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Nurturing and stable relationships with caring adults are essential to healthy human development, beginning from birth. Early, secure attachments contribute to the growth of a broad range of competencies, including a love of learning, a comfortable sense of one-self, positive social skills, multiple successful relationships at later ages, and a sophisticated understanding of emotions, commitment, morality, and other aspects of human relationships. Stated simply, establishing successful relationships with adults and other children provides a foundation of capacities that children will use for a lifetime. (National Scientific Council on the Developing Child 2004, p. 1)

1 Introduction

The World Health Organization (WHO) defines child maltreatment as “all forms of physical and/or emotional ill-treatment, sexual abuse, neglect, or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power” (World Health Organization 1999). The phenomenon of child maltreatment is old; it has existed “since the beginning of recorded history” (ten Bensel et al. 1997, p. 3). In the past, children have commonly been victims of infanticide, abandonment, harmful child-rearing practices, mutilation, labor exploitation, or sexual abuse. Fortunately, these practices are now considered unacceptable by most of society and child maltreatment is recognized as a social problem throughout the world (International Society for the Prevention of Child Abuse and Neglect 2008; Krug et al. 2002). Article 19 of the Convention on the Rights of the Child (1989) specifically addresses child maltreatment in the family, indicating:

  • States Parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has the care of the child (art. 19.1), and

  • Such protective measures should, as appropriate, include effective procedures for the establishment of social programmes to provide necessary support for the child and for those who have the care of the child, as well as for other forms of prevention and for identification, reporting, referral, investigation, treatment and follow-up of instances of child maltreatment described heretofore, and, as appropriate, for judicial involvement (art. 19.2).

Despite public recognition and international legislation aimed at preserving and protecting children’s rights, child maltreatment in the family still exists and continues to be a serious social issue. Physical violence, neglect, sexual abuse, psychological maltreatment, and other harmful practices such as forced marriages and female genital mutilation still occur, as documented in reports of international organizations such as the WHO (Krug et al. 2002), the United Nations (Pinheiro 2006) and the International Society for the Prevention of Child Abuse and Neglect (2008, 2010).

Scientific interest in the field of child maltreatment began in the early 1960s after the publication of Henry Kempe’s “The Battered Child Syndrome” (Kempe et al. 1962). Child physical abuse was the first type of maltreatment to appear in the research and practice literature. Initially, most of the publications came from the medical field and were focused on the diagnosis of child physical abuse. Other disciplines such as psychology, mental health, and social work joined the study of child maltreatment later on. As a result, child maltreatment literature expanded significantly over the last quarter of the twentieth century. Initially, most of the theoretical and quantitative publications continued to focus on child physical abuse. In the early to middle 1980s, an important change came about and child sexual abuse became the dominant topic in the published literature. Today, child sexual abuse remains the most frequent form of child maltreatment examined in the literature, followed by physical abuse (Behl et al. 2003; Chaffin 2006). Research into child neglect, and especially psychological maltreatment, has consistently been much less frequent, although there has been an increase in the number of publications on these two forms of maltreatment recently (Feiring and Zielinski 2011). Particularly noteworthy since the 1990s is the growing amount of research in the maltreatment literature about children’s exposure to intimate partner violence.

This chapter reviews and discusses current available knowledge about the scope, definition, and consequences of child maltreatment. Some of the issues presented are broadly linked to all maltreatment types and developmental stages (childhood, adolescence, and adulthood). However, where appropriate, specific types of maltreatment and developmental stages are differentiated.

2 Scope of the Problem

According to the WHO (Krug et al. 2002), in 2000 an estimated 57,000 deaths of children younger than 15 years of age were attributed to intentional injuries. The data from WHO indicated that the death rates for infants and young children were two to three times higher in low- to middle-income countries than in high-income countries. However, the intentional death of children is not exclusive to low-income countries. A report from UNICEF (2003) estimated that almost 3,500 children younger than 15 years die from maltreatment every year in the industrialized world. Estimates of the number of intentional deaths of children per year in such countries during the 1990s show broad variations, ranging from 0.2 to 3.7 children per 100,000. Countries with the lowest rates of child death from maltreatment were also those with the lowest rates of adult deaths from assaults. Although these rates have been in marked decline in industrialized countries from the 1970s to 1990s, deaths due to child maltreatment continue to be considered an important problem. In countries like the US, the UK, and Australia, proof of this point is the established institutionalized processes and teams that determine what occurred in these cases (Axford and Bullock 2005; Covington 2010; Durfee et al. 2002; Shanley et al. 2010; Vincent 2009). Reports from UNICEF, WHO, and other sources (Gilbert et al. 2009) agree that available statistics probably underestimate the true number of deaths from child maltreatment because a significant proportion are incorrectly attributed to other causes (e.g., poisoning, falls, drowning), and some adolescent deaths due to suicide, deliberate self-harm, or risk-taking behavior related to maltreatment are not included. Such reports agree that children below the age of 4 years are at the greatest risk of death from maltreatment, with a rate more than double that for 5–14 year olds.

Some authors claim that it is appropriate to differentiate child death resulting from single-assault fatalities with no evidence of previous maltreatment (e.g., neonaticides or parents who kill their children before committing suicide) from child death resulting from prolonged neglect or escalating levels of parental violence. Child homicide appears to represent a special category rather than the extreme of a continuum of child maltreatment, so it seems best to consider these as independent phenomena (UNICEF 2003; Trocmé 2008).

The number of children who are victims of nonfatal maltreatment is much higher. Some studies place the rate of maltreatment cases between 150 and 1,000 times more than the number of fatal cases (UNICEF 2003). Data from community studies based on self-reports by victims and parent reports show cumulative prevalence estimates ranging between 5 % and 35 % for severe physical abuse, 6 % and 11.8 % for severe neglect, and 4 % and 9 % for severe psychological abuse (Gilbert et al. 2009). Global prevalence rates for child sexual abuse are estimated to be 18.0 % for girls and 7.6 % for boys, although rates decrease (5–10 % for girls and 1–5 % for boys) when only more intrusive forms of sexual abuse are considered (Gilbert et al. 2009; Stoltenborgh et al. 2011). Despite these available data, the precise scope of child maltreatment is unknown. There is a wide gap between studies with respect to prevalence estimates for the general population due to differences in the definition of maltreatment (e.g., types included, breadth of the definition, consideration of co-occurrence of types), the characteristics of the sample (e.g., adults, adolescents, or children, representative or specific samples), the method of collecting information (e.g., personal interviews, telephone interviews, surveys), or the number and wording of questions used.

