8.4 Injuries and Abuse

In almost all families of every income, ethnicity, and nation, parents want to protect their children while fostering their growth. Yet more children die from violence—either accidental or deliberate—than from any specific disease.

The contrast between disease and accidental death is most obvious in developed nations, where medical prevention, diagnosis, and treatment make fatal illness rare until late adulthood. In the United States in 2010, almost six times as many 1- to 4-year-olds died of accidents or homicide than died of cancer (National Center for Health Statistics, 2013).

Avoidable Injury

Worldwide, injuries cause millions of premature deaths among adults as well as children: Not until age 40 does any specific disease overtake accidents as a cause of mortality, and 14 percent of all life-years lost worldwide are caused by injury (World Health Organization, 2010).

In some nations, malnutrition, malaria, and other infectious diseases combined cause more infant and child deaths than injuries do, but nations with high rates of child disease also have high rates of child injury. India, for example, has one of the highest rates worldwide of child motor-vehicle deaths; most children who die in such accidents are pedestrians (Naci et al., 2009). Everywhere, 2- to 6-year-olds are at greater risk than slightly older children. In the United States, for instance, children are more than twice as likely to be seriously hurt in early childhood as in middle childhood.

Why are 2- to 6-year-olds so vulnerable? Some of the reasons have just been explained. Immaturity of the prefrontal cortex makes young children impulsive; they plunge into danger. Unlike infants, their motor skills allow them to run, leap, scramble, and grab in a flash. Their curiosity is boundless; their impulses uninhibited. If they do something that becomes dangerous, such as playing with matches, fear and stress might make them slow to get help.

Age-related trends are apparent in particulars. Falls are more often fatal for the youngest (under 24 months) and oldest (over 80 years); preschoolers have high rates of poisoning and drowning; motor vehicle deaths peak during ages 15–25.

Instead of using the term accident prevention, public health experts prefer injury control (or harm reduction). Consider the implications. Accident implies that an injury is random, unpredictable; if anyone is at fault, it’s a careless parent or an accident-prone child. This is called the “accident paradigm”—as if “injuries will occur despite our best efforts,” allowing the public to feel blameless (Benjamin, 2004, p. 521).

A better phrase is injury control, which implies that harm can be minimized with appropriate controls. Minor mishaps (scratches and bruises) are bound to occur, but serious injury is unlikely if a child falls on a safety surface instead of on concrete, if a car seat protects the body in a crash, if a bicycle helmet cracks instead of a skull, or if swallowed pills come from a tiny bottle.

Less than half as many 1- to 5-year-olds in the United States were fatally injured in 2012 as in 1982, thanks to laws that limit poisons, prevent fires, and regulate cars. Control has not yet caught up with newer hazards, however. For instance, many homes in California, Florida, Texas, and Arizona now have swimming pools: In those states drowning is a leading cause of child death.

Same Situation, Far Apart: Keeping Everyone Safe Preventing child accidents requires action by both adults and children. In the United States (below left), adults passed laws and bought safety seats—and here two sisters have taught each other how to buckle themselves in. In France (below right), teachers stop cars while children hold hands to cross the street—each child keeping his or her partner moving ahead.

© BLUE JEAN IMAGES/ALAMY
© DAVID R. FRAZIER/DANITADELIMONT.COM

Prevention

Prevention begins long before any particular child, parent, or legislator does something foolish. Unfortunately, no one notices injuries and deaths that did not happen. For developmentalists, two types of analysis are useful to predict danger and prevent it.

One is called an accident autopsy. Whenever a child is seriously injured, analysis can find causes in the microsystem and exosystem as well as in the macrosystem, and thus protect children in the future. For example, when a child is hit by a car and dies, an autopsy might point not only to parental neglect (microsystem), but also to the lack of parks, speed limits, traffic lights, sidewalks, or curbs (exosystem) or to the fact that the entire nation values fast cars over slow pedestrians (macrosystem).

