Child Abuse, Physical

Child Abuse, Physical

Alternative Terms: Battered Child, Child Maltreatment, Family Violence

Physical child abuse refers to harm to the child inflicted by the caregiver. Every year, nearly 1,400 cases of fatal child abuse are reported. Recent information from investigators of child fatality records suggests that the actual number of children killed by their caregivers may be much, much larger. Child Death Review Teams are now being formed in many states to investigate child fatalities that may come from physical abuse. Legal definitions of child abuse vary from state to state, but injuries requiring medical attention are typically regarded as abusive. Nonetheless, the difficulties associated with making these kinds of distinctions are well known, and are often characterized by saying that "one person's 'abuse' is another person's 'discipline'." Many states explicitly note that spanking "when administered in a reasonable manner" does not constitute abuse. Thus, how severely parents can inflict physical punishment upon their children without it being considered abusive remains subject to interpretation.

Child abuse is costly to society in a number of ways. Medical costs for direct care to children injured by their parents exceed $20 million each year; the bulk of this amount is paid by taxpayers through Medicaid. Special education services for abused children cost $7 million per year. The direct costs are small in comparison to the $460 million annual costs of foster care for children removed from their home due to parental maltreatment. None of these costs reflect the dysfunction and misery that are seen later in the lives of some abused children.

Physical abuse differs from emotional abuse, in which the child may be ridiculed, blamed or terrorized; sexual abuse, in which the child is subject to sexual behaviors ranging from exposure to intercourse; and child neglect, in which the parents fail to provide the necessities of life or fail to protect the child from harm. However, the factors that place the child at risk for emotional abuse, sexual abuse, and neglect are similar to the factors that lead to physical child abuse. These factors include personality and social class of the parent and the temperament of the child. Understanding why these factors increase the risk of child abuse may ultimately help intervention efforts. This entry will consider the impact of physical child abuse across several developmental levels, explore the risk factors for child abuse, and look at methods of treatment and prevention.

The U.S. Department of Health and Human Services collects data on the incidence of child abuse in the United States. The accompanying table on page 140 provides information on the distribution by age.

Infancy

Infants who are premature, mentally retarded, or have physical handicaps are more likely to provoke abuse from their caregiver than are infants without such problems. Similarly, nonhandicapped infants who are nonrhythmic (that is, have uneven sleep and eating patterns) are more likely to be abused. It appears that it is the child's tendency to learn slowly, to be less coordinated, or less affectionate—rather than any physical problem per se—that promotes abuse.

Nonabusive parents are responsive to their infants' emotional cues, and tend to alter their interaction with the infant based on the success of their actions. Abusive parents, in contrast, tend to have rigid patterns of responding, regardless of how their infants react. They become angry when their infant does not respond as they think he or she should. In turn, the infants become wary and fail to become comfortably attached to the mother; when the mother tries to leave them, they either cling to her or display negative affect (e.g., fearful expression, screaming), and when she returns they give conflicted messages, demanding the mother and then pushing her away.

Infants, because of their fragility, are more susceptible to injury from physical discipline than older children. Infants are especially susceptible to head injury from shaking or being thrown. A baby can be fatally injured by being thrown even onto a soft mattress. The baby's

brain hits the back of the skull if thrown with even mild force and intracranial bleeding can result. One expert suggested that the majority of fatal head injuries in infants are inflicted by caregivers.

Toddlerhood

Toddlers are among the most difficult children to control. They make the most demands on parents in terms of efforts to feed them and keep them safe, and are the most attention seeking. All of these attributes contribute to the likelihood of a toddler being abused.

Abusive parents are particularly sensitive to threats to their ability to maintain control over the child. Thus, when their children approach the developmental tasks of the "terrible twos," which involve learning autonomy and beginning control over their environment, their normal behavior is often seen by abusive parents as willfulness that must be controlled. Because abusive parents often have inaccurate ideas about the capabilities of toddlers, normal soiling of clothes that occur with eating and toileting are seen as deliberate misbehaviors. If the child is punished inconsistently for behaviors that he or she cannot help, the child feels helpless, angry, and confused about how he or she is supposed to respond. With abusive parents as models, the child begins to react aggressively and with a tantrum to parental discipline, responses which actually serve to heighten the potential for abuse. It is not surprising that 60% of the major physical injuries inflicted by caregivers occur in children under age 4.

Preschool

Children who have been abused typically show developmental delays by the time they are in preschool. It is unclear if these delays occur due to inadequate stimulation and uncertainty in the child about the learning environment, and absence of positive parental interactions that would stimulate language and motor processes, or cumulative neurological damage. These delays, in concert with their parents' higher-than-normal expectations for their children's self-care and self-control abilities, generally provoke additional abuse.

Abused preschoolers respond to peers and other adults with more aggression and anger than do nonabused children. A coercive cycle in which parents and children mutually control one another with threats of negative behavior is evident in many abused preschoolers.

