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The field of child maltreatment enters its fifth decade
Child Abuse & Neglect 27 (2003) 1–4
Editorial
The field of child maltreatment enters its fifth decade John M. Leventhal (Editor-in-Chief) Department of Pediatrics, Yale University School of Medicine, P.O. Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA
As the Journal begins 2003 with its first issue, I thought that each of us who works in the field of child maltreatment should reflect on the 41st anniversary of the publication of the article in which Kempe, Silverman, Steele, Droegemueller, and Silver (1962) described “The Battered-Child Syndrome.” Although this article was not the first to describe physically abused children (Caffey, 1957; Elmer, 1960; Gwinn, Lewin, & Peterson, 1961; Woolley & Evans, 1955), earlier articles were sometimes much more tentative about concluding that parents could severely hurt their children (e.g., Woolley & Evans, 1955). The article by Kempe et al. was remarkable for several features: first, the title was graphic, striking, and difficult to forget; second, the authors provided a clear description of the clinical and radiographic characteristics of abused children, including associated findings such as failure-to-thrive and poor hygiene; third, the authors focused attention on the difficulties that physicians had in believing that parents could do such horrible things to their children; fourth, there was an important discussion about the factors in parents and families that could lead to abuse; and fifth, the authors provided the first epidemiological data on the problem based on a national survey of children’s hospitals and district attorneys in the United States. Perhaps most importantly, the description of “the battered child” helped clinicians “see” what they had not seen before. While readers of the Journal are certainly aware of the tremendous changes both in the United States and throughout the world in the field of child maltreatment during the last four decades, it is often difficult to take the long view of progress. For many in the field, progress in helping maltreated children comes much too slowly when measured from week to week or even year to year. It may be useful to realize that progress in other fields also can be slow. In a recent commentary in The Lancet, Yusuf (2002) noted that from the mid-1950s until the early 1980s, myocardial infarctions and strokes were not believed to be preventable diseases. These views contrast with the results of recent studies indicating how individuals can reduce the risk of these vascular diseases. 0145-2134/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 5 - 2 1 3 4 ( 0 2 ) 0 0 5 1 6 - 1
2
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
A brief look back over the last 40 years shows some of the progress made since the publication of “The Battered-Child Syndrome.” For a more detailed review of the history of the field and some of the most important publications, see two recent books—Classic Papers in Child Abuse (Donnelly & Oates, 2000) and An International Movement to End Child Abuse: The Story of ISPCAN (Donnelly, 2002), and the article by Oates and Donnelly (1997) in which experts in the field nominated the most influential papers. Outlined below are a few of the major advances in the field’s understanding of the disease of child maltreatment. I have chosen as a framework the seven characteristics of a disease: (1) epidemiology, (2) etiology, (3) definition and recognition, (4) pathogenesis, (5) prognosis and consequences, (6) treatment, and (7) prevention.
Epidemiology One of the most important advances is the recognition that child maltreatment in its various forms of physical abuse, sexual abuse, emotional maltreatment, and neglect is prevalent in all societies and is much more common than Kempe et al. (1962) ever imagined. Recent epidemiological studies have highlighted the co-occurrence of different types of child maltreatment and the importance of other types of family violence, such as interpersonal violence between parents. The recent publication of the World Health Organization (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002) on violence as a major public health problem worldwide is a striking example of how international health agencies now view problems such as child maltreatment and family violence.
Etiology The development of the ecological model of parenting has provided a useful framework to help understand the multifactorial nature of child maltreatment (Belsky, 1980). This model considers aspects of the child, parents, family, social setting, and culture when trying to understand how maltreatment can occur.
Definition and recognition A major advance has been the recognition of different forms of the disease: for example, the recognition of sexual abuse in the 1980s, Munchausen Syndrome by Proxy, or infant murder versus SIDS (Sudden Infant Death Syndrome).
Pathogenesis Over the last decade, there has been a growing body of evidence indicating that child maltreatment affects the development of the brain and the hypothalamic-pituitary-adrenal
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
3
axis and that these changes can be long-lasting in an individual (Teicher, 2002). This area of research likely will become more important in the coming years as more sophisticated and specialized methodologies become available to understand how trauma and adverse childhood events affect the human organism.