The second type of analysis involves looking at statistics. For example, the rate of childhood poisoning decreased markedly when pill manufacturers adopted bottles with safety caps that are difficult for 2-year-olds to open; such a statistic goes a long way in countering complaints about the inconvenience of the bottles. New statistics show a rise in the number of children being poisoned by taking adult recreational drugs, such as cocaine, which has become another target for prevention.

Three levels of prevention apply to every health and safety issue.

• primary prevention Actions that change overall background conditions to prevent some unwanted event or circumstance, such as injury, disease, or abuse.

  In primary prevention, the overall situation is structured to make harm less likely. Primary prevention fosters conditions that reduce everyone’s chance of injury.

• secondary prevention Actions that avert harm in a high-risk situation, such as stopping a car before it hits a pedestrian.

  Secondary prevention is more specific, averting harm in high-risk situations or for vulnerable individuals.

• tertiary prevention Actions, such as immediate and effective medical treatment, that are taken after an adverse event (such as illness or injury) and that are aimed at reducing harm or preventing disability.

  Tertiary prevention begins after an injury has already occurred, limiting damage.

In general, tertiary prevention is the most visible of the three levels, but primary prevention is the most effective (Cohen et al., 2010). An example comes from data on pedestrian deaths. Fewer people in the United States die after being hit by a motor vehicle than did 35 years ago (see Figure 8.6). How does each level of prevention contribute?

While the Population Grew This chart shows dramatic evidence that prevention measures are succeeding in the United States. Over the same time period, the total population has increased by about one-third, making these results even more impressive.

Source: United States Department of Transportation, 2012.

Primary prevention includes sidewalks, speed bumps, pedestrian overpasses, streetlights, and traffic circles. Cars have been redesigned (e.g., better headlights, windows, and brakes), and drivers’ competence has improved (e.g., with stronger drunk-driving penalties). Reduction of traffic via improved mass transit provides additional primary prevention.

Secondary prevention reduces danger in high-risk situations. School crossing guards and flashing lights on stopped school buses are secondary prevention as are salt on icy roads, warning signs before blind curves, speed bumps, and walk/don’t walk signals at busy intersections.

Finally, tertiary prevention reduces damage after an accident. Examples include laws against hit-and-run drivers, speedy ambulances, efficient emergency room procedures, and effective rehabilitation, all of which have been improved from decades ago. Medical personnel speak of the golden hour, the hour following an accident, when a victim should get to emergency care. Of course, there is nothing magical about 60 minutes in contrast to 61 minutes, but the faster an injury victim reaches a trauma center, the better the chance of survival (Bansal et al., 2009).

Child Maltreatment

Until about 1960, people thought child maltreatment was rare and consisted of a sudden attack by a disturbed stranger. Today we know better, thanks to a pioneering study based on careful observation in one Boston hospital (Kempe & Kempe, 1978). Maltreatment is neither rare nor sudden, and the perpetrators are usually one or both of the child’s own parents. That makes it much worse: Ongoing maltreatment, with no protector, is much more damaging than a single incident, however injurious.

Child maltreatment now refers to all intentional harm to, or avoidable endangerment of, anyone under 18 years of age. Thus, child maltreatment includes both child abuse, which is deliberate action that is harmful to a child’s physical, emotional, or sexual well-being, and child neglect, which is failure to meet essential physical or emotional needs.

The more that researchers study the long-term effects of maltreatment, the worse neglect seems to be, especially in early childhood. It also is increasingly common. Data on cases of substantiated maltreatment from all 50 U.S. states in 2010 found that 78 percent were cases of neglect, 18 percent physical abuse, and 9 percent sexual abuse (a few were tallied in two categories) (U.S. Department of Health and Human Services, 2012).

Substantiated maltreatment means that a case has been reported, investigated, and verified (see Figure 8.7). The U.S. rate was about 700,000 in 2011; almost 200,000 of these incidents occurred during the victims’ preschool years. Annually about 1 in every 90 young children, aged 2 to 5 years old, is substantiated as a maltreatment victim.