With regard to official records from Child Protection Services (CPS), not all countries have national data collection systems. Data for many countries, especially those that are low- and middle-income, are lacking (International Society for the Prevention of Child Abuse and Neglect 2008). The number of CPS-substantiated maltreatment cases per 1,000 children in countries that do have these systems is approximately 6.5 in Australia (year 2008–2009) (Australian Institute of Health and Welfare 2011), 9.3 in the US (year 2009) (US Department of Health and Human Services 2010), and 14.9 in Canada (year 2008) (Public Health Agency of Canada 2010). However, these data should be interpreted with caution. First, official records appear to reflect only a part of all maltreatment cases, even in countries where mandatory reporting exists (Krug et al. 2002). Second, data are not directly comparable because of the different collection systems and definitions employed. As the International Society for the Prevention of Child Abuse and Neglect (2010) concluded, even countries with similar resources and relatively sophisticated administrative data systems have difficulty with consistently determining estimates of the problem, making “reliable international estimates of child maltreatment virtually impossible” (p. 18).

3 Child Maltreatment: Definition, Types, and Levels of Severity

Intervention by Child Protection Services relies on a legal-administrative definition of what constitutes child maltreatment. Such a definition involves a judgment about the appropriateness of relationships between the parents/legal caretakers and the child. It establishes when the state must intervene to either offer and provide supportive services to families in order to correct inadequate patterns of child care, or protect the child when such patterns are so grossly inappropriate that they place the child’s safety at risk. As Garbarino (1991) stated, maltreatment “is a social judgment regarding the appropriateness and likely outcomes of parental behavior, a community’s assertion of minimal standards of care. It is a social judgment that arises as a kind of negotiated settlement between ‘culture’ (as represented by community standards that are articulated through a political process) and ‘science’ (as made incarnate in ‘professional expertise’)” (p. 45). Minimal standards of child care vary from culture to culture, so legal-administrative definitions of child maltreatment have varied and still do.

Constructing universally acceptable definitions of child maltreatment is an unresolved task. Some of the key points of divergence include the specification of the forms of parenting that should be considered maltreatment; whether to define maltreatment based on adult characteristics, adult behavior, and the outcome for the child and/or the environmental context; whether standards of harm or risk of harm should be used in the construction of definitions; and whether similar definitions should be used for scientific, legal-administrative, and clinical purposes (James 2000). However, notable progress has been made. Researchers have made important contributions to the definition of child maltreatment with the identification of the basic needs for healthy development of the child (e.g., human needs and attachment theories) and with noteworthy efforts to identify and operationalize the parental behaviors that can cause significant harm to child development. This had led the legal-administrative, clinical, and research areas to begin to converge, in some important aspects, on a definition of child maltreatment.

There appears to be an important agreement in the professional literature to define child maltreatment as the acts or failure to act on the part of a parent or caretaker that results in actual or potentially significant harm to a child’s physical, cognitive, social, or emotional development. Maltreatment can occur by commission or omission and it can be of a physical, psychological, or sexual nature. Thus, four main types of maltreatment are identified: physical abuse, neglect, psychological maltreatment, and sexual abuse.

Physical abuse is defined as the intentional (nonaccidental) use of physical force against a child that results in, or has the potential to result in, physical injury (Knutson and Heckenberg 2006; Leeb et al. 2008). Physical injuries can include physical marks, burns, lacerations, contusions, abrasions, broken bones, internal injuries, organ damage, poisoning, asphyxiation, or death (Dubowitz and Bennett 2007; Reece 2011). Generally, such injuries result from punching, beating, kicking, biting, shaking, throwing, stabbing, choking, hitting with a hand, stick, strap, or other object, or burning. In many cases, physical abuse results from severe discipline or physical punishment that is inappropriate for the child’s age or condition. Physical abuse can occur as a single incident or in repeated episodes.

Neglect refers to the failure to meet a child’s basic physical, emotional, medical, and/or educational needs. Neglect laws often exclude circumstances in which a child’s needs are not met because of poverty or an inability to provide. It includes different subtypes: abandonment; physical neglect, i.e., failure to provide adequate attention to the child’s basic physical needs such as nutrition, clothing, hygiene, and shelter, and failure to protect a child from harm as best one can; medical neglect, i.e., denial or delay in providing essential medical care to the child, noncompliance with health-care appointments, treatment, or recommendations resulting in actual or potentially significant harm to the child; mental health neglect, i.e., refusal to comply with recommended therapeutic interventions for a child with a serious emotional or behavioral disorder; educational neglect, i.e., permitted chronic truancy, failure to enroll a child of mandatory school age, or inattention to a child’s special education needs without reasonable cause; supervisory neglect, i.e., lack of appropriate supervision, exposure to in- and out-of-home hazards, intentional failure to protect the child from pervasive violence within the home, neighborhood, or community, and failure to ensure appropriate supervision by adequate substitute caregivers; and prenatal drug or alcohol exposure (DePanfilis 2006; Dubowitz 2011; Erickson and Egeland 2011). Emotional neglect is defined as the persistent inattention to the child’s needs for affection, emotional support, or attention, and/or denial of opportunities to interact or communicate with peers or adults outside or inside the home. Many classification systems include emotional neglect as a form of psychological maltreatment. Neglect is usually chronic or repetitive.

Psychological maltreatment is doubtless the maltreatment type whose definition has posed, and still poses, the greatest challenge. Even in the professional and specialized literature, it is called by different terms (e.g., emotional maltreatment, psychological maltreatment, emotional abuse, psychological abuse). The term psychological maltreatment seems to be the most recommended because it encompasses emotional and cognitive processes and acts of commission (abuse) and omission (neglect) (Baker 2009; Hart et al. 2011). Probably the most cited definition of psychological maltreatment is the one presented in the Practice Guidelines for Psychosocial Evaluation of Suspected Psychological Maltreatment in Children and Adolescents, published by the American Society on the Abuse of Children (APSAC). The APSAC Guidelines (1995) define psychological maltreatment as “a repeated pattern or extreme incident(s) of caregiver behavior that conveys the message that a child is worthless, flawed, unloved, unwanted, endangered, or only valuable on meeting someone else’s needs” (p. 7). As Glaser (2002) pointed out, psychological maltreatment refers to a pervasive psychologically undesirable interaction that characterizes the parent-child relationship rather than an event or a series of repeated events. Six forms of psychological maltreatment are differentiated in the APSAC Guidelines: spurning (hostile rejecting/degrading), i.e., verbal and nonverbal caregiver acts that reject and degrade a child; terrorizing, i.e., caregiver behavior that threatens or is likely to physically hurt, kill, abandon, or place the child or child’s loved ones/objects in recognizably dangerous situations (this includes exposure to intimate partner violence); exploiting/corrupting, i.e., caregiver acts that encourage the child to develop inappropriate behaviors (self-destructive, antisocial, criminal, deviant, or other maladaptive behaviors); denying emotional responsiveness (ignoring), i.e., caregiver acts that ignore the child’s attempts and needs to interact (failing to express affection, caring, and love for the child) and showing no emotion in interactions with the child; and isolating, i.e., caregiver acts that consistently deny the child opportunities to meet the needs for interacting/communicating with peers or adults inside or outside the home. APSAC Guidelines include mental health, medical, and educational neglect as a sixth form of psychological maltreatment.

