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Child maltreatment in the “children of the nineties:” the role of the child
Child Abuse & Neglect 27 (2003) 337–352
Child maltreatment in the “children of the nineties:” the role of the child夽 Peter Sidebotham a,∗ , Jon Heron b , The ALSPAC Study Teamc a
Institute of Child Health, University of Bristol, St. Michael’s Hill, Bristol BS2 8BJ, UK b Unit of Pediatric and Perinatal Epidemiology, University of Bristol, Bristol, UK c University of Bristol, Bristol, UK
Received 8 October 2001; received in revised form 15 August 2002; accepted 15 August 2002
Abstract Aim: To determine characteristics of children that may predispose to maltreatment. Methods: The research is based on a large cohort study, the Avon Longitudinal Study of Parents and Children. Out of 14,256 children participating in the study, 115 have been identified as having been placed on local child protection registers prior to their 6th birthday. Data on the children have been obtained from obstetric data and from a series of parental questionnaires administered during pregnancy and the first 3 years of life. Risk factors have been analysed using logistic regression analysis. Results: Significant relationships were found between low birthweight (OR 2.08), unintended pregnancies (OR 2.92), poor health (OR 1.91) and developmental problems (OR 1.99) in infancy, and subsequent maltreatment. In addition, mothers of registered children were less likely to have reported positive attributes in their 4-week-old infant. In contrast, negative attributes in infancy, feeding and crying problems, and frequent temper tantrums were not significantly associated with maltreatment. Conclusions: While child factors are significant, they are only a small part of the overall complex set of circumstances and conditions that ultimately lead to abuse or neglect. Parental attitudes towards the child may be more significant than the actual characteristics of the child. © 2003 Elsevier Science Ltd. All rights reserved. Keywords: Child abuse; Child maltreatment; Risk factors; Etiology; Child health; Behavior; Development
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This study could not have been undertaken without the financial support of the Medical Research Council, the Department of Health, the Department of the Environment, the Wellcome Trust and other funders including the NHS executive, South West, Research and Development Directorate. The ALSPAC study is part of the WHO initiated European Longitudinal Study of Pregnancy and Childhood. ∗ Corresponding author. 0145-2134/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0145-2134(03)00010-3
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Background While it is clear that maltreated children are victims and cannot be blamed for the maltreatment they have suffered, there do seem to be some children who for a variety of reasons are more prone to maltreatment. As Frodi (1981) has pointed out, “infants can be ‘at risk’ for abuse because they are born with mental, physical, or behavioral abnormalities that render them vulnerable to abuse or because they have developed characteristics (perhaps through interaction with their parents) that affect the likelihood of abuse.” Several characteristics of the child have been shown in previous studies to be associated with risk of maltreatment. These include prematurity, health, behavior or developmental problems (Friedrich & Boriskin, 1976). Other factors that have been cited include gender, twin status, ethnicity, and disability (Creighton, 1985; Groothius et al., 1982; Sullivan & Knutson, 2000). Furthermore, there is some suggestion that the maltreated child, while no different from other children, may be perceived by the parents as somehow different, and therefore singled out for maltreatment (Friedrich & Boriskin, 1976). Most of the studies that have explored infant or child characteristics have been retrospective in nature, or purely descriptive with no comparison group other than quoted population norms. Interpretation of these associations is therefore difficult. It may not be possible to determine whether any observed abnormalities in the child predated the maltreatment, or were a consequence of it. This is particularly difficult for reported developmental and behavioral problems, both of which are recognized sequelae of maltreatment (Aber, Allen, Carlson, & Cicchetti, 1989; Elmer & Gregg, 1967; Erickson, Egeland, & Pianta, 1989). Aspects such as prematurity or low birthweight may reflect underlying socio-economic differences which predispose to both the proposed risk factor and the maltreatment itself. In order to understand fully the importance of child characteristics in relation to maltreatment, these characteristics must be interpreted within a comprehensive framework that explores different levels of the child’s ecological milieu (Belsky, 1980). Within such models, the child is seen as developing within the immediate “microsystem” of his home and family. This in turn is embedded in an “exosystem” comprising the neighborhood and wider social structures affecting family life. The whole is further influenced by prevailing cultural norms (the “macrosystem”) and by the parents’ background or “ontogeny.” In order to draw conclusions about the impact of risk factors, data should ideally be collected prospectively, with a clear comparison group from the normal population. This research project, based on a large cohort of children born in the early 1990s, examines prospective data on the children. The hypothesis being explored is that children who are maltreated during their preschool years are in some way different from their non-maltreated peers. Previous papers have reported on other levels of the ecological model (Sidebotham, Golding, & The ALSPAC Study Team, 2001; Sidebotham, Heron, Golding, & The ALSPAC Study Team, 2002). This earlier work has particularly highlighted the importance of socio-economic factors, strong relationships being found with all measures of deprivation; the effect of social isolation; and the impact of parental age, education and psychiatric illness. Thus, factors in different levels of the ecological model have been shown to be important in understanding maltreatment. Subsequent work will aim to integrate the different levels and further explore the interactions between them.
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Methods Setting The Avon Longitudinal Study of Parents and Children (ALSPAC) is a large study following a cohort of children born to mothers resident in Avon while pregnant with expected dates of delivery between 1.4.91 and 31.12.92 (Golding & The ALSPAC Study Team, 2001). The ALSPAC study area—the three Bristol-based health districts of Avon—has a population of approximately one million and includes the city of Bristol (population 500,000), a mixture of inner city deprivation (7% of Avon children live in poor urban areas), rural areas (15%), leafy suburbs and moderate sized towns. Children living in Avon have similar proportions to the rest of Britain of single parents (4.0% Avon, 5.0% GB), and non-Caucasian parents (5.1% vs. 6.4%). They are less likely to have a father in a manual occupation (51.6% vs. 65.1%). Comparative data on the representative nature of the sample are provided in Golding and The ALSPAC Study Team (2001). Study population All pregnant mothers resident in the Avon area during the enrolment period were invited to participate. In total, 14,893 mothers enrolled, representing an estimated 85–90% of the eligible population. Allowing for fetal or early infancy loss and attrition, a total of 14,256 children were followed up beyond infancy. To prevent any bias being introduced by repeated data, second and subsequent children in a multiple pregnancy were excluded from the analysis. Participation in the study was entirely voluntary. Enrollment was primarily through midwives, backed up by considerable local publicity, and direct contact of non-enrolled mothers. The issue of confidentiality and the voluntary nature of the study were stressed to mothers at enrollment, and their participation taken as signifying consent. The mothers were not specifically told that social services data would be searched; however, strict measures were taken to ensure confidentiality. Once identified through social services, the children were matched with the cohort data, and entered into the database in such a way that this information could not be traced back to individual children. Given that specific consent had not been sought, social services records were not scrutinized for details of the abuse (nature, severity, alleged perpetrator, etc.), but only that information which was readily available from the social services database was obtained. Ethical approval for the study was obtained from the ALSPAC ethics committee and through them from each of the local hospital ethics committees. Approval to use the child protection register data were obtained from the custodians of the registers and the area child protection committees. Data collection: criterion variables The local Social Services child protection registers were screened for any children with birth dates in the cohort range who had been investigated for possible child abuse or neglect, or had been placed on the child protection register during the period 1.1.91–31.12.98. This involved initially searching one register covering the entire Avon area. Following local government
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reorganization in 1996, this register was replaced by four local registers which were in turn checked to update the information. Full data were therefore obtained on all children to the age of 6. Following referrals of suspected maltreatment a social services investigation will lead to a multi agency case conference at which, if there is evidence of significant harm or risk of harm to the child, the child is placed on a child protection register. Children may be placed on the register under one of four categories of maltreatment: physical abuse, sexual abuse, emotional abuse, or neglect. For the purposes of this study, registration on the child protection register was taken as the single outcome variable. This approximates to those children in whom maltreatment has been substantiated. Data collection: predictor variables Direct obstetric data were obtained providing gender and birthweight for each child, along with details of multiple pregnancies. A series of questionnaires were sent to the parents during pregnancy and after the birth of the child. Questionnaires at 4 weeks, and at 6, 18, 24, and 30 months asked the parents about various characteristics of their child including ethnicity, health, development and behavior. As well as asking whether their child was generally healthy, or had minor or frequent illnesses, parents were asked about hospital admissions. Developmental concerns were assessed by questions asking specifically whether the mother had any worries about her infant’s speech development, behavior development or general development. In addition, any referrals for hearing or visual problems were reported. Parents were asked whether their child’s crying was a problem, whether they had any feeding difficulties and whether they had frequent temper tantrums (defined as daily). Qualities of temperament at 4 weeks were assessed using a series of questions relating to specific behavior traits. These questions were designed for the study as a simple means of looking at early temperament, but have not been validated as a research tool. These qualities were divided into seven positive (communicative, placid, cuddly, active, sociable, happy, alert) and seven negative traits (grizzly, fretful, demanding, angry, withdrawn, stubborn, unresponsive). In addition, in an antenatal questionnaire, mothers were asked whether the pregnancy was intended, and about their and their partners’ reaction to the pregnancy. Details of the variables collected are given in Appendix A. Analysis Univariate analysis was carried out using chi-square statistics taking the outcome as registration prior to 6 years of age. Those factors which were significant on univariate analysis were entered into a logistic regression equation for the same outcome (Appendix A). Given the large overall dataset and the fact that a number of parents, particularly among the registered group did not respond to all the questionnaires, listwise deletion of all cases with some missing data were not thought practical in this model. The resulting dataset would have contained only 43 registered children out of the initial total of 115. The method employed here was to include missing cases as a separate category in each explanatory variable—known as the missing indicator method (Little & Rubin, 1987). For our regression model we report odds ratios for both the categories of interest and the missing category but we only consider there to be a significant effect if there is evidence of differences between the non-missing groups.
