mental recovery of child abuse victims case study

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• Contemp Clin Dent
• v.5(2); Apr-Jun 2014

Child abuse: A classic case report with literature review

Arthur m. kemoli.

Department of Paediatric Dentistry and Orthodontics, University of Nairobi, Kenya

Mildred Mavindu

Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. In the present case report, a 12-year-old orphaned boy was physically abused by a close relative who caused actual bodily and emotional trauma to the boy. After satisfactorily managing the trauma and emotional effects to the patient, in addition to the counseling services provided to the caregiver, the patient made a steady recovery. He was also referred to a child support group for social support, and prepare him together with his siblings for placement in a children's home in view of the hostile environment in which they were living.

Introduction

For a long time, child protection in general has been perceived as a matter for the professionals specializing in social service, health, mental health, and justice systems. However, this problem remains a duty to all, and more so a concern for other social scientists such as anthropologists, economists, historians, planners, political scientists, sociologists, and humanists (e.g., ethicists, legal scholars, political theorists, and theologians) who contribute to the understanding of the concepts of and strategies in child protection and the responsibility for adults and institutions with roles in ensuring the safety and the humane care of children under their care. Child abuse, therefore, is when harm or threat of harm is made to a child by someone acting in the role of caretaker.[ 1 , 2 ] It is a worldwide problem with no social, ethnic, and racial bounds.[ 3 ] Child abuse can be in the form of physical abuse, when the child suffers bodily harm as a result of a deliberate attempt to hurt the child, or severe discipline or physical punishment inappropriate to the child's age. It can be sexual abuse arising from subjecting the child to inappropriate exposure to sexual acts or materials or passive use of the child as sexual stimuli and/or actual sexual contacts. Child abuse can also be in the form of emotional abuse involving coercive, constant belittling, shaming, humiliating a child, making negative comparisons to others, frequent yelling, threatening, or bullying of the child, rejecting and ignoring the child as punishment, having limited physical contact with the child (e.g., no hugs, kisses, or other signs of affection), exposing the child to violence or abuse of others or any other demeaning acts. All these factors can lead to interference with the child's normal social or psychological development leaving the child with lifelong psychological scars. Lastly, child abuse can be in the form of child neglect, when an able caregiver fails to provide basic needs, adequate food, clothing, hygiene, supervision shelter, supervision, medical care, or support to the child.[ 4 ]

It is usually difficult to detect child abuse, unless one creates an atmosphere that would encourage disclosure by the child being abused.[ 5 ] Nonetheless, a good medical and social history may help to unravel the problem. Signs and symptoms of child abuse commonly include subnormal growth of the child, unexplained head and dental injuries, soft-tissue injuries like bruises and bite marks, burns and bony injuries like broken ribs, in the absence of a history pointing to the cause or causes of the trauma. The present case report describes a child who was abuse by a very close relative, and who caused physical and psychological trauma to the young lad.

Case Report

Peter, a 12-year-old boy, accompanied by his maternal aunt, presented at the local university Dental Hospital (Pediatric Dental Clinic) in Kenya in October 2012, with a complaint of a large, painful left facial swelling related to the left upper incisors. He had been referred from a local rural hospital where he had been taken by the same aunt, for treatment of the swelling. The swelling had occurred only 2 days prior to visiting the local hospital, and 4 days before presenting himself at the University Dental Hospital. Enquiry about the causes of the swelling provided unclear answers. Family history indicated that the young boy was a first-born among three siblings (9-year-old girl, 5-year-old boy), and that their single parent (mother) had been deceased for 6 years due to HIV-related complications. The three children had moved to live with their maternal grandparents and their seven sons. The patient had no adverse past medical history and had never consulted a dentist previous to the present problem. The boy was in grade seven in a local primary school and had the aspiration of becoming a medical doctor in future. It was not possible to establish from the aunt or the boy the situation of the patient's other siblings.

An extra-oral examination showed a young boy with a normal gait, sickly, unkempt, rather withdrawn, and small for his age. He had asymmetrical face due to the swelling involving his left submandibular region and spreading upwards to the inferior orbital margin, febrile (39.1°C), a marked submandibular lymphadenopathy on the left side, the skin overlying the swelling was warm, shiny and fluctuant, and the lips were dry and incompetent (2 cm) and as shown in [Figures ​ [Figures1a 1a – c ]. However, the temporomandibular joint movements were normal. The patient was also found to have a big, healing scar on the dorsal surface of the left foot, the cause of which was also unclear [ Figure 1 ].

