Indicators of Child Maltreatment
Physical Indicators of child maltreatment are usually observable. However, radiological examination, as well as laboratory data, may be necessary to discover the full extent of the injury or harm. Physical indicators should be considered in light of the medical history and the developmental ability of the child to injure or harm him/herself.
Behavioral Indicators are less tangible than physical indicators. however, you must be cognizant of the range of behavior expected of children in a given developmental stage. A child's behavior which falls outside this range can often be a clue to the presence of child abuse or neglect. Behaviors exhibited by physically abused children are often hard to differentiate from behaviors of neglected children. For that reason, consider the listed behavioral indicators as an another clue which may indicate a child has been injured or harmed.
Familial Indicators. We now understand that the maltreatment of children recognizes no boundaries of race, creed, nationality, educational attainment, or socioeconomic status. Further, parents responsible for a child's injury or harm may have a caring attitude toward the child, yet lack appropriate parenting skills. We need to be alert for valuable clues in the behaviors and attitudes of the parents as well as the family history. The familiar indicators are based on a composite of many cases and you are cautioned that the clues are not exhaustive and that the presence of a single parental characteristic does not necessarily mean that maltreatment exists.
Physical, behavioral and familial indicators must be interpreted as pieces of a puzzle which, when pieced together, allow for an informed 'reason to believe' that a child has been injured or harmed.
When identifying child maltreatment , in general, you should be alert for cases in which there is:
•   a reversal of parent/child roles;
•   a lack of parental impulse control;
•   a delay in seeking medical attention;
•   an inadequate or inconsistent explanation of the injury/harm;
•   a previous history of unexplained injury/harm to the child or a sibling;
•   an abnormally high frequency of injury;
•   parental admission of the injury/harm;
•   direct parental threats toward the child; and
•   avoidance in answering questions.
Always be aware that child neglect and child abuse are not on the same continuum. A person who neglects a child does not necessarily physically abuse a child. A simple rule of thumb may be helpful:

Child abuse generally invokes an act of commission (striking, sexual molestation) while child neglect generally involves an act of omission (withholding care and attention, abandonment). It is true, however, that both abuse and neglect may be present in the same household.
More specific clues are listed below. They are not all inclusive. Nor does the presence of a single indicator necessarily denote child abuse or neglect. however, the repeated occurrence of an indicator, the presence of several indicators in combination, or the appearance of serious injury/harm or suspicious death should alert you to the possibility of child abuse or neglect.
CHILD NEGLECT  

Child neglect is the most common form of child maltreatment reported to CPS agencies. Child neglect is a major problem. Although not always as physically apparent or dramatic as physical abuse, child neglect occurs more frequently and can be just as harmful to the child.

Rejection by care-takers, various stages of starvation, lack of medical care, improper clothing and unsanitary living conditions are some of the ways children are neglected. Left to fend for themselves and lacking the necessary parental guidance and supervision, children may suffer long-lasting physical, mental and emotional deficiencies.

We know that neglected children are more likely to be below average in height and weight, have substandard performance in school, and become delinquent. They are also more prone to be angry and hostile and to manifest these feelings in antisocial and self-destructive behaviors.

Even so, we must always be certain to distinguish between child neglect and living conditions that are a function of the family's poverty, because child neglect is the most over-reported form of child maltreatment. Most instances of neglect occur in poor and minority families. Compared to families in the general population, families who are reported for child neglect are four times more likely to be recipients of public assistance.

Nevertheless, children who are truly neglected need protection. The neglect of children cannot be excused simply because the parents are poor. Thus, in assessing whether or not a child is the victim of an omission of care, consider the following guideline:

•   To justify a report of child neglect to CPS, the deviation of care must be clear and not the product of reasonable variances in cultures or living style. For example, blaming the care-takers for burns that occur from a space heater, despite numerous precautions taken by them.

•   Has the child's physical or mental condition been impaired or is in danger of being impaired? If a child seems hungry and emaciated, a report should definitely be made to CPS.