School age

School-age children are expected to function within a variety of social and academic environments. Abused children have more problems within these arenas than do nonabused children. Academic problems are typical, with both poorer grades and poorer performance on standardized achievement tests. Studies that have examined abused children's intellectual performance find lower scores in both verbal and performance (e.g., math, visual-spatial) areas. Abused children also tend to be distractible and overactive, which makes school a very difficult environment.

Peers become increasingly important to school-age children. Abused children are often more aggressive with their peers and are more likely to be socially rejected than other children. They tend to be less mature socially and show difficulty in developing trusting relationships with others.

Abused children are also more disruptive and aggressive within the home, and are frequently viewed by their parents as defiant and noncompliant. Although observational measures confirm their higher levels of disruptiveness, it also appears that the number and intensity of problem behaviors seen by abusive parents in their children may be partially a function of the parents' lower threshold of tolerance for children's noncompliance.

Adolescence

By the time abused children become adolescents, they are more likely to be in contact with the juvenile justice system than children with a comparable family constellation and income level. Many of these children are labeled "ungovernable" for committing such offenses as running away and truancy, but a higher proportion of abused than nonabused delinquent youth are also involved in crimes of assault.

Follow-up on abused children in later adolescence shows that in addition to having problems with the law, they are more likely to be substance abusers or to have emotional disturbances such as depression. Children who are abused are more likely to grow up to be adults who abuse their own children.

Socioculturel factors

Poverty is the sociocultural factor most strongly linked to abuse. Although physical abuse occurs at all income levels, it happens more often in very poor families. It is true that in middle-class families, child injuries are treated by a sympathetic personal physician who may be less likely to diagnose and report abuse-related injuries than the physician in the emergency room who is more likely to treat poor families. Even with such reporting bias, however, poverty seems strongly linked to abuse. It seems that the frustrating effects of poverty on parents are instrumental in creating situations for parents' abuse.

Physical crowding, more likely to occur in poverty, is also associated with abuse. If too many people share a small living space, severe punishment of children as a means of maintaining control is more likely.

If a parent lacks social support, abuse is more likely. Having no one to assist with child care and no one to question the use of severe discipline increase the chance that a parent may injure a child.

Caregiver factors

Parents who were themselves abused as children are more likely to abuse their own children. However, not every parent who was abused becomes an abuser; some parents go to great lengths to insure that they never harm their child.

Parents who abuse their children are likely to be younger than the average parent. They are more likely to be single parents. Having emotional problems such as depression or abusing drugs or alcohol also makes a parent more likely to abuse a child.

Child factors

As noted earlier, children from birth to age 4 are the most likely to be injured from abuse. This may be because young children are physically more vulnerable to severe discipline and because children at this age are the most dependent upon the caregiver, the most in need of parental control, and the most provocative (in terms of making messes, saying "no," and other behaviors).

Children who are handicapped and those who are nonrhythmic (that is, with unpredictable eating and sleeping patterns), are more likely to be abused. Similarly, children who are distractible, impulsive, or who have high activity levels are more likely to draw severe physical discipline.

Components to nonabusive parenting skills

Abusive parents socialize differently from nonabusive parents. Nonabusive parents tend to use ignoring or time-out procedure, whereas abusive parents tend to shout, threaten, and spank. Some forms of child abuse escalate over time, with the parent spanking harder and more frequently to get the same effect or resorting to abuse to get results. Female caregivers inflict more soft tissue injuries, broken bones, and internal injuries than male caregivers. Severe injuries from a single, explosive incident in which the child is shaken, thrown, or struck are more likely to involve male caregivers.

Awareness of child development

Abusive parents often expect the child to perform behaviors he or she is not yet capable of performing. Parents who abuse their young children expect them to be able to control their impulses, recall and obey complex parental rules, and perform mature chains of behavior such a getting up, washing, and getting dressed by themselves. Nonabusive parents recognize that toddlers and preschool children are incapable of such behaviors. Understanding the limitations of a young child's memory, ability to be controlled by words, impulse control, and attention span is essential to developing reasonable expectations for the child. Parents who expect behavior the child cannot deliver are apt to progressively increase their control techniques in order to get the child to comply.

Beliefs and attitudes

Abusive discipline is often the result of the belief that the young child is capable of better behavior and that he or she is deliberately misbehaving to cause the parent difficulty. Such parents often claim that their 18-month-old could stay clean if she wanted to but she dirties her pants just to make more work for the mother. Abusive parents, who believe a child has chosen to misbehave, inflict more punishment on their children than parents who accurately recognize when a child's behavior is not intentional.

Such abusive parents also often believe that effective parenting involves maintaining tight control over the child. A mother who can toilet train her child early and keep the child in line at the grocery store is viewed by abusive parents as a "good" mother. Closely tied to beliefs about the importance of control are aphorisms such as "spare the rod, spoil the child" and "respect comes through fear," which indicate that children learn best through the application of force. Before abusive parents will use skills such as ignoring or time-out, they have to change their beliefs about the importance of control, especially control through physical means.