(a) Frontal and (b) lateral (c) profiles of the patient showing the facial asymmetry with the left submandibular to infra-orbital and the healing scar on the foot

Intra-oral examination revealed a young boy in the permanent dentition with un-erupted third permanent molars, poor oral hygiene with heavy plaque deposits on the tongue and a generalized but moderate inflammation of the gingiva. There was a grade three mobility in relation to 11, 12, 21, 22 and a grade two mobility in relation to 23, 24, 25 (Miller mobility index). There was intramucosal swelling in relation to 21-24 extending labially/buccally (measuring 4 cm × 3 cm) and palatally (measuring 3 cm × 2 cm). On elevation of the upper lip, active discharge of pus mixed with blood and some black granules could be seen emanating from the abscess. There were no alveolar/bone fractures elicited, but carious lesions were present on 46 (occlusal), 47 and 37 (buccal). Orthodontic evaluation showed Angles class I molar relation on the left and edge to edge tending to class II on the right side. The canines were in class I relationship bilaterally. There was an anterior over-jet of 3 mm (11/21), an overbite of 20%, coincidental dental/facial midline and crowding on the upper right arch with 15 palatally displaced as can be seen in Figure ​ Figure2a 2a – c .

(a) Intra-oral photographs of the patient showing the labial and (b) palatial swelling in relation to displaced 21 and 22 (c), generalized marginal gingival inflammation, palatally displaced 15, moderate dental plaque deposits and a moderate anterior dental crowding in the lower dental arch

For investigations, orthopantogram, intra-oral periapical 11, 12, upper and lower standard occlusal and bite wing radiographs were taken and examined. In addition, clinical photographs, study models, and vitality tests for the traumatized teeth were undertaken. A diet and nutrition assessment, full blood count, stool microscopic analysis for ova and cyst and bacterial culture and sensitivity were also undertaken.

The results of the radiographs showed un-erupted with potential impaction of 48 and 38, an upper midline radioluscence, widened periodontal space in relation to 11, 21 (with a mesial tilt), 22, occlusal caries on 46 and buccal caries on 47 and 37. There was the presence of root fractures involving the apical one-third of 21, 22. Vitality tests conducted on the traumatized incisors showed false positive (may be due to the presence of infection). The blood analysis showed the presence of neutrophilia (suggestive of bacterial infection), mild iron deficiency, but he was sero-negative. From the diet chart, the boy was generally on a noncariogenic diet that lacked the intake of fruits and animal proteins. Nutritional assessment revealed a boy with a height of 144 cm, a weight of 28 kg, and a body mass index (BMI) of 13.5 Kg/m 2 (below 5 th percentile (given the ideal BMI should be 17.8 Kg/m 2 in the 50 th percentile).

From the history adduced and the results of the investigations, a diagnosis of child abuse and neglect was reached, with the boy having suffered traumatic injuries resulting in facial cellulitis, Ellis class VI fracture involving 21, 22 associated dentoalveolar abscess and subluxation of 11, 12. In addition, there were dental carious lesions on 46 (occlusally), 47 and 37 (buccally) and a relatively severe malnutrition. The patient had also moderate plaque induced gingivitis, mild anemia (microcytic and iron deficiency), mild dental fluorosis, potentially impacted 48 and 38 and crowding in the upper right and lower anterior arches.

The objective of treating the boy was to eliminate the pain, infection, improve the general and oral health, restore carious teeth, improve esthetic and report the child abuse and neglect to the relevant authorities. In the initial phase of treatment, the patient was admitted for 4 days and placed on dexamethasone 8 mg stat, cefuroxime 750 mg 3 times a day, metronidazole 500 mg 3 times a day, diclofenac 50 mg tablets alternating 4 hourly with oral paracetamol 1000 mg 3 times a day, to run for 5 days. Patient was also placed on chlorhexidine mouthwash 10 ml twice daily for 7 days and ranferon (hematinics) 10 ml to be used twice a day for 1 month. The second phase of treatment included incision and drainage of the abscess, followed by the splinting of the mobile teeth in the upper dental arch using semi-rigid splint of 0.6 mm stainless steel round wire for 4 weeks while. Root canal treatment of 11, 21, 12, and 22 followed thereafter.[ 6 ] A referral of the patient was made the child support center in the main referral hospital, plus the patient was placed on future recalls to determine whether the patient would have overcome the problem and the oral health was maintained in good condition.