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In previous models, we have restricted our sample size to cases for which we had any one of the explanatory variables. In the current analysis, birthweight was the most completely observed variable, with only a very small number of cases in the birthweight-missing category. To have included these cases would have led to an excessive standard error and ludicrous parameter prediction. We therefore altered our criteria to include only those cases for which the birthweight was available.
Results One hundred and fifteen ALSPAC children were placed on the child protection register prior to their 6th birthday. There were no birthweight data for 36 of the non-registered children who were therefore excluded from the analysis; no registered children were excluded. The final analysis was therefore based on 115 registered and 14,105 non-registered children. Ten children (8.7% of all registrations) had been registered by 1 month of age, eight of these prenatally. By 6 months, a further 13 (11.3%) had been registered (Table 1). Overall questionnaire response rates ranged from 79 to 86% for antenatal questionnaires, 71 to 77% for questionnaires in the first year of life and 61 to 70% for later questionnaires. Response rates for parents of registered children were lower, ranging from 51 to 62% for antenatal questionnaires, 39 to 54% in the first year and 24 to 37% for later questionnaires. The pattern of registration has been previously reported with 31.7% of registrations being for physical injury; 10.9% for sexual abuse; 25.1% for emotional abuse; 29.0% for neglect and 3.3% for other reasons (Sidebotham & The ALSPAC Study Team, 2000). Basic child characteristics The characteristics of the registered and non-registered children are given in Table 2. Children on the child protection register had a lower mean birthweight. The trend was for more Table 1 Age at registration Age in months
Number of children registered
Cumulative percent
0–<1 1–5 6–11 12–17 18–23 24–29 30–35 36–41 42–47 48–53 54–59 60–65 66–71
10 13 12 9 11 7 6 6 7 8 9 13 4
8.7 20.0 30.4 38.3 47.8 53.9 59.1 64.3 70.4 77.4 85.2 96.5 100.0
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Table 2 Characteristics of the registered and non-registered population
Males Multiple pregnancy Ethnicity: non-White Mean birthweight (g) (SE)
Registered children n = 115 (%)
Non-registered children n = 14141 (%)
Significance
64 (55.7) 2 (1.7) 6/59 (10.2) 3123 (56.5)
7288 (51.5) 183 (1.3) 585/11800 (5.0) 3398 (4.6)
χ 2 .77 N.S. χ 2 .18 N.S. χ 2 3.37 N.S. t test mean difference 274; p < .001
males and more non-White children to be placed on the register, although neither difference was significant. Only two twins were registered. Pregnancy intentions Of those children whose pregnancies had not been intended, 47/3907 (1.2%) were subsequently registered, compared to 30/8823 (.3%) of intended pregnancies (χ 2 = 33.5, p < .001). Child health Six out of the 808 babies admitted to the Special Care Baby Unit (Neonatal intensive care and high dependency unit) were subsequently registered (.7%) compared to .6% of those not admitted (χ 2 = .43, N.S.). A total of 1075 (out of 12,090 responding, 8.9%) children were reported to have been sometimes or mostly unwell during the first 3 years. Of these children, 9 (.8%) were placed on the child protection register, compared to 55/11,015 (.5%) of those reported to have been healthy or with minor health problems only (χ 2 = 2.12, N.S.). Of those children described by their parents as sometimes or mostly unwell, 645 (60.0%) had been admitted to hospital during the first 30 months compared to 2240/11,015 (20.3%) of the children described as healthy. Of the total 2919 children admitted to hospital in the first 30 months, 27 (.9%) were placed on the child protection register, compared to 49/9774 (.5%) of those not admitted (χ 2 = 6.77, p < .01). Development Of 11,454 parents responding to questions about their child’s development, 2391 (16.8% of the total) reported some concerns about speech, behavior or general development. Of these children, 19 (.8%) were placed on the child protection register compared to 31/9063 (.3%) whose parents had no reported concerns (χ 2 = 8.92, p < .01). Of the 19 registered children, 13 parents expressed worries about speech development, 11 about behavior development, and 2 about general development. Two thousand one hundred and ninety-four children were referred to a specialist for hearing or visual assessment of whom 16 (.8%) were registered, compared to 45/9747 (.5%) of those not referred (χ 2 = 2.52, N.S.).
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Table 3 Reported child characteristics at 4 weeks of age Characteristic
Registered children (n = 70)
Non-registered children (n = 12059)
Significance
Positive characteristics Placid Communicative Cuddly Active Sociable Happy Alert
42 (60.0) 34 (48.6) 61 (87.1) 49 (70.0) 42 (60.0) 60 (85.7) 57 (81.4)
8901 (73.8) 8418 (69.8) 11300 (93.7) 10011 (83.0) 8834 (73.3) 11005 (91.3) 11610 (96.3)
p < .01 p < .001 p < .05 p < .005 p < .05 N.S. p < .001
Negative characteristics Grizzly Fretful Demanding Angry Withdrawn Stubborn Unresponsive
13 (18.6) 6 (8.6) 29 (41.4) 7 (10.0) 1 (1.4) 15 (21.4) 3 (4.3)
2455 (20.4) 1462 (12.1) 5325 (44.2) 1117 (9.3) 49 (.4) 2195 (18.2) 454 (3.8)
N.S. N.S. N.S. N.S. N.S. N.S. N.S.
Behavior and temperament Seven hundred and fifty-nine children were reported to have feeding problems in infancy (6.0% of the total). Of these, 9 (1.2%) were registered, compared to 66/11,882 (.6%) without feeding problems (χ 2 = 4.81, p < .05). Similarly, children with reported frequent temper tantrums were more likely to be registered (11/988, 1.1%) than those with infrequent tantrums (39/10,436, .4%; χ 2 = 11.33, p < .001). There was a trend for more children with reported problem crying in infancy to be registered, although this was not significant. When asked about aspects of their child’s temperament at 4 weeks, all mothers were more likely to report positive rather than negative characteristics. There was, however, a significant trend for mothers of registered children to have reported fewer positive attributes in their child at 4 weeks (χ 2 for trend 15.83, p < .001). This held true for each individual characteristic (Table 3). Conversely, these mothers were no more likely to have reported negative characteristics of their child. Separate analyses of different groupings of the infant characteristics did not reveal any other significant associations. Logistic regression analysis The seven variables that proved significant on univariate analysis (low birthweight, unintended pregnancy, hospital admissions, developmental concerns, reported positive attributes, feeding difficulties and temper tantrums) were entered into a forward stepwise analysis. Because of the difficulties in treating missing values, “reported positive attributes” was treated as a categorical variable taking the lowest quintile as a cutoff (fewer than five positive attributes reported). Five of the seven variables remained significant risks in the logistic regression model (Table 4): low birthweight, unintended pregnancy, hospital admissions during the first 3 years,
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Table 4 Child variables affecting registration (variables remaining significant on multivariate analysis) Non-registered children (n = 14105) n (%)
Unadjusted OR (CI)
Adjusted OR (CI)
Birthweight ≥2500 g Low birthweight (<2500 g)
93 (85.2) 17 (14.8)
13395 (95.0) 710 (5.0)
1.00 Reference 3.27 (1.95, 5.51)
1.00 Reference 2.08 (1.22, 3.56)
Pregnancy intended Intended pregnancy Pregnancy not intended Missing
30 (39.0) 47 (61.0) 38
8793 (69.5) 3860 (30.5) 1452
1.00 Reference 3.57 (2.25, 5.64) 7.48 (4.62, 12.10)
1.00 Reference 2.92 (1.83, 4.64) 2.92 (1.61, 5.30)
Child health No hospital admission Any hospital admission Missing throughout
49 (64.5) 27 (35.5) 39
9725 (77.1) 2892 (22.9) 1488
1.00 Reference 1.85 (1.16, 2.97) 5.11 (3.34, 7.80)
1.00 Reference 1.91 (1.16, 3.14) .66 (.30, 1.42)
Developmental problems No reported problems Developmental concerns Missing throughout
31 (62.0) 19 (38.0) 65
9032 (79.2) 2372 (20.8) 2701
1.00 Reference 2.34 (1.32, 4.14) 6.94 (4.52, 10.67)
1.00 Reference 1.99 (1.12, 3.56) 5.09 (2.95, 8.79)
Reported positive attributes of child 5–7 positive attributes reported Lowest quintile (0–4 positive attributes reported) Missing
44 (66.7) 22 (33.3) 49
10044 (84.5) 1845 (15.5) 2216
1.00 Reference 2.72 (1.62, 4.54) 4.99 (3.31, 7.52)
1.00 Reference 2.29 (1.36, 3.85) 2.08 (1.03, 4.19)
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Registered children (n = 115) n (%)
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parental concerns about the child’s development, and not seeing the child in a positive light. Once these factors were controlled for, the specific behavior problems of feeding difficulties and frequent temper tantrums were no longer significant.