Prognosis and consequences Long-term studies of maltreatment have shown that this disease is not just a childhood problem, but has important effects on adult functioning in the areas of physical health, mental health, use of substances, interpersonal relationships, criminality, and parenting. These studies have relied on long-term longitudinal studies, such as those by Widom (1999) and cross sectional studies, such as those by Dietz et al. (1999). In this latter design, adults are surveyed about both their current functioning and childhood experiences and analyses examine the outcomes in adults who report having the childhood experience (e.g., sexual abuse) compared with those who did not report such experiences.
Treatment A major advance has been in the recognition that maltreated children can benefit from mental health counseling. The field has done less well in evaluating the effectiveness of treatment programs, and even less attention has been paid to evaluating interventions provided by child protective service agencies.
Prevention Henry Kempe would be pleased at the recent widespread attention on the prevention of abuse and neglect in certain developed countries. This focus has resulted in renewed interested in providing to socially high-risk, first-time parents intensive support, modeling of parenting, advice, and linking to services in the community. Research has shown that these preventive services can successfully help parents and reduce the occurrence of maltreatment (Olds et al., 1997). An ongoing challenge will be to reach enough families so that there are substantial reductions in the occurrence of abuse and neglect. These are just a few of the advances in the field; there are, of course, many others. I am not suggesting that the advances to date are enough or that we stop trying to move the field forward, but just that we pause for a moment and recognize that progress has been made. May the next four decades see continued progress as we aim to reduce and eventually eliminate child maltreatment. For the field to continue to advance, it will need help in at least four ways. First, we will need the ongoing recognition by those outside the field, such as society in general, public and private funding agencies, and colleagues who believe in the importance of the problem. Second, to
4
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
ensure ongoing high quality research, there will need to be funding from the national research agencies of countries. Research on maltreatment is substantially underfunded compared to the frequency of the problem and its impact on children and families (Theodore & Runyan, 1999). Third, we will need to encourage young clinicians and researchers to enter the field. This encouragement will be made easier if training programs are adequately funded (which is not currently the case) and if trainees know that research funds are available and that there are academic positions for those interested in the scholarly issues related to child maltreatment. Finally, it will be critical for funding to be available to provide the necessary services for children and families. New knowledge without the appropriate translation into practice and care will not be useful towards the goal of helping children and families.
References Belsky, J. (1980). Child maltreatment: An ecological integration. American Psychologist, 35, 320–335. Caffey, J. (1957). Some traumatic lesions in growing bones other than fractures and dislocations: Clinical and radiological features. British Journal Radiology, 30, 225–238. Dietz, P. M., Spitz, A. M., Anda, R. F., Williamson, D. F., McMahon, P. M., Santelli, J. S., Nordenberg, D. F., & Felitti, V. J. (1999). Unintented pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of the American Medical Association, 282, 1359–1364. Donnelly, A. C. (Ed.). (2002). An international movement to end child abuse: the story of ISPCAN. Carol Stream, IL: International Society for Prevention of Abuse and Neglect. Donnelly, A. C., & Oates, K. (Eds.). (2000). Classic papers in child abuse. Thousand Oaks, CA: Sage Publications. Elmer, E. (1960). Abused young children seen in hospitals. Social Work, 5, 98–102. Gwinn, J. L., Lewin, K. W., & Peterson, H. G., Jr. (1961). Roentgenographic manifestations of unsuspected trauma in infancy. Journal of the American Medical Association, 176, 926–929. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered-child syndrome. Journal of the American Medical Association, 251, 3288–3300. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A., & Lozano, R. (Eds.). (2002). World report on violence and health. Geneva: World Health Organization. Oates, R. K., & Donnelly, A. C. (1997). Influential papers in child abuse. Child Abuse & Neglect, 21, 319–326. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettit, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278, 637–643. Teicher, M. H. (2002). Scars that won’t heal: The neurobiology of child abuse. Scientific American, 286, 68–75. Theodore, A. D., & Runyan, D. K. (1999). A medical research agenda for child maltreatment. Negotiating the next steps. Pediatrics, 104, 168–177. Widom, C. S. (1999). Posttraumatic stress disorder in abused and neglected children growing up. American Journal of Psychiatry, 156, 1223–1229. Woolley, P. V., Jr., & Evans, W. A., Jr. (1955). Significance of skeletal lesions in infants resembling those of traumatic origin. Journal of the American Medical Association, 158, 539–543. Yusuf, S. (2002). Two decades of progress in preventing vascular disease. Lancet, 360, 2–3.