The third phase of treatment involved interceptive orthodontics with the extraction of 15 to relieve the crowding in the area. Oral hygiene instructions were availed to the patient and the guardian, placement of fissure sealants was done for the premolars and molars to help reduce plaque retention on these teeth, preventive resin restorations were placed on 37, 46, and 47. The root fractures involving the apical one-third of 21 and 22 meant that the two teeth were to be initially dressed using non setting calcium hydroxide, and after healing, root canals are filled in the usual manner [ Figure 3 ].

Postobturation intraoral periapial radiograph showing the restoration on 12, 11, 21, and 22

Nutrition evaluation had initially been done and when the patient was re-evaluated after 1 month, he had gained bodyweight up to 1 kg. The child support center continued to carry out psychotherapy, and during one of the sessions, the patient confessed to having undergone physical abuse and threatened not to divulge any information by one of the uncles. The center considered placing the boy into a children's home, probably together with his siblings. Radiographic examinations evaluation after 3 months indicated some external apical root resorption taking place on 21 and 22. Further follows-ups were to continue.[ 7 ] After 10 months, the oral health and general heath of the patient had remarkably improved as shown in Figure 4 .

Posttreatment photographs taken after 10 months showing improved oral health of the patient and the glimmer of confidence in the patient as shown in a-d respectively

All types of child abuse and neglect leave the affected child with long-lasting scars that may be physical or psychological, but they are the emotional scars that leave the child with life-long effects, damage to the child's sense of self, the ability to build healthy relationships and function at home, work or school. This situation can in turn result in the child turning to alcohol or drugs to numb the painful feelings. On the other hand, the exposure by the child to violence during childhood can increase vulnerability of that child to mental and physical health problems like anxiety disorder, depression, etc.,[ 8 , 9 ] and make victims more likely to become perpetrators of violence later in life.[ 10 ] The oral cavity can be a central focus for physical abuse due to its significance in communication and nutrition.[ 3 , 11 ]

A neglected and abused child like the one described here, can become helpless and passive, displaying less affect to anything whether positive or negative in his or her encounters.[ 12 ] The patient described was vulnerable to abuse as he already lacked the parental protection in his early life, and was living in a poor, but large family where competition for available resources must have been stiff. The abuser, therefore, his own uncle, probably did not like their presence gave him the assumption that the children would grow up to take away what he probably thought would be his dues from the family.

In Kenya and even in many other countries, data on the prevalence of child abuse is still scarce. A Kenyan study undertaken in 2013 showed that violence against children was very high, with 31.9% and 17.5% female and male, respectively reporting having been exposed to sexual violence, 65.8% and 72.9% female and male respectively to physical violence. In the same study, 18.2% and 24.5% female and male, respectively had been abused prior to attaining 18 years of age, and only 23.8% female and 20.6% male reported not having experienced any form of violence during childhood.[ 13 ] Child abuse in Kenya, therefore, appears to be a rampant problem within the society. In all cases of abuse reported in the literature, the perpetrators were most often well-known to the children. The motive of child abuse has not always clear, just as it was the case with the patient described here. The patient under study here hailed from a family with low socio-economic background where providing for extra needs in the family could have been a problem. Even during treatment of the patient the family found the cost of treatment to be very high and unaffordable to them, and a waiver of the cost had to be sought and obtained from the University Dental Hospital. Further, the child having been orphaned with the death of their single parent (mother) left these children unprotected and vulnerable to such abuse from uncles who may have been competing for same needs in an already crowded family. It is possible that factors as poverty, social isolation, and familial disruption could have contributed to the abuse meted by this boy.[ 1 ] The fact that the problem was established at this stage, it probably provided the patient and his siblings with the opportunity to get early support and avert serious health problems for them. The referral to the local child protection authority was done to attain this goal and also to have the children monitored consistently for their safety from further child abuse. The child protection agency was indeed considering placing them in the custody of a children's home, though sadly, according to a report by the Kenyan Government, the utilization of these support services had not been very high,[ 13 ] for reasons unknown.

The treatment of the patient was carried out in a humane manner, and assistance provided whenever possible to have the full treatment completed. The problem of nutrition was still a difficult one for this large family with a poor background. Nonetheless, the guardian was still briefed on the issue, and informed about the importance of a balanced diet for optimal growth and immunity boosting for such young child, and suggestions for alternative cost-effective foods for the child. It was hoped that the support services of giving the patient and probably his siblings a new home would help the young child to grow and develop normally without fear of abuse.