There have been many other proposals to operationalize psychological maltreatment (for a complete review, see Brassard and Donovan 2006; Baker 2009). According to Brassard and Donovan (2006), these definitions are similar to the constructs of belittling; singling out; public humiliation; placing in an unpredictable or chaotic environment; threatening a child and/or his or her loved one(s); modeling or permitting antisocial and developmentally inappropriate behavior; and failing to show affection, caring, and love. Less agreement is observed with the categories of placing children in recognizably dangerous situations and mental health, medical, and educational neglect, which are typically categorized as neglect.

Sexual abuse is defined as any completed or attempted (noncompleted) sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child by a caregiver (Leeb et al. 2008). Sexual acts include contact involving penetration, however slight, between the mouth, penis, vulva, or anus of the child and another individual; they also include penetration of the anal or genital opening by a hand, finger, or other object. Abusive sexual contact includes intentional touching (not involving penetration), either directly or through the clothing, of the child’s penis, vulva, anus, groin, breast, inner thigh, or buttocks. Sexual acts and abusive sexual contact can be performed by the caregiver on the child or by the child on the caregiver. The caregiver can also force or coerce a child to commit a sexual act or to maintain a sexual contact with another child or adult. Exploitation does not involve physical contact of a sexual nature between the caregiver and the child. It includes exposure of the child to sexual activity (e.g., pornography, exhibitionism), filming of a child in a sexual manner, sexual harassment of a child, and prostitution or sexual trafficking of the child. Sexual abuse can occur as a single incident or in repeated episodes.

Available CPS official records mostly coincide in identifying child neglect as the most commonly substantiated maltreatment type, followed by psychological maltreatment when intimate partner violence is included in its definition. Physical and sexual abuse represent the third and fourth more frequent types of child maltreatment (Australian Institute of Health and Welfare 2011; Gilbert et al. 2009; Euser et al. 2010; Public Health Agency of Canada 2010; US Department of Health and Human Services 2010). However, it is important to note that many maltreated children are victims of multitype maltreatment, where they experience some combination of physical abuse, sexual abuse, psychological maltreatment, and neglect (Herrenkohl and Herrenkohl 2009; Higgins and McCabe 2001). Although the rates vary widely between studies, partly due to differences in the sources of data used to identify the experience of maltreatment, the finding that a substantial proportion of maltreated children experience more than one type of maltreatment is consistent. As Lau et al. (2005) stated, comorbid types of maltreatment are “the norm rather than the exception” (p. 534). These findings have raised several questions about, for instance, the independent nature and influence of maltreatment types and the need to differentiate mixed types that could have their own specific etiological factors and impact on the child (Herrenkohl and Herrenkohl 2009).

Child maltreatment may present in different levels of severity. A review of some of the proposed classifications shows that most of them differentiate three to four severity levels: low-mild (in most of the legal-administrative definitions, such cases are not considered child maltreatment but improper parental behaviors), moderate, severe, and very severe (e.g., Children’s Bureau of Southern California 1997; English and the LONGSCAN Investigators 1997; Magura and Moses 1986; Ontario Association of Children’s Aid Societies 2006; Slep and Heyman 2004; Srivastava and Polnay 1997; Straus and Hamby 1997; Trocmé 1996). In accordance with this, the severity of most types of child maltreatment is determined by the level of harm that the parental behavior has caused, or could cause, to the child. In some cases, severity is established exclusively by the parental behavior. This applies to cases where parental behavior is so extreme, inherently traumatic, or inadequate in its nature (e.g., incest, abandonment) that it is assumed to have produced, or that it will produce, significant harm to the child even if he/she does not show any obvious signs of harm, either physical or behavioral. The concept of significant harm is a core element in the definition of child maltreatment and in the assessment of its severity. However, determining what constitutes significant harm is not easy, especially when it refers to psychological effects. Psychological harm has frequently been defined in general terms (e.g., impaired psychological functioning or development; damage to the behavioral, cognitive, or affective functioning of the child), although there have been valuable efforts to develop more specific definitions (American Professional Society on the Abuse of Children 1995; Baker 2009; Little et al. 2003). In any case, limitations in the available current scientific knowledge prevent, except for extreme cases, the formation of unequivocal links between specific parental behaviors and future psychological harm to the child. This is why many legal-administrative definitions have restricted the definition of psychological maltreatment to those cases where significant harm is clearly observable, especially if coercive state intervention into family life is involved (Sedlak et al. 2010; Wald 1991).

4 Consequences of Child Maltreatment

Research into the consequences of child maltreatment is abundant. Available scientific knowledge leads to some important conclusions, although such knowledge is hampered by methodological limitations and differences between studies. Some of the most frequently cited methodological limitations include the scarcity of longitudinal studies, confusion between types of maltreatment, lack of consideration of maltreatment co-occurrence and other factors that can mediate maltreatment effects, and the lack of comparison or control groups. Methodological differences between studies have included differences in the definition of maltreatment, the sample selection, or the measures selected to assess maltreatment impact (e.g., parental reports of child behavior, retrospective accounts of adults, Child Protective Services records). Although in the most recent research, one can see that there have been efforts to overcome the aforementioned methodological limitations, methodological differences between studies persist. This has hindered comparisons between studies, sometimes generating contradictory results, and has limited the validity and generalization of some research findings (Hecht and Hansen 2001).

Despite all this, there is solid evidence that child maltreatment can have a significant negative and even devastating impact on all areas of child development and functioning and that such effects can be long-term. Research has also shown that apart from the most severe cases of child maltreatment and those that affect young children, most of the harmful effects resulting from maltreatment are psychological in nature (Hart et al. 2011). Many researchers have pointed out the central role of the psychological components in all types of child maltreatment to explain their negative effects on children. As Garbarino et al. (1986) stated in the first book dedicated entirely to psychological maltreatment: “Rather than casting psychological maltreatment as an ancillary issue, subordinated to other forms of abuse and neglect, we should place it as the centerpiece of efforts to understand family functioning and to protect children. In almost all cases, it is the psychological consequences of an act that define that act as abusive …. Psychological maltreatment is the core issue in the broader picture of abuse and neglect. It provides the unifying theme and is the critical aspect in the overwhelming majority of what appear as physical and sexual maltreatment cases” (pp. 7–8).

However, except for extreme cases and in contrast to physical and sexual abuse, there is some social tolerance toward nonphysical or less evident forms of child maltreatment. The signs of psychological maltreatment and nonextreme neglect tend to be less visible and, in most cases, their effects are of a progressive nature, not very evident except medium- or long-term. However, contrary to popular belief, there is clear evidence that psychological maltreatment can cause significant and enduring impairment across most domains of child functioning. Research has also shown that psychological maltreatment, including emotional neglect, can be just as detrimental, and even more detrimental, to child development than physical or sexual abuse (DePanfilis 2006; Egeland 2009; Erickson and Egeland 2011; Hildyard and Wolfe 2002; Perry 2002).