Still Far Too Many The number of substantiated cases of maltreatment of children under age 18 in the United States is too high, but there is some good news: The rate has declined significantly from its peak in 1993.

Source: U.S. Department of Health and Human Services, 2003 (Fig. 3-2), 2008 (p. 26), 2011 (p. 22)

Reported maltreatment means simply that the authorities have been informed. Since 1993, the number of children reported as maltreated in the United States has ranged from about 2.7 million to 3.6 million per year.

The three-to-one ratio of reported versus substantiated cases occurs because:

1. Each child is counted only once. Thus, five verified reports about a single child can result in one substantiated case.
2. Substantiation requires proof. Not every investigation finds unmistakable injuries, severe malnutrition, or a witness willing to testify.
3. Many professionals are mandated reporters, required to report any signs of possible maltreatment. Some signs are caused by something that could be maltreatment, but investigation finds another cause (Pietrantonio et al., 2013).
4. A report may be false or deliberately misleading (though few are) (Kohl et al., 2009).

Abuse Victim? Fair-skinned Anna, age 5, told the school nurse she was sunburned because her mommy, Patricia, took her to a tanning salon. Patricia said Anna was gardening in the sun; Anna’s father and brother (shown here) said all three waited outside the salon while Patricia tanned inside. The story led to an arrest for child endangerment, a court trial, and a media frenzy. Was the media abusive, the nurse intrusive, or the opposite? If your child is sunburned, is it your fault?

CHRISTOPHER SADOWSKI/SPLASH NEWS/NEWSCOM

How often does maltreatment actually occur? No one knows. Not all cases are noticed; not all that are noticed are reported; and not all reports are substantiated. Similar issues apply in every nation, city, and town, with marked variations in reports and confirmations.

If we rely on official U.S. statistics, interesting trends are apparent. Officially, substantiated child maltreatment increased from about 1960 to 1990 but decreased thereafter (see Figure 8.8). Physical and sexual abuse declined but neglect did not. Other sources also report declines over the past two decades. That seems to be good news; perhaps national awareness of child abuse led to better reporting and then better prevention.

Getting Better? As you can see, the number of victims of child maltreatment in the United States has declined in the past decade. The legal and social-work responses to serious maltreatment have improved over the years, which is a likely explanation for the decline. Other, less sanguine explanations are possible, however.

Source: U.S. Bureau of the Census, 201Ib.

Unfortunately official reports leave room for doubt. For example, Pennsylvania and Maine reported almost identical numbers of substantiated victims in 2010 (3,388 and 3,270, respectively), but the child population of Pennsylvania is ten times that of Maine. No one thinks that Maine children suffer ten times more than Pennsylvania children; something in reporting or substantiating must differ between those two states. Whether or not maltreatment is reported is powerfully influenced by culture (one of my students asked, “When is a child too old to be beaten?”) and by personal willingness to report. The United States has become more culturally diverse; could that be why reports are down?

In a confidential nationwide survey of young adults in the United States, 1 in 4 said they had been physically abused (“slapped, hit, or kicked” by a parent or other adult caregiver) before sixth grade, and 1 in 22 had been sexually abused (“touched or forced to touch someone else in a sexual way”) (Hussey et al., 2006). Almost never had their abuse been reported. The authors of this study think these rates are underestimates (Hussey et al., 2006)!

One reason for these high rates may be that the respondents were asked if they had ever been mistreated by someone who was caring for them; most other sources report annual rates. Another reason is that few children report their own abuse. Indeed, many children do not realize that they are mistreated until later, when they compare their experiences with those of their friends. Even then, some adults who were slapped, hit, or kicked in childhood do not think they were abused.

Often the first sign of maltreatment is delayed development, such as slow growth, immature communication, lack of curiosity, or unusual social interactions. All these difficulties may be evident even at age 1 (Valentino et al., 2006).