The management of child abuse can be complicated, and often require a multidisciplinary approach, encompass professionals who will identifying the cause of the abuse or neglect, treatment of the immediate problems and referral of the child to the relevant child protection authority for action. Counseling services for the child and the caregivers should form part of the management regime. In the present case, the objectives were met and the patient got full benefits of this approach.

Source of Support: Nil

Conflict of Interest: None declared.

• Case report
• Open access
• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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What Haunts Child Abuse Victims? The Memory, Study Finds

A study of adults who were mistreated in childhood found that those who did not recall it showed fewer psychological aftereffects.

By Ellen Barry

For generations, our society has vacillated about how best to heal people who experienced terrible things in childhood.

Should these memories be unearthed, allowing their destructive power to dissipate? Should they be gently molded into something less painful? Or should they be left untouched?

Researchers from King’s College London and the City University of New York examined this conundrum by conducting an unusual experiment.

Researchers interviewed a group of 1,196 American adults repeatedly over 15 years about their levels of anxiety and depression. Unbeknown to the subjects, 665 of them had been selected because court records showed they had suffered mistreatment such as physical abuse, sexual abuse or neglect before age 12.

Not all of them told researchers that they had been abused, though — and that was linked to a big difference.

The 492 adults who reported having been mistreated and were in court records substantiating the abuse had significantly higher levels of depression and anxiety than a control group with no documented history of abuse, according to the study, which was published last week in JAMA Psychiatry. The 252 subjects who reported being abused without court records reflecting it also had higher levels.

But the 173 subjects who did not report having been abused, despite court records that show that it occurred, had no more distress than the general population.

The findings suggest how people frame and interpret events in their early childhood powerfully shapes their mental health as adults, said Dr. Andrea Danese, a professor of child and adolescent psychiatry at King’s College London and one of the study’s joint authors.

“It goes back to almost the stoic message, that it’s what you make of the experience,” he said. “If you can change how you interpret the experience, if you feel more in control at present, then that is something that can improve mental health in the longer term.”

In a meta-analysis of 16 studies of childhood maltreatment published in 2019, Dr. Danese and colleagues found that 52 percent of people with records of childhood abuse did not report it in interviews with researchers, and 56 percent of those who reported it had no documented history of abuse.

This discrepancy could be partly because of problems in measurement — court records may not have all abuse history — and may also reflect that self-reporting of abuse is influenced by a person’s levels of anxiety and depression, Dr. Danese said.

“There are many reasons why people may, in some ways, forget those experiences, and other reasons why others might misinterpret some of the experiences as being neglect or abuse,” he said.

But even considering these caveats, he said, it was notable that adults who had a documented history of having been abused but did not report it — because they had no memory of the events, interpreted them differently or chose not to share those memories with interviewers — seemed healthier.

“If the meaning you give to these experiences is not central to how you remember your childhood so you don’t feel like you need to report it, then you are more likely to have better mental health over time,” he said.

Traumatic childhood experiences have been the subject of some of psychiatry’s most pitched battles. Sigmund Freud postulated early in his career that many of his patients’ behaviors indicated a history of childhood sexual abuse but later backtracked, attributing them to subconscious desires.

In the 1980s and 1990s, therapists used techniques like hypnosis and age regression to help clients uncover memories of childhood abuse. Those methods receded under a barrage of criticism from mainstream psychiatry.

Recently, many Americans have embraced therapies designed to manage traumatic memories, which have shown to be effective in the treatment of post-traumatic stress disorder. Experts increasingly advocate screening patients for adverse childhood experiences as an important step in providing physical and mental health treatment.

The new findings in JAMA Psychiatry suggest therapy that seeks to alleviate depression and anxiety by trying to unearth repressed memories is ineffective, said Dr. Danese, who works at the Institute of Psychiatry, Psychology & Neuroscience at King’s College London.

But he cautioned that the results of the study should not be interpreted as endorsing the avoidance of distressing memories, which could make them “scarier” in the long term. Instead, they point to the promise of therapies that seek to “reorganize” and moderate memories.

“It’s not about deleting the memory, but having the memory and being more in control of that so that the memory feels less scary,” he said.

Memory has always posed a challenge in the field of child protection because many abuse cases involve children below the age of 3, when lasting memories begin to form, said David Finkelhor, the director of the Crimes Against Children Research Center at the University of New Hampshire, who was not involved in the study.

In treating people with histories of having been abused, he said, clinicians must rely on sketchy, incomplete and changing accounts. “All we have is their memories, so it’s not like we have a choice,” he said.