Discussion The results of these analyses suggest that children who are subsequently maltreated differ from other children in respect of their birthweight, health, development and behavior and in the way they are perceived by their mothers. These differences are present from early on in the child’s life. The association between prematurity or low birthweight and maltreatment has previously been highlighted (e.g., Browne & Saqi, 1988; Creighton, 1985), but not universally reported (Brown, Cohen, Johnson, & Salzinger, 1998; Leventhal, Egerter, & Murphy, 1984). In our study, children who are of low birthweight are more than twice as likely to be maltreated than are normal birthweight children. It has been postulated that these children are in some way less attractive, or more demanding of their parents. For example, Belsky and Vondra (1989) suggest that these infants have a narrow band of arousal making it relatively easy to both overand under-stimulate them, thus making parent-child interactions more difficult. The lack of any association with crying or other behavioral problems does not rule out this hypothesis, but neither does it lend any weight to it. It was not possible in our study to explore interactive effects between prematurity and behavioral traits as the numbers in individual cells were too small. Other researchers have suggested that through early separation, the bonding process is disrupted (Lynch, 1975; Lynch & Roberts, 1977). In our study, admission to a Special Care Baby Unit was not a significant factor in relation to later maltreatment, suggesting that it is something else in the relationship between parent and low birthweight child that is disrupted. One further explanation for the increased risk is that of surveillance bias, with premature babies being subjected to heightened surveillance by health professionals, who might therefore be more likely to detect maltreatment. We do not have any data that would allow this hypothesis to be explored. Other, more observational, studies are required to explore the pathways through which low birthweight or prematurity increases risk, particularly exploring the relationship between separation, bonding and later maltreatment. Children who suffer from poor health (as evidenced by hospital admission) in the first 30 months were more likely to be maltreated. A number of possible explanations for this association should be considered. First, some of the hospital admissions could have been as a consequence of the maltreatment, either through physical injury or through the effects of neglect on children’s health. Since our data relied on parental report and did not collect any information on the causes of admission we are unable to assess this. Such an effect may well have been important for some of the children in this study. The second possibility is that poor health increases the risk of a child being maltreated. This might be through the stress imposed on parents looking after an unwell child who might demand more of their time, the worry experienced on account of the child’s illness, or the extra demands on
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parents through hospital attendances, and so forth. A further measure of parental perception of ill-health (parents reporting that their child had been sometimes or mostly unwell during the first 3 years) did not show a significant relationship. If the relationship were mainly due to the stress induced by ill-health, one would expect more parents of registered children to have reported that their children were sometimes or mostly unwell. Third, hospital admission may increase the risk through the separation of a mother from her baby. This effect has previously been shown by Lynch (1975). In her sample, ill-health and early separation were both more common in abused children than in their non-abused siblings. In our contemporary society, hospital admission very rarely involves separation of a child and mother, making this less likely as an etiological pathway. Finally, poor health and hospital admission may not be a risk factor in its own right, but rather a marker of the same underlying risk factors that operate for maltreatment. It is well recognized that disabled children are particularly vulnerable to maltreatment (Goldson, 1998; Sullivan & Knutson, 2000). While we did not specifically identify disability, we were able to elicit parental concerns regarding early development and these have been shown to correlate with later disability (Glascoe, 1999). Our data thus support the vulnerability of children with disabilities, but also widens the scope of this, suggesting that children with developmental problems and those with poor health in infancy may also be more vulnerable. This finding could, however, be a reflection of deeper underlying socio-demographic factors. Children growing up in adverse socio-economic environments may well suffer worse health in infancy and be more likely to have developmental problems than those in more privileged circumstances (Newberger, Reed, Daniel, Hyde, & Kotelchuck, 1977; Spencer, 1996). It is surprising that behavior problems in early childhood were not strongly related to maltreatment. While feeding problems and frequent temper tantrums were more commonly reported in the registered group, these differences did not remain significant once other child factors were controlled for. The trend for more problems with crying in infancy amongst the registered group was not significant even on univariate analysis. This, combined with the finding that at 4 weeks mothers in the registered group were no more likely to have reported negative characteristics of their child, suggests that “difficult” babies are no more likely to be maltreated than their peers. This contrasts with previous work that has shown that infants with difficult temperaments can adversely affect their parents’ interaction with them, and also their parents’ general psychological state and well-being (Belsky & Vondra, 1989). Many studies have in fact suggested significant differences in temperament and behavior between maltreated children and matched controls (e.g., Brayden, Altemeier, Tucker, Dietrich, & Vietze, 1992; Famularo, Fenton, & Kinscherff, 1992). However, where this work is done retrospectively, or even with prospective data, the later they are collected, the more difficult it is to disentangle the temperament or behavior as a cause rather than a consequence of poor parenting. One prospective German study found that subsequently abused children did not differ in temperament from controls as newborns, but did show differences by 8 months and again at 33 months (Engfer & Gavranidou, 1988, quoted in Belsky, 1993). The lack of a significant relationship between infant temperament at 4 weeks and child maltreatment in the first 6 years as reported in our study suggests that we cannot attribute the maltreatment to the infant’s temperament. The pathways are likely to be complex, and it may well be that the
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child’s developing temperament is molded by his or her experiences and in turn influences the parental responses to that child. Of far more significance seems to be the attitudes of the parents, both in terms of their intentions for the pregnancy and in the ability of the mother to recognize positive attributes in her child. Children who are born following unintended pregnancies are more likely to be abused than those whose pregnancies were intended. This reflects the findings of others (Altemeier, O’Connor, Vietze, Sandler, & Sherrod, 1984; Zuravin, 1991). However, it is important to note that even in the unintended pregnancy group, the majority (98.8%) of children are not maltreated, and the fact that a pregnancy is not intended does not necessarily imply that it is not wanted. In early infancy, while mothers of subsequently maltreated children are no more likely than other mothers to report negative characteristics in their child, they are less likely to report positive characteristics. This could suggest that the problem lies more in the mother’s perception of her infant: that maltreating mothers find it more difficult to see positive attributes in their child. In the above area, as with all our data, it is important to stress the limitations of odds ratios in relation to prediction. Any variable showing an increased odds ratio implies that the factor in question does increase the risk of maltreatment. Where, however, the overall probability of the outcome occurring is small, even an odds ratio of 2.9, effectively trebling the risk, still means that the majority of children with that risk factor will not be maltreated. Thus, while such findings argue the case for tackling the identified risk factors, they cannot be used effectively for screening or prediction. The prospective nature of this study has avoided some of the major obstacles to clarifying the nature of the role of the child in maltreatment. Nevertheless some limitations are evident. Firstly, there is a recognized bias in participation in the study. Although initial enrollment was high, subsequent questionnaire returns did drop off amongst the registered group, hence the large numbers of missing values for some of the data. Response rates for the different questionnaires varied from 34 to 69% for mothers of registered children compared to overall response rates of 71–90%. We have made allowances for this in the statistical analysis, but some caution is required in interpreting the figures particularly those relating to later infancy. Secondly, with the exception of birthweight, the data are entirely dependent on mother’s questionnaire responses, without more objective measures. This is particularly relevant in relation to the reported developmental problems, child health, and behavior problems. Finally, in this paper we have not taken account of different forms of maltreatment, preferring to use a single outcome of registration. It is well recognized that official recognition with registration does not equate to all maltreatment, and inevitably the onset of maltreatment must predate its recognition by statutory agencies. Nevertheless, such registration represents the most complete ascertainment we have of substantiated maltreatment.
