Johns Hopkins Psychiatry Guide

Abuse and Neglect

Edore Onigu-Otite, M.D., Mariflor Suarez Jamora, M.D.

DEFINITION

  • Child Abuse is any act, or failure to act, on the part of a parent or caretaker which results in harm, risk of harm, or threat of harm to a child.
  • Types:
    • Physical abuse: non-accidental physical injury to a child
    • Psychological abuse (emotional abuse): non-accidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child
    • Sexual abuse: any sexual act involving a child that is intended to provide sexual gratification to a parent, caregiver, or other individual who has responsibility for the child
    • Neglect: any confirmed or suspected egregious act or omission by a child’s parent or other caregiver that deprives the child of basic age-appropriate needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the child. This includes educational, medical, physical, or psychological neglect, or abandonment
  • Other useful terms:
    • Child maltreatment: a more general term used by the Children’s Bureau (US federal agency that monitors child welfare)
    • Trauma: a neuropsychological response to an adverse life experience such as abuse
    • Complex trauma: a profound neuropsychological response to multiple and diverse traumatic experiences which are often invasive and intrapersonal in nature, and recurrent over a period of time.

EPIDEMIOLOGY

Economic cost:

  • Lifetime cost for each victim of child maltreatment: $210,012 (comparable to other costly health conditions such as diabetes)
  • Total lifetime economic burden from new US cases of fatal and nonfatal child maltreatment in 2008: $124 billion

Children’s bureau report, 2011:

  • 3.4 million referrals received by child protective service agencies nationally
  • 676,569 victims of child abuse and neglect identified nationally
  • Victims frequently encountered more than one form of abuse, which included:
    • Neglect 78.5%
    • Physical abuse 17.6%
    • Sexual abuse 9.1%
    • Psychological abuse 7.6%

Risk factors for child abuse:

  • Age: Younger children have greater rates of abuse, with the greatest mortality occurring in infants
  • Disabilities: Intellectual or physical disability, visual and hearing impairment, learning disability
  • Behavioral or emotional disturbance
  • Caregiver factors: parental substance use disorders, mental illness, young parental age
  • Family factors: low-income households, domestic violence, multigenerational trauma
  • Adverse socio-environmental conditions: communities with concentrated poverty, high violence, low social cohesion and limited support services

DIAGNOSIS

Clinical Presentation

Due to the varying individual factors and responses to abusive experiences, manifestations of abuse in children and adolescents are highly variable and influenced by developmental stage. Clinical presentation could include:

SYMPTOMS

  • Neurodevelopmental symptoms:
    • Primary attachment difficulties: disorganized attachment, quasi-autistic behaviors; ambivalent, or disinhibited social behaviors toward adults
    • Developmental delays and deficits: late achievement of developmental milestones, deficits in self-regulation, awareness of self and other social awareness
    • Cognitive deficits: attention and learning difficulties, lower academic achievement
  • Neuropsychiatric symptoms:
    • Sleep: sleep difficulties, bad dreams, nightmares
    • Impulse control: sudden aggressive behavioral outbursts
    • Mood: depression, mood dysregulation, intermittent explosive mood symptoms
    • Anxiety: separation or generalized anxiety, panic symptoms, obsessions or preoccupation with aspects of trauma, specific phobias
    • Disruptive behavior: oppositional behavior, anger outbursts; verbal, physical or sexual aggression
    • Psychotic symptoms: disorganized behavior, vivid flashbacks may seem like hallucinations, reenacting past abusive traumatic experiences may present as a child being out of touch with reality
  • Peculiar behaviors:
    • Survival behaviors: in children with neglect, e.g. scavenging for food, hoarding behaviors, stealing
    • Sexualized behavior: in children with history of sexual abuse, e.g. self-stimulation, age-inappropriate sexual knowledge and erotized behavior
    • Dissociative symptoms: when under severe psychological stress
    • Disorganized behavior: when under severe stress
    • Elimination symptoms: new onset or worsening enuresis or encopresis
  • In adolescents:
    • High-risk behaviors: running away, unsafe sexual behavior, promiscuity, substance-related disorders
    • Conduct-related legal problems

FUNCTIONING

  • A change in functioning may follow an experience or reminder of an abusive situation including:
    • Dysregulation of behavior and emotions
    • Regression: Reversion to an earlier psychosocial developmental stage
    • Play: May change to include repetitive play with themes or aspects of past abusive traumatic experiences, e.g. sexualized behavior in sexually abused children
    • Social: withdrawal from, limitation of, or avoidance of certain activities or specific locations

* Symptoms may occur following the initial abuse or upon re-exposure to an aspect of the abuse.