He warned against concluding that forgotten maltreatment has no lingering effect. Early abuse may emerge through what he described as “residues” — difficulty in modulating emotions, feelings of worthlessness or, in the case of sexual abuse victims, the urge to provide sexual gratification to others.

Elizabeth Loftus, a psychologist at the University of California, Irvine, and a prominent skeptic of the reliability of memories of abuse , noted that the study stops short of another conclusion that could be supported by the data: Forgetting about abuse might be a healthy response.

“They could have said, people who don’t remember in some ways are better off, and maybe you don’t want to tamper with them,” she said. “They don’t say that, and that, to me, is of great interest.”

Ellen Barry covers mental health. She has served as The Times’s Boston bureau chief, London-based chief international correspondent and bureau chief in Moscow and New Delhi. She was part of a team that won the 2011 Pulitzer Prize for International Reporting. More about Ellen Barry

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A Trauma-Informed Approach to Assessment, Case Conceptualization, and Treatment Planning for Youth Exposed to Intimate Partner Violence

• Published: 28 January 2022
• Volume 48 , pages 3–11, ( 2022 )

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• Damion J. Grasso 1  

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Children’s exposure to intimate partner violence (IPV) is a prevalent public health problem that can result in serious mental health impairments, including traumatic stress. These can emerge early and persist across development. IPV early in life has also been described as a “gateway exposure” to other forms of adversity and trauma. Children and families impacted by IPV have complex needs that complicate assessment and intervention. This paper highlights these issues and reviews best practices in assessment, case conceptualization, and treatment planning as they pertain to the treatment of IPV-exposed children. A case vignette illustrates the complex nature of IPV and application of best practices by telling the story of Isaiah, a 13-year-old boy with an extensive history of IPV exposure and co-occurring adversity and trauma.

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Clinical Vignette—Isaiah

Isaiah, a 13-year-old boy, is referred for mental health services after a child protective services (CPS) investigation substantiated emotional neglect and identified intimate partner violence (IPV) in the home. He lives with his biological mother, Sandra, and Sandra’s partner of three years, Joseph. Sandra and Joseph have two children who also live with Isaiah: 2-year-old Dimitri and 9-month-old Juliana. Isaiah’s biological father, George, is not currently in contact with Isaiah.

Although Joseph and Sandra would historically engage in loud arguments that would occasionally involve slammed doors and broken furniture, the conflicts did not become physical until the COVID-19 pandemic. Joseph was laid off and Sandra lost work hours, making it hard to cover the bills. Isaiah’s school went virtual and childcare became unavailable. Sandra and Joseph struggled to effectively parent the children, especially Isaiah, whose behavior had become more disruptive and who could not engage in remote learning. The increased stress and stay-at-home orders led both Sandra and Joseph to start using substances again.

During this time, arguments increased in intensity to include physical altercations. During one heated argument, when Sandra and Joseph were both intoxicated, Sandra threw a shoe at Joseph, which hit his nose. In response, he became irate and threatened to kill Sandra. When Joseph advanced toward Sandra, Isaiah got in the way and was shoved, causing him to fall backwards into a piece of furniture. He managed to call 911. The fighting had already subsided when the police arrived. Both Sandra and Joseph were implicated. Police called CPS and all children were temporarily placed into foster care. Isaiah was separated from his siblings, who were placed in a different foster home that only accepted infants and young children.

This is not the first time CPS had been involved. Isaiah was placed into foster care on two separate occasions when he was 2 years old and again when he was 6 years old. Both involved substance use and IPV—this time perpetrated by Isaiah’s birthfather, George. George became abusive when Sandra was pregnant with Isaiah and this continued into Isaiah’s early childhood. The abuse led to police intervention when Isaiah was 2 years old. George and Sandra were under the influence of substances and got into an argument in which George hit Sandra. CPS substantiated emotional neglect but did not remove Isaiah from the home.

The IPV escalated over the years to the point at which George had socially isolated Sandra and exerted complete control over all aspects of her life. George would threaten to take Isaiah away and sometimes to kill the family pet Chihuahua. The physical violence was also becoming quite intense, for both Sandra and Isaiah. George would beat Sandra a few times a week and give Isaiah excessive spankings. George was also sexually violent toward Sandra and would assault her, including times when Isaiah was in the room. Isaiah would become highly distressed, cover his face, and cry while this was happening.

On one occasion, George nearly killed Sandra when he intercepted messages on her phone that she intended to leave the relationship. He punched Sandra in the face and strangled her until she temporarily lost consciousness. Isaiah, then 6 years old, jumped on top of George and was thrown against a wall, hitting his head hard enough to result in a concussion. George left abruptly and Isaiah had to rouse Sandra, who contacted police. CPS was contacted and Isaiah was placed into foster care.