Another belief abusive parents often hold is that their children should engage in reciprocal parenting. They believe that if they sometimes comfort, wait on, and take care of the child, the child should do the same for them. Such beliefs fit with abusive parents' lack of awareness of children's developmental capabilities and may also stem from the parents' own immaturity and lack of support from other adults. Regardless of the source, when such expectations for children are not met, the parent often responds with anger and hostility.

Emotion

Anger is the most frequent trigger for parental abuse. Abusive parents appear to have a lower threshold for childish behaviors than average parents. Abusive parents are more upset by the same child cues than nonabusive parents. Thus, child behaviors that are merely irritating to average parents are infuriating to abusive parents. Finally, abusive parents may have less control over their anger than nonabusive parents, either because they are unaware of their level of anger, because they are chronically angry, or because they lack anger management skills.

When considering how emotion influences child abuse, it seems important to consider positive emotions as well. Abusive parents experience their children as less rewarding than nonabusive parents. In observation, abusive parents touch their children less, cuddle them less, less frequently call the affectionate names ("honey," "sweetheart"), and smile less at their children. Nonabusive parents respond flexibly to their children, letting the child lead the play interaction. Even in play, abusive parents have expectations that their children seem unable or unwilling to fulfill, making play a disagreeable chore rather than a rewarding endeavor. Abusive parents seem trapped by their own lack of skills, limited developmental understanding, inappropriate expectations, high negative emotion, and low enjoyment of the child.

Altering the parental role

In order to alter abusive parenting, changes need to occur at every level. As abusive parents experience more positive child behaviors, they can respond with praise and rewards to increase the behaviors they like. As positive behaviors increase, negative behaviors decrease. Further, as parents accept the notion that absolute, tight control over the child is not the best goal of parenting, it becomes easier for them to ignore rather than to punish annoying behaviors. If the parent understands that some irritating child behaviors (such as saying "no" or wanting to do it him or herself) are positive and normal developmental behaviors, less anger is directed at the child. Similarly, when the parent's expectations are more in line with what the child can actually do, the parent is not so often annoyed by the child's failure to complete certain tasks, and the parent becomes more competent in requesting appropriate behavior change from the child. When the parent has given up the belief that fear is necessary for children to learn, then the parent is ready to use skills such as ignoring, time-out, and appropriate compliance requests.

Barriers

There are many barriers to change in abusive parental behavior. Most parents' own history suggests that strong physical discipline is the preferred model of parenting. Further, most abusive parents live in families and neighborhoods in which violence is not only condoned but viewed as a necessary vehicle for interpersonal influence. The stresses that are omnipresent in abusive parents' lives assist in maintaining high levels of anger and depression, which block the positive enjoyment of the child. When the parent responds with strong physical discipline, the child's misbehavior typically stops, for that moment at any rate. Thus, the parent is intermittently rewarded for responding abusively. Thus, changing abusive parenting is a challenging task.

It may be preferable to prevent the development of abusive parenting by early interventions to give skills, alter developmental knowledge, change unreasonable parenting expectations, and block the steady build-up of anger and extinguishing of affection for the child. Prevention programs now target teenagers before pregnancy as well as young mothers to try to break the cycle of abuse.

Books

Calam, Rachel, and Cristina Franchi. Child Abuse and Its Consequences: Observational Approaches. New York: Cambridge University Press, 1987. Ludwig, Stephen, and Allan E. Kornberg. Child Abuse: A Medical Reference. 2d ed. New York: Churchill Livingstone, 1992.

Owen, Hilary, and Jacki Pritchard. Good Practice in Child Protection: A Manual for Professionals. Bristol, PA: Jessica Kingsley Publishers, 1993.

Park, Angela. Child Abuse. New York: Gloucester Press, 1988.

Squyres, Suzanne B., Alison Landes, and Jacquelyn Quiram. (eds.) Child Abuse. Wylie, TX: Information Plus, 1997.

Tzeng, Oliver C. S., Jay W. Jackson, and Henry H. Karlson.Theories of Child Abuse and Neglect: Differential Perspectives, Summaries, and Evaluations. New York: Praeger, 1991.

Walker, C. Eugene, Barbara L. Bonner, and Keith L. Kaufman. The Physically and Sexually Abused Child: Evaluation and Treatment. New York: Pergamon Press, 1987.

Audiovisual Recording

Bass, Ellen. The Courage to Heal. New York, NY: Caedmon, 1989.
(Two audio cassettes [three hours].)

. The Courage to Heal. Part 2, Changing Patterns. New York: Harper Audio, 1993.
(Two audio cassettes [3 hours]. )

Battered Child, Battered Trust. New York: Columbia University Seminars on Media and Society, 1986.
(One 60-minute videocassette.)

Childhood Sexual Abuse. Princeton, NJ: Films for the Humanities and Sciences, 1990.
(One videocassette.)

—Lizette Peterson, Ph.D.
University of Missouri-Columbia