5 Developmental Effects

Exposure to stressful events, adversity, traumatic experiences, and even victimization can be common childhood experiences. Stress is an inevitable part of life and the ability to cope with it is essential to survive; it constitutes an important part of the development process. Stress can be beneficial, tolerable, or harmful, depending on the child’s ability to cope with it (National Scientific Council on the Developing Child 2005). Throughout childhood, children are exposed to many short-lived, moderate, adverse experiences (e.g., entering a new child-care setting, meeting new people). These experiences can constitute positive learning experiences if the child has the support needed to cope with them satisfactorily and to develop a sense of mastery (positive stress). Children can also be exposed to more intense adverse experiences, but still short-lived (e.g., death or serious illness of a loved one, parental separation or divorce, victimization). If the child has the support of caring adults that help him or her to cope with it, the stress can usually be tolerated and overcome (tolerable stress). Localized effects are common post-traumatic symptoms specific to these types of traumatic experiences, which “can be pervasive and persistent, yet not interfere to a great extent with child development” (Finkelhor 1995, p. 185). However, when the adverse experiences faced by the child are chronic or repetitive, uncontrollable, and/or experienced without having access to support from caring adults, children become unable to effectively manage this stress (toxic stress). Profound and generalized negative effects can then emerge, particularly when serious stressors occur simultaneously, and crucial developmental transitions are interrupted. These effects, called developmental effects, “result when a victimization experience and its related trauma interfere with developmental tasks or dysfunctionally distort their course” (Finkelhor 1995, p. 184). Child maltreatment in the family constitutes one of the more – perhaps the most – adverse situations that a child can experience, particularly when sensitive periods of the developmental process are affected. Moreover, many maltreated children are victims of multiple abuse experiences, and a disproportionate number of them live in family environments where other risk factors are present (e.g., parental mental health problems; substance abuse; chaotic, unstable, and disorganized environments; family violence; other victimization). Such children are exposed to multiple adverse experiences, which have been shown to be highly associated with increased risk of negative outcomes (Finkelhor et al. 2007; Middlebrooks and Audage 2008).

When maltreatment negatively affects crucial developmental milestones and transitions, this not only implies problems in achieving the salient tasks specific to the developmental stage in which the maltreatment begins or occurs, it also implies long-term effects, increasing the likelihood of subsequent difficulties and maladaption in later stages. The organizational perspective on child development provides a useful framework to understand such processes (Cicchetti 1989; Cicchetti and Toth 2005). In this framework, development is thought of as the hierarchical integration of the interrelated social, emotional, cognitive, and sociocognitive competencies acquired in the successive developmental stages. Each new development builds on and incorporates prior developmental structures. Successful development requires the competent resolution of stage-salient issues, moving through a course of increasing competence and adaptation. Thus, early disturbances in functioning derived from maltreatment experiences predispose a child to disturbances in later stages of development, and these disturbances are worse the earlier the maltreatment occurs.

It is important to note, however, that the relationship between early and later disturbances in child development and functioning is far from inevitable. There are many pathways between maltreatment and later adaptation. According to Cicchetti (1989), “there are many factors that may mediate between early and later adaptation or maladaption that may allow alternative outcomes to occur” (p. 414). Thus, just as the successful resolution of stage-salient issues does not necessarily ensure later competence/adaptation, disturbances in such milestones do not necessarily imply later incompetence/maladaption. We return to this issue below.

6 Health and Physical Effects

6.1 Physical Health

Infants and young children are particularly vulnerable to the physical effects of maltreatment. Children under 4 years of age – and to a greater extent, children under 1 year of age – are the ones who are at greatest risk of death. Physical abuse, and especially extreme neglect, are the most common causes of death in such age groups (Krug et al. 2002; UNICEF 2003).

Infant and young child victims of Shaken Baby Syndrome and Nonorganic Failure to Thrive can suffer severe physical consequences. The Shaken Baby Syndrome is caused by vigorously shaking a child. According to the National Center on the Shaken Baby Syndrome, the majority of victims are infants younger than 1 year of age. Approximately 25 % of victims die as a result of their injuries. Of those who survive, 80 % suffer permanent disability such as severe brain damage, cerebral palsy, mental retardation, behavioral disorders, and impaired motor and cognitive skills. Other consequences include concussions, respiratory distress, seizures, partial or complete loss of vision, or learning disabilities (Goldman et al. 2003). Nonorganic Failure to Thrive (NOFT) usually affects infants and toddlers younger than 2 years old. It refers to situations where children’s growth (weight, height, and motor development) deviates significantly from the norms for their age and gender, with no medical or organic cause. NOFT results from a severe lack of stimulation and affection towards the child. It may have significant long-term consequences for children, such as growth retardation, diminished cognitive ability, mental retardation, socioemotional deficits, and poor impulse control (DePanfilis 2006). Impairments to physical growth and development as well as to intellectual and psychological functioning throughout childhood have also been observed in neglected children who have failed to thrive as a result of malnutrition (Urquiza and Winn 1994).

In childhood, psychological maltreatment has been associated with allergies, asthma, and other respiratory ailments, eating disorders, and somatic complaints (Hart et al. 2011). Sexual abuse has been associated with direct injuries to the genital area or sexually transmitted diseases, secondary problems, including enuresis, encopresis, and/or recurrent problems with urinary tract infections, and other somatic or psychophysiological problems (Urquiza and Winn 1994).

Physical effects of child maltreatment also can be observed in adolescence and adulthood. These include poor health, obesity, and physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers. Some research suggests an association between child maltreatment and other physical problems, such as heart disease, cancer, chronic lung disease, and liver disease, through the relationship between child maltreatment and depression, which appears to influence the immune system and lead to higher-risk behaviors such as smoking, alcohol and drug use, and overeating. Observed consequences of child sexual abuse in adulthood include noncyclical pelvic pain, other gynecologic problems, psychosomatic problems, gastrointestinal problems, eating disorders, headaches, and sexual dysfunctions (Child Welfare Information Gateway 2008; Gilbert et al. 2009; Goldman et al. 2003; Maniglio 2009).

6.2 Brain Development

Optimum development of the brain depends on the mutual influence of genetics, environment, and experience. Brain growth and development begin in the prenatal period. Although it continues throughout life, the greatest growth occurs in the first 3 years of life. Brain development implies creating, strengthening, and discarding connections among neurons. This process occurs in a sequential and hierarchical fashion, organizing from least complex to more complex brain regions and functions. These different brain regions develop, organize, and become fully functional at different times of development (sensitive periods), constantly adapting to the environment. Neuronal pathways that are used more frequently are strengthened, whereas the available pathways that are not used or that do not receive the appropriate stimulation are pruned or broken away.