Physical Indicators of Child Neglect  

•   extremely dirty, unbathed and unkempt
•   clothes inadequate for the weather
•   obvious medical or physical problems unattended; dental problems left unattended
•   inadequately supervised
•   always hungry, undernourished, emaciated
•   ingestions of noxious substances
•   below average in height, weight
•   various stages of starvation:
abdominal distention
brittle and broken fingernails
pale or sunken skin

Behavioral Indicators of Neglect  
(NOTE: Most of these behaviors are also indicators of physical abuse)

•   chronic fatigue, listlessness
•   overly adaptive behavior:
excessive compliance and passivity
aggressive and damaging
•   chronically late for day care or school or chronically absent
•   arrive at school early and stay late
•   begging for or steals food
•   self-destructive, antisocial, habit disorders
•   does not look to parent for comfort; child shows no real expectation of being comforted
•   demonstrates poor self-concept
•   becomes apprehensive when adults approach another crying child
•   extremes of crying:
very little in public
hopelessly under treatment
•   substandard school performance, developmentally slow
•   extremely lonely and exhibits an extreme need for affection

Familial Indicators of Neglect  

In general, the parent will:

•   be apathetic
•   show little concern or awareness of the child's needs
•   show anger when questioned about the child's care
•   be impulsive in making decisions
•   is inconsistent with disciplinary practice
•   have overwhelming personal needs

The literature describes various typologies of neglectful parents:  

The Apathetic/Futile parent is characterized by:

•   little motivation or skill to effect changes in their lives
•   emotional numbness
•   clinging relationships
•   passive/aggressive displays of anger; low self-esteem; makes the helping person feel futile and frustrated
•   social isolation, no support systems.

The Impulse Ridden parent is characterized by:

•   a restless personality
•   inability to tolerate stress or frustration
•   aggressive and defiant behavior
•   seeking immediate gratification without regard to long term consequences
•   manipulative behavior
•   superficial relationships

The Developmentally Delayed parent is characterized by three essential features:

•   significantly average general functioning (IQ of 70 or below in an individually administered intellectual IQ test)
•   resulting in, or in association with deficits or impairments in adaptive behavior
•   with onset before the age of 18. (Because abilities vary, assessment of individual potentialities for adequate parents is necessary.)

The parent in a Post Traumatic Stress Disorder is characterized by:

•   recurrent and intrusive distressing recollections of the event or dreams
•   acting or feeling as if the traumatic event were recurring
•   intense psychological distress
•   efforts to avoid thoughts, feelings, conversations, activities, places, or people associated with the trauma
•   inability to recall an important aspect of the trauma
•   feeling of detachment or estrangement from others
•   difficulty falling or staying asleep, irritability or outbursts of anger
•   difficulty concentrating
•   hyper vigilance

The parent experiencing a Major Depressive Episode is characterized by:

•   depressed mood most of the day for nearly every day
•   markedly diminished interest or pleasure in all or almost all activities
•   significant weight loss or gain
•   insomnia or hypersomnia nearly every day
•   fatigue or loss of energy
•   feelings of worthlessness or excessive or inappropriate guilt
•   diminished ability to think or concentrate
•   recurrent thoughts of death or suicidal ideation

The Psychotic parent is characterized by:

•   delusions, disorganized speech (e.g. frequent derailment or incoherence)
•   loss of contact with reality
•   inappropriateness of mood
•   bizarre behavior
•   disturbances in stream of thought
•   hallucinations
•   severe anxiety
•   grossly disorganized or catatonic behavior


PHYSICAL ABUSE  

Physical abuse is the most visible form of child maltreatment and is defined as physical injury resulting from punching, kicking, beating, biting, burning or otherwise harming of a child.

  In many States (Maryland included) the use of corporal punishment is not considered child maltreatment. However, child development specialists and child welfare professionals believe that the use of corporal punishment is damaging to a child's emotional well-being. And most often, once physical punishment is used, it can and does escalate into more often and more severe punishment. For those parents who discipline physically, when you `see' an injury on a child in your care, you must consider the following to determine if the use of force was reasonable:

•   Developmentally, does the child have the ability to understand the reason for the discipline.
•   Was the punishment a reasonable use of force for the degree of the child's misbehavior? Could a less severe physical punishment be equally effective? (No matter what, extremely injurious punishment IS physical abuse.)
•   Was the physical punishment directed toward a 'safe' area of the child's body?
•   Was the reason for the use of force to discipline?
•   Was the punishment degrading, unusually brutal?