Conclusions The picture emerging from this study is that there are some early differences between maltreated children and their peers. This lends some support to the hypothesis proposed by
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Helfer (quoted in Friedrich & Boriskin, 1976) that maltreatment requires a stressful environment, a parent who reacts in a particular way and a child who is in some way different. It does however suggest that such status could arise from a range of circumstances and is more likely to be in the way the parent perceives the child than in any individual characteristic of the child himself. Belsky (1993), in his review of the literature, concludes that while parents play a larger role in the etiological equation, children themselves do inadvertently contribute too. It seems likely that the prime differences are in parental characteristics and attitudes; the way the parent interacts with the child then influences the child’s developing personality and temperament which in turn can elicit further negative responses from the parent setting up a series of interactions that may eventually lead to actual maltreatment either through abuse or neglect. The infants in our study who were subsequently maltreated were more likely to be small at birth, to have poor health during infancy and to have had problems with their development. However, put the other way round, 98% of low birthweight babies, 99% of those admitted to hospital in infancy, and 99% of those with developmental problems did not go on to be maltreated. All these factors could be a reflection of other underlying factors at different levels of the ecological model, rather than being prime etiological agents in themselves. In particular, all could be related to adverse socio-economic or environmental circumstances, which in themselves predispose to maltreatment. Surprisingly, our data do not support the hypothesis that it is babies who are temperamentally difficult who go on to be maltreated. None of the negative aspects of temperament at 4 weeks was more common in the registered group. In addition, while there was a trend for more feeding problems and temper tantrums, these did not prove significant once other factors were controlled for. There do, however, appear to be some differences in the way these mothers perceive their infants and their intentions for the pregnancy, although again the differences are small. This study has shown that while there is a greater risk amongst some groups of children, the majority of maltreated children are initially no different from their peers. In contrast to the conclusions of Friedrich and Boriskin (1976), we would suggest that while child factors are significant, they are only a small part of the overall complex set of circumstances and conditions that ultimately lead to abuse or neglect. Acknowledgments We are extremely grateful to all the mothers who took part and to the midwives for their cooperation and help in recruitment. The whole ALSPAC Study Team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers, and managers who continue to make the study possible. References Aber, J. L., Allen, J. P., Carlson, V., & Cicchetti, D. (1989). The effects of maltreatment on development during early childhood: Recent studies and their theoretical, clinical, and policy implications. In D. Cicchetti & V.
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Sullivan, P. M., & Knutson, J. F. (2000). Maltreatment and disabilities: A population-based epidemiological study. Child Abuse & Neglect, 24, 1257–1273. Zuravin, S. (1991). Unplanned childbearing and family size: Relationship to child neglect and abuse. Family Planning Perspectives, 23, 155–161.
Resumen But: Déterminer les caractéristiques qui pourraient prédisposer des enfants à devenir victimes de mauvais traitements. Méthode: La recherche s’appuie sur une vaste étude longitudinale, la Avon Longitudinal Study of Parents and Children. Parmi les 14,256 enfants ayant participé à cette étude, 115 ont été inscrits dans les registres locaux de la protection de l’enfance avant d’avoir atteint leur sixième année. Les données parviennent de données obstétriques et d’une série de questionnaires administrés aux parents durant la grossesse et durant les trois premières années de l’enfant. On a analysé les facteurs de risque au moyen d’une analyse de régression logique. Résultats: On a note des liens importants entre, d’une part, les mauvais traitements, et d’autre part, le poids inférieur à la naissance, la grossesse non voulue, une mauvaise santé et des difficultés au niveau du développement en très bas aˆ ge. De plus, les mères des enfants inscrits dans les registres étaient moins aptes à voir en leur enfant des traits positifs, à l’ˆage de quatre semaines. Par contre, on note peu de liens entre les mauvais traitements d’une part, et d’autre part les problèmes d’alimentation, les pleurs et les crises de colères. Conclusions: Bien que les caractéristiques de l’enfant soient importantes, elles ne représentent qu’une part minime de l’ensemble complexe de circonstances et de conditions qui mènent à la négligence ou aux mauvais traitements. En toute probabilité, les attitudes des parents envers leur enfant seraient plus importantes que les caractéristiques de l’enfant.
Résumé Objetivo: Determinar las caracter´ısticas de los niños que pueden predisponer para el maltrato. Método: La investigación está basada en un amplio estudio de cohorte, el Estudio Avon Longitudinal de Padres y Niños. Del total de 14.256 niños que participaron en el estudio, 115 hab´ıan sido identificados como registrados en el sistema de protección local antes de haber cumplido los seis años. Los datos sobre los niños han sido obtenidos de registros de obstetricia y de una serie de cuestionarios administrados a los padres durante el embarazo y los primeros tres años de vida. Los factores de riesgo fueron analizados utilizando análisis de regresión log´ıstica. Resultados: Se observaron relaciones significativas entre el bajo peso al nacer, los embarazos no deseados, problemas de salud y problemas evolutivos en la infancia y la presencia posterior de maltrato infantil. Además, las madres de los niños que tienen expediente en protección infantil hab´ıan notificado menos atributos positivos de ellos en las primeras semanas de vida. En contraste, la notificación de atributos negativos, de problemas de lloro y alimentación y la frecuencia de “casquetas” no estaban significativamente asociadas con el maltrato. Conclusiones: A pesar de que los factores del niño son significativos, constituyen sólo una pequeña parte del complejo grupo de circunstancias y condiciones que acaban provocando el maltrato o negligencia. Las actitudes parentales hacia el niño pueden ser más significativas que las caracter´ısticas reales del niño.
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Appendix A Variables studied: categories and sources of data Those variables marked with an asterisk were entered into the final logistic regression model. Variable Low birthweight∗
Admission to Special Care Baby Unit Hospital admission∗
Categories Birthweight ≥2500 g (Reference) Birthweight <2500 g Missing Admitted Not admitted No reported hospital admission during first 3 years (Reference) Any hospital admission Missing throughout
Reported health of infant
Developmental problems∗
Feeding difficulties∗
Mostly unwell Sometimes unwell Minor health problems only Healthy No reported problems (Reference)
Any reported worry about development Missing throughout No reported problems (Reference) Any reported feeding difficulty
Problem crying
Missing throughout Crying reported as a problem Not reported as a problem
Notes Taken from obstetric records
Reported in 4-week questionnaire Hospital admissions reported at 4 weeks, 6, 18 and 30 months Recorded as missing if no data available Any reported admission taken as positive, otherwise recorded as no reported admission As reported by parents at 6, 18 and 30 months
Questions at 18 and 30 months asking if the mother was worried about her child’s speech development, general development or behaviour development Recorded as any reported worry; no reported problems; or as missing if no data available Questions at 4 weeks, 6 and 15 months asking if the child had any feeding difficulty Recorded as any reported difficulty; no reported problems or as missing if no data available Questions at 4 weeks, 6, 18 and 30 months asked if the parents felt that their child’s crying was a problem
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Appendix A (Continued ) Temper tantrums∗
Infrequent (Reference) Frequent temper tantrums
Missing throughout Intended pregnancy∗ Pregnancy intended (Reference) Pregnancy not intended Missing Mother’s report of Child seen in positive light child’s (5–7 positive characteristics characteristics∗ reported) (Reference) Not seen in positive light (0–4 positive characteristics reported) Missing
Frequency of temper tantrums recorded at 18 and 30 months Recorded as frequent if reported daily tantrums on either occasion; otherwise infrequent; or as missing if no data available Asked at 12 weeks gestation
Number of positive characteristics reported by mother at 4 weeks out of a total possible seven characteristics: placid, communicative, cuddly, active, sociable, alert, happy
Child maltreatment in the “children of the nineties:” the role of the child夽 Peter Sidebotham a,∗ , Jon Heron b , The ALSPAC Study Teamc a
Institute of Child Health, University of Bristol, St. Michael’s Hill, Bristol BS2 8BJ, UK b Unit of Pediatric and Perinatal Epidemiology, University of Bristol, Bristol, UK c University of Bristol, Bristol, UK
Received 8 October 2001; received in revised form 15 August 2002; accepted 15 August 2002
Abstract Aim: To determine characteristics of children that may predispose to maltreatment. Methods: The research is based on a large cohort study, the Avon Longitudinal Study of Parents and Children. Out of 14,256 children participating in the study, 115 have been identified as having been placed on local child protection registers prior to their 6th birthday. Data on the children have been obtained from obstetric data and from a series of parental questionnaires administered during pregnancy and the first 3 years of life. Risk factors have been analysed using logistic regression analysis. Results: Significant relationships were found between low birthweight (OR 2.08), unintended pregnancies (OR 2.92), poor health (OR 1.91) and developmental problems (OR 1.99) in infancy, and subsequent maltreatment. In addition, mothers of registered children were less likely to have reported positive attributes in their 4-week-old infant. In contrast, negative attributes in infancy, feeding and crying problems, and frequent temper tantrums were not significantly associated with maltreatment. Conclusions: While child factors are significant, they are only a small part of the overall complex set of circumstances and conditions that ultimately lead to abuse or neglect. Parental attitudes towards the child may be more significant than the actual characteristics of the child. © 2003 Elsevier Science Ltd. All rights reserved. Keywords: Child abuse; Child maltreatment; Risk factors; Etiology; Child health; Behavior; Development
夽
This study could not have been undertaken without the financial support of the Medical Research Council, the Department of Health, the Department of the Environment, the Wellcome Trust and other funders including the NHS executive, South West, Research and Development Directorate. The ALSPAC study is part of the WHO initiated European Longitudinal Study of Pregnancy and Childhood. ∗ Corresponding author. 0145-2134/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0145-2134(03)00010-3
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Background While it is clear that maltreated children are victims and cannot be blamed for the maltreatment they have suffered, there do seem to be some children who for a variety of reasons are more prone to maltreatment. As Frodi (1981) has pointed out, “infants can be ‘at risk’ for abuse because they are born with mental, physical, or behavioral abnormalities that render them vulnerable to abuse or because they have developed characteristics (perhaps through interaction with their parents) that affect the likelihood of abuse.” Several characteristics of the child have been shown in previous studies to be associated with risk of maltreatment. These include prematurity, health, behavior or developmental problems (Friedrich & Boriskin, 1976). Other factors that have been cited include gender, twin status, ethnicity, and disability (Creighton, 1985; Groothius et al., 1982; Sullivan & Knutson, 2000). Furthermore, there is some suggestion that the maltreated child, while no different from other children, may be perceived by the parents as somehow different, and therefore singled out for maltreatment (Friedrich & Boriskin, 1976). Most of the studies that have explored infant or child characteristics have been retrospective in nature, or purely descriptive with no comparison group other than quoted population norms. Interpretation of these associations is therefore difficult. It may not be possible to determine whether any observed abnormalities in the child predated the maltreatment, or were a consequence of it. This is particularly difficult for reported developmental and behavioral problems, both of which are recognized sequelae of maltreatment (Aber, Allen, Carlson, & Cicchetti, 1989; Elmer & Gregg, 1967; Erickson, Egeland, & Pianta, 1989). Aspects such as prematurity or low birthweight may reflect underlying socio-economic differences which predispose to both the proposed risk factor and the maltreatment itself. In order to understand fully the importance of child characteristics in relation to maltreatment, these characteristics must be interpreted within a comprehensive framework that explores different levels of the child’s ecological milieu (Belsky, 1980). Within such models, the child is seen as developing within the immediate “microsystem” of his home and family. This in turn is embedded in an “exosystem” comprising the neighborhood and wider social structures affecting family life. The whole is further influenced by prevailing cultural norms (the “macrosystem”) and by the parents’ background or “ontogeny.” In order to draw conclusions about the impact of risk factors, data should ideally be collected prospectively, with a clear comparison group from the normal population. This research project, based on a large cohort of children born in the early 1990s, examines prospective data on the children. The hypothesis being explored is that children who are maltreated during their preschool years are in some way different from their non-maltreated peers. Previous papers have reported on other levels of the ecological model (Sidebotham, Golding, & The ALSPAC Study Team, 2001; Sidebotham, Heron, Golding, & The ALSPAC Study Team, 2002). This earlier work has particularly highlighted the importance of socio-economic factors, strong relationships being found with all measures of deprivation; the effect of social isolation; and the impact of parental age, education and psychiatric illness. Thus, factors in different levels of the ecological model have been shown to be important in understanding maltreatment. Subsequent work will aim to integrate the different levels and further explore the interactions between them.
