and neglect). As a general rule, physical abuse refers to the infliction of physical harm on a child by a parent or caregiver. It is not necessary for the harm to be intentionally inflicted, and in the majority of situations physical abuse is the unintentional end result of harsh disciplinary methods or corporal punishment that have escalated to point of physical injury or the risk of physical injury. Physical abuse often occurs simultaneously with other forms of child maltreatment. An unfortunate but common example of this is when a boy is hit with closed fists by his father while also being belittled and verbally insulted. In this case, the boy would be considered to have experienced both physical and emotional abuse.

Establishing a precise definition of physical abuse is difficult due to the different standards that can be applied to this term. For example, at what point do normal child-rearing behaviors cross the line into the realm of abuse? Although exact legal definitions vary in the United States from state to state, there are two commonly accepted types of definitional standards that can be used to specify what is meant by physical abuse. The first is the harm standard, which considers behavior as abusive only if it results in demonstrable harm or injuries. Demonstrable harm could mean bruises, abrasions, cuts, burns, fractures, bites, or any of a number of other injuries. The second definitional standard for physical abuse is that of endangerment. Under this standard, physical assault by a parent or caregiver that presents a substantial risk of physical injury is considered abuse. Behaviors that would be considered abusive under this standard include hitting a child with a hard instrument or with closed fists, burning, scalding, poisoning, suffocating, drowning, kicking, shaking, choking, and stabbing. Although these actions may not result in observable injuries such as bruises or cuts, they are still considered abusive under an endangerment standard. Comparing these two standards, it can be seen that injury to the child is central to harm definitions while perpetrator behavior is the focus of endangerment definitions. Furthermore, harm definitions are more restrictive and more objective than endangerment standards.


Incidence and Prevalence

Physical abuse is a widespread problem in the United States and its incidence appears to be increasing according to figures from the Third National Incidence Study of Child Abuse and Neglect, or NIS-3 (Sedlak & Broadhurst, 1996). The NIS-3 is the most recent of a series of congressionally mandated studies on the current incidence of child abuse and neglect in the United States. It is based on data collected in 1993 and compiles statistics for child maltreatment using both harm and an endangerment standard. The NIS-3 revealed that physical abuse as defined under its endangerment standard nearly doubled between 1986 and 1993, with the number of children being affected increasing from 311,500 to 614,100. Under its harm standard, the number of physically abused children increased during this period by 42%. Even under this more restrictive standard, the number of children who were physically abused during 1993 totaled 381,700. This corresponds to an annual incidence rate of roughly 5 out of every 1,000 children. It has been suggested that the increase in incidence rates is a reflection of an actual increase in the rate of physical abuse as well as a result of increased awareness among professionals of the signs and indications of physical abuse, leading to a greater likelihood that abuse will be identified and reported. In the majority of cases of physical abuse, a birth parent is found to be the perpetrator. Overall, physical abuse constitutes 22% of all child maltreatment in the United States.

The phenomenon of physical abuse is not limited to any specific subset of the population. Families from all racial/ethnic and socioeconomic backgrounds engage in physical abuse, and children can be subjected to physical abuse regardless of their sex or age. However, certain social and demographic factors are correlated with higher levels of reported physical abuse. According to the NIS-3, children of single parents were 77 percent more likely to be harmed by physical abuse. This increased level of risk can be understood as a likely result of the stress and pressure of single parenthood. Single parents often find themselves socially isolated from sources of support that could help decrease the burdens of parenting, and they can also lack adequate models to help them make disciplinary choices that are less likely to lead to physical abuse. Additionally, compared to children from families earning more than $30,000 a year, children from families making less than $15,000 annually were almost sixteen times more likely under the harm standard and nearly twelve times more likely under the endangerment standard to experience physical abuse. Again, this finding is understandable given the association of low income with stressors that may lead parents to engage in discipline methods that are likely to become physically abusive.

In other studies examining risk for physical abuse, it is clear than any conditions that increase distress for the family, parent or disrupt interaction between parent and child will increase risk for physical abuse. Such conditions include: children with complex medical problems or developmental delays, children who are unwanted, “difficult" children who are hyperactive, children whose caregivers are under significant life stressors or have unrealistic developmental expectations of children.
 

