Interpersonal relationships and child-rearing practices in 214 parents of battered children

Pediatric abusive head trauma

Abusive head trauma (AHT), used to be named shaken baby syndrome, is an injury to the skull and intracranial components of a baby or child younger than 5 years due to violent shaking and/or abrupt impact. It is a worldwide leading cause of fatal head injuries in children under 2 years. The mechanism of AHT includes shaking as well as impact, crushing or their various combinations through acceleration, deceleration and rotational force. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal hemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. As for the treatment, most of the care of AHT is supportive. Vital signs should be maintained. Intracranial pressure, if necessary, should be monitored and controlled to ensure adequate cerebral perfusion pressure. There are potential morbidity and mortality associated with AHT, ranging from mild learning disabilities to severe handicaps and death. The prognosis of patients with AHT correlates with the extent of injury identified on CT and MRI imaging. The outcome is associated with the clinical staging, the extent of increased intracranial pressure and the existence of neurological complications such as acquired hydrocephalus or microcephalus, cortical blindness, convulsive disorder, and developmental delay. AHT is a potentially preventable disease, therefore, prevention should be stressed in all encounters within the family, the society and all the healthcare providers.

Testing the cycle of maltreatment hypothesis: Meta-analytic evidence of the intergenerational transmission of child maltreatment

It has long been claimed that "maltreatment begets maltreatment," that is, a parent's history of maltreatment increases the risk that his or her child will also suffer maltreatment. However, significant methodological concerns have been raised regarding evidence supporting this assertion, with some arguing that the association weakens in samples with higher methodological rigor. In the current study, the intergenerational transmission of maltreatment hypothesis is examined in 142 studies (149 samples; 227,918 dyads) that underwent a methodological quality review, as well as data extraction on a number of potential moderator variables. Results reveal a modest association of intergenerational maltreatment (k = 80; d = 0.45, 95% confidence interval; CI [0.37, 0.54]). Support for the intergenerational transmission of specific maltreatment types was also observed (neglect: k = 13, d = 0.24, 95% CI [0.11, 0.37]; physical abuse: k = 61, d = 0.41, 95% CI [0.33, 0.49]; emotional abuse: k = 18, d = 0.57, 95% CI [0.43, 0.71]; sexual abuse: k = 18, d = 0.39, 95% CI [0.24, 0.55]). Methodological quality only emerged as a significant moderator of the intergenerational transmission of physical abuse, with a weakening of effect sizes as methodological rigor increased. Evidence from this meta-analysis confirms the cycle of maltreatment hypothesis, although effect sizes were modest. Future research should focus on deepening understanding of mechanisms of transmission, as well as identifying protective factors that can effectively break the cycle of maltreatment.

Antecedents of Child Abuse

An integrative framework is provided for interpretation of the wide array of findings in the child abuse literature. This multiple aetiology model has implications for treatment and prevention, which would provide programmes which are far more comprehensive than those inspired by a single aetiology approach. The role of the school psychologist as a critical participant in identification and treatment of'at risk' families is discussed.

Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment

Non-accidental trauma (NAT) is a leading cause of childhood traumatic injury and death in the United States. It is estimated that 1,400 children died from maltreatment in the United States in 2002 and abusive head trauma (AHT) accounted for 80% of these deaths. This review examines the epidemiology and risk factors for NAT as well as the general presentation and required medical work up of abused children. In addition, potential algorithms for recognizing cases of abuse are reviewed as well as outcomes in children with NAT and potential neurosurgical interventions which may be required. Finally, the evidence for seizure prophylaxis in this population is addressed.

Does maltreatment beget maltreatment? A systematic review of the intergenerational literature

In this article, the authors critically review the literature testing the cycle of maltreatment hypothesis which posits continuity in maltreatment across adjacent generations. That is, the authors examine whether a history of maltreatment victimization is a significant risk factor for the later perpetration of maltreatment. The authors begin by establishing 11 methodological criteria that studies testing this hypothesis should meet. They include such basic standards as using representative samples, valid and reliable measures, prospective designs, and different reporters for each generation. The authors identify 47 studies that investigated this issue and then evaluate them with regard to the 11 methodological criteria. Overall, most of these studies report findings consistent with the cycle of maltreatment hypothesis. Unfortunately, at the same time, few of them satisfy the basic methodological criteria that the authors established; indeed, even the stronger studies in this area only meet about half of them. Moreover, the methodologically stronger studies present mixed support for the hypothesis. As a result, the positive association often reported in the literature appears to be based largely on the methodologically weaker designs. Based on this systematic methodological review, the authors conclude that this small and methodologically weak body of literature does not provide a definitive test of the cycle of maltreatment hypothesis. The authors conclude that it is imperative to develop more robust and methodologically adequate assessments of this hypothesis to more accurately inform the development of prevention and treatment programs.