Editorial
The field of child maltreatment enters its fifth decade John M. Leventhal (Editor-in-Chief) Department of Pediatrics, Yale University School of Medicine, P.O. Box 208064, 333 Cedar Street, New Haven, CT 06520-8064, USA
As the Journal begins 2003 with its first issue, I thought that each of us who works in the field of child maltreatment should reflect on the 41st anniversary of the publication of the article in which Kempe, Silverman, Steele, Droegemueller, and Silver (1962) described “The Battered-Child Syndrome.” Although this article was not the first to describe physically abused children (Caffey, 1957; Elmer, 1960; Gwinn, Lewin, & Peterson, 1961; Woolley & Evans, 1955), earlier articles were sometimes much more tentative about concluding that parents could severely hurt their children (e.g., Woolley & Evans, 1955). The article by Kempe et al. was remarkable for several features: first, the title was graphic, striking, and difficult to forget; second, the authors provided a clear description of the clinical and radiographic characteristics of abused children, including associated findings such as failure-to-thrive and poor hygiene; third, the authors focused attention on the difficulties that physicians had in believing that parents could do such horrible things to their children; fourth, there was an important discussion about the factors in parents and families that could lead to abuse; and fifth, the authors provided the first epidemiological data on the problem based on a national survey of children’s hospitals and district attorneys in the United States. Perhaps most importantly, the description of “the battered child” helped clinicians “see” what they had not seen before. While readers of the Journal are certainly aware of the tremendous changes both in the United States and throughout the world in the field of child maltreatment during the last four decades, it is often difficult to take the long view of progress. For many in the field, progress in helping maltreated children comes much too slowly when measured from week to week or even year to year. It may be useful to realize that progress in other fields also can be slow. In a recent commentary in The Lancet, Yusuf (2002) noted that from the mid-1950s until the early 1980s, myocardial infarctions and strokes were not believed to be preventable diseases. These views contrast with the results of recent studies indicating how individuals can reduce the risk of these vascular diseases. 0145-2134/02/$ – see front matter © 2002 Elsevier Science Ltd. All rights reserved. PII: S 0 1 4 5 - 2 1 3 4 ( 0 2 ) 0 0 5 1 6 - 1
2
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
A brief look back over the last 40 years shows some of the progress made since the publication of “The Battered-Child Syndrome.” For a more detailed review of the history of the field and some of the most important publications, see two recent books—Classic Papers in Child Abuse (Donnelly & Oates, 2000) and An International Movement to End Child Abuse: The Story of ISPCAN (Donnelly, 2002), and the article by Oates and Donnelly (1997) in which experts in the field nominated the most influential papers. Outlined below are a few of the major advances in the field’s understanding of the disease of child maltreatment. I have chosen as a framework the seven characteristics of a disease: (1) epidemiology, (2) etiology, (3) definition and recognition, (4) pathogenesis, (5) prognosis and consequences, (6) treatment, and (7) prevention.
Epidemiology One of the most important advances is the recognition that child maltreatment in its various forms of physical abuse, sexual abuse, emotional maltreatment, and neglect is prevalent in all societies and is much more common than Kempe et al. (1962) ever imagined. Recent epidemiological studies have highlighted the co-occurrence of different types of child maltreatment and the importance of other types of family violence, such as interpersonal violence between parents. The recent publication of the World Health Organization (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002) on violence as a major public health problem worldwide is a striking example of how international health agencies now view problems such as child maltreatment and family violence.
Etiology The development of the ecological model of parenting has provided a useful framework to help understand the multifactorial nature of child maltreatment (Belsky, 1980). This model considers aspects of the child, parents, family, social setting, and culture when trying to understand how maltreatment can occur.
Definition and recognition A major advance has been the recognition of different forms of the disease: for example, the recognition of sexual abuse in the 1980s, Munchausen Syndrome by Proxy, or infant murder versus SIDS (Sudden Infant Death Syndrome).
Pathogenesis Over the last decade, there has been a growing body of evidence indicating that child maltreatment affects the development of the brain and the hypothalamic-pituitary-adrenal
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
3
axis and that these changes can be long-lasting in an individual (Teicher, 2002). This area of research likely will become more important in the coming years as more sophisticated and specialized methodologies become available to understand how trauma and adverse childhood events affect the human organism.
Prognosis and consequences Long-term studies of maltreatment have shown that this disease is not just a childhood problem, but has important effects on adult functioning in the areas of physical health, mental health, use of substances, interpersonal relationships, criminality, and parenting. These studies have relied on long-term longitudinal studies, such as those by Widom (1999) and cross sectional studies, such as those by Dietz et al. (1999). In this latter design, adults are surveyed about both their current functioning and childhood experiences and analyses examine the outcomes in adults who report having the childhood experience (e.g., sexual abuse) compared with those who did not report such experiences.