Identification and Reporting

It is important to remember that “child abuse thrives in the shadows of privacy and secrecy; it lives by inattention (Bakan, 1971).” The first step in preventing and treating physical abuse is identification and reporting. Children may disclose physical abuse to teachers, physicians, family friends, or their own friends. Disclosures may be indirect, such as a child saying, “I have a friend whose father hits them and hurts them.” Many children find it difficult to openly discuss the abuse that is occurring. They might also be frightened, since many abusers threaten the child in order to make him or her remain silent and not discuss family matters outside of the home. Any disclosures by children of any age should be taken seriously and reported to law enforcement officials.

Further complicating the identification of physical abuse is the fact that children will often cover up for abusive parents and not discuss the cause of an injury, even when questioned. The child may say, “I can't remember,” or, “It was an accident.” Sadly, many children experience abuse from such a young age, they may think abusive behavior is normal. All children, particularly adolescents, are more likely to disclose physical abuse to an adult with whom they have developed a trusting relationship such as a teacher or counselor. It takes great courage for children to speak about physical abuse, particularly if the abuser is a parent.

Physical Indicators

Physical abuse is the most visible form of child abuse or maltreatment because physical indicators are the first to be noticed. The first step to eliminating child physical abuse is to acknowledge that it occurs. The next step is to learn to recognize the signs and symptoms in order to determine if a child is being abused. There are several factors to be considered in raising the question of possible physical abuse. First, the location, nature, and extent/severity of the injury are important to consider. Does the injury fit with the explanation given? Is the child's age or developmental stage consistent with the type of injury? For example, burns that are in the shape of an iron, grill, or cigarette, or immersion burns that children could not have inflicted upon themselves. Other indicators may include human bite marks, fingernail scratches that leave parallel linear marks, or other lacerations or abrasions that may indicate an instrument used. Some children may have missing, loose, or broken teeth, bald spots on their head, or bruises/welts in various stages of healing all over the body.

Behavioral Indicators

Depending on the child’s age, level of functioning, and developmental stage, behavior can be an indication that something is wrong. The following are some of the behavioral indicators which may suggest possible physical abuse: the child is unusually wary of physical contact with adults, seems frightened of parents or other adults, is afraid to go home, or is overly compliant with authority. These children may wet the bed and exhibit regressed behavior. Abused children may be shy, withdrawn, and uncommunicative or hyperactive, aggressive, and disruptive. Many abused children do not show emotion when they are hurt, and as discussed earlier, offer implausible explanations of injuries. A caution flag should be raised when a child is habitually absent from school or late without an explanation from the parents. Parent may be keeping the child at home until physical evidence of abuse has disappeared. When they come to school, they may wears inappropriate long-sleeved or high collared clothing on hot days to hide injuries. It may appear to others that the child is accident prone or just moves/walks awkwardly. It is important to pay attention to these indicators and not dismiss them as insignificant, especially when several of these occur together. Older children may exhibit different behavioral signs than younger children. For example, they may engaging in acting out behavior such as running away, getting involved in criminal activities, or engaging in self-destructive behaviors such as abuse of drugs and alcohol.

Mandatory Reporting

All fifty states currently have mandatory child abuse reporting laws in order to qualify for funding under the Child Abuse Prevention and Treatment Act (CAPTA, 1996; U.S. Department of Health and Human Services, 2001). Although all states have some type of reporting law, each state differs in their application of mandatory reporting laws.

Mandatory reporting refers to a legal obligation to report suspected or known child maltreatment. Many people do not know that failure to report carries a legal penalty. Mandatory reporting legislation overrides any professional code of conduct or ethical guidelines. For example, although psychologists must maintain client confidentiality, they may break this confidentiality if a client reports that a child is being abused. Medical practitioners, psychologists, police officers, social workers, welfare workers, teachers, principals, and in many states film developers are all mandatory reporters. Several states have broadened the list of mandatory reporters to any person suspecting abuse.

Although mandatory reporting laws vary from state to state, there are some general guidelines to follow when determining whether to report abuse. The most obvious would be when a child reveals that he or she has been abused. However, often it will be a sibling, relative, friend or acquaintance that reveals the abuse. In some cases, a child may reveal that he or she knows someone who being abused. In such a case, there is a legal responsibility to report the abuse to the proper authorities, either the police or children’s protective services. As noted earlier, there are many indicators of abuse. Based on observations of a child, if abuse is suspected, it must be reported. It is important to note that proof of abuse is not required to make a report. The requirement is whether there is knowledge or suspicion of abuse. If there is suspicion or knowledge, the name of the suspected abuser and child should be reported to children’s protective services or the police. Most states have toll-free abuse reporting hotlines where anonymous reports can be made.