Tests and Procedures

Most cases of child abuse and neglect are ascertained from verbal reports and observation of the child. Providers should interview and examine the child separately from the caregiver whenever possible.

  • Psychiatric evaluation:
  • History:
    • The abuse: circumstances, type(s), duration
    • Assess the child’s response to the abuse
      • Identify any new-onset symptoms or changes to previous symptoms
      • Identify any changes in functioning across various settings (home, school, other social activities)
    • Assess for mental illness
    • Placement factors:
      • Household factors: current members, changes and stressors
      • Note placement history and assess for adequacy of current placement
  • Mental status examination:
    • Assess risk of harm to self or others
    • Estimate of cognitive ability and developmental level
    • Assess interaction between child and caregiver
  • Physical examination:
    • Note any injuries or deformities, including soft-tissue injuries and physical abnormalities
    • Note any neurodevelopmental deficits
  • Other assessments/investigations:
    • Assessment and treatment of physical injuries, usually done by pediatrician, including radiological investigations as indicated
    • Laboratory investigations: age-appropriate health screening
    • Educational testing: to identify educational needs to be addressed: e.g. learning disabilities
    • Developmental assessment: to identify needs to be addressed: e.g. speech and language services, occupational therapy services
    • Neuropsychological testing: to assess neurocognitive and psychological functioning
    • Assessment of caregiver competencies, deficits, mental health difficulties and needs
    • Assessment and treatment of the abuser, if indicated

Differential Diagnosis

Disorders specifically related to child abuse and neglect:

  • Trauma- and stressor-related disorders:
    • Reactive attachment disorder
    • Disinhibited social engagement disorder
  • Other conditions that may be a focus of clinical attention include:
    • Child maltreatment and neglect problems
      • Child physical abuse
      • Child psychological abuse
      • Child sexual abuse
      • Child neglect

The following conditions may be the manifestations of, comorbid with, or worsened by child abuse and neglect:

TREATMENT

General

The effects of child abuse can be treated and addressed. This is best done comprehensively with a combination of:

  • Social interventions:
    • Removal from, or mitigation of, the abusive or neglectful condition, including foster care placement if needed
    • General counseling to provide support to child and family
    • Child protective services reporting (review state and institute guidelines)
  • Psychological interventions:
    • To address the psychological effects of the abuse in the child and caregiver
    • To address deficits in the caregiver or child
  • Biological interventions:
    • Psychotropic medications, are used:
      • When the safety of the child or others in the child’s environment are of concern due to the child’s symptoms
      • When symptoms are severe or significantly impact functioning
      • When therapy alone does not adequately address symptoms

Pharmacotherapy

Medication use is guided by symptom type and severity while taking into consideration the functional impact on the psychosocial development of the child.

Goal of pharmacotherapy:

  1. To reduce risk of harm to self or others
  2. To target disabling symptoms
  3. To improve or restore age-appropriate functioning

Common medications:

  • Antidepressants: for depressive or anxiety symptoms
    • SSRIs e.g. sertraline, fluoxetine, citalopram, escitalopram
  • Mood stabilizers:
    • Atypical antipsychotics: for mood dysregulation, aggressive behavior, psychotic symptoms; e.g. risperidone, aripiprazole, quetiapine
    • Anticonvulsants: for severe or explosive mood dysregulation accompanied with physical aggression; e.g. valproate, oxcarbazepine, carbamazepine
  • Anti-adrenergic agents:
    • Alpha agonists: e.g. clonidine, guanfacine extended release; useful for sleep difficulties, hypervigilant symptoms, hyperreactivity
  • Sleep medications:
    • Melatonin, diphenhydramine, hydroxyzine, trazodone
    • Sedative side effects of prescribed medications can be helpful for sleep.

Additionally:

  • Assess for and treat underlying neuropsychiatric disorder(s).
  • Treat underlying medical illnesses.
  • Periodically reassess medication use to treat current symptomatology.


* For each medication, check updated FDA approval for use in the child’s age group

Psychotherapy

Goal of psychotherapy:

  1. To address psychological effects of abuse including trauma-related distress symptoms, and to promote age-appropriate coping strategies
  2. To develop or repair disrupted attachment with caregiver, and enhance caregiver skills
  3. To improve or restore age-appropriate functioning

Types:

  • TF-CBT (Trauma-Focused Cognitive Behavior Therapy): a psychosocial treatment model designed to treat trauma-related distress and related emotional and behavioral problems in children and adolescents and their families; generally delivered in 12-16 sessions of individual and parent-child therapy. It also may be provided in the context of a longer-term treatment process or in a group therapy format.
  • For young children: parenting skills training programs:
    • ABC (Attachment and Biobehavioral Catch-up): up to 36 months
    • CPP (Chicago Parenting Program): ages 2-5
    • PCIT (Parent Child Intervention): ages 2-7
    • IYPT (Incredible Years Parenting Training): ages 3-10
  • Foster care:
    • EIFC (Early-Intervention Foster Care): ages 3–6
  • Problematic Sexual Behavior:
    • SMART (Safety, Mentoring, Advocacy, Recovery, Treatment): ages 3 - 11
  • Adolescents:
    • SPARCS (Structured Psychotherapy for Adolescents Responding to Chronic Stress): ages 12 - 19
    • DBT (Dialectical Behavior Therapy): useful in developing coping skills in trauma-related distressed adolescents
  • Families:
    • AF-CBT (Alternatives for Families: A Cognitive-Behavior Therapy approach)

Other

FACTORS AFFECTING TREATMENT OUTCOME:

  • Child factors: age of abuse; individual child resiliency; early intervention (e.g. early removal from abusive or neglectful conditions)
  • Caregiver factors: caregiver competencies; caregiving systems support
  • Placement factors: adequacy and stability of placement; early age of adoption
  • Psychosocial factors: availability of services and relevant resources; social systems support
  • Treatment factors: remediation of deficits in child; remediation of deficits in caregiver (e.g. parent training); early development or repair of disrupted attachment with primary caregiver; treatment of child or caregiver psychiatric disorder

SPECIAL CONSIDERATIONS

  • In acute situations (e.g. recent disclosure of abuse):
    • A supportive and non-judgmental approach is best.
    • Address acute emotional and behavioral dysregulation:
      • Provide a safe, calming, supportive environment for the child
      • Provide support to the caregiver, who may have difficulty accepting and coping with the disclosure of abuse
      • Use medications if necessary to stabilize the child
      • Facilitate a return to a developmentally appropriate daily routine (as tolerated)
    • Assess and address safety, including the need for Child Protective Services reporting.
    • Conduct a psychosocial evaluation to assess the adequacy of placement.
  • In adolescents:
    • Address high-risk behaviors.
    • Assess peer influences.
    • Assess for substance use problems.
    • Address the adequacy of supervision and placement.
    • Work with the legal system to facilitate monitoring and to ensure adherence to treatment recommendations.
    • Address academic/vocational preparation for future work.
  • The physically abused child:
    • Examination, treatment, and forensic work is usually completed by a pediatrician, who refers the patient for mental health evaluation and services.
  • The psychologically abused child:
    • Recognition is important, as the damage could be lifelong and severe.
    • Examples include caregiver spurning, terrorizing, isolating, exploiting, or corrupting, as well as a lack of responsiveness to the child’s needs.
  • The sexually abused child:
    • Protection of the child from further sexual abuse is paramount.
    • Refer to guidelines for evaluation in the reference section.
  • The neglected child:
    • This is the most frequent type of abuse, with the most deleterious consequences.
    • Early intervention (before 6 months) and early remediation of deficits can improve attachment and neurodevelopmental outcomes.

WHEN TO REFER

  • The Department of Social Services can provide additional services or support to the child and family.
  • Contact Child Protective Services to report events or risk of harm to children.
  • Counseling is important to address the psychosocial impact of abuse on the child and the family.
  • Psychotherapy is indicated when the child manifests symptoms of distress.
  • Refer to a psychiatrist (preferably a child and adolescent psychiatrist) when:
    • The child manifests trauma-related distress symptoms that are moderate to severe or chronic (lasting over 1 month).
    • The child has other psychiatric conditions.
  • Refer children with complicated cases to a mental health clinic specializing in trauma: e.g. severe or chronic trauma-related stress disorder symptoms, severe emotional or behavioral problems, sexual abuse, complex trauma, multigenerational trauma.

FOLLOW UP

Children with a history of abuse and neglect should be monitored and followed, as some manifestations of abuse may be delayed. Developmental progress should be re-assessed periodically by treating professionals.

COMMENTS

SUMMARY POINTS

  • Due to the multifactorial contributors and variable individual responses to child abuse and neglect experiences, individual presentations are highly variable and affected by the developmental stage of the child.
  • Addressing the effects of child abuse and neglect at earlier developmental stages improves outcomes.
  • Unaddressed effects of child abuse and neglect can have long-lasting consequences, resulting in a lifetime of mental and medical problems, with significant public health implications.
  • Identifying and addressing deficits in the child or caregiving system could mitigate the risk of abuse or neglect being perpetuated, including to future offspring.
  • Given the substantial economic burden of child abuse and neglect, continued efforts are needed to bolster effective prevention, prompt identification, and early intervention measures.


RESOURCES

References

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Last updated: October 16, 2014