Isaiah’s foster placement lasted almost a year. He had supervised visits with his mother, who had eventually followed through with substance use treatment. With the help of a domestic violence advocate, she was no longer with George. Unfortunately, Isaiah’s foster home did not prevent further victimization. There were several other children in the home and one of the adolescents in the home sexually assaulted Isaiah on a number of occasions without the foster parents knowing. When this was finally discovered, Isaiah was pulled from the home and placed into a different home until being reunified with Sandra.

Sandra started seeing Joseph when Isaiah was about 9 years old and shortly thereafter gave birth to his brother Dimitri, followed by his sister Juliana. Pre-pandemic, things were going okay. Joseph had a job at a restaurant and Sandra was working part-time as a house cleaner. Sandra and Joseph would often engage in loud arguments, but only seldom did they resort to anything physical, and never anything to cause injury. While Joseph and Isaiah’s relationship was at times rocky, they got along okay most of the time; however, Joseph took more responsibility for parenting his birth children than he did Isaiah.

After the incident when Isaiah called the police, he was placed into foster care where he struggled emotionally and behaviorally. He was able to continue with his current school, which had just started to provide hybrid in-person and remote learning options. However, just a month into his placement, Isaiah had an issue at school. His teacher was frustrated that Isaiah had his head down on the desk and was not paying attention. After trying to redirect Isaiah without success, he eventually went over and put his hand on his shoulder to get his attention. That’s when Isaiah sprung from the desk, knocked it over, and threw a punch at his teacher.

Clinical Challenge

Intimate partner violence (IPV) has been considered a “gateway exposure” to other forms of childhood adversities and can lead to a plethora of stress-relevant mental health impairments that can span multiple diagnostic categories (Grasso, 2020 ). Two significant challenges exist for children exposed to IPV. First, too many of these children are unidentified as needing intervention, both to prevent subsequent exposure to adversity and to address emerging stress-related psychopathology. Second, when identified as in need of services, many of these children are not connected to appropriate mental health services, nor are the complex circumstances of IPV adequately considered in the delivery of mental health treatment and adjunct services. The remainder of this article elaborates on these challenges and discusses recommendations for more effectively engaging and supporting IPV-exposed children, referring to the case of Isaiah for illustration.

Intimate Partner Violence—Not Just a Partner Problem

IPV is more than a partner problem, it is a family problem. In fact, it is a community problem. IPV is pervasive and affects at least 1 out of 5 children in the United States (Hamby et al., 2011 ; Turner et al., 2016 ). The majority of households with known IPV contain children, many of them young children who are proximally bound to the caregiving environment. The majority of victims receiving domestic violence shelter services are caregivers (National Network to End Domestic Violence, 2021 ). More than a third of domestic violence-related arrests involve children who are directly present (Reaves, 2017 ). Studies that conduct thorough reviews of case records report that the majority of children involved with child protective services have documented IPV exposure in their lifetime (Grasso et al., 2019 ). Further, more than half of older children and adolescents involved with juvenile justice services have experienced IPV at some point in their lives (Ford et al., 2013b ). In effect, IPV is a public health crisis that imposes significant risk of mental health impairment that can emerge early and cascade across development—and across generations.

The Pandemic Has Exacerbated IPV

Research published since the pandemic has provided evidence that pandemic-related stressors combined with unintended consequences of policies and practices implemented to reduce virus spread have exacerbated IPV (Grasso et al., 2021 ; Holmes et al., 2020 ). Survey research has revealed that 1 in 5 individuals have experienced an increase in verbal or physical conflict with a partner during the pandemic (Grasso et al., 2021 ), which aligns with an uptick in IPV-related arrests (Boserup et al., 2020 ). For some IPV victims, the pandemic may have been the “tipping point” for physical conflict to occur. Stay-at-home orders have reduced opportunities for respite and help-seeking among victims, with a 50% reduction in hotline calls over the pandemic (Evans et al., 2020 ) despite a paradoxical increase in emergency shelter utilization—with many domestic violence shelter agencies reporting well over 100% capacity (Connecticut Coalition Against Domestic Violence, n.d. ). In a similar manner, school closures, interrupted healthcare, and transition to remote services have meant fewer opportunities for child-serving professionals to interact with and identify IPV and adversity-exposed children, with a paradoxical reduction in mandated CPS reports despite increased hospitalizations attributed to maltreatment (Nguyen, 2021 ; Swedo et al., 2020 ). Not surprisingly, these increases in violence exposure among children seem to correspond with the surge of mental health impairment and suicidal behavior reported across the country in the later phase of the pandemic.

