We have saved for the end of this chapter the most disturbing topic: child maltreatment. The assumption thus far has been that adults seek the best for young children and that their disagreements (e.g., what to feed, what kind of preschool, how to discipline) arise from contrasting theories about how best to foster happy and healthy children.

However, sometimes parents angrily harm their own offspring and other adults do not protect children. When a child is officially deemed abused or neglected, almost always (90 percent of the time) the perpetrator was the child’s biological parent (U.S. Department of Health and Human Services, January 15, 2015).

Parents are not the only ones to blame. The food, air, play space, and medical care that all children need is not always available, in part because communities and governments have other priorities. Often preventive and protective measures that could stop injuries, abuse, or other forms of harm are missing. Far more children die from violence—either accidental or deliberate—than from any specific disease, and almost every child is harmed by hazards that could have been prevented.

Overall, an important change in terminology is needed. Instead of using the term accident prevention, public health experts prefer harm reduction. Accident implies that an injury is random, unpredictable; if anyone is at fault, it’s a careless parent or a child. Further, accident usually refers to a sudden, unexpected event. Instead, harm reduction makes it clear that much can be done long before an injury or illness occurs to reduce the damage from any hazard.

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Many community practices and national policies to reduce harm have already been mentioned. Among them are measures to ensure adequate nutrition, oral health, safe play spaces, preventive immunization, and quality preschools.

There is neither time nor space to explore all the other ways young children may be harmed by social neglect of their needs. We present only two examples, motor-vehicle accidents and lead. In both cases, a long process began with research, eventually protecting thousands of young lives.

INJURIES FROM CARS AND TRUCKS Worldwide, motor vehicles cause millions of premature deaths among adults as well as children: Not until age 40 does any specific disease overtake cars and trucks as a cause of mortality. Of all the life years lost worldwide, 14 percent are caused by accidents, with motor-vehicle accidents the most common (World Health Organization, 2010).

In some nations, malnutrition, malaria, and other infectious diseases cause most infant and child deaths, but even in those nations too many children are killed by cars. 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, young children are at greater risk than slightly older ones. In the United States, 2- to 5-year-olds are more than twice as likely to be seriously hurt in crashes as 6- to 10-year-olds.

Why are young children so vulnerable? Some 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 into the street in a flash, before a watching adult can stop them. Their curiosity is boundless; their impulses uninhibited.

Fatal accidents for young passengers and pedestrians are less common than they were a few decades ago, even though more cars are on the road and more miles are driven. In the United States, in 2012, fewer than 3 preschoolers per 100,000 were killed by motor vehicles compared to almost 12 per 100,000 in 1970. How did this victory occur?

A major reason is mandated child-safety seats. In the 1970s, doctors and nurses in a leading hospital in Washington State advised new parents to take their newborn babies home in a restraining seat. That doubled the rate of newborns in car seats, from 9 percent to 22 percent—considered a major victory (Scherz, 1976).

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As more parents took that advice from experts, the data began to confirm that safety seats saved lives. One by one, each of the 50 states has made it illegal to transport a young child not in a secure car seat. Unsafe transportation included a passenger holding the baby, as almost all mothers (including me) once did.

ELIMINATING LEAD Lead was recognized as a poison a century ago (Hamilton, 1914). The symptoms of plumbism, as lead poisoning is called, were obvious—-intellectual disability, hyperactivity, and even death if the level reached 70 micrograms per deciliter of blood.

The lead industry defended the heavy metal. Manufacturers argued that low levels were harmless and blamed parents for letting their children eat flaking chips of lead paint (which tastes sweet).

Lead remained a major ingredient in paint (it speeds drying) and in gasoline (it raises octane) for most of the twentieth century. The fact that babies in lead-painted cribs, preschoolers playing near traffic, and children living beside industrial waste all demonstrated intellectual disability and hyperactivity was claimed to be correlation, not causation.

Finally, chemical analysis of blood and teeth, with careful longitudinal and replicated research, proved that lead was indeed a poison for children (Needleman et al., 1990; Needleman & Gatsonis, 1990). The United States banned lead in paint (in 1978) and automobile fuel (in 1996). The blood level that caused plumbism was set at 40 micrograms per deciliter, then 20, then 10. Recently, danger has been thought to begin at 5 micrograms, with no level proven safe (MMWR, April 5, 2013).

Regulation has made a difference: The percentage of U.S. 1- to 5-year-olds with more than 5 micrograms of lead per deciliter of blood was 8.6 percent in 1999–2001, 4.1% in 2003–2006, and 2.6 percent in 2007–2010 (see Figure 6.3). It continues to fall. Children who are young, low-SES, and/or living in old housing have higher levels (MMWR, April 5, 2013).

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In most areas, pediatricians test infant blood levels, and parents take precautions, such as increasing their children’s calcium intake, wiping window ledges clean, testing drinking water, avoiding lead-based medicines and crockery (available in some nations), and never letting children eat peeling paint.