Treatment A major advance has been in the recognition that maltreated children can benefit from mental health counseling. The field has done less well in evaluating the effectiveness of treatment programs, and even less attention has been paid to evaluating interventions provided by child protective service agencies.
Prevention Henry Kempe would be pleased at the recent widespread attention on the prevention of abuse and neglect in certain developed countries. This focus has resulted in renewed interested in providing to socially high-risk, first-time parents intensive support, modeling of parenting, advice, and linking to services in the community. Research has shown that these preventive services can successfully help parents and reduce the occurrence of maltreatment (Olds et al., 1997). An ongoing challenge will be to reach enough families so that there are substantial reductions in the occurrence of abuse and neglect. These are just a few of the advances in the field; there are, of course, many others. I am not suggesting that the advances to date are enough or that we stop trying to move the field forward, but just that we pause for a moment and recognize that progress has been made. May the next four decades see continued progress as we aim to reduce and eventually eliminate child maltreatment. For the field to continue to advance, it will need help in at least four ways. First, we will need the ongoing recognition by those outside the field, such as society in general, public and private funding agencies, and colleagues who believe in the importance of the problem. Second, to
4
J.M. Leventhal / Child Abuse & Neglect 27 (2003) 1–4
ensure ongoing high quality research, there will need to be funding from the national research agencies of countries. Research on maltreatment is substantially underfunded compared to the frequency of the problem and its impact on children and families (Theodore & Runyan, 1999). Third, we will need to encourage young clinicians and researchers to enter the field. This encouragement will be made easier if training programs are adequately funded (which is not currently the case) and if trainees know that research funds are available and that there are academic positions for those interested in the scholarly issues related to child maltreatment. Finally, it will be critical for funding to be available to provide the necessary services for children and families. New knowledge without the appropriate translation into practice and care will not be useful towards the goal of helping children and families.
References Belsky, J. (1980). Child maltreatment: An ecological integration. American Psychologist, 35, 320–335. Caffey, J. (1957). Some traumatic lesions in growing bones other than fractures and dislocations: Clinical and radiological features. British Journal Radiology, 30, 225–238. Dietz, P. M., Spitz, A. M., Anda, R. F., Williamson, D. F., McMahon, P. M., Santelli, J. S., Nordenberg, D. F., & Felitti, V. J. (1999). Unintented pregnancy among adult women exposed to abuse or household dysfunction during their childhood. Journal of the American Medical Association, 282, 1359–1364. Donnelly, A. C. (Ed.). (2002). An international movement to end child abuse: the story of ISPCAN. Carol Stream, IL: International Society for Prevention of Abuse and Neglect. Donnelly, A. C., & Oates, K. (Eds.). (2000). Classic papers in child abuse. Thousand Oaks, CA: Sage Publications. Elmer, E. (1960). Abused young children seen in hospitals. Social Work, 5, 98–102. Gwinn, J. L., Lewin, K. W., & Peterson, H. G., Jr. (1961). Roentgenographic manifestations of unsuspected trauma in infancy. Journal of the American Medical Association, 176, 926–929. Kempe, C. H., Silverman, F. N., Steele, B. F., Droegemueller, W., & Silver, H. K. (1962). The battered-child syndrome. Journal of the American Medical Association, 251, 3288–3300. Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A., & Lozano, R. (Eds.). (2002). World report on violence and health. Geneva: World Health Organization. Oates, R. K., & Donnelly, A. C. (1997). Influential papers in child abuse. Child Abuse & Neglect, 21, 319–326. Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettit, L. M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278, 637–643. Teicher, M. H. (2002). Scars that won’t heal: The neurobiology of child abuse. Scientific American, 286, 68–75. Theodore, A. D., & Runyan, D. K. (1999). A medical research agenda for child maltreatment. Negotiating the next steps. Pediatrics, 104, 168–177. Widom, C. S. (1999). Posttraumatic stress disorder in abused and neglected children growing up. American Journal of Psychiatry, 156, 1223–1229. Woolley, P. V., Jr., & Evans, W. A., Jr. (1955). Significance of skeletal lesions in infants resembling those of traumatic origin. Journal of the American Medical Association, 158, 539–543. Yusuf, S. (2002). Two decades of progress in preventing vascular disease. Lancet, 360, 2–3.