Early environments and experiences have an exceptionally strong influence on brain architecture. There is evidence that impoverished early experiences and early high or chronic levels of stress, including child maltreatment, can interrupt normal brain development. Such circumstances are related to severe and long-lasting disturbances in brain chemistry, structure, and function that could explain many of the physical, cognitive, social, and emotional problems observed in maltreated children throughout infancy, adolescence, and adulthood (Child Welfare Information Gateway 2009; Hagele 2005; National Scientific Council on the Developing Child 2005, 2007; Perry 2002; Pechtel and Pizzagalli 2011).

Child maltreatment can alter brain growth and development in many different ways. Brain development can be directly damaged by prenatal exposure to alcohol and other drugs, head traumas resulting from baby shaking, or malnutrition. It can also be affected by early child maltreatment that involves an extreme lack of sensory and cognitive experiences. Such experiences can alter the brain’s ability to use serotonin (linked to feelings of well-being and emotional stability), decrease brain growth, and provoke neuronal loss, all of which are related to abnormalities in cognitive, emotional, behavioral, and social functioning. Research has also shown that repeated child maltreatment associated with a permanent activation of the stress response systems disrupts developing brain circuits. As a consequence of the chronic stimulation of the brain’s fear response, young children who are victims of chronic or extreme maltreatment form templates or memories in the brain in which the fear responses become fixed. These children are in a constant state of high alert and hyperarousal that prevents them from adapting to nurturing environments, achieving the calm necessary for learning and engaging in activities necessary for the development of complex emotional, behavioral, and cognitive functioning such as emotional regulation and impulse control. Permanent activation of stress response systems is also related to high levels of stress hormones that can suppress the body’s immune response, leaving the child vulnerable to a variety of infections and chronic health problems. Maltreatment experiences can also provoke dissociative responses as an effort to separate painful experiences from conscious awareness. When carried to an extreme, dissociative responses can result in disorders in self-identity, dysfunctions in memory, amnesia, and hallucinations (Child Welfare Information Gateway 2009; National Scientific Council on the Developing Child 2005; Pechtel and Pizzagalli 2011; Perry 2002).

Effects of maltreatment on the developing brain in childhood may persist into adolescence and adulthood. In maltreated adolescents, the underdevelopment of the brain’s cortex has been related to increased impulsive behavior, difficulties with tasks that require higher-level thinking and feeling, delays in both academic and social skills, and a propensity to taking risks. In adults with a history of severe maltreatment, abnormalities in brain growth, in the hippocampus and limbic system, and in the connection between the two brain hemispheres have been identified. These conditions have been associated with an increased risk of memory impairments and diverse psychopathological disorders such as depression, panic, post-traumatic stress, and dissociative and attention-deficit disorders (Child Welfare Information Gateway 2009).

7 Effects on Emotional, Psychosocial, and Behavioral Development

7.1 Attachment Disturbances

The first developmental task that children must achieve in the process of development is the establishment of a secure attachment with their primary caregiver – usually the mother. This is the most important relationship in a child’s life. Attachment is built gradually and slowly by repetitive bonding experiences between the child and his/her primary caregiver. The attachment process is very significant to child development because it affects the current and future ability of the child to cope with stress, regulate emotions, benefit from social supports, and form nurturing relationships. Secure attachment is essential to establish a child’s feelings of self-esteem and worth, providing the working framework for all subsequent relationships that the child will develop.

All these abilities come into question for maltreated youngsters because their attachment process is disrupted. Research has consistently shown that a high percentage of physically and psychologically maltreated infants and toddlers show insecure and disorganized/disoriented attachment patterns with their primary caregivers (Carlson et al. 1989; Cicchetti and Toth 2005; Erickson and Egeland 2011; Hart et al. 2011; Perry 2001). Disruption in the attachment process decreases the youngsters’ feelings of security and trust in their caregivers, contributes to a poor self-image as unworthy of love, and to perception of others as unavailable and rejecting, thus contributing to a vision of the world as a dangerous and an unhappy place (Hildyard and Wolfe 2002).

Attachment disturbance patterns tend to continue into preschool and school-age periods and can significantly impair a child’s ability to develop future healthy relationships with peers and adults, to competently explore the environment, and to cope with the demands of new and stressful situations later in development (Crittenden and Ainsworth 1989). Distorted attachment patterns in maltreated children have been associated with a mistrust of others, less willingness to learn from adults, difficulty understanding the emotions of others, difficulty regulating one’s own emotions, difficulty forming and maintaining relationships with others, limited ability to feel remorse or empathy, and a lack of self-confidence and social skills (DePanfilis 2006; Perry 2001). Attachment theory is one of the most sophisticated and cited perspectives when explaining the varied and lifelong negative outcomes observed in the development and functioning of many maltreated children, with important implications for maltreatment prevention and treatment (Bacon and Richardson 2001; Crittenden and Ainsworth 1989; Erickson and Egeland 2011).

7.2 Affect Regulation

Affect regulation refers to “the intra and extraorganismic factors by which emotional arousal is redirected, controlled, modulated, and modified so that an individual can function adaptively in emotionally challenging situations” (Cicchetti and Toth 2005, p. 416). Research on maltreated children has shown that these children display more problems in regulation of affect and emotions than their nonmaltreated counterparts (as manifested in deficits in the recognition, expression, and understanding of their own and other people’s emotions). They also show affective lability/negativity and socially inappropriate emotional expressions. Maltreated children are also more likely to have difficulties in mentally representing and processing social information, and often display deviations in understanding negative affect and in affective processing. Different patterns of social information processing have emerged in neglected and physically abused children. Neglected children appear to be more likely to feel confused by the emotional displays of others, to have difficulties discriminating emotional expressions, and to show the poorest coping skills in stressful situations. Physically abused children appear to be more likely to overattend angry emotional expressions and threat-related signals, to fail to adequately attend relevant nonhostile cues, and to respond with anger to stressful situations. Distortions in affect regulation have been related to poorly regulated and situationally inappropriate affect and behavioral responses to peer distress (anger, fear, aggression, lack of empathy and concern), and to disruptive and aggressive actions and later symptoms such as anxiety or depression (Cicchetti and Toth 2005; Hildyard and Wolfe 2002).

7.3 Peer Relations and Interpersonal Relationships

As previously mentioned, attachment and emotional regulation disturbances are linked to difficulties in establishing positive relationships with other people, including peers. Research has shown that maltreatment can deleteriously affect the ability of preschool and school-aged children to develop and sustain relationships with peers. When compared to their nonmaltreated counterparts, maltreated children tend to exhibit fewer prosocial behaviors and more antisocial behaviors, interact with their peers either by being overly hostile and aggressive or excessively withdrawn and avoidant (being passive around other children, and actively avoiding or resisting the friendly overtures of other children), and more often cause distress to their peers. They also tend to be more disliked, less popular, and more socially withdrawn from peers.