  While some these types of injuries can occur by accident, child abuse should be suspected if the explanations do not fit the injury or if there is a pattern of repeated injury. There are some basic guidelines to follow when considering whether or not you have `a reason to believe' that a child is being physically maltreated:

Does the injury match the child's developmental level?
Any injury on an infant should be suspect. It requires a certain degree of force to accidentally cause injury to oneself and you must consider the age-appropriate level of mobility of the injury on the child.

Is there a certain recognizable shape to the injury?
A majority of non-accidental injuries sustained on a child are inflicted by and leave marks of an identifiable objects. For example, the image of a hot iron on the child's back,  a belt buckle, teeth marks, pinch marks, cigarette burns, a looped cord shape on the child's buttocks?

Where is the injury located?
Consider the normal locations of accidents (for example when a child falls) versus the not-normal areas of injury. Is the site of the injury above or below the knee, the forehead or the nose, the elbows or the upper arm, the front of legs or the back of the legs, the genital and rectal areas? Physically abusive parents often injury a child such that the marks are under clothing so as to not be easily `seen.'

What degree of force was necessary to produce the injury?
It takes quite a bit of force for children to be obviously injured. What caused a young bone to be fractured, a bruise to last for more than a short time?

What type of injury is it?
You must consider if it was possible for the injury to be inflicted by the child; they cannot create a spiral fracture of their forearm bones, a shaking injury to their brains.

What are the number of old and new injuries?
Physical abuse of a child usually occurs more than once and with increased severity. Bruises, burns (especially cigar/cigarette burns), broken bones are often in various stages of healing.

Physical Indicators of Physical Abuse  
Fractures and visible bruises are familiar types of abuse which, taken together, represent the phenomenon known as the "battered child syndrome" as described by Dr. Henry Kempe in 1962.

BRUISES OR WELTS
Especially on any infant; facial bruises (lips, mouth and eyes); in unusual patterns; clustered in one area of the body; in various stages of healing.

•   on buttocks and back
•   pinch marks (small crescent-shaped facing each other)
•   pressure bruises on the neck, torso, shoulders or around elbows and knees suggesting an intense grip
•   on several surface areas

BURNS
Caused by immersion in hot liquid; cigarette/cigar burns usually on palms of hands or soles of feet (leaving crater-shaped burns); caused by a hot implement and  leaving a distinct mark such as a curling iron; or caused by ropes or cords that indicate confinement.

•   multiple burns in different stages of healing
•   immersion burns that indicate dunking leaving sock-like, doughnut-shaped burns on buttocks or genitalia
•   splash burns on the child's back
•   flame burns especially on the tips of fingers or toes

LACERATIONS OR ABRASIONS

•   human bite marks
•   abrasions/cuts on external genitalia
•   puncture marks that resemble the tine of a fork, comb, etc.

MOUTH AND FACIAL INJURIES

•   `gag' marks at the corners of the mouth
•   torn frenulum
•   swollen lips, broken, chipped or missing teeth
•   ulcers or caustic burns in the mouth or on the tongue
•   two black eyes without accompanying injury to the nose
•   retinal hemorrhages and detachments when accompanied with other evidence of severe shaking

HEAD INJURIES

•   absence of hair and/or hemorrhaging beneath the scalp due to vigorous hair pulling
•   jaw and nasal fractures
•   concussion

SKELETAL INJURIES

•   any long bone fractures
•   fractures in different stages of healing
•   any skull fracture (shaking can cause a simple linear fracture)
•   rib fractures with accompanying pressure bruises
•   epiphyseal separation
•   spiral fracture of the long bones

INGESTED SUBSTANCES

•   any poisoning, especially if the child is less than one year
•   any ingestion of sedatives, tranquilizers, narcotics or other drugs
•   the ingestion of excessive amounts of salts, diuretics or laxatives

REPEATED/UNTREATED/MULTIPLE INJURIES

•   a history of repeated, traumatic injuries, suggesting an ongoing pattern of physical abuse
•   severe injuries that are not treated or show signs of delays in seeking treatment

Behavioral Indicators of Physical Abuse  
(NOTE: Most of these behaviors are also indicators of neglect.)