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Methods Setting The Avon Longitudinal Study of Parents and Children (ALSPAC) is a large study following a cohort of children born to mothers resident in Avon while pregnant with expected dates of delivery between 1.4.91 and 31.12.92 (Golding & The ALSPAC Study Team, 2001). The ALSPAC study area—the three Bristol-based health districts of Avon—has a population of approximately one million and includes the city of Bristol (population 500,000), a mixture of inner city deprivation (7% of Avon children live in poor urban areas), rural areas (15%), leafy suburbs and moderate sized towns. Children living in Avon have similar proportions to the rest of Britain of single parents (4.0% Avon, 5.0% GB), and non-Caucasian parents (5.1% vs. 6.4%). They are less likely to have a father in a manual occupation (51.6% vs. 65.1%). Comparative data on the representative nature of the sample are provided in Golding and The ALSPAC Study Team (2001). Study population All pregnant mothers resident in the Avon area during the enrolment period were invited to participate. In total, 14,893 mothers enrolled, representing an estimated 85–90% of the eligible population. Allowing for fetal or early infancy loss and attrition, a total of 14,256 children were followed up beyond infancy. To prevent any bias being introduced by repeated data, second and subsequent children in a multiple pregnancy were excluded from the analysis. Participation in the study was entirely voluntary. Enrollment was primarily through midwives, backed up by considerable local publicity, and direct contact of non-enrolled mothers. The issue of confidentiality and the voluntary nature of the study were stressed to mothers at enrollment, and their participation taken as signifying consent. The mothers were not specifically told that social services data would be searched; however, strict measures were taken to ensure confidentiality. Once identified through social services, the children were matched with the cohort data, and entered into the database in such a way that this information could not be traced back to individual children. Given that specific consent had not been sought, social services records were not scrutinized for details of the abuse (nature, severity, alleged perpetrator, etc.), but only that information which was readily available from the social services database was obtained. Ethical approval for the study was obtained from the ALSPAC ethics committee and through them from each of the local hospital ethics committees. Approval to use the child protection register data were obtained from the custodians of the registers and the area child protection committees. Data collection: criterion variables The local Social Services child protection registers were screened for any children with birth dates in the cohort range who had been investigated for possible child abuse or neglect, or had been placed on the child protection register during the period 1.1.91–31.12.98. This involved initially searching one register covering the entire Avon area. Following local government
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reorganization in 1996, this register was replaced by four local registers which were in turn checked to update the information. Full data were therefore obtained on all children to the age of 6. Following referrals of suspected maltreatment a social services investigation will lead to a multi agency case conference at which, if there is evidence of significant harm or risk of harm to the child, the child is placed on a child protection register. Children may be placed on the register under one of four categories of maltreatment: physical abuse, sexual abuse, emotional abuse, or neglect. For the purposes of this study, registration on the child protection register was taken as the single outcome variable. This approximates to those children in whom maltreatment has been substantiated. Data collection: predictor variables Direct obstetric data were obtained providing gender and birthweight for each child, along with details of multiple pregnancies. A series of questionnaires were sent to the parents during pregnancy and after the birth of the child. Questionnaires at 4 weeks, and at 6, 18, 24, and 30 months asked the parents about various characteristics of their child including ethnicity, health, development and behavior. As well as asking whether their child was generally healthy, or had minor or frequent illnesses, parents were asked about hospital admissions. Developmental concerns were assessed by questions asking specifically whether the mother had any worries about her infant’s speech development, behavior development or general development. In addition, any referrals for hearing or visual problems were reported. Parents were asked whether their child’s crying was a problem, whether they had any feeding difficulties and whether they had frequent temper tantrums (defined as daily). Qualities of temperament at 4 weeks were assessed using a series of questions relating to specific behavior traits. These questions were designed for the study as a simple means of looking at early temperament, but have not been validated as a research tool. These qualities were divided into seven positive (communicative, placid, cuddly, active, sociable, happy, alert) and seven negative traits (grizzly, fretful, demanding, angry, withdrawn, stubborn, unresponsive). In addition, in an antenatal questionnaire, mothers were asked whether the pregnancy was intended, and about their and their partners’ reaction to the pregnancy. Details of the variables collected are given in Appendix A. Analysis Univariate analysis was carried out using chi-square statistics taking the outcome as registration prior to 6 years of age. Those factors which were significant on univariate analysis were entered into a logistic regression equation for the same outcome (Appendix A). Given the large overall dataset and the fact that a number of parents, particularly among the registered group did not respond to all the questionnaires, listwise deletion of all cases with some missing data were not thought practical in this model. The resulting dataset would have contained only 43 registered children out of the initial total of 115. The method employed here was to include missing cases as a separate category in each explanatory variable—known as the missing indicator method (Little & Rubin, 1987). For our regression model we report odds ratios for both the categories of interest and the missing category but we only consider there to be a significant effect if there is evidence of differences between the non-missing groups.
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In previous models, we have restricted our sample size to cases for which we had any one of the explanatory variables. In the current analysis, birthweight was the most completely observed variable, with only a very small number of cases in the birthweight-missing category. To have included these cases would have led to an excessive standard error and ludicrous parameter prediction. We therefore altered our criteria to include only those cases for which the birthweight was available.