Although such problems affect both physically abused and neglected children, externalizing problems such as aggressive, uncooperative, and noncompliant behaviors appear to be particularly associated with physical abuse, whereas social avoidance, withdrawal, and lack of social skills appear to be particularly linked to neglect. Other studies have found a relationship between physical and sexual abuse and bullying others or being victimized by peers (Cicchetti and Toth 2005; Hildyard and Wolfe 2002; Mills 2004). Social competency problems are more common in psychologically maltreated children and include self-isolating behavior, low social competency, social phobia, low empathy, and noncompliance (Hart et al. 2011).

Peer-relationship problems in maltreated children may not be related only to deficits in social skills. Maltreatment also appears to impair the development of a working model of relationships based on sharing, equality, and nonexploitation, the child’s capacity to seek and obtain support and security from peers, and the capacity to trust others (Mueller and Silverman 1989). Avoidance of intimacy in relationships has been identified as a frequent characteristic of maltreated children. Such difficulties may persist into adolescence and adulthood, affecting areas such as sexual intimacy (Lowenthal 2000; Urquiza and Winn 1994).

An increased likelihood of aggressive and violent behaviors has also been observed in adolescents and adults with a history of physical abuse, sexual abuse, or neglect, as indicated by higher rates of arrests than individuals without such a history. Physical and sexual abuse have been linked to delinquency and violence in adolescence, particularly for girls (Gilbert et al. 2009; Hart et al. 2011).

7.4 Emotional Disturbances and Psychopathology

Research has consistently found higher rates of emotional disturbances in maltreated children than in their nonmaltreated counterparts. Neglect appears to be associated with the most severe socioemotional problems and with internalizing symptoms, whereas physical abuse appears to be more closely associated with externalizing problems (Hildyard and Wolfe 2002). Psychological maltreatment has been related to higher risk of emotional instability, impulse control problems, and borderline instability (Hart et al. 2011).

The literature on maltreated children reveals a greater prevalence of psychiatric symptoms and diagnoses across infancy, preschool and school ages, adolescence, and adulthood. Different forms of maltreatment have been linked to depressive symptomatology, anxiety, self-esteem impairment, attention deficit hyperactivity disorder, oppositional disorder, post-traumatic stress disorder, personality disorders, conduct disorders, dissociation, and somatization (Cicchetti and Toth 2005; Gilbert et al. 2009; Hart et al. 2011; Hildyard and Wolfe 2002; Maniglio 2009). Other studies have identified strong associations between sexual abuse and major depression and dysthymia from infancy into adulthood (Putnam 2003). Converging evidence also suggests an association between maltreatment and an increased risk of alcohol problems (particularly for girls) and substance abuse in adolescence and adulthood. Physical, sexual, and psychological abuse have been linked to suicidal ideation and higher risk of attempted suicide in young people (Gilbert et al. 2009; Hart et al. 2011; Maniglio 2009), although other psychological variables such as low self-esteem appear to act as important mediating variables in this relationship (Evans et al. 2005).

7.5 Effects on Cognitive Development and Academic Functioning

Research has consistently shown that physical abuse, neglect, and psychological maltreatment are related to learning and academic performance problems at different developmental stages. Such problems include a decline in mental competence, lower scores on intelligence measures, language delays and disorders, impaired learning, and lack of concentration on cognitive tasks. Higher dropout rates, referrals to special education, and retention have also been found in school-aged maltreated children when compared to nonmaltreated children. Negative effects of neglect on cognitive development and academic achievement across all developmental stages appear to be much more severe than the effects of other types of maltreatment (DePanfilis 2006; Hart et al. 2011; Hildyard and Wolfe 2002; Lowenthal 2000; Mills 2004). Some research has found that the negative effects of emotional neglect on the cognitive abilities of infants and preschoolers are more severe than those associated with physical abuse, suggesting that physical contact occurring in the form of abuse may be less harmful to early cognitive development than no contact at all (Hildyard and Wolfe 2002). Negative effects of sexual abuse on academic performance seem less evident (Lowenthal 2000). Reduced levels of educational achievement in maltreated children persist into adulthood, although differences between adults with and without a history of child maltreatment appear to be largely explained by social, parental, and individual factors (Gilbert et al. 2009).

Observational studies and teachers’ ratings of the behavior of maltreated children at school indicate common patterns of disruptive and noncompliant behaviors, impulsivity, disorganization, distractibility, lack of persistence in schoolwork, poor work habits, lack of motivation, anxiety, overactivity, and inattentiveness. Social behaviors of many maltreated children at school range from withdrawal to aggression, with the consequence of rejection by peers. Other common characteristics of maltreated preschool children include dependency on adults and a strong need for the approval of their teachers. As with cognitive development and academic performance, neglect appears to be associated with the poorest behavioral functioning at school. Fearfulness, inattention, apathy, and lack of demonstration of positive affect, humor, or enjoyment have been found as common characteristics of neglected children in the school context (Lowenthal 2000).

7.6 Effects on Sexual Behavior

A consistent finding in research about the consequences of child sexual abuse is the increase in children’s sexualized behavior. About one third of sexually abused boys and girls display sexual behavior problems, a higher proportion than that of nonmaltreated, physically abused, and neglected children. Sexual behavior problems observed in children, adolescents, and adults with a history of sexual abuse include increased sexual ideation and fantasies, sexual preoccupation, sexualized interactions, poor boundaries, excessive masturbation, involvement in sexual behavior with peers, early involvement in sexual activity or prostitution, sexually risky behaviors (such as engaging in unprotected sexual intercourse), sexual promiscuity, sexual perpetration, sex trading (sex for money, drugs, or shelter), and unwanted pregnancy (Berliner 2011; Gilbert et al. 2009; Maniglio 2009). Sexual behavior problems appear to be most pronounced in younger children, in children abused at earlier ages, and when children are examined relatively proximal to abusive experiences (Putnam 2003).

Sexual behavior problems also appear to be related to other types of maltreatment. There is evidence that sexual behavior problems in childhood and adolescence are also associated with a history of child physical abuse (Friedrich et al. 2003; Merrick et al. 2008). The relationship with child neglect and psychological maltreatment is less certain, although there are some references to the associations between neglect and engagement in sexual activity leading to teen pregnancy (DePanfilis 2006), as well as psychological maltreatment and sexualized behaviors and sexual maladjustment (Hart et al. 2011; Merrick et al. 2008). Some researchers have suggested that sexualized behaviors and early pregnancy in maltreated children and adolescents can reflect the desire to gain physical closeness and intimacy and to fulfill unmet psychological needs (Merrick et al. 2008; Putnam 2003). Physical abuse, sexual abuse, and neglect have also been associated with a higher frequency of subsequent arrest for prostitution or being paid for sex (Gilbert et al. 2009).