•   overly adaptive behavior:
•   excessive compliance and passivity
•   aggressive and damaging
•   chronically late for day care or school or chronically absent
•   arrives at school early and stay late
•   self-destructive, antisocial, and/or displays habit disorders
•   does not look to parent for comfort; child shows no real expectation of being comforted
•   demonstrates poor self-concept
•   apprehensive when other children cry and/or becomes apprehensive when adults approach another crying child
•   displays extremes of crying:
very little in public
hopelessly under treatment
•   substandard school performance and/or is developmentally slow
•   offers bizarre explanations of injuries/harm
•   cautious when asked to respond to questions regarding injury/harm and looks to parents for answers
•   appears to be hyperactive and reacts to all stimuli
•   wary of physical contact initiated by parents or anyone else
•   has low tolerance for frustration
•   seems less afraid than peers when admitted to the hospital and settles in quickly; child assumes a flat affect when discharge to home is mentioned or is occurring
•   constantly on the alert for danger and is guarded and distrustful
•   constantly in search of something--food, favors, things, services, affection
•   constantly asking in words, and through actions about what will happen next
•   capable of only superficial relationships
•   chronic runaway
•   school dropout
•   asks, "When am I going home?" or announces "I am not going home" rather than crying "I want to go home"

Familial Indicators of Physical Abuse  

•   holds unrealistic expectations for the child's physical or emotional development
•   seems unconcerned about the child's injury, treatment, and or prognosis
•   projects negative characteristics onto the child and sees the child as `bad,' `different' or `evil'
•   shows concern not about the child, but about what will happen to themselves and others involved in the child's illness or injury
•   does not volunteer information about the child's illness or injury
•   offers illogical, unconvincing, contradictory explanations about the child's illness or injury
•   lacks attachment to the child, characterized by lack of eye contact, touching and emotional response
•   history of their own dependence needs not being met (perhaps they were maltreated as a child)
•   has low self-esteem, sees themselves as inadequate and worthless
•   has a low frustration level and impulsive traits
•   has inappropriate or rigid expectations for the child, often views the child as a small adult capable of meeting their needs
•   has a sense of self-righteousness about harshly `disciplining' the child
•   isolates emotionally if not physically, has little support (if any) system
•   exhibits a reversal of roles with the child, the child `mothers' the parent
•   presents a history of family discord and personal problems such as alcoholism, psychosis or family violence
•   has taken the child to different health care providers each time medical attention is needed
•   does not involve themselves in the child's care at the facility
•   maintains that the child has injured or harmed her/himself or projects cause of injury or harm onto a sibling or third party
•   reacts inappropriately to the severity of the child's condition, either an overreaction or indirection

Shaken Baby Syndrome  

Shaken Baby Syndrome occurs when a child is shaken back and forth in a whiplash motion. Delicate veins over the brain tear and bleed causing pressure on the brain which destroys brain tissue. The damages brain begins to swell. This swelling and pressure pushes down on the brainstem , which controls the vital functions such as heart rate and breathing, if the swelling and pressure are not stopped, the child will die.

The symptoms of Shaken Baby Syndrome can range from mild forms of irritability, appetite loss, vomiting and lethargy to more serious symptoms such as breathing difficulty, seizures, coma and death.

Twenty-five to thirty percent of the shaken babies die. The survivors suffer from permanent brain damage, cerebral palsy, paralysis, blindness, deafness, and permanent vegetative state, as well as severe learning and behavioral problems.

The age range of the victims of Shaken Baby Syndrome is one month to four and one-half years, with an average of eight months. Boys are more frequently reported as victims than girls (57% versus 43% respectively). Twenty-five to 30% of the children die, and the percentage of fatalities is highest in the 13-24 month age range.
  
