The Still-Harrowing Extent of Child Abuse and Neglect

The Institute of Medicine released a report today that describes the continued plague—and proposes an ambitious strategy to address it.

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It’s hard to contemplate, but it wasn't too long ago that beating, berating, or leaving a child to fend for himself might be considered acceptable behavior. As Cris Beam explains in her new book on the foster care system, To the End of June, the U.S. only began defining the “battered child syndrome” in the early 1960s, thanks to the advent of X-ray technology.

X-rays allowed radiologists to see unexplained bone fractures. Sometimes there were several. One enterprising pediatrician, C. Henry Kempe, surveyed emergency rooms and discovered shocking patterns of non-accidental injuries like burns and brain damage.

These brutal trespasses were secrets closely guarded in all manner of American households, but once the evidence was marshaled before the public there was outcry. So followed a wave of legislation to protect the vulnerable from both neglect and abuse.

Fifty years later, then, we might expect a near eradication of child abuse and neglect. Yet, according to a new report published today by the Institute of Medicine, much of it remains endemic and we still don’t know why or how best to stop it. The report’s authors call for “swift and effective” action from government and local communities to finally uproot this stubborn problem by conducting new research, creating new partnerships and improving the child welfare system.

Nine out of every 1,000 children are victims of abuse and neglect every year, according to the report, but that likely underestimates the extent of maltreatment as it counts only those whose situations are so dire they are referred to authorities. That number could be as high as 17 out of every 1,000 children.

Since the last IOM report on child maltreatment was issued 20 years ago, numerous studies have demonstrated the awful effects of physical and emotional cruelty – a literature the report calls a “new science of child abuse and neglect.”

We now know that maltreatment puts kids at risk for learning problems, depression and anxiety, conduct disorders and post-traumatic stress. As adults, many of these battered children find it difficult to thrive, and they experience psychiatric illness, drug and alcohol addiction, and chronic disease.

Just the original abuse and neglect is expensive, on par with the cost of type 2 diabetes and stroke. The IOM report notes that abuse and neglect cases cost as much as $80 billion annually—there are hospitalizations, child welfare and law enforcement expenses, early intervention services, adult homelessness programs, mental health care and more.

And yet despite the clear threat to public health, we still know little about the causes of maltreatment and how to effectively prevent it. Risk factors include substance abuse, depression, and a childhood history of harm, but then there are variables like poverty and stressful environments, all of which complicate why and when a parent abuses or neglects his or her kid. The report calls for longitudinal studies that would start before birth and track children throughout their lives to see which parents abuse and neglect and in which circumstances.

There is one spot of truly encouraging news from the report, which is that sexual abuse has unequivocally dropped by as much as 62 percent in the past two decades. There is also data indicating that the rate of physical abuse has fallen significantly as well, but there are caveats, according to the report. Surveys show a decrease, but largely for peer and sibling assaults. When parents report their own behavior, it is perhaps more flattering than reality as children continue to report physical abuse.

Neglect, a broad category that includes physical, emotional and educational needs, is where the least progress has been made. Think of a child that is sent to school for days without a bath or clean clothes. Or a toddler that is routinely denied affection. Lest the public think these are the most benign types of maltreatment, neglect accounts for three-quarters of all cases and may very well be the most harmful.

Mary Dozier, an IOM panel member and expert on child development at the University of Delaware, told me that neglect is the “absence of parental involvement,” which is critical during early childhood. The committee responsible for the report, she said, concluded that neglect is at least as “pernicious” in its effect on development as abuse.

While the IOM committee is eager to stress that great strides have been made in the past 20 years, one can’t help but feel a bit of déjà vu.

“We called for the same kind of thing in the ’93 report,” said Anne Petersen, a research professor at University of Michigan’s Center for Human Growth and Development, and chair of both IOM committees.

The kind of thing she’s referring to is a systematic overhaul of the way we research and prevent maltreatment. The committee envisions a federal-public-private partnership that sets a research agenda for investigating the causes and consequences of maltreatment. It would also create a national surveillance system and urges legislatures to actually evaluate the impact of related laws and policies.

Such ambition is sorely needed in the field. Recently, the U.S. Preventive Services Task Force said it couldn't recommend existing maltreatment prevention interventions to primary care doctors because of insufficient evidence. This included the popular home visitation program in which a nurse provides parent education, counseling and other services to a pregnant or new mother.

While there’s promising evidence that this program helps stop maltreatment before it begins, according to the IOM report, it also has many different adaptations, making it difficult to compare across multiple studies. In short, studies in this field need to be more rigorous. Even when there are effective interventions, the report points out that the child welfare system has limited capacity to deliver them because of high caseloads and poorly trained staff, among other factors.

The IOM committee is hopeful that a new start is imminent. They would like to see collaboration among every entity that touches a maltreatment case – from social workers to physicians to researchers to law enforcement. Whether or not the political will exists to take on a billion-dollar problem with new funding is another question. But it may be the only way to put an end to the quiet, everyday tragedies that too many children face.