Sexual behavior problems are related not only to child physical and sexual abuse. Research has shown their relationship with other indicators of family dysfunction, parental stress, parental substance abuse, and other social adversity. An association has also been found with early, age-inappropriate exposure to sexual behavior or knowledge such as witnessing parental sex and pornography (Friedrich et al. 2003).

7.7 Intergenerational Continuity of Child Maltreatment

Research has shown that being a victim of child maltreatment is a risk factor for becoming a maltreating parent, although the relationship is far from inevitable or direct. Most parents who were maltreated as children do not maltreat their children. Kaufman and Zigler (1989) suggested a base rate for maltreatment among adults with a history of maltreatment of 30 % (±5 %), approximately six times higher than the base rate in the general population.

Retrospective studies have found that parents who had experienced physical abuse in childhood were two to five times more likely to engage in physically abusive behaviors toward their own children, and parents who reported having been neglected were 2–2.6 times more likely to engage in neglectful behaviors toward their own children than those who did not report such histories in their childhood (DePanfilis 2006; Kim 2009; Pears and Capaldi 2001). However, results of longitudinal and well-controlled studies investigating the intergenerational continuity of child physical abuse have found mixed and contradictory results (Ertem et al. 2000). Research into the intergenerational transmission of child sexual abuse is more limited. Studies of juvenile and adult offenders have found a wide ranging rate – between 17 % and 92 % – of offenders with a previous history of sexual victimization. Although findings may suggest that there may be a relationship between being sexually abused and being a sexual offender – juvenile, adult, or both, conclusions about a causal relationship are faulty (Urquiza and Winn 1994; Wilcox et al. 2004). Other research findings suggest that women who were sexually abused in childhood may be more likely to fail to protect their offspring from sexual abuse by other people, whereas men may be more likely to abuse (Putnam 2003). Later revictimization has been found to be significantly related to child sexual abuse in female samples (Maniglio 2009). Exposure to intimate partner violence (IPV) during childhood has also been linked to being violent or abused in later adult intimate relationships, although effects of other forms of maltreatment frequently associated with IPV (such as the case of physical and sexual abuse) are difficult to differentiate (Bedi and Goddard 2007; Goddard and Bedi 2010; Graham-Bermann and Howell 2011; Holt et al. 2008; Tomison 2000).

8 Factors Influencing Child Maltreatment Outcomes

As seen in previous sections of this chapter, there is a wide heterogeneity of maltreatment effects. Child maltreatment experience does not necessarily lead to the same outcomes in every individual. Such variability derives from the fact that the relationship between the occurrence of maltreatment and the child’s adjustment is complex, not a lineal and simple relationship of cause and effect. There is a multiplicity of influences on a child’s adaptation. Child development is the result of continuous dynamic transaction and reciprocal influences on the child, the caretaking environment, and social context. These factors exert a moderating influence (either potentiating or compensating) on child outcomes, so “there are multiple pathways to the same developmental outcome, and the same event or environmental circumstances may cause very different developmental outcomes” (Egeland 1991, p. 38). Thus, child maltreatment should be considered a significant risk factor for short-term and long-term adjustment problems, but not the only important one. Factors that have been identified and influence child maltreatment outcomes include characteristics of the maltreatment itself, of the child, of the family, and of the environment.

8.1 Characteristics of Maltreatment

Understanding the impact of maltreatment on children’s growth and development requires considering child maltreatment as a multidimensional construct. Analyzing child maltreatment as a one-dimensional or dichotomous variable (yes/no, presence/absence) seems insufficient in order to understand its effects. The review presented in previous sections of this chapter has shown that type, severity, chronicity, and age of onset of maltreatment are significantly related to child outcomes. Findings of the Longitudinal Studies Consortium on Child Abuse and Neglect (LONGSCAN) have shown that compared with a single-dimension model (yes/no), the inclusion of such maltreatment dimensions, both individually and in combination, significantly increases the explained variance of child outcomes (English et al. 2005). In general terms, the effects of child maltreatment are more detrimental and lasting insofar as the child suffers more maltreatment experiences – particularly when psychological maltreatment and emotional neglect are involved – when maltreatment is more serious, repetitive, or chronic and begins at an earlier age.

Co-occurrence of maltreatment types also appears to be an important factor to take into account when maltreatment effects are studied. Although there is evidence that different types of maltreatment have different effects on child outcomes, some research has shown that combinations of maltreatment types have specific and qualitatively different effects from the effects of the individual types (Bagley and Mallick 2000; Hart et al. 2011; McGee et al. 1997; Ney et al. 1994). Consistent evidence suggests a cumulative effect of different types of maltreatment (Gilbert et al. 2009). In a review of the long-term effects of child maltreatment, Higgins and McCabe (2001) conclude that “where comparisons between single- and multi-type maltreatment have been made, multi-type maltreatment was associated with greater adjustment problems than single types” (p. 576). However, more research is needed about the impact of the co-occurrence of multiple maltreatment types and how they interact to produce specific effects. As Herrenkohl and Herrenkohl (2009) indicated, more efforts are needed to address “whether it is the combination of maltreatment types that exerts its own singular effect, dependent on the specific combination involved, or whether it is the specific types of maltreatment in any combination each of which exerts its own independent effect” (p. 493). Consideration of the co-occurring maltreatment experiences affecting a child is useful not only to know which maltreatment types, singly and in combination, result in which outcomes and why, but also to interpret correctly the results of some studies that may erroneously attribute child outcomes to a particular type of maltreatment, which in fact should be attributed to an ignored specific combination of different types (Lau et al. 2005).

8.2 Characteristics of the Child

As seen previously, maltreatment effects vary at different stages of development. According to Finkelhor (1995), the impact of maltreatment may differ as a result of three factors. First is the developmental tasks or developmentally critical periods the child is facing, where effects of maltreatment vary depending on the state-specific processes or tasks that are interfered with (for example, secure attachment relationships with the primary caregiver, autonomy and self-development, symbolic representation, peer relations). The second factor is the types of symptoms evidenced by maltreated children, given that the available types of behavior and symptom expression vary at specific stages of development. The third factor is the children’s appraisal, interpretation, and understanding of the maltreatment, which depends partially on cognitive-developmental abilities.

There are a variety of characteristics of children that appear to moderate the experience of maltreatment and to play a significant role in their adjustment to victimization. These include child temperament, gender, premaltreatment adjustment (intelligence and cognitive skills, internal vs. external locus of control, coping strategies, and self-esteem) and medical, biological, or physical deficits (Gilbert et al. 2009; Pearce and Pezzot-Pearce 1997). A history of prior psychological problems, particularly anxiety conditions, and a child’s subjective perception that he/she is in severe danger or could be killed or seriously harmed have also been found to be related to the severity of child sexual abuse outcomes (Berliner 2011).