Percentage of Perpetrators of Shaken Baby Syndrome

Most often--in 44% of the cases--the perpetrator of shaken baby injuries is the child's father. Mothers' boyfriends are responsible for 23% of the incidents. Paid caregivers account for 14% and mothers, 9 percent.

While it's easy to believe that shaken baby injuries occur only among the poor, the uneducated, the drug-addicted, and/or the violent criminals, that simply isn't true. One Utah study found that 75% of offenders had no history of substance abuse, and 81% had no previous history (in police, court or social service records) of child abuse. Shaking occurs in families of all races, income and education levels. Shaken baby injuries, like all other forms of child maltreatment, is not discriminating.

Crying--whether from colic, illness, pain or plain fussiness--is the number one provocation that sparks shaking. As infancy gives way to the toddler years, toilet training and misbehavior become the most common triggers. It's the soiling of a diaper before a special event, the second glass of milk thrown onto the floor, the third wall scribbled on with crayons, the fourth whinny interruption of the parent's phone conversation.

It may seem inconceivable that such minor transgressions could provoke someone to violence. But many experts believe that, in most cases, no serious harm is intended, usually the caregivers simply want to stop the child's undesirable behavior.

Shaken Baby Syndrome is the most preventable form of child maltreatment:

•   Never shake a baby under any circumstances. For instance, never rouse an infant who has stopped breathing during sleep by shaking him. Doctors recommend patting and calling out to a baby or blowing on his face. If he doesn't waken, phone 911 and begin CPR.
•   Avoid rough play. Normal play activities are miles away from the kind of violence it takes to cause shaken baby injuries. Even so, avoid tossing a baby in the ait, swinging him around or bouncing him wildly.
•   Do your homework before hiring a caregiver. Carefully check references. Call Child Care Choices/Frederick County Mental Health Association at 301-662-4549 to inquire about licensed child caregivers.
•   Interview candidates thoroughly. Ask a prospective babysitter to describe ways to cope with a child crying. If a person seems at all uneasy or shot-tempered around babies, don't leave your child with him no matter what.
•   Warn anyone who spends time with your child about Shaken Baby Syndrome. this includes relatives and friends--anyone who's keeping an eye on your child.
•   Get a grip on yourself before you get a grip on your child. If a baby cries incessantly, lay her in a crib and leave the room to soothe your impatience.

Some Rare Diseases Mimic Abuse Symptoms  

•   A four-month-old Amish girl died in 2000. The pathologist saw blood in her brain and hemorrhaging in one retina and determined that the infant died as a result of Shaken Baby Syndrome. Days later her death was ruled as a result of a Vitamin K deficiency and a rare liver disease, an 'Amish' illness.
•   In 1998, a 1-year-old in California, had many bone fractures and was taken away from her parents. She was later diagnosed with osteogenesis imperfecta, `brittle bone disease.'
•   An infant with the liver disease Alagille's Syndrome was briefly sent to a Nashille foster home in 1993.
•   A newborn in Denver was taken away in 1991 before doctors diagnosed her with glutaric aciduria type 1, a liver disorder.

Glutaric aciduria: This disorder, also known as acidemia and
GA-1, causes bleeding behind the eyeball, which is a symptom
sometimes found in children who have been violently shaken.
Methylmalonic acidemia: Symptomatically similar in nature to
glutaric acidemia.
Von Willebrand's disease: This is one of the most common
inherited bleeding disorders in humans.
Osteogenesis imperfecta: This is a temporary brittle bone
disease which causes the child to be more susceptible to fractures.
Alagille's syndrome: This is a disorder whose symptoms can
include jaundice and liver disease.

SEXUAL ABUSE  
Child sexual abuse is the exploitation of a child for the sexual gratification of an adult or other child. Child sexual assault is all about sex and is facilitated by the inherent power of the perpetrator. The victims are coerced into sexual activities by way of subtle deceit and emotional manipulation, bribery and threats, and occasionally, the use of physical force. Sexual abuse is NEVER the fault of the child.