In some states (e.g., Colorado and Wyoming), average lead levels of young children are close to zero. In other states that once had extensive lead-based manufacturing, young children are still at risk, as there is lead in the soil and dust. In 2010, Pennsylvania documented 509 children under age 6 with more than 20 micrograms per deciliter in their blood; Ohio had 417; and Michigan had 254 (National Center for Environmental Health, 2012).

Scientists sometimes use data collected for other reasons to draw new conclusions. This is the case with lead. About 15 years after the sharp decline in blood lead levels in preschool children, the rate of violent crime committed by teenagers and young adults fell sharply. Coincidence? Some scientists decided to test it.

International research was crucial, because the year in which nations passed laws reducing lead varied. The year crime rates plummeted also varied, but generally it occurred about 15 years after the laws reducing lead. The correlation between reduced lead and reduced impulsive crime occurs in every nation that has reliable data on lead and crime—Canada, Germany, Italy, Australia, New Zealand, France, and Finland (Nevin, 2007). Researchers also found that lead levels in childhood predict later attention deficits and school suspensions (Amato et al., 2013; Goodlad et al., 2013).

There is now no doubt that lead harms the brain. Might some of the thousands of new chemicals in the air, water, or soil also cause brain damage? That raises questions about government priorities.

The U.S. government in 2000 planned to follow 100,000 children, beginning before birth, in the National Children’s Study. Various substances in the blood would have been tested. However, that study was reduced, revised, redesigned, and finally canceled at the end of 2014 (Kaiser, 2014). Developmentalists hope that other research will inform us about harmful substances more quickly than the 100 years that elapsed with lead. The U.S. Congress might reinstate the National Children’s Study in 2015.

Child maltreatment includes any form of serious harm to a child under age 18, and it includes abuse (deliberate physical or sexual action) and neglect (failure to provide essential physical or emotional care). Although abuse makes headlines, neglect is “the most common and most frequently fatal form of child maltreatment” (Proctor & Dubowitz, 2014, p. 27).

In the United States, of all the substantiated cases of child maltreatment in 2013, 80 percent were neglect, 18 percent physical abuse, 9 percent sexual abuse, and 9 percent emotional abuse. [A few were tallied in two categories (U.S. Department of Health and Human Services, January 15, 2015).]

Substantiated maltreatment means that a case has been reported, investigated, and verified (see Figure 6.4). In 2013, almost 679,000 children suffered substantiated abuse in the United States. Substantiated maltreatment harms about 1 in every 90 children aged 2 to 5 annually.

Reported maltreatment means simply that the authorities have been informed. Since 1993, the number of reports per year in the United States has ranged from about 2.7 million to 3.6 million, with 3.5 million (involving more than 6 million children, since often a report is about all the children in a family) in 2013 (U.S. Department of Health and Human Services, January 15, 2015).

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The 5-to-1 ratio of reported versus substantiated cases occurs because:

Officially, substantiated child maltreatment increased from about 1960 to 1990 and decreased thereafter, and it continued to decrease from 2012 to 2013 (see Figure 6.5). Physical and sexual abuse declined but neglect did not. Other sources also report declines, particularly in sexual abuse, over the past two decades (Finkelhor & Jones, 2012). Perhaps national awareness has led first to more reporting and then to better prevention.

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Unfortunately, official reports leave room for doubt. Wide disparities are evident from state to state in number of victims and categories of maltreatment. For example, Pennsylvania reports fewer victims of child maltreatment than Maine (3,260 compared to 3,820 in 2013), but the child population of Pennsylvania is ten times that of Maine. Why?

Disparities are also evident in rates among people of various ethnic backgrounds. For example, compared to European Americans, in Alaska the rate of child maltreatment is a third lower for African Americans but nine times higher for Alaska Natives. Why?

For developmentalists, a particular problem is that maltreatment is most common early in life, when children are too young to ask for help or to be required to go to school (where teachers would notice a problem). In fact, the substantiated maltreatment rate for those age 2 to 6 is 50 percent higher than for those age 6 and older (U.S. Department of Health and Human Services, January 15, 2015). Are many more young children mistreated but not reported?

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 are evident during early childhood or even infancy. Maltreated children may seem fearful, startled by noise, defensive and quick to attack, and confused between fantasy and reality.

Posttraumatic stress disorder (PTSD) was first identified in combat veterans and then in adults who had experienced some emotional injury or shock (after a serious accident, natural disaster, or violent crime). But the symptoms of maltreated children (as in the previous paragraph) coincide with PTSD. We now believe that some maltreated children suffer from PTSD, with signs of neurological, emotional, and behavioral damage (Neigh et al., 2009; Weiss et al., 2013).