IPV—the Gateway Exposure

It is well-established that IPV often co-occurs with other forms of childhood adversity, with most children exposed to IPV also experiencing direct forms of child emotional and physical abuse (Turner et al., 2017 ). For example, it is not uncommon for IPV offenders to behave toward their children as they do their partners. This violent behavior among IPV offenders can include non-optimal and harsh parenting that is sometimes reported by victimized caregivers. Furthermore, caregivers, who are IPV victims, may be depleted of the personal and social resources necessary for optimal parenting, further contributing to neglect or related childhood adversity (Grasso et al., 2016b ; Pu & Rodriguez, 2021 ). Many children exposed to IPV are also poly-victims, with cumulative exposure to adversity exponentially increasing risk for subsequent exposure to adversity and trauma, as well as serious mental health impairments (Finkelhor et al., 2009a ). There is also evidence that IPV-associated poly-victimization in early childhood is predictive of persistent poly-victimization across developmental periods (Finkelhor et al., 2007 ; Turner et al., 2017 ). Notably, a study using data from the National Child Traumatic Stress Network (NCTSN) Core Data Set demonstrated that 87% of a subgroup of 0- to 5-year-old poly-victims with IPV exposure went on to experience new adversity that characterized poly-victimization in middle childhood, with 74% of these youth also experiencing poly-victimization in adolescence (Dierkhising et al., 2019 ; Grasso et al., 2016a ). In this study and others, poly-victimized youth at any developmental period were significantly more likely to have diagnosable mental health disorders and serious impairments in functioning. These data underscore the pernicious nature of IPV and how it can contribute to poly-victimization and serious implications for children’s development, with the possibility for disruptions in the attainment of vital developmental competencies and emergence of mental health impairment. These data also reflect our overall failure as preventionists and interventionists to interrupt the persistent and pervasive nature of violence exposure and its repercussions.

In what we have learned about Isaiah’s history of exposure to IPV and adversity in the opening vignette, it is evident that he would meet our definition of poly-victim, having experienced numerous types of adversities in multiple contexts and across the entirety of his young development. Isaiah’s exposure to IPV came early in life and was severe, with incidents in which he would attempt to intervene to stop the violence, sometimes getting hurt in the process. In addition to direct forms of emotional and physical abuse, Isaiah experienced forms of deprivation and neglect, lacking stable and nurturing caregiving because of parental substance abuse and ongoing violence. These circumstances led to CPS involvement and foster care, which opened the door for sexual assault by the older peer, loss of contact with his siblings, and repeat maltreatment after reunification. Except for school, there was little respite for Isaiah—and even that disappeared when schools moved to remote learning during the COVID-19 pandemic. Isaiah was stuck and, up to this point, the system had not protected him.

Isaiah’s Trauma History Assessment

After Isaiah’s school incident he was referred to a community-based mental health agency specializing in trauma-informed care and scheduled for an intake. Previous records indicated a history of Attention-Deficit Hyperactivity Disorder (ADHD) diagnosed and treated by his pediatrician and known to the school. He had never been assessed for other forms of mental health impairment.

Isaiah was initially resistant to talking with the psychologist and provided only one-word responses. The psychologist spent some time with him before getting into questions about symptoms. The psychologists showed Isaiah his office basketball hoop and threw him the Nerf basketball. Isaiah took some shots. This helped to establish some rapport. The psychologist explained that he was interested in learning more about the types of experiences Isaiah has had and how this makes him feel now. The psychologist explained that what they talked about would be confidential within certain limits; however, also explained that if he learned that Isaiah was being hurt now that he may need to tell someone who could help him. The psychologist used a validated trauma exposure inventory to ask Isaiah about his experiences. He explained that Isaiah would not have to provide him with details about what happened, just whether they happened or not. Isaiah endorsed experiences of witnessing IPV and physical abuse, but withheld information about the sexual assault. The psychologist knew about the sexual assault because he had reviewed Isaiah’s CPS records. He went back to the question about sexual assault and told Isaiah, “I wanted to go back to this question of whether someone touched your private sexual body parts or made you touch their body parts because I had learned from your CPS caseworker that this may have happened in one of your foster homes six years ago. Again, I don’t need you to tell me details about what happened, but I’d like to hear from you whether this happened or not.”