Of all of the forms of child maltreatment, sexual abuse of children is the one that most people find it difficult to accept that adults could engage children in sexual activity and they surely don't want to even discuss child sexual abuse.

Incest is the non-justified sexual acts or contacts between non-married family members. (Justified adult/child sexual contact is for the purposes of health or hygiene.)

In Maryland Child Protective Services agencies address only sexual abuse that is perpetrated by a parent, guardian, or caretaker. Other forms of child sexual abuse are addressed by law enforcement.

Physical Indicators of Sexual Abuse  

•   difficulty in walking or sitting
•   pain or itching in genital/anal area
•   bruises on external genitalia, vaginal or anal regions
•   bleeding from external genitalia, vaginal or anal regions
•   swollen or red cervix, vulva or perineum
•   recurrent urinary tract or yeast infections
•   positive tests for sexually transmitted diseases
•   poor anal sphincter tone
•   scarring, healed injuries of the hymen, vulva or anus
•   pain on urination or bowel movement
•   torn, stained with vaginal or penile discharge or bloody underclothing
•   tearing or irritated corners of the mouth
•   evidence of semen on the child's face or hands

Behavioral Indicators of Sexual Abuse  

•   sudden, dramatic change in the child's personality or behavior
•   sudden fear and attempts of evasion of a particular person
•   sleep disturbance, nightmares
•   bed-wetting, sleeps in clothing versus pajamas
•   poor peer relationships
•   withdrawal, chronic depression, fantast or infantile behavior
•   unwillingness to participate in physical activities
•   hysteria, lack of emotional control
•   excessive seductiveness, inappropriate sex play
•   bizarre, sophisticated or unusual (for developmental level) sexual behavior
•   medical complaints with no apparent basis in fact
•   confiding in someone (these confidences may be subtle, "I'm afraid to go home tonight," "I want to live with you" or a direct statement that describes the nature of their sexual abuse); even when retracted later, rarely are these disclosures untrue
•   eating disorders
•   self-mutilation such as cutting
•   suicidal ideation, suicide attempts
•   premature understanding and knowledge of sex
•   child/adult role reversal
•   overly concerned for siblings
•   unwillingness to change clothes in front of others
•   delinquent acts, running away
•   stealing or other risk-taking behaviors

The presence or intensity of those behavioral indicators of child sexual abuse may vary according to circumstances, including the following factors:

•   the perpetrator's identity and relationship to the child
•   a single incident occurring over time may be easier for a child to integrate
•   the degree of force or violence used in the sexual activity
•   the degree of fear and/or shame invoked in the child by the offender
•   an intentional disclosure by the child as opposed to another discovering the molestation
•   the level of physical intrusiveness of the sexual activity (fondling versus vaginal intercourse)
•   the time elapsed since the sexual contacts

Familial Indicators of Sexual Abuse  

•   parent has low self-esteem
•   extreme paternal dominance, restrictiveness and/or over-protectiveness
•   parent is passive outside of the home
•   family is isolated from the community and support systems
•   parent has a distorted perception of the child's role in the family/role reversal
•   history of sexual and/or physical abuse by either parent
•   alcohol and/or drug abuse by either parent
•   other types of violence is in the home
•   school absence excused by chronic illness, depression, divorce or separation
•   severe over crowding in the home
•   the sexually abusive parent initiates sexual contact by kissing/hugging which escalates to more intrusive sexual behavior
•   psychological manipulation of the child
•   parent has extreme objection to implementation of child sexual abuse curriculum in the child's school
General Observations of Child Sexual Offenders  

•   Most sexual offenders are heterosexual males who often have sexual relationships with adult women as well as the children they molest.
•   Some offenders (usually pedophiles) are attracted only to girls or only to boys; others are attracted to both sexes, but only to a certain age group.
•   Sexual offenders function quite normally and even excel in other aspects of their life such as work or community activities.
•   Offenders put a lot of time and energy into creating situations in which the have access to children.
•   Many offenders have a long history of sexually abusing children. They may have begun the behavior in adolescence. When a child discloses that an uncle or grandfather molested her, it is not uncommon for the parent to discover that this same person molested other members of the family 20 or 30 years ago.
•   Pedophiles are sometimes compared to alcoholics in terms of the addictive quality of their behavior. The pedophile has a compulsive need to molest children and, as with alcoholism, effective treatment requires that the offender learn to control his behavior for the rest of his life.
•   Sexual offenders most often deny or minimize their behavior.
•   Although most offenders are males, it is generally accepted that the number of sexual assaults by females may be under-reported.