CONSEQUENCES OF MALTREATMENT The immediate harm of maltreatment is obvious, as when a child is bruised, broken, afraid to talk, or failing in school (see Table 6.3 for other signs). However, that is just the beginning. When researchers follow maltreated children over the years, enduring deficits in social skills seem more crippling than physical harm.

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Even if a child was mistreated in the early years and then not after age 5, emotional problems linger (Godinet et al., 2014). The effects (drug abuse, social isolation, poor health) are still evident in adulthood (Sperry & Widom, 2013; Mersky et al., 2013).

Finding and keeping a job is a critical aspect of adult well-being, yet adults who were maltreated suffer in this way 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 maltreatment had stopped, those who had been mistreated were 14 percent less likely to be employed.

The researchers concluded, “abused and neglected children experience large and enduring economic consequences” (Currie & Widom, 2010, p. 111). In this study, women were more impaired than men: It 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 concluding that childhood maltreatment affects people decades after broken bones, frail bodies, or medical neglect disappear. To protect the future health of the entire society, prevention of child maltreatment is crucial.

The role of laws in keeping children safe is dramatically highlighted in the data on car seats and blood lead levels. Over the same decades, a much better understanding of prevention has occurred. Social measures, not merely parental love and vigilance, are important.

We now see three levels of prevention: Primary prevention changes the social context; secondary prevention focuses on high-risk situations, and tertiary prevention limits harm after the injury. Each makes a difference.

FOR CARS AND LEAD For motor-vehicle accidents, primary prevention includes sidewalks, pedestrian overpasses, streetlights, speed limits, traffic lights, and stop signs. Redesigned cars (e.g., better headlights, windows, and brakes) and improved driver competence (e.g., strong penalties against drunk driving, more effective licensing tests) are also primary prevention. Improved mass transit provides additional primary prevention.

Secondary prevention reduces danger in high-risk situations, or for high-risk people. Car seats for children, school crossing guards and flashing lights on stopped school buses, salt on icy roads, warning signs before blind curves, and speed bumps are all secondary.

Finally, tertiary prevention reduces damage after an accident. Examples include harsh penalties for hit-and-run drivers, use of speedy ambulances, efficient emergency room procedures, and effective follow-up care, all of which have been improved from decades ago.

The same triad works for every harm. For lead, laws about gasoline were primary prevention, while testing children and keeping them away from renovation of old houses was secondary prevention. Tertiary prevention sometimes meant giving the child drugs to remove the toxic metal from the bloodstream. This is called chelating, which is itself hazardous as well as a sign that prevention should have begun much earlier.

FOR ABUSE AND NEGLECT The ultimate goal with regard to child maltreatment is primary prevention, a social network of customs and supports that make parents, neighbors, and professionals protect every child. Neighborhood stability, parental education, income support, and fewer unwanted children all reduce maltreatment.

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Secondary prevention involves spotting warning signs and intervening to keep a risky situation from getting worse. For example, insecure attachment, especially of the disorganized type, is a sign of a disrupted parent–child relationship, which is a risk factor for maltreatment. Many programs seek to repair insecure attachment before harm occurs.

One famous program, first reported decades ago, sent nurses to visit new, low-SES parents repeatedly at home, teaching them about their babies. Years later, less maltreatment occurred. This program has now been replicated many times, usually fostering better mother–child relationships and lower mortality rates over the decades—not only for the children but also for the mothers (e.g., Olds et al., 2014).

Early, free preschool education, especially when it includes close parent–teacher relationships, prevents serious maltreatment in two ways: (1) Parents learn how to help rather than mistreat their children; and (2) teachers can spot problems and find solutions before too much damage occurs.

Tertiary prevention limits harm after maltreatment. Reporting and substantiating abuse are the first steps. Often the caregiver needs help in providing better care. Sometimes the child needs another home. Ironically, primary and secondary prevention are more effective in the long run, but projects are more likely to be funded and implemented if they begin with children who are already mistreated, and thus are tertiary prevention (Nelson & Caplan, 2014).

All levels of prevention require helping caregivers—biological, foster, or adoptive parents—to provide a safe, nurturing, and stable home. Whenever a child is removed from an abusive or neglectful family, plans need to be made to nurture the child until adulthood, either by supporting the original family or finding a new home (Scott et al., 2013).

In foster care, children are officially taken from their parents and entrusted to another adult; foster parents are reimbursed for the expenses they incur in meeting the children’s needs. In every year from 2000 to 2014, almost half a million children in the United States were in foster care. Many 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.

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Children in both kinds of foster care do better, academically and emotionally, than children who continue to be mistreated by their biological parents. Supportive services are especially needed in kinship care, since the grandparent may also be the parent of the abusive adult and typically lives with the same poverty, racism, and violence that contributed to the original problems. All of this affects the foster child as well (Hong et al., 2011).

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. Beyond the microsystem, however, complications abound.