Results One hundred and fifteen ALSPAC children were placed on the child protection register prior to their 6th birthday. There were no birthweight data for 36 of the non-registered children who were therefore excluded from the analysis; no registered children were excluded. The final analysis was therefore based on 115 registered and 14,105 non-registered children. Ten children (8.7% of all registrations) had been registered by 1 month of age, eight of these prenatally. By 6 months, a further 13 (11.3%) had been registered (Table 1). Overall questionnaire response rates ranged from 79 to 86% for antenatal questionnaires, 71 to 77% for questionnaires in the first year of life and 61 to 70% for later questionnaires. Response rates for parents of registered children were lower, ranging from 51 to 62% for antenatal questionnaires, 39 to 54% in the first year and 24 to 37% for later questionnaires. The pattern of registration has been previously reported with 31.7% of registrations being for physical injury; 10.9% for sexual abuse; 25.1% for emotional abuse; 29.0% for neglect and 3.3% for other reasons (Sidebotham & The ALSPAC Study Team, 2000). Basic child characteristics The characteristics of the registered and non-registered children are given in Table 2. Children on the child protection register had a lower mean birthweight. The trend was for more Table 1 Age at registration Age in months
Number of children registered
Cumulative percent
0–<1 1–5 6–11 12–17 18–23 24–29 30–35 36–41 42–47 48–53 54–59 60–65 66–71
10 13 12 9 11 7 6 6 7 8 9 13 4
8.7 20.0 30.4 38.3 47.8 53.9 59.1 64.3 70.4 77.4 85.2 96.5 100.0
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Table 2 Characteristics of the registered and non-registered population
Males Multiple pregnancy Ethnicity: non-White Mean birthweight (g) (SE)
Registered children n = 115 (%)
Non-registered children n = 14141 (%)
Significance
64 (55.7) 2 (1.7) 6/59 (10.2) 3123 (56.5)
7288 (51.5) 183 (1.3) 585/11800 (5.0) 3398 (4.6)
χ 2 .77 N.S. χ 2 .18 N.S. χ 2 3.37 N.S. t test mean difference 274; p < .001
males and more non-White children to be placed on the register, although neither difference was significant. Only two twins were registered. Pregnancy intentions Of those children whose pregnancies had not been intended, 47/3907 (1.2%) were subsequently registered, compared to 30/8823 (.3%) of intended pregnancies (χ 2 = 33.5, p < .001). Child health Six out of the 808 babies admitted to the Special Care Baby Unit (Neonatal intensive care and high dependency unit) were subsequently registered (.7%) compared to .6% of those not admitted (χ 2 = .43, N.S.). A total of 1075 (out of 12,090 responding, 8.9%) children were reported to have been sometimes or mostly unwell during the first 3 years. Of these children, 9 (.8%) were placed on the child protection register, compared to 55/11,015 (.5%) of those reported to have been healthy or with minor health problems only (χ 2 = 2.12, N.S.). Of those children described by their parents as sometimes or mostly unwell, 645 (60.0%) had been admitted to hospital during the first 30 months compared to 2240/11,015 (20.3%) of the children described as healthy. Of the total 2919 children admitted to hospital in the first 30 months, 27 (.9%) were placed on the child protection register, compared to 49/9774 (.5%) of those not admitted (χ 2 = 6.77, p < .01). Development Of 11,454 parents responding to questions about their child’s development, 2391 (16.8% of the total) reported some concerns about speech, behavior or general development. Of these children, 19 (.8%) were placed on the child protection register compared to 31/9063 (.3%) whose parents had no reported concerns (χ 2 = 8.92, p < .01). Of the 19 registered children, 13 parents expressed worries about speech development, 11 about behavior development, and 2 about general development. Two thousand one hundred and ninety-four children were referred to a specialist for hearing or visual assessment of whom 16 (.8%) were registered, compared to 45/9747 (.5%) of those not referred (χ 2 = 2.52, N.S.).
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Table 3 Reported child characteristics at 4 weeks of age Characteristic
Registered children (n = 70)
Non-registered children (n = 12059)
Significance
Positive characteristics Placid Communicative Cuddly Active Sociable Happy Alert
42 (60.0) 34 (48.6) 61 (87.1) 49 (70.0) 42 (60.0) 60 (85.7) 57 (81.4)
8901 (73.8) 8418 (69.8) 11300 (93.7) 10011 (83.0) 8834 (73.3) 11005 (91.3) 11610 (96.3)
p < .01 p < .001 p < .05 p < .005 p < .05 N.S. p < .001
Negative characteristics Grizzly Fretful Demanding Angry Withdrawn Stubborn Unresponsive
13 (18.6) 6 (8.6) 29 (41.4) 7 (10.0) 1 (1.4) 15 (21.4) 3 (4.3)
2455 (20.4) 1462 (12.1) 5325 (44.2) 1117 (9.3) 49 (.4) 2195 (18.2) 454 (3.8)
N.S. N.S. N.S. N.S. N.S. N.S. N.S.
Behavior and temperament Seven hundred and fifty-nine children were reported to have feeding problems in infancy (6.0% of the total). Of these, 9 (1.2%) were registered, compared to 66/11,882 (.6%) without feeding problems (χ 2 = 4.81, p < .05). Similarly, children with reported frequent temper tantrums were more likely to be registered (11/988, 1.1%) than those with infrequent tantrums (39/10,436, .4%; χ 2 = 11.33, p < .001). There was a trend for more children with reported problem crying in infancy to be registered, although this was not significant. When asked about aspects of their child’s temperament at 4 weeks, all mothers were more likely to report positive rather than negative characteristics. There was, however, a significant trend for mothers of registered children to have reported fewer positive attributes in their child at 4 weeks (χ 2 for trend 15.83, p < .001). This held true for each individual characteristic (Table 3). Conversely, these mothers were no more likely to have reported negative characteristics of their child. Separate analyses of different groupings of the infant characteristics did not reveal any other significant associations. Logistic regression analysis The seven variables that proved significant on univariate analysis (low birthweight, unintended pregnancy, hospital admissions, developmental concerns, reported positive attributes, feeding difficulties and temper tantrums) were entered into a forward stepwise analysis. Because of the difficulties in treating missing values, “reported positive attributes” was treated as a categorical variable taking the lowest quintile as a cutoff (fewer than five positive attributes reported). Five of the seven variables remained significant risks in the logistic regression model (Table 4): low birthweight, unintended pregnancy, hospital admissions during the first 3 years,
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Table 4 Child variables affecting registration (variables remaining significant on multivariate analysis) Non-registered children (n = 14105) n (%)
Unadjusted OR (CI)
Adjusted OR (CI)
Birthweight ≥2500 g Low birthweight (<2500 g)
93 (85.2) 17 (14.8)
13395 (95.0) 710 (5.0)
1.00 Reference 3.27 (1.95, 5.51)
1.00 Reference 2.08 (1.22, 3.56)
Pregnancy intended Intended pregnancy Pregnancy not intended Missing
30 (39.0) 47 (61.0) 38
8793 (69.5) 3860 (30.5) 1452
1.00 Reference 3.57 (2.25, 5.64) 7.48 (4.62, 12.10)
1.00 Reference 2.92 (1.83, 4.64) 2.92 (1.61, 5.30)
Child health No hospital admission Any hospital admission Missing throughout
49 (64.5) 27 (35.5) 39
9725 (77.1) 2892 (22.9) 1488
1.00 Reference 1.85 (1.16, 2.97) 5.11 (3.34, 7.80)
1.00 Reference 1.91 (1.16, 3.14) .66 (.30, 1.42)
Developmental problems No reported problems Developmental concerns Missing throughout
31 (62.0) 19 (38.0) 65
9032 (79.2) 2372 (20.8) 2701
1.00 Reference 2.34 (1.32, 4.14) 6.94 (4.52, 10.67)
1.00 Reference 1.99 (1.12, 3.56) 5.09 (2.95, 8.79)
Reported positive attributes of child 5–7 positive attributes reported Lowest quintile (0–4 positive attributes reported) Missing
44 (66.7) 22 (33.3) 49
10044 (84.5) 1845 (15.5) 2216
1.00 Reference 2.72 (1.62, 4.54) 4.99 (3.31, 7.52)
1.00 Reference 2.29 (1.36, 3.85) 2.08 (1.03, 4.19)
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Registered children (n = 115) n (%)
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parental concerns about the child’s development, and not seeing the child in a positive light. Once these factors were controlled for, the specific behavior problems of feeding difficulties and frequent temper tantrums were no longer significant.