Tips for Trauma Assessment

The extension of the vignette with Isaiah was intended to illustrate key components of trauma assessment with children exposed to IPV. First, given that IPV-exposed children typically experience other forms of co-occurring adversities, psychologists should look beyond IPV exposure to obtain a comprehensive history of the child’s exposure to adversity and trauma using one of many available validated instruments. This should be accomplished using multiple sources, including information from child protective services, school personnel, past mental health providers, caregivers, and child self-report. There are many reasons why information may be missing or discordant across sources (e.g., Isaiah withholding information about the sexual assault or caregivers’ worry about CPS involvement).

Second, psychologists should consider the optimal timing for administration of a trauma history inventory. Obtaining valid information necessitates a good working rapport with the youth and a sense of safety. Assessing trauma history when the child is in crisis, for example, will not yield valid information.

Third, psychologists should be transparent with the child (and parent) about how the information obtained will and will not be used. Explain any limits to confidentiality, including the potential need to make a mandated report. Emphasize that the intention is to use this information to determine how best to help the child.

Fourth, psychologists should be non-judgmental and avoid making assumptions about how the child perceives their experiences, including perceptions of perpetrators of violence (e.g., it is not uncommon for children to align with an offending parent). Also, in many cases, offending parents resume caregiving or remain a part of the child’s life.

Fifth, psychologists should not fear asking questions about trauma. Asking questions does not “re-traumatize” the child, as is often the misconception. Rather, it is a means to getting the child help. Know that the child (or parent) may become uncomfortable or distressed, and this is okay. Be mindful of their reactions and ensure that support is available should the child (or parent) need it. Make explicit the option to talk to and seek support from you during or after completion.

Sixth, psychologists should explain to the child (and parent) that they need not provide extensive detail about any specific trauma exposure, but that the goal is to broadly understand what happened. Many children are not ready to narrate or process the trauma, which may be a goal later in treatment. The caveat here is if there is a necessity to obtain sufficient information in order to make a mandated report of suspected child abuse or neglect.

Finally, if there is knowledge of verified trauma exposure that the child denies or fails to report (e.g., Isaiah’s sexual assault), psychologists might consider gently probing a second time, acknowledging where the conflicting information was obtained.

Isaiah’s Symptom Assessment

After assessing Isaiah’s trauma history, the health service psychologist used validated symptom rating scales to assess a range of mental health impairments, including posttraumatic stress disorder (PTSD). The psychologist read items aloud to Isaiah, who had difficulty reading, and asked him to provide a rating for reach. Isaiah endorsed symptoms characteristic of posttraumatic stress, which included having frequent thoughts and memories about IPV, trouble sleeping and bad dreams, having negative thoughts about himself, feeling irritable and quick to anger, feeling sad for no reason, and feeling like he is always on “high alert.” According to the rating scales, Isaiah exceeded the clinical threshold for posttraumatic stress and depressive symptoms. The psychologist used a semi-structured instrument to determine that Isaiah indeed met criteria for PTSD and that the depressive symptoms were associated with the trauma. Because Isaiah’s trauma exposure began shortly after birth and extended across his development, the psychologist was not able to differentiate functioning before and after trauma exposure, as many PTSD symptom scales attempt to do. Rather, as best he could, the psychologist assessed whether each symptom was associated with trauma exposure.

The psychologist was also successful engaging and interviewing Sandra, Isaiah’s mother, who was seeing Isaiah weekly in supervised visits. She provided useful context around the IPV and elaborated on her family’s troubled history. Sandra described Isaiah as being “a handful” and a highly sensitive kid who was quick to react, even to the smallest of things. However, she also described him as a “sweet” kid who “looked out” for her and his siblings—and more than children should have to do. Sandra had separated from Joseph for now, but continued to have contact with him. She still loved Joseph and insisted that he was not the same type of person as George. Sandra once again began substance abuse treatment. Joseph was referred to a father-focused intervention for IPV offenders called Fathers for Change, which aims to enhance emotion regulation and interpersonal functioning, thereby reducing aggression and violent behavior. He had supervised visitation with the younger children, but had not yet communicated with Isaiah.

Isaiah’s foster mother was present during the intake and completed a broad-based measure of internalizing and externalizing behavior, which revealed elevated scores on observable behavior problems such as impulsivity, oppositionality, and irritability. She also endorsed symptoms of hyperarousal on an assessment of PTSD symptoms. Even though Isaiah’s foster mother only knew him for a few months, she noted significant difficulties regulating his emotions. She