During early childhood, maltreated children may seem fearful, startled by noise, defensive and quick to attack, and confused between fantasy and reality. These are symptoms of post-traumatic stress disorder (PTSD), first identified in combat veterans, then in adults who had experienced some emotional injury or shock (after a serious accident, natural disaster, or violent crime), and more recently in some maltreated children, who suffer neurologically, emotionally, and behaviorally (Neigh et al., 2009; Weiss et al., 2013). Table 8.1 lists signs of child maltreatment, both neglect and abuse. None of these signs are proof that a child has been abused, but whenever any of them occurs, it signifies trouble.

The impact of any child-rearing practice is affected by the cultural context. Certain customs (such as circumcision, pierced ears, and spanking) are considered abusive in some cultures but not in others; their effects vary accordingly. Children suffer if their parents seem to love them less than most parents in their neighborhood. If a parent forbids something other children have (from candy to cell phones) or punishes more severely or not at all, children might feel unloved. However, although culture is always relevant, there is no doubt that the impact of maltreatment is multifaceted and long-lasting.

The biological and academic impairment resulting from maltreatment is substantial and thus relatively easy to notice, as when a teacher sees when a child is bruised, broken, shivering, or failing. However, when researchers follow maltreated children over the years, enduring deficits in social skills usually seem more crippling than physical damages. Some research finds that maltreated children tend to hate themselves, and then hate everyone else, with effects still evident in adulthood (Sperry & Widom, 2013).

Hate is corrosive. A warm and enduring friendship might repair some of the damage, but maltreatment itself makes such a friendship unlikely. Many studies have found that mistreated children typically regard other people as hostile and exploitative; hence, abused children are less friendly, more aggressive, and more isolated than other children. The earlier the abuse starts and the longer it continues, the worse their peer relationships are (Scannapieco & Connell-Carrick, 2005). Neglected children may have greater social deficits than abused ones because they never had healthy relationships with their parents (Stevenson, 2007).

Deficits are lifelong. Maltreated children may become bullies or victims or both, not only in childhood and adolescence but also in adulthood. They tend to dissociate, that is, to disconnect their memories from their understanding of themselves (Valentino et al., 2008). Adults who were severely maltreated as children (physically, sexually, or emotionally) often abuse drugs or alcohol, enter unsupportive relationships, become victims or aggressors, sabotage their own careers, eat too much or too little, and engage in other self-destructive behavior (Sperry & Widom, 2013). They also have a much higher risk of emotional disorders and suicide attempts, even after other risk factors (e.g., poverty) are considered (Afifi et al., 2008).

In the current economic climate, finding and keeping a job is a critical aspect of adult well-being; adults who were maltreated suffer with regard to employment as well. One study carefully matched 807 children who had experienced substantiated abuse with other children who were of the same sex, ethnicity, and family SES. About 35 years later, long after the maltreatment had stopped, those who had been mistreated were 14 percent less likely to be employed than those who had not been abused. The researchers concluded: “abused and neglected children experience large and enduring economic consequences” (Currie & Widom, 2010, p. 111). In this study, the women were more impaired than the men: The reason may be that self-esteem, emotional stability, and social skills are even more important for female than for male workers.

This study is just one of hundreds of longitudinal studies, all of which find that maltreatment affects children decades after the broken bones, or skinny bodies, or medical neglect disappear. To protect the health of the entire society in the future, we need to stop maltreatment now.

Three Levels of Prevention, Again

Just as with injury control, the ultimate goal with regard to child maltreatment is primary prevention, in which a changed social context makes parents and neighbors more likely to protect every child. Neighborhood stability, parental education, income support, and fewer unwanted children all reduce the rate of maltreatment.

Secondary prevention involves spotting warning signs and intervening to keep a risky situation from getting worse (Giardino & Alexander, 2011). For example, insecure attachment, especially of the disorganized type, is a sign of a disrupted parent–child relationship. [Lifespan Link: Attachment types are explained in detail in Chapter 7].