Discussion The results of these analyses suggest that children who are subsequently maltreated differ from other children in respect of their birthweight, health, development and behavior and in the way they are perceived by their mothers. These differences are present from early on in the child’s life. The association between prematurity or low birthweight and maltreatment has previously been highlighted (e.g., Browne & Saqi, 1988; Creighton, 1985), but not universally reported (Brown, Cohen, Johnson, & Salzinger, 1998; Leventhal, Egerter, & Murphy, 1984). In our study, children who are of low birthweight are more than twice as likely to be maltreated than are normal birthweight children. It has been postulated that these children are in some way less attractive, or more demanding of their parents. For example, Belsky and Vondra (1989) suggest that these infants have a narrow band of arousal making it relatively easy to both overand under-stimulate them, thus making parent-child interactions more difficult. The lack of any association with crying or other behavioral problems does not rule out this hypothesis, but neither does it lend any weight to it. It was not possible in our study to explore interactive effects between prematurity and behavioral traits as the numbers in individual cells were too small. Other researchers have suggested that through early separation, the bonding process is disrupted (Lynch, 1975; Lynch & Roberts, 1977). In our study, admission to a Special Care Baby Unit was not a significant factor in relation to later maltreatment, suggesting that it is something else in the relationship between parent and low birthweight child that is disrupted. One further explanation for the increased risk is that of surveillance bias, with premature babies being subjected to heightened surveillance by health professionals, who might therefore be more likely to detect maltreatment. We do not have any data that would allow this hypothesis to be explored. Other, more observational, studies are required to explore the pathways through which low birthweight or prematurity increases risk, particularly exploring the relationship between separation, bonding and later maltreatment. Children who suffer from poor health (as evidenced by hospital admission) in the first 30 months were more likely to be maltreated. A number of possible explanations for this association should be considered. First, some of the hospital admissions could have been as a consequence of the maltreatment, either through physical injury or through the effects of neglect on children’s health. Since our data relied on parental report and did not collect any information on the causes of admission we are unable to assess this. Such an effect may well have been important for some of the children in this study. The second possibility is that poor health increases the risk of a child being maltreated. This might be through the stress imposed on parents looking after an unwell child who might demand more of their time, the worry experienced on account of the child’s illness, or the extra demands on
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parents through hospital attendances, and so forth. A further measure of parental perception of ill-health (parents reporting that their child had been sometimes or mostly unwell during the first 3 years) did not show a significant relationship. If the relationship were mainly due to the stress induced by ill-health, one would expect more parents of registered children to have reported that their children were sometimes or mostly unwell. Third, hospital admission may increase the risk through the separation of a mother from her baby. This effect has previously been shown by Lynch (1975). In her sample, ill-health and early separation were both more common in abused children than in their non-abused siblings. In our contemporary society, hospital admission very rarely involves separation of a child and mother, making this less likely as an etiological pathway. Finally, poor health and hospital admission may not be a risk factor in its own right, but rather a marker of the same underlying risk factors that operate for maltreatment. It is well recognized that disabled children are particularly vulnerable to maltreatment (Goldson, 1998; Sullivan & Knutson, 2000). While we did not specifically identify disability, we were able to elicit parental concerns regarding early development and these have been shown to correlate with later disability (Glascoe, 1999). Our data thus support the vulnerability of children with disabilities, but also widens the scope of this, suggesting that children with developmental problems and those with poor health in infancy may also be more vulnerable. This finding could, however, be a reflection of deeper underlying socio-demographic factors. Children growing up in adverse socio-economic environments may well suffer worse health in infancy and be more likely to have developmental problems than those in more privileged circumstances (Newberger, Reed, Daniel, Hyde, & Kotelchuck, 1977; Spencer, 1996). It is surprising that behavior problems in early childhood were not strongly related to maltreatment. While feeding problems and frequent temper tantrums were more commonly reported in the registered group, these differences did not remain significant once other child factors were controlled for. The trend for more problems with crying in infancy amongst the registered group was not significant even on univariate analysis. This, combined with the finding that at 4 weeks mothers in the registered group were no more likely to have reported negative characteristics of their child, suggests that “difficult” babies are no more likely to be maltreated than their peers. This contrasts with previous work that has shown that infants with difficult temperaments can adversely affect their parents’ interaction with them, and also their parents’ general psychological state and well-being (Belsky & Vondra, 1989). Many studies have in fact suggested significant differences in temperament and behavior between maltreated children and matched controls (e.g., Brayden, Altemeier, Tucker, Dietrich, & Vietze, 1992; Famularo, Fenton, & Kinscherff, 1992). However, where this work is done retrospectively, or even with prospective data, the later they are collected, the more difficult it is to disentangle the temperament or behavior as a cause rather than a consequence of poor parenting. One prospective German study found that subsequently abused children did not differ in temperament from controls as newborns, but did show differences by 8 months and again at 33 months (Engfer & Gavranidou, 1988, quoted in Belsky, 1993). The lack of a significant relationship between infant temperament at 4 weeks and child maltreatment in the first 6 years as reported in our study suggests that we cannot attribute the maltreatment to the infant’s temperament. The pathways are likely to be complex, and it may well be that the
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child’s developing temperament is molded by his or her experiences and in turn influences the parental responses to that child. Of far more significance seems to be the attitudes of the parents, both in terms of their intentions for the pregnancy and in the ability of the mother to recognize positive attributes in her child. Children who are born following unintended pregnancies are more likely to be abused than those whose pregnancies were intended. This reflects the findings of others (Altemeier, O’Connor, Vietze, Sandler, & Sherrod, 1984; Zuravin, 1991). However, it is important to note that even in the unintended pregnancy group, the majority (98.8%) of children are not maltreated, and the fact that a pregnancy is not intended does not necessarily imply that it is not wanted. In early infancy, while mothers of subsequently maltreated children are no more likely than other mothers to report negative characteristics in their child, they are less likely to report positive characteristics. This could suggest that the problem lies more in the mother’s perception of her infant: that maltreating mothers find it more difficult to see positive attributes in their child. In the above area, as with all our data, it is important to stress the limitations of odds ratios in relation to prediction. Any variable showing an increased odds ratio implies that the factor in question does increase the risk of maltreatment. Where, however, the overall probability of the outcome occurring is small, even an odds ratio of 2.9, effectively trebling the risk, still means that the majority of children with that risk factor will not be maltreated. Thus, while such findings argue the case for tackling the identified risk factors, they cannot be used effectively for screening or prediction. The prospective nature of this study has avoided some of the major obstacles to clarifying the nature of the role of the child in maltreatment. Nevertheless some limitations are evident. Firstly, there is a recognized bias in participation in the study. Although initial enrollment was high, subsequent questionnaire returns did drop off amongst the registered group, hence the large numbers of missing values for some of the data. Response rates for the different questionnaires varied from 34 to 69% for mothers of registered children compared to overall response rates of 71–90%. We have made allowances for this in the statistical analysis, but some caution is required in interpreting the figures particularly those relating to later infancy. Secondly, with the exception of birthweight, the data are entirely dependent on mother’s questionnaire responses, without more objective measures. This is particularly relevant in relation to the reported developmental problems, child health, and behavior problems. Finally, in this paper we have not taken account of different forms of maltreatment, preferring to use a single outcome of registration. It is well recognized that official recognition with registration does not equate to all maltreatment, and inevitably the onset of maltreatment must predate its recognition by statutory agencies. Nevertheless, such registration represents the most complete ascertainment we have of substantiated maltreatment.
Conclusions The picture emerging from this study is that there are some early differences between maltreated children and their peers. This lends some support to the hypothesis proposed by
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Helfer (quoted in Friedrich & Boriskin, 1976) that maltreatment requires a stressful environment, a parent who reacts in a particular way and a child who is in some way different. It does however suggest that such status could arise from a range of circumstances and is more likely to be in the way the parent perceives the child than in any individual characteristic of the child himself. Belsky (1993), in his review of the literature, concludes that while parents play a larger role in the etiological equation, children themselves do inadvertently contribute too. It seems likely that the prime differences are in parental characteristics and attitudes; the way the parent interacts with the child then influences the child’s developing personality and temperament which in turn can elicit further negative responses from the parent setting up a series of interactions that may eventually lead to actual maltreatment either through abuse or neglect. The infants in our study who were subsequently maltreated were more likely to be small at birth, to have poor health during infancy and to have had problems with their development. However, put the other way round, 98% of low birthweight babies, 99% of those admitted to hospital in infancy, and 99% of those with developmental problems did not go on to be maltreated. All these factors could be a reflection of other underlying factors at different levels of the ecological model, rather than being prime etiological agents in themselves. In particular, all could be related to adverse socio-economic or environmental circumstances, which in themselves predispose to maltreatment. Surprisingly, our data do not support the hypothesis that it is babies who are temperamentally difficult who go on to be maltreated. None of the negative aspects of temperament at 4 weeks was more common in the registered group. In addition, while there was a trend for more feeding problems and temper tantrums, these did not prove significant once other factors were controlled for. There do, however, appear to be some differences in the way these mothers perceive their infants and their intentions for the pregnancy, although again the differences are small. This study has shown that while there is a greater risk amongst some groups of children, the majority of maltreated children are initially no different from their peers. In contrast to the conclusions of Friedrich and Boriskin (1976), we would suggest that while child factors are significant, they are only a small part of the overall complex set of circumstances and conditions that ultimately lead to abuse or neglect. Acknowledgments We are extremely grateful to all the mothers who took part and to the midwives for their cooperation and help in recruitment. The whole ALSPAC Study Team comprises interviewers, computer technicians, laboratory technicians, clerical workers, research scientists, volunteers, and managers who continue to make the study possible. References Aber, J. L., Allen, J. P., Carlson, V., & Cicchetti, D. (1989). The effects of maltreatment on development during early childhood: Recent studies and their theoretical, clinical, and policy implications. In D. Cicchetti & V.