The epidemiology of nonaccidental trauma in children

BACKGROUND

Abuse of children is abhorrent in Western society and, yet, is not uncommon. Nonaccidental trauma (NAT) is the result of a complex sociopathology. Not all of the causative factors of NAT are known, many are incompletely described, not all function in each case, and many are secondary to preexisting pathology in other areas.

QUESTIONS/PURPOSES

We therefore addressed the following questions in this review: (1) what is the general incidence of NAT; (2) what factors are intrinsic to the abused child, family, and society; and (3) what orthopaedic injuries are common in NAT?

METHODS

We searched Medline, Medline In Process & Other Non-Indexed Citations, and Embase using OVID. Only one article fit our inclusion criteria; therefore, this is a descriptive generalized review of the epidemiology of NAT.

RESULTS

The general incidence of NAT ranges from 0.47 per 100,000 to 2000 per 100,000. Younger children are at greater risk of NAT than older children. Parents are often the perpetrators of the abuse. Rib fractures are highly indicative of NAT in young children.

CONCLUSIONS

It is important to consider child, family, and societal factors when confronted with suspicions of child abuse. Our review demonstrates the currently limited information on the true incidence of NAT. To determine a much more accurate incidence of NAT, there needs to be a population-based surveillance program conducted through primary care providers.

Abnormal, abusive, and stress-related behaviors in baboon mothers

BACKGROUND

Psychiatric disturbances during pregnancy and the postpartum period are especially serious, given the negative effects on the mother as well as the child. Understanding the causes of such disturbances has been difficult owing to the complexity of psychological, social, experiential, biological, and genetic factors involved.

METHODS

To determine the potential utility of a nonhuman primate model for the study of postpartum disorders, the pathologic and stress-related behavior of 62 female baboons living in social groups was studied during pregnancy and after the birth of an infant.

RESULTS

The prevalence of abnormal behavior and self-directed scratching (a measure of stress response) was higher after birth of the infant. Subjects displayed a significantly higher frequency per hour of these behaviors postpartum, which increased over 8 weeks. Abusive behaviors toward the infant were common, occurring in 55% of the subjects. Mothers with low dominance rank, who usually have lower levels of social support, had higher levels of abusive behavior during the postpartum period.

CONCLUSIONS

Baboons show variation in measurable behaviors related to stress and abnormal functioning during the pre- and postpartum periods, indicating that a nonhuman primate model may be useful in the study of factors affecting postpartum psychiatric disorders and infant abuse.

Intergenerational continuity of child physical abuse: how good is the evidence?

BACKGROUND

There is widespread belief that individuals who were physically abused during childhood are more likely to abuse their own children than those who were not abused, but the empirical studies examining this belief have not been systematically reviewed. The aim of this study was to evaluate systematically, based on eight methodological standards derived from a hypothetical randomised controlled trial, the design of studies investigating the intergenerational transmission of child physical abuse.

METHODS

We reviewed studies published between 1965 and 2000 in English that provided information about physical maltreatment in two generations and included a comparison group. Two investigators independently assessed whether each study met the methodological standards.

FINDINGS

In the ten studies identified (four cohort, one cross-sectional, and five case-control), the relative risks of maltreatment in the children of parents who were abused during childhood were significantly increased in four studies (relative risks 4.75-37.8), but in three other studies the relative risks were less than 2. Most study reports provided a clear description of abuse of parents during childhood and abuse of their children. Five studies failed to avoid recall and detection bias; five did not ensure that controls were not themselves maltreated; eight did not provide adequate follow-up; and in six the report did not state whether the enrolled parent was responsible for the maltreatment. Most studies did not control for intervening factors, such as sociodemographic characteristics during the time of abuse of the parent generation and at the time their children were abused. Only one study met all eight criteria (relative risk of abuse transmission 12.6 [95% CI 1.82-87.2]) and one met six (1.05 [0.53-2.06]).

INTERPRETATION

The one study that met all eight methodological standards provided evidence for the intergenerational continuity of child physical abuse, but that which met six standards did not support the hypothesis. Use of our model and methodological standards should improve the scientific quality of studies examining the effects of risk factors for adverse outcomes that may continue across generations.

Aspects of perinatal psychiatric illness

BACKGROUND

In view of the current changes in the National Health Service, it was considered an opportune time to review the literature on perinatal psychiatric illness.

METHOD

A systematic review was undertaken of relevant articles on MEDLINE, ClinPsych and Excerpta Medica Psychiatry.

RESULTS

Sixty-eight articles were used in the review.