The National Incidence Study of Child Abuse and Neglect reports that there has been a forty-one percent increase in the number of reports made nationwide since 1988 (U.S. Department of Health and Human Services, 2001). However, reporting abuse does not necessarily mean that all abused and neglected children are being identified. Some research has indicated that many professionals fail to report most of the maltreated children they encounter. Hence, underreporting continues to be a major problem in the war against child abuse.

 

Impact of Physical Abuse on Children

Child physical abuse damages children physically, emotionally and socially. The most obvious and immediate result is physical.

Physical

An abused child may experience one of more of the following: hitting, shaking, choking, biting, kicking, punching, burning, poisoning, suffocating, or being held underwater. Physical abuse may lead to bruises, cuts, welts, burns, fractures, internal injuries, or in the most extreme cases death.

Initial impact on children will be the immediate pain and suffering and medical problems caused by the physical injury. However, the pain will last long after the bruises and wounds have healed. The longer physical abuse of a child occurs, the more serious the impact. Chronic physical abuse can result in long term physical disabilities, including brain damage, hearing loss, or eye damage. The age at which the abuse takes place influences the impact of the damage. For example, infants who are physically abused are more likely to experience long-term physical effects and neurological alterations such as irritability, lethargy, tremors, and vomiting. In more serious cases where the abuse was more forceful or longer in duration, the infant may experience seizures, permanent blindness or deafness, mental and developmental delays or retardation, coma, paralysis, and in many cases death. This has recently been called the “Shaken Baby Syndrome” since it most often occurs as a result of violent shaking or shaking of the head.

Emotional

Beyond the physical trauma experienced by children, there are other consequences of physical abuse. Studies of physically abused children and their families indicate that a significant number of psychological problems are associated with child physical abuse. Abused children compared with non-abused children may have more difficulty with academic performance, self- control, self-image and social relationships. A recent US study comparing physically abused and non-abused children provided considerable evidence of the negative and lasting consequences of physical abuse. The physically abused children in the study experienced far greater problems at home, at school, amongst peers and in the community.

Children who are physically abused have a predisposition to a host of emotional disturbances. They may experience feelings of low self-esteem and depression or may be hyperactive and overly anxious. Many of these children may exhibit behavioral problems such as aggression towards other children or siblings. Other emotional problems include anger, hostility, fear, humiliation, and an inability to express feelings. The long-term emotional consequences can be devastating. For example, children who are abused are at risk of experiencing low self-esteem, depression, drug/alcohol dependence, and increased potential for child abuse as a parent.

Social

The social impact on children who have been physically abused is perhaps less obvious, yet still substantial. Immediate social consequences can include an inability to form friendships with peers, poor social skills, poor cognitive and language skills, distrust of others, over-compliance with authority figures, and a tendency to solve interpersonal problems with aggression. In their adult life, the long-term consequences can impact both their family and their community. There are financial costs to the community and society in general, e.g., funding social welfare programs and services and the foster care system. Studies have shown that physically abused children are at a greater risk for mental illness, homelessness, crime, and unemployment. All of these affect the community and society in general and are the social costs of physical abuse.

Interventions

Every family that experiences physical abuse is different. Therefore, effective interventions must target the problems and deficits specific to each family that increase the risk of physical abuse. An inability to appropriately control and express anger is an example of a risk factor that is frequently associated with parents who engage in physical abuse. For these parents, anger management would be a useful intervention. Goals of anger management include the lessening of heightened arousal levels during challenging parenting situations, the improvement of abusive parents’ coping skills, and the reduction of the probability that parents will have uncontrolled emotional reactions that end in physical abuse. Techniques that can be used to attain these goals including training parents in the use of positive imagery and relaxation methods, helping them identify when they are angry before their emotions get out of control, and teaching them how to come up with thoughts that help them stay calm.