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Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 579–619). Cambridge, UK: Cambridge University Press. Altemeier, W. A., O’Connor, S., Vietze, P., Sandler, H., & Sherrod, K. (1984). Prediction of child abuse: A prospective study of feasibility. Child Abuse & Neglect, 8, 393–400. Belsky, J. (1980). Child maltreatment: An ecological integration. American Psychologist, 35, 320–335. Belsky, J. (1993). Etiology of child maltreatment: A developmental-ecological analysis. Psychological Bulletin, 114, 413–434. Belsky, J., & Vondra, J. (1989). Lessons from child abuse: The determinants of parenting. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 153–202). Cambridge, UK: Cambridge University Press. Brayden, R. M., Altemeier, W. A., Tucker, D. D., Dietrich, M. S., & Vietze, P. (1992). Antecedents of child neglect in the first two years of life. Journal of Pediatrics, 120, 426–429. Brown, J., Cohen, P., Johnson, J. G., & Salzinger, S. (1998). A longitudinal analysis of risk factors for child maltreatment: Findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse & Neglect, 22, 1065–1078. Browne, K., & Saqi, S. (1988). Approaches to screening for child abuse & neglect. In K. D. Browne, C. Davies, & P. Stratton (Eds.), Early prediction and prevention of child abuse (pp. 57–83). Chichester, UK: Wiley. Creighton, S. J. (1985). An epidemiological study of abused children and their families in the United Kingdom between 1977 and 1982. Child Abuse & Neglect, 9, 441–448. Elmer, E., & Gregg, G. (1967). Developmental characteristics of abused children. Pediatrics, 40, 596–602. Erickson, M. F., Egeland, B., & Pianta, R. (1989). The effects of maltreatment on the development of young children. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 647–684). Cambridge, UK: Cambridge University Press. Famularo, R., Fenton, T., & Kinscherff, R. (1992). Medical and developmental histories of maltreated children. Clinical Pediatrics, 31, 536–541. Friedrich, W., & Boriskin, J. (1976). The role of the child in abuse: A review of the literature. American Journal of Orthopsychiatry, 46, 580–590. Frodi, A. M. (1981). Contribution of infant characteristics to child abuse. American Journal of Mental Deficiency, 85, 341–349. Glascoe, F. P. (1999). A method for deciding how to respond to parents’ concerns about development and behavior. Ambulatory Child Health, 5, 197–208. Golding, J. G., & The ALSPAC Study Team. (2001). ALSPAC: The Avon Longitudinal Study of Parents and Children Aims and Study Design (7th ed.). Bristol, UK: Institute of Child Health. Available at: http://www.ich.bris.ac.uk/ALSPACext/Default.html. Goldson, E. (1998). Children with disabilities and child maltreatment. Child Abuse & Neglect, 22, 663–667. Groothius, J. R., Altemeier, W. A., Robarge, J. P., O’Connor, S., Sandler, H., Vietze, P., & Lustig, J. V. (1982). Increased child abuse in families with twins. Pediatrics, 70, 769–773. Leventhal, J. M., Egerter, S. A., & Murphy, J. M. (1984). Reassessment of the relationship of perinatal risk factors and child abuse. American Journal of Diseases of Children, 138, 1034–1039. Little, R. J. A., & Rubin, D. B. (1987). Statistical analysis with missing data. New York: Wiley. Lynch, M. A. (1975). Ill-health and child abuse. Lancet, 2, 317–319. Lynch, M. A., & Roberts, J. (1977). Predicting child abuse: Signs of bonding failure in the maternity hospital. British Medical Journal, 1, 624–626. Newberger, E. H., Reed, R. B., Daniel, J. H., Hyde, J. N., & Kotelchuck, M. (1977). Pediatric social illness: Toward an etiological classification. Pediatrics, 60, 178–185. Sidebotham, P. D., & The ALSPAC Study Team. (2000). Patterns of child abuse in early childhood, a cohort study of the “children of the nineties.” Child Abuse Review, 9, 311–320. Sidebotham, P. D., Golding, J., & The ALSPAC Study Team. (2001). Child maltreatment in the “children of the nineties”: A longitudinal study of parental risk factors. Child Abuse & Neglect, 25, 1177–1200. Sidebotham, P. D., Heron, J., Golding, J., & The ALSPAC Study Team. (2002). Child maltreatment in the “children of the nineties”: Deprivation, class and social networks. Child Abuse & Neglect, 26, 1243–1259. Spencer, N. (1996). Poverty & child health. Oxford: Radcliffe Press.
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Sullivan, P. M., & Knutson, J. F. (2000). Maltreatment and disabilities: A population-based epidemiological study. Child Abuse & Neglect, 24, 1257–1273. Zuravin, S. (1991). Unplanned childbearing and family size: Relationship to child neglect and abuse. Family Planning Perspectives, 23, 155–161.
Resumen But: Déterminer les caractéristiques qui pourraient prédisposer des enfants à devenir victimes de mauvais traitements. Méthode: La recherche s’appuie sur une vaste étude longitudinale, la Avon Longitudinal Study of Parents and Children. Parmi les 14,256 enfants ayant participé à cette étude, 115 ont été inscrits dans les registres locaux de la protection de l’enfance avant d’avoir atteint leur sixième année. Les données parviennent de données obstétriques et d’une série de questionnaires administrés aux parents durant la grossesse et durant les trois premières années de l’enfant. On a analysé les facteurs de risque au moyen d’une analyse de régression logique. Résultats: On a note des liens importants entre, d’une part, les mauvais traitements, et d’autre part, le poids inférieur à la naissance, la grossesse non voulue, une mauvaise santé et des difficultés au niveau du développement en très bas aˆ ge. De plus, les mères des enfants inscrits dans les registres étaient moins aptes à voir en leur enfant des traits positifs, à l’ˆage de quatre semaines. Par contre, on note peu de liens entre les mauvais traitements d’une part, et d’autre part les problèmes d’alimentation, les pleurs et les crises de colères. Conclusions: Bien que les caractéristiques de l’enfant soient importantes, elles ne représentent qu’une part minime de l’ensemble complexe de circonstances et de conditions qui mènent à la négligence ou aux mauvais traitements. En toute probabilité, les attitudes des parents envers leur enfant seraient plus importantes que les caractéristiques de l’enfant.
Résumé Objetivo: Determinar las caracter´ısticas de los niños que pueden predisponer para el maltrato. Método: La investigación está basada en un amplio estudio de cohorte, el Estudio Avon Longitudinal de Padres y Niños. Del total de 14.256 niños que participaron en el estudio, 115 hab´ıan sido identificados como registrados en el sistema de protección local antes de haber cumplido los seis años. Los datos sobre los niños han sido obtenidos de registros de obstetricia y de una serie de cuestionarios administrados a los padres durante el embarazo y los primeros tres años de vida. Los factores de riesgo fueron analizados utilizando análisis de regresión log´ıstica. Resultados: Se observaron relaciones significativas entre el bajo peso al nacer, los embarazos no deseados, problemas de salud y problemas evolutivos en la infancia y la presencia posterior de maltrato infantil. Además, las madres de los niños que tienen expediente en protección infantil hab´ıan notificado menos atributos positivos de ellos en las primeras semanas de vida. En contraste, la notificación de atributos negativos, de problemas de lloro y alimentación y la frecuencia de “casquetas” no estaban significativamente asociadas con el maltrato. Conclusiones: A pesar de que los factores del niño son significativos, constituyen sólo una pequeña parte del complejo grupo de circunstancias y condiciones que acaban provocando el maltrato o negligencia. Las actitudes parentales hacia el niño pueden ser más significativas que las caracter´ısticas reales del niño.
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Appendix A Variables studied: categories and sources of data Those variables marked with an asterisk were entered into the final logistic regression model. Variable Low birthweight∗
Admission to Special Care Baby Unit Hospital admission∗
Categories Birthweight ≥2500 g (Reference) Birthweight <2500 g Missing Admitted Not admitted No reported hospital admission during first 3 years (Reference) Any hospital admission Missing throughout
Reported health of infant
Developmental problems∗
Feeding difficulties∗
Mostly unwell Sometimes unwell Minor health problems only Healthy No reported problems (Reference)
Any reported worry about development Missing throughout No reported problems (Reference) Any reported feeding difficulty
Problem crying
Missing throughout Crying reported as a problem Not reported as a problem
Notes Taken from obstetric records
Reported in 4-week questionnaire Hospital admissions reported at 4 weeks, 6, 18 and 30 months Recorded as missing if no data available Any reported admission taken as positive, otherwise recorded as no reported admission As reported by parents at 6, 18 and 30 months
Questions at 18 and 30 months asking if the mother was worried about her child’s speech development, general development or behaviour development Recorded as any reported worry; no reported problems; or as missing if no data available Questions at 4 weeks, 6 and 15 months asking if the child had any feeding difficulty Recorded as any reported difficulty; no reported problems or as missing if no data available Questions at 4 weeks, 6, 18 and 30 months asked if the parents felt that their child’s crying was a problem
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Appendix A (Continued ) Temper tantrums∗
Infrequent (Reference) Frequent temper tantrums
Missing throughout Intended pregnancy∗ Pregnancy intended (Reference) Pregnancy not intended Missing Mother’s report of Child seen in positive light child’s (5–7 positive characteristics characteristics∗ reported) (Reference) Not seen in positive light (0–4 positive characteristics reported) Missing
Frequency of temper tantrums recorded at 18 and 30 months Recorded as frequent if reported daily tantrums on either occasion; otherwise infrequent; or as missing if no data available Asked at 12 weeks gestation
Number of positive characteristics reported by mother at 4 weeks out of a total possible seven characteristics: placid, communicative, cuddly, active, sociable, alert, happy