General Observations of the Victims of Child Sexual Abuse

•   Children are not capable of giving informed consent to sexual activity because they cannot understand or predict the consequences of adult-child sexual contact
•   Children who are isolated from others, with few friends, and little contact with their siblings, are at a greater risk of victimization. Some offenders are able to take advantage of a child's isolation, while others manage to isolate the child. Some children may isolate themselves because they feel different or afraid of being stigmatized.
•   The closer the social relationship, not necessarily the biological one, between the child and the offender, the greater the potential trauma to the child. Sexual assault by a trusted neighbor, for example, might be more damaging to the child than abuse by a distant uncle.
•   Children find it more difficult to break the silence. In a child's world, adults control most of the resources and they seem to know all the answers. If the offender threatens the child or someone the child loves, the child will seldom question the power of the adult to carry out the threat,
•   Children invariably want to tell about their abuse so that it can be stopped, but they are often afraid that they will not be believed or protected, or are afraid of the possible consequences of disclosure.
•   Especially in cases of incest, enforced secrecy and a child's fear of destroying the privacy and security of the family are such powerful obstacles to disclosure that children rarely reveal their sexual victimization until they are adults. Many never tell even then.
•   In the few recorded cases where children have made false allegations, it has almost always been the result of manipulation by an adult.
•   Adult women sexually molested as children are more likely than non-victims to manifest depression, self-destructive behavior, anxiety, feelings of isolation and stigma, poor self-esteem, a tendency toward re-victimization and substance abuse.

Factors that Contribute to Sexually Abusive Behavior  

Two general dynamics usually occur  in all forms of child maltreatment:

•   lack of impulse control
•   a parent/child role reversal

Additionally, the following condition most often exist in order for child sexual abuse to occur:

•   the ability for the offender to overcome internal inhibitions against committing child sexual abuse
•   the ability to ignore or rationalize external inhibitions such as the attitudes of society about child sexual abuse and the prospect of criminal sanctions
•   the opportunity to be alone with the child
•   the victims lacks the power to evade the offender

The Process of Child Sexual Victimization  
In their incredibly insightful study, The Process of Victimization: The Victims' Perspective, Lucy Berliner and Jon R. Conte (Child Abuse and Neglect, Volume 14, pp. 29-40, 1990), identified three common elements in the victimization process:

•   Sexualization of the adult-child relationship almost always occurred gradually and usually beginning with `normal' affection such as hugs or tickling, and accidentally-on-purpose touching of genitals or breasts. This behavior started as nonsexual behavior to sexual behavior that increased to more intrusive forms of sexual contact.

•   Rationalization of the sexual maltreatment was in the form of an assertion that the behavior was not really sexual or it was merely for purposes of education or preparation; a game or an inspection of the child's body; or a persuasion that the child is old enough or unusually mature for the child's age. Many offenders, however, say nothing about the sexual activity.

•   Cooperation of the child in the activity is necessary in order for the sexual abuse to continue. Offenders must keep the child engaged and prevent the child from telling. The adult uses threats, intimidations, bribery and other various forms of coercion. Offenders have an uncanny ability to target the isolated, lonely child and convince the child that the sexual activity is how the adult expresses the love for the child. The abuser makes threats concerning the child's loved ones, threatens to withdraw affection, or perhaps the child is dependent upon the abuser.

A good rule of thumb when trying to determine if a child's sexual behavior is normal or not normal is to consider the following points:

•   Is the behavior developmentally appropriate?
•   Normal sexual play usually includes a tone of spontaneity, joy, laughter, embarrassment and sporadic levels of inhibition and disinhibition.
•   Are there themes of dominance, coercion, threats or force and do the children seem agitated, anxious, fearful and habitual?

