Intergenerational transmission of child abuse: rates, research, and clinical implications

OBJECTIVE

The author reviews current wisdom concerning the rates and mechanisms of intrafamilial components of intergenerational transmission of child abuse and illustrates the unreliability of basic data and of assumptions made by reviewers and partisan advocates, most of whom underestimate the importance of intrafamilial factors in child abuse.

METHOD

The information in the report was derived from original research plus a recently prepared compilation of 60 studies, mainly from the United States and the United Kingdom.

RESULTS

The crude rates of intergenerational transmission of child abuse according to the studies reviewed are as follows: one-third of child victims grow up to continue a pattern of seriously inept, neglectful, or abusive rearing as parents. One-third do not. The other one-third remain vulnerable to the effects of social stress on the likelihood of their becoming abusive parents. Intrafamilial factors appear to be the cause of personally directed, as opposed to culturally condoned, child abuse. Broad social factors, and some medical and psychiatric conditions, lower or raise thresholds in which family and personal vulnerabilities and propensities operate.

CONCLUSIONS

There is no justification for any extremist advocacy in apportioning responsibility between the "sins of the parents" and the failings of society. The contention that clinical research on abuse is inferior to, and must give way to, large-scale or statistically balanced self-report and questionnaire surveys is plausible, popular, convincing, and wrong.

Outcome and socioeconomic aspects of suspected child abuse scald burns

Fifty-two children suffering from abuse-related scald burns were admitted between January 1, 1986, and June 30, 1991. Their clinical and socioeconomic aspects were compared with those of 50 nonabused scalded children. Patients were matched for age, total body surface area burn, and percentage of full-thickness burn. Patient characteristics and initial nutritional parameters were similar except for race; a higher percentage of black children were in the abused group. A significantly longer length of hospital stay was found in the abused children after using analyses of covariance to control for percentages of total and full-thickness body surface area burn. The number of operations and frequency of complications were increased in the abused group, but not significantly so. Several significant differences were found in the socioeconomic characteristics of the two groups. Children suspected of being scalded intentionally were more likely to be part of a broken home, belong to a single parent, and have a younger mother than were children in the control group. The majority of the parents of abused children were unemployed, and all but two earned less than $20,000/year. All but one of the abused children were discharged with a person other than their parents, and compliance with rehabilitation follow-up was significantly worse than with the control group. The person suspected of performing the abuse was always a family member, except in cases where the baby-sitter was the suspected abuser. Child abuse hurts not only the child but also society by increasing the need for resources to pay for extended hospital admissions.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical and developmental histories of maltreated children

This paper represents a first attempt at delineating and summarizing the issues in a child's medical and developmental history associated with the probability of suffering abuse. The sample consisted of 96 children between 5 and 10 years of age, 61 of whom had been maltreated and 35 of whom served as controls. There were 22 items about which the medical and developmental histories of the maltreated children revealed a significantly greater risk than those of the controls. A factor analysis revealed that 78% of the variance in these items can be represented by eight independent factors. None of these factors was dominant; rather, each accounted for a significant amount of the variation among the original items. The individual items tended to load on the four strongest factors in a coherent, interpretable manner: Factor 1 represented behavior problems; factor 2, neonatal issues and failure to thrive; factor 3, familial disruption, with the child suffering mental illness and/or head injury; and factor 4, a "difficult" temperament during the first year of life. We conclude there are numerous independent factors in the medical and developmental histories of maltreated children which should be considered by pediatricians involved in cases of child abuse and neglect.

Causes of child abuse and neglect

This paper is a study of child abuse and neglect from the perspective of the child. Generally, the mistreatment of children was associated with "poor care" from parents, attributed mainly to immaturity, marital problems, alcohol abuse, unemployment, drug abuse and lack of money. Differences in attribution are noted between males and females, and some differences are noted by the age of the child. When factors other than the causes given by the children were taken into account, mistreatment was significantly related to family break-up, as well as long-term disinterest and lack of affection from the parents. When the children were asked for their "worst experience in life," the most common responses were "abuse" "family break-up," and for the juvenile offenders "getting charged with a crime."

Incarceration in parents of day hospital youth: relationship to parental substance abuse and suspected child abuse/maltreatment

The number of individuals incarcerated in penal institutions in the United States has increased dramatically in recent years. Children of incarcerated parents have been studied infrequently. They appear to be at high risk for present and future behavioral disorders, although their rate of utilization of mental health services is not known. This study compares a group of behaviorally disturbed children in day hospital treatment who have had incarcerated parents with a group of children without this history who were treated in the same facility at the same time. Children with histories of incarcerated parents account for almost 40% of those treated. They are more likely than their peers without histories of having had an incarcerated parent to have had substance abusing parents and to have been involved in at least one report of suspected child abuse/maltreatment. These variables together are taken as signs of severe family disorganization or dysfunction. In previous studies they have also been associated with poor outcome in mental health treatment. Clinical and social implications of these findings are discussed.

The health effects of economic insecurity

BACKGROUND

Interest in the health and behavioral effects of economic insecurity appears to vary with the performance of the economy. The current recession in the United States and Western Europe and growing unemployment in Eastern Europe make it timely to analytically review the recent research concerned with the health effects of economic contraction.

METHODS

The research concerned with the health and behavioral effects of economic insecurity is organized by dependent variable and method. Rules for determining which effects are supported by strong and which by weak evidence are developed and applied to the literature.

RESULTS

Evidence for effects on symptoms of psychological distress, seeking help for psychological distress, and nonspecific physiological illness is strong. Evidence for effects on suicide, child abuse, adverse birth outcomes, and heart disease is characterized as weak or sufficiently controversial to warrant skepticism.