Children’s perception of, and the meaning attributed to, the maltreatment is one of most cited moderators of maltreatment impact. Research has found that children’s beliefs about their experiences of maltreatment are linked to individual differences in adjustment and to resilient functioning. As Egeland (1991) noted in relation to child psychological maltreatment, “identical observable parental behaviors may have very different meanings for the child, depending on parent’s intent, the context, the attribution and vulnerability of the child, the child’s developmental history, and the history of the relationship between the parents and the child” (p. 40). In the same vein are Wilcox et al. (2004) when they note, with regard to child sexual abuse, that independent of the abuse characteristics, “it is the perception of the abuse held by the child which will often determine the degree to which they are adversely affected by the abuse” (p. 344).

8.3 Ecological Influences

Research has shown the significant contributions of the ecological context surrounding the child (i.e., the immediate family, the school, peers, and the neighborhood community contexts) to the child’s adjustment. On the one hand, contextual risk factors frequently associated with the occurrence and/or maintenance of child maltreatment, e.g., social isolation, poverty, stress, parental psychopathology, parental psychological distress, marital discord, family violence, distorted patterns of parent-child relationship, or limited parenting skills, have their own and independent negative impact on child development and adjustment (Hecht and Hansen 2001). The same can be said about the effect of other types or patterns of child victimization (e.g., violent and property crimes, community violence, peer assault) that some researchers have found frequently associated with child maltreatment (Finkelhor et al. 2007). Apart from their own adverse impact on the child, such factors can exacerbate the negative effects of maltreatment (Zielinski and Bradshaw 2006). Negative contextual factors seem to act in a cumulative fashion, leading to worse outcomes as they increase in quantity (Middlebrooks and Audage 2008).

Analysis of contextual factors is essential for a better understanding of the complex relationship between the occurrence of maltreatment and its effects, and a better understanding of the heterogeneity in the outcomes associated with maltreatment (Zielinski and Bradshaw 2006). This analysis will help to avoid an overestimation of the influence of particular types of child maltreatment on negative outcomes (Hecht and Hansen 2001; Maniglio 2009).

9 Resilience and Protective Factors

Despite the fact that child maltreatment has a significant negative impact on child development, not all maltreated children display long-term social or psychological impairment. Some of them show positive adjustment and success in developmental tasks. Up to 40 % of sexually abused children present few or no symptoms of psychiatric sequelae, although some data suggest that 10–20 % of initially asymptomatic sexually abused children deteriorate over time and that some of the initially least symptomatic may be the most likely to deteriorate with time (Putnam 2003). Research about other types of maltreatment has yielded varied results, with percentages ranging from none to approximately 20 % of maltreated children functioning competently on global indices of healthy functioning in childhood and adolescence. The lowest percentages of resilient children were found in studies where the definition of resilience encompassed more domains of functioning and included a temporal dimension, whereas the highest percentages were found in studies with narrower consideration of domains of functioning and focused on a particular moment in time (Haskett et al. 2006).

The study of resilience has gained considerable attention in the child maltreatment literature. The field of research is moving beyond a focus on negative impacts of maltreatment to increasing efforts to understand why some maltreated children demonstrate a resilient functioning. A growing body of research has aimed to identify the variables and mechanisms that lead some maltreated children to have a good or relatively good outcome despite suffering an experience that would be expected to have serious consequences.

Research has identified some features at the individual, family, and environmental levels that are associated with short-term and long-term resilient functioning. At the individual level, characteristics of maltreated children that have been linked to resilient functioning include self-regulatory capacity, perception of personal control over events and relationships, locus of control, self-esteem, social problem-solving ability, beliefs about their experiences of maltreatment, and academic engagement. Findings about the relationship between cognitive ability (IQ) and resilience are mixed. Characteristics of the family environment related to resilient functioning in maltreated children include specific dimensions of parenting quality (affection, sensitivity, and support for autonomy), children’s perception of family coherence, family stability, and support from siblings or other family members. These findings suggest that while the family environment of maltreated children tends to be much more dysfunctional than that of nonmaltreated children, there are individual differences in parenting and family processes within these families that are important for child outcomes. Finally, there is also evidence that positive interpersonal relationships, including emotional support from adults outside the family, a warm relationship with at least one adult who provides support and moderate discipline, positive experiences with peers and adults at school, prosocial peer relationships, and good and stable social relationships in young to middle adulthood, may serve as a potential buffer to the effects of maltreatment (Berliner 2011; Haskett et al. 2006; Rutter 2007; Wilcox et al. 2004; Zielinski and Bradshaw 2006).

Until now, most of the research on resilience has focused on the identification of the influences that protect children from negative impacts. From a transactional perspective, child functioning is the result of the mix and balance between risk and protective influences that are found in the individual, familiar, and environmental levels. Such balance increases or decreases the likelihood of positive or negative developmental outcomes: “As the balance between risk and protective factors tips in the direction of risk factors, the likelihood of a negative outcome increases. Once a certain number is reached, the probability of a negative outcome increases in an exponential fashion” (Egeland 2009, pp. 24–25). However, the study of individual traits or external factors that can act as risk and protective factors appears to be insufficient to explain resilience. On the one hand, there are huge and marked individual differences in people’s responses to even the same experiences. On the other hand, resilience is not a stable trait or state: individuals may be resilient to some sorts of environmental hazards but not to others, they may be resilient to some kinds of outcomes but not to others, and they may be more resilient in some periods of their life but not in others. As some leaders in the field have suggested, the understanding of resilience not only requires paying attention to risk/protective factors, but also, and perhaps more importantly, to individual (dynamic mental and neurobiological) processes or mechanisms that determine how resilient individuals deal with risks (Cicchetti and Toth 2005; Rutter 2007).

10 Summary

Available data indicate that child maltreatment in the family is a global and widespread problem. Significant progress has been made in the identification of child-rearing practices that can significantly harm child health and development and the mechanisms through which such practices exert their impact. Retrospective and prospective studies have established that child maltreatment can have strong and long-lasting effects on diverse domains of child development and functioning (physical, emotional, behavioral, and social). However, there is also evidence that some maltreated children manifest resilient functioning and psychological adaptation despite experiencing significant adversity. Noteworthy advances have been made in the identification and analysis of the protective factors and processes that lead to resilience, although much more research is needed. Available evidence supports the importance of preventive and early intervention efforts to help children avoid maltreatment or its negative consequences. Such efforts must incorporate a global perspective, as the occurrence and impact of child maltreatment cannot be adequately understood and addressed as independent of other adverse circumstances (e.g., poverty, substance abuse, parental psychological problems, social isolation, violence) that affect maltreated children and their families.