Another risk factor associated with physical abuse is social isolation, a concern that can be addressed through the use of education and support groups. Parents also engage in physically abusive behaviors because they are unaware of effective parenting techniques. Educating these parents about such useful skills as active listening, unambiguous communication, nonviolent means of discipline, and setting meaningful rewards and consequences for specific behaviors can go a long way towards reducing the risk for the recurrence of physical abuse. Interventions focusing on skills training should give parents plenty of opportunities to observe others model parenting techniques and should also provide parents with role-playing and real-life exercises that allow them to practice what they’ve learned in a safe, non-threatening environment. These interventions can also allow parents to receive honest feedback about their parenting behaviors from experienced professionals.

Finally, other conditions that go beyond simple deficits in knowledge or difficulty managing anger can interfere with the ability of parents to appropriately discipline their children. These include external pressures such as financial problems, interpersonal difficulties like marital strife or domestic violence, and serious mental health conditions such as schizophrenia, major depression, and substance abuse problems. When these circumstances are linked to physical abuse, wide-ranging solutions must be sought, whether this means connecting parents with appropriate social services or locating referrals for marital counseling, psychotherapy or psychiatric care.

Intervening when physical abuse is identified not only involves working with the perpetrators of the abuse but also includes treating the wide-ranging emotional and behavioral consequences that physical abuse can have for children. For example, it is common for children to experience symptoms of post-traumatic stress in the aftermath of physical abuse. Providing these children with anxiety management techniques and psychoeducation about family violence can be a useful intervention for these symptoms. Play therapy can also be helpful in providing children with an opportunity to express and work through the painful emotions that may be contributing to anxiety, depression, or behavioral difficulties. Often, those who have been physically abused need help expressing their anger in appropriate ways. For these children, interventions include teaching them relaxation techniques, engaging them in role-playing exercises, providing them with supervised group interactions and feedback, and helping them identify the signs of anger early in order to prevent inappropriate outbursts. Children who exhibit difficulties in their relationships with peers and adults as a result of their abuse can benefit from social skills training that teaches them how to have positive interactions with other children and come up with solutions to problems and ways of handling negative social situations. Another useful intervention with children who have poor peer relationship skills pairs them with children who have been identified as having strong social skills. These children then engage in positive play activities together with the expectation that the less socially-adept children will begin to behave in more appropriate ways towards their peers. While mental health professionals deliver the majority of these interventions, school personnel can also be brought in to help with both the academic deficits and behavioral problems that can result from a history of abuse.


Prevention

A number of prevention and intervention efforts have been designed to help decrease the scope and frequency of child physical abuse. Knowledge is the first step to prevention of child abuse.
Early detection of physical abuse starts with teachers, day care center, hospitals, and other agencies that serve children and families. Professionals that work with children must be educated about identifying abuse. In all states, these professionals are considered mandatory reporters and are required by law to report abuse. Beyond educating those who might detect abuse, prevention efforts have focused on both the population in general as well as population subgroups that have been identified to have a higher risk of engaging in abusive behaviors. They include such indirect means as using media campaigns designed to spread information on child development or parenting skills. Other prevention efforts involve establishing peer helplines to provide support for parents experiencing crises that could increase their likelihood of abusing their children. Another approach is to develop ways to get parents who would otherwise be isolated from their child-rearing peers linked to social support networks.

An example of a more direct prevention program would be one that provides in-home family support for parents who are considered to be at risk: families with lower socioeconomic status, single parents, inexperienced or isolated parents, or those with alcohol or drug problems. Health services professionals often offer such preventative measures to parents at stressful transition points in their lives when the risk of physical abuse is judged to increase. Because abuse is transferred from one generation to the next, it is important to understand that children who are abused are at higher risk for being abusers. It is understandable that children who have not received the needed nurturance and support from their parents may find it difficult to provide this for their children. Prevention efforts must acknowledge the intergenerational patterns of violence and work with children who are abused to prevent them from becoming abusers themselves.


Future Directions

The majority of studies related to physical abuse have been descriptive, focusing primarily on prevalence and possible causes, or retrospective in nature. Little empirical research has been conducted with children who have experienced physical maltreatment despite the fact that it remains one of the foremost reasons for referral to child protective services. Areas for future research include examining longitudinal outcomes for children who have experienced physical maltreatment. Such longitudinal studies could include duration and treatment modalities. Focus on information related to the child’s placement in foster care is also important, especially length of stay in custody, types of placements (e.g., foster home, group home, residential treatment), placement disruptions, and type of permanent placement. Examining the long-term effects of physical abuse would provide important direction for treatment and the potential placement of children who have similar experiences in the future.



References

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