Maltreatment is reduced by home visits from helpful nurses or social workers and by high-quality day care that gives vulnerable parents a break and helps children make friends. Families with several young children are at higher risk, especially when the head of the family is a single parent with money problems. If a nation has free health care for everyone, and if every health worker is a mandated reporter, children can be protected before serious harm occurs.

Tertiary prevention is geared to the limitation of harm after maltreatment has occurred. Reporting and substantiating abuse are the first steps. Often the caregiver needs help in providing better care. Sometimes the child needs another home. If hospitalization is required, that signifies failure: Intervention should have begun much earlier. At that point, treatment is very expensive, harm has already been done, and hospitalization itself further strains the parent–child bond (Rovi et al., 2004).

Children need caregivers they trust, in safe and stable homes, whether they live with their biological parents, a foster family, or an adoptive family. Whenever a child is removed from an abusive or neglectful home, permanency planning must begin, through which a family is found to nurture the child until adulthood.

This requires cooperation among social workers, judges, and psychologists as well as the caregivers themselves (Edwards, 2007). Sometimes the child’s original family can become better caregivers; sometimes a relative can be found who will provide good care; sometimes a stranger is the best caregiver.

Similar problems arise for homeless children, who often not only move from place to place but also move in and out of the foster care system (Zlotnick et al., 2012). The best ways to help such children are not obvious, as research-based solutions are rarely tested, but it is clear that children whose parents cannot care for them need a permanent family who will guide them throughout childhood.

In foster care, children are officially taken from their parents and entrusted to another adult or family; foster parents are reimbursed for the expenses they incur in meeting the children’s needs. In every year from 2000 to 2011, about half a million children in the United States were in foster care. More than half of them were in a special version of foster care called kinship care, in which a relative—usually a grandmother—becomes the caregiver. This estimate is for official kinship care; three times as many children are unofficially cared for by relatives.

Mother-Daughter Love, Finally After a difficult childhood, 7-year-old Alexia is now safe and happy in her mother’s arms. Maria Luz Martinez was her foster parent and has now become her adoptive mother.

AURELIA VENTURA/LA OPINION/NEWSCOM

In every nation, most foster children are from low-income, ethnic-minority families, a statistic that reveals problems in the macrosystem as well as the microsystem. In the United States, children in foster care often have experienced severe maltreatment and multiple physical, intellectual, and emotional problems (Jones & Morris, 2012). Despite these problems, most develop better in foster care (including kinship care) than with their original abusive families if a supervising agency provides ongoing financial support and counseling (MacMillan et al., 2009; Oosterman et al., 2007).

Adequate support is not typical, however. One obvious failing is that many children move from one foster home to another for reasons that are unrelated to the child’s behavior or wishes (Jones & Morris, 2012). Each move increases the risk of a poor outcome (Oosterman et al., 2007). Another problem is that kinship care is sometimes used as an easy, less expensive solution. Kinship care may be better than stranger care, but supportive services are especially needed since the grandparent who gets the child is also the parent of the abusive adult (Edwards, 2010; Fechter-Leggett & O’Brien, 2010).

Adoption (when an adult or couple is legally granted parenthood) is the best permanent option when a child should not be returned to a parent. However, adoption is difficult for many reasons, among the following:

• Judges and biological parents are reluctant to release children for adoption.
• Most adoptive parents prefer infants.
• Some agencies screen out families not headed by a heterosexual married couple.
• Some professionals insist that adoptive parents be of the same ethnicity and religion as the child.
• Some adults who want to adopt are not ready for the responsibilities entailed.

As detailed many times in this chapter, caring for young children is not easy, whether it involves making them brush their teeth or keeping them safe from harm. Parents shoulder most of the burden, and their love and protection usually result in strong and happy children. Teachers can be crucial during these years, working closely with the parents. Beyond the microsystem, however, complications abound. Parents and teachers are failing with at least a million young children in the United States. The benefit to the entire community of well-nurtured children is obvious; the ways for the society to achieve that goal seem less clear.