CONCLUSIONS

The health effects of economic security are undoubtedly mediated by economic policies. Estimating the effect of policy alternatives on the incidence of various outcomes is, however, very difficult given the current state of the research. The effect of rising unemployment on health in Eastern Europe cannot, moreover, be estimated from existing research. Effects estimated from Western economies probably do not generalize to situations in which the meaning of economic insecurity is conditioned by profound social and political reforms.

Domestic violence. Risk factors and outcomes

Domestic violence is a pervasive and frequently unrecognized cause of injury among women. We reviewed data from standardized interviews with 218 women who presented to an emergency department with injuries due to domestic violence. Victims ranged in age from 16 to 66 years and constituted a wide range of socioeconomic and ethnic backgrounds. Domestic violence often resulted in severe injury; 28% of the women interviewed required admission to hospital for injuries, and 13% required major surgical treatment. The typical presentation was injuries to the face, skull, eyes, extremities, and upper torso. A third of the cases involved a weapon, such as a knife, club, or gun. In all, 10% of the victims were pregnant at the time of abuse, and 10% reported that their children had also been abused by the batterer. Most victims (86%) had suffered at least one previous incident of abuse, and about 40% had previously required medical care for abuse. Victim recognition and referral to appropriate agencies could be improved if primary care physicians were more aware of the prevalence, severity, frequency of occurrence, and typical presentation of domestic violence.

[Trauma caused by shaking the infant--a special form of child abuse]

The shaking of infants is an often underestimated cause of head-injuries in children. Without any external signs the diagnosis can be missed. The combination of subdural hematoma of typically interhemispheric site and retinal bleeding is pathognomonic of the shaked-baby syndrome. It is caused by acceleration-deceleration movements of the head. We present three patients with whiplash-shaken-injuries who were admitted to our hospital with impaired consciousness or in coma. With little external signs of injury more detailed investigations revealed other, older injuries suggesting previous abuse. The outcome was not favourable. Two of the children were discharged with minor or mild psychomotor retardation and one child was severely handicapped. As in the battered-child-syndrome a good history, assessing child specific and familial risk-factors and the socioeconomic background are most important to confirm a diagnosis. This type of injury is usually part of the spectrum of child abuse.

Birth outcomes, health problems, and neglect with prenatal exposure to cocaine

Thirty children exposed prenatally to maternal use of cocaine were compared to 30 nonexposed subjects on maternal variables, birth outcomes, health problems in early childhood, and issues related to child maltreatment. Cocaine-exposed infants were more likely to have mothers who received inadequate prenatal care, have adverse birth outcomes including prematurity and retarded intrauterine growth, and have health problems beyond the newborn period including small stature and hypertonia. More cocaine-exposed children were placed in foster homes due to maternal neglect.

Child abuse of one of a pair of twins in Japan

A nationwide survey in Japan on child abuse and neglect revealed that 10% of the victims were products of multiple births. None of the victims who were singletons had multiple-birth siblings, and only in a few cases were both twins abused. The findings indicated that one rather than both of a pair of twins was likely to be abused in Japan. Abuse of both twins was likely when there were serious parental or family problems, whereas abuse of one twin was associated with the child's medical problems or non-home care. There was no instance of abuse of a pair of twins when both were handicapped. Comparisons of the abused twin with the non-abused co-twin and examination of the abuser's attitude to the victim suggested that the difference between twins in their development or in their response to parents increased the stress of child-rearing and encouraged favouritism, which resulted in abuse of only one twin. Comparison by parents of children with their siblings may be a common factor in general child abuse because it is a natural thing for parents to do.

Münchausen's syndrome by proxy as a form of child abuse

Munchausen's syndrome by proxy (MSBP) is an emotional disorder in which the parent, almost always the mother, induces or fabricates illness in her child in order to gain medical attention. Although numerous case studies exist in pediatric and medical literature, most nurses are unaware of the warning signs of this disorder. Psychiatric consultation liaison nurses are in an ideal position to identify and intervene in MSBP situations and can also support the pediatric nursing staff through feelings of denial, shock, and guilt as they recognize the syndrome and its danger to the child.

Substance abuse and child abuse. Impact of addiction on the child

At least 1 in 10 children in the United States is born into a chemically dependent family. Parental addiction has long-lasting detrimental effects on the health and safety of children. We must mobilize to free children from the double jeopardy of substance abuse and child abuse, and interrupt the multigenerational pattern of both problems. The short-term costs may be high, but the long-term costs will be much higher if we do not act. Simultaneous efforts are needed to prevent and treat both addiction and its too frequent consequence, child maltreatment.

The hand as a target organ in child abuse

The authors reviewed the abuse reports submitted by the staff of The Children's Hospital, Columbus, Ohio, to determine the incidence and types of injuries inflicted to children's hands. The authors did not study hand injuries in children who were not reported as physically abused. The authors examined two time periods to ascertain changes injury severity. Of the 631 abuse reports submitted from 1980 to 1982, there were 52 injuries (8.2%) involving the hands. From July 1987 to July 1988 there were 42 hand injuries (13.4%) among 313 reports. In the 94 total cases, 19 (2%) children sustained injury to the hand only, including eight with burns, two with bruises, two with human bites, two with erythema, two with fractures, and one with a laceration. Children with burns to the hand alone were significantly younger than those with other types of injuries. Of the 94 children with hand and other injuries, 18 (20%) required hospital admission. Of the 19 with injuries to the hand only, five required hospital admission. A variety of instruments were used to injure these children. The hand is a delicate organ, and it is frequently the primary or incidental target of child abuse. Familiarity with the patterns and types of hand injury suffered in child abuse is essential for early recognition, reporting, and child protection.