CONCLUSIONS

Developments in the field of perinatal psychiatry include a greater understanding of the nosology and aetiology of the conditions, the effect of maternal illness on the child, as well as transcultural factors. The perspective of the individual sufferer has been somewhat ignored. New treatments with both pharmacotherapy and hormones are emerging, but perhaps the greatest current challenge is to adapt our management strategies to community care.

Child-rearing violence

In 1989, a national, random sample of 801 adults was questioned about the punishment they received as children and the way they discipline their own offspring. Analysis revealed that verbal and physical discipline are not substitutes, but, instead, are commonly used together. Parents who yell frequently are the ones most likely to hit frequently, and vice versa. In addition, both physical and verbal violence appear to be transgenerational. Respondents who were spanked (yelled at) frequently as children are more prone to frequently spank (yell at) their own children. Still, most people are able to break out of the transgenerational cycle of punitive child rearing. This outcome may be found particularly among those who consider themselves to have been abused.

Psychiatric diagnoses of self-reported child abusers

In order to evaluate lifetime psychiatric diagnoses and prevalence of dyssocial behaviors among self-reported child abusers, three large databases of clinical, community, and family study subjects were examined. Subjects who had acted as parents and who reported any episodes of child battery were compared to those without any history of child battery on prevalence of psychiatric disorders and dyssocial behaviors. Overall, 4% of subjects from the community sample reported child abuse. Abusers not selected through alcoholism treatment were more likely to receive diagnoses of alcoholism, antisocial personality disorder, and major depression. Those selected through alcoholism treatment were more likely to have antisocial personality disorder. Abusers in general were found to have a history of disciplinary problems, property destruction, and as adults to engage in other violent behaviors. It was concluded that self-identified child abusers have increased lifetime rates of antisocial personality disorder, alcoholism, and depression. The association between child abuse and other violence is not explained by selection of cases through the medical or legal systems.

Avoidance of criminality in abused and neglected children

This paper compares previously abused and neglected children who have avoided official records of delinquency and adult criminality with those who have not. The goal of this analysis is to uncover potential mediating variables that may act to buffer or protect maltreated children from later delinquency and criminality. It is hoped that this analysis will provoke others to consider the "invulnerable" among the abused and neglected so that we might ultimately learn what works to protect them. In terms of "competence" as an outcome, these findings must be treated as preliminary.

The self-report of punitive childhood experiences of young adults and adolescents

A questionnaire designed to assess childhood disciplinary experiences was administered to a large sample of university students. The responses of these subjects indicated many of these predominantly middle-class young adults had experienced disciplinary activities that could be considered abusive. The results provide prevalence data on child abuse histories in a nonclinical sample and were seen as supporting the idea that physical abuse of children is widespread and not restricted to groups identified on the basis of clinical service or social deviance. Regardless of the criterion for physical abuse applied to the data, most respondents who met a criterion for having been abused failed to label themselves as having been abused. Additionally, correlations between severe physical punishment and abuse-related domains were shown to obtain in these nonclinical samples in a manner consistent with descriptions of abusive families in the clinical literature. A second study conducted with truly abused and nonabused adolescents established the validity of the questionnaire approach used in this research, and the two studies indicated the feasibility of conducting research on physical child abuse in natural collectivities of nonclinical subjects.

Disentangling life events, stress and social support: implications for the primary prevention of child abuse and neglect

There is a growing body of literature linking stress and child abuse and neglect, but the relationship is not unambiguously supported by empirical data. Two considerations regarding Garbarino's ecological model of child abuse and neglect may explain this research problem. First, any of the predisposing factors, which are grouped into four levels called individual, familial, social, and cultural, may either positively or negatively affect the potential for child abuse and neglect depending upon the quality of social networks and social supports available to families. Second, these factors operate most importantly, not between the perception of stress and the act of abuse or neglect, but through the interpretation of whether a given life event is stressful or not. This clarification of the ecological model points the way to redefining interventions for the primary prevention of child abuse and neglect. Existing support systems can be strengthened in order to increase a family's ability to cope with untoward events before these become stressful. In addition, advocacy activities which support children and families in general can be major components in the primary prevention of child abuse and neglect.

Behavioral intervention with child abuse and neglect

The range of factors identified as related to child maltreatment has expanded over the years. The literature clearly calls for an ecological approach in which individual, family, community, and societal factors are considered. The behavioral literature to date reflects an unevenness in terms of acceptance of such an approach. Studies are also uneven concerning the faithfulness with which hallmarks of a behavioral approach have been applied. These include individually tailored assessment and intervention based on empirical data and planning for generalization and maintenance. Most intervention programs do attend to positive as well as negative parent behaviors. Little attention is devoted to environmental characteristics, such as poverty level incomes and impoverished social support systems that may contribute to maltreatment. Lack of comprehensive assessment and intervention programs is no doubt responsible for the modest changes described in many reports. Behavioral studies suffer from uncritical acceptance of the term "abuse" or "at risk" in a number of ways, one of which is a failure to clearly describe the nature of the alleged maltreatment and the immediate situational context. Another is in the assumption that one particular factor is responsible for the maltreatment, such as ineffective parenting skills. Too often a label identifies only one characteristic of a person, ignoring other attributes and related factors. Like all deviant labels, the poor and minority groups are more likely to receive negative labels (Newberger et al., 1976). Investigaters have not taken advantage of relevant literature in the area of child welfare. Familiarity with this material would be helpful in avoiding myths in the field to which many have fallen prey, such as the myth of classlessness of child maltreatment. Acceptance of this myth interferes with the development of programs that deal with difficult environmental problems. Reports suggest that a behavioral approach is promising. Attention to enhancement of child management skills is supported by research that shows that most abuse occurs as an extension of parental discipline attempts. A focus on describing the relationships between behaviors of concern and what happens before and afterward has yielded valuable information concerning interaction patterns in abusive, neglectful, and normal families. Advantages of viewing child abuse in the general context of family interaction are illustrated by the work of Patterson and his colleagues and by Gelles.(ABSTRACT TRUNCATED AT 400 WORDS)

MMPI traits of incestuous fathers

Compared MMPI scores of a group of 10 documented incestuous fathers and stepfathers to those of a matched control group of nonincestuous fathers. Analyses of variance and covariance reflected more pathological scores for incest fathers than control fathers on the psychopathic deviate scale, the psychasthenia scale and the schizophrenia scale of the MMPI. Results were discussed in terms of a character disordered personality type among incestuous fathers.

Relationship of self-concept during late pregnancy to neonatal perception and parenting profile

Thirty-one gravidas were studied to examine the relationship between a woman's feelings about herself during late pregnancy, her perception of her newborn, and her profile of parenting. The Tennessee Self-Concept Scale was completed during the third trimester of pregnancy, the Neonatal Perception Inventory I at one-to-two days postpartum, and the Neonatal Perception Inventory II and the Michigan Screening Profile of Parenting at four-to-six weeks postpartum. When considered separately, no positive significant relationships were found between scores on these variables. However, all subjects with negative scores on both self-concept and neonatal perception had negative scores on at least two subscales of the parenting profile.

Prevention of child abuse and neglect through early diagnosis of serious disturbances in the mother-child relationship in Italy

At the obstetrical clinic of Modena University and a family center of the same municipality during the first six months of 1980 a questionnaire based on "Risks of Child Abuse" by Kempe, Gray and others was administered to 33 expectant mothers during the third trimester of pregnancy, a few days after delivery, and a month and one-half after childbirth, for the purpose of examining the mother-child relationship. Two principal groups of "risk factors" which may lead to child abuse and neglect appeared: mothers with preceding personal and social experiences, and cases of medical intervention (e.g., prematurity, caesarean). Use of a questionnaire that permitted early diagnosis made possible help in establishing a good mother-child relationship in the first months of life. Such help can be given by the hospital and public centers both before and after birth.

Abused children: A Review of the Literature

This article is a brief overview of the data on the characteristics of abused children and the psychological sequelae of abuse. The relationship between abuse and the sex of the child, age of the child, the child's ordinal position in the family, bonding failure, congenital handicap and temperament are explored within the context of conflicting views. The available data concerning the sequelae of abuse for the child e.g. intelligence and personality are critically reviewed.

Narcissistic traits in certain abused children

Three groups of severely abused, emotionally disturbed children are described, one of which is made up of "private" children, who seem to share many of the characteristics of the adult narcissistic personality disorder. These children appear pleasant and tractable, seem better adjusted, and are rarely referred for treatment; they are remarkably able to assess their environment and made predictions. However, they remain aloof, fear dependency, and are unable to form meaningful relationships. The therapy of one such child is described in detail.

A study of institutionalized mentally retarded patients in Manitoba. I: Classification and preventability

This preliminary report concerns the types, and the possibility of prevention, of mental retardation found among 406 patients less than 20 years of age and with IQs less than or equal to 50 who had been admitted to institutions for the retarded in Manitoba prior to 1977. The retardation appeared to be of genetic origin in 27.8 per cent of cases, and acquired in a further 30.3 per cent. 31 per cent of the genetic and 55 per cent of the acquired, or 25.4 per cent of the total group, are considered to have been avoidable, given the full application of current techniques and knowledge.