MENTAL INJURY  
Mental injury is a pattern of behavior by a parent or care-taker that can seriously interfere with a child's mental/psychological development. Acts of omission or commission by an adult that place the child's normal emotional development in jeopardy are considered mentally injurious.

Maryland's law pertaining to a child's mental injury define this form of child maltreatment as "the observable, identifiable, and substantial impairment of a child's mental or psychological ability to function."



There are five types of mental injury that are most common:  

1/Rejecting: An explicit refusal to accept the child is rejection. Researchers have characterized rejection as a "psychologically malignant" force in human development and have found that rejection increases when parents are given unrealistic responsibility for children in the absence of support, encouragement, and feedback fro the outside. Children thrive on acceptance and are consumed by rejection.

2/Ignoring: Being psychologically unavailable to the child is ignoring. A psychologically unavailable parent deprives the child of essential stimulation and responsiveness, and stifles emotional growth and  intellectual development. Children need a partner for development to proceed normally.

3/Terrorizing: Verbally assaulting the child, creating a climate of fear, and bullying the child all constitute terrorizing. When the parent destroys the child's possessions or attacks beloved people or pets, that parent terrorizes the child and teaches the lesson that the world is capricious and hostile.

4/Isolating: Cutting the child from normal social experiences is isolating. Such a parent works at preventing the child from forming friendships. This teaches the child that he or she is alone in the world, and deprives the child of the healing that can come from social networks and relationships.

5/Corrupting: Teaching the child socially deviant patterns of behavior is corrupting. Such a parent stimulates deviant behavior directing (e.g., by rewarding aggression, delinquency, or sexually precocious behavior) and thus mis-socializes the child. This parent's actions tend to make the child unfit for normal social relationships--at school, in the community, and with peers.
(Emotional Maltreatment of Children, James Garbarino & Anne C. Garbarino; National Committee to Prevent Child Abuse, Chicago IL: 1994)

Physical Indicators of Mental Injury  

•   non-organic failure to thrive
•   speech disorders
•   ulcers, asthma, severe allergies
•   slowed growth in trunk and distinctively short limbs, dwarfism
•   circulatory problems
•   small abrasions on limbs that heal slowly
•   gastrointestinal and bowel problems including chronically loose stools, refusal to urinate

Behavioral Indicators of Mental Injury  

•   substance abuse
•   habits disorders such as head banging, sucking, biting and rocking
•   accident prone
•   self-destructive both physically and socially
•   suicidal ideation, suicide attempts
•   conduct disorders such as anti-social
•   extremes of behavior such as excessive compliance and passivity  or overly aggressive and damaging behavior
•   overly adaptive behavior such as inappropriately adult or inappropriate infantile
•   sudden and severe drop in school performance, emotional appearance or general functioning
•   eating disorders, obesity
•   reduce energy level, lethargy
•   sexually precocious behavior
•   lies notably when it is not to protect self but in circumstances when there is nothing to lose by telling the truth
•   cheats, steals
•   tantrums, bizarre behavior
•   aggressive, defiant domineering
•   controlling but lacking self-control
•   seeking love, acceptance and affection outside of home
•   motor delays
•   lack of exploration and curiosity

Familial Indicators of Mental Injury   (See also 5 Types of Mental Injury)
•   frequently threatens to harm or kill the child
•   threatens to harm or kill the child's pet
•   constantly denigrates the child
•   subjects the child to extensive emotional or physical isolation or confinement

Resources: Recognizing & Reporting Child Abuse & Neglect: Resource Handbook for Health Care Professionals, 4th Edition,Revised June 1999, Prepared by Gisele Ferretto Meek, LCSW, Social Services Administration, Illustrations by Daniel S. Conrad; Maryland State Department of Human Resources, Family Preservation Services, 311 West Saratoga Street, Baltimore MD 21201, 410-767-7112, http://www.dhr.state.md.us/

Recognizing Child Abuse: A Guide for the Concerned, Douglas J. Besharov, The Free Press, New York: 1990; mailto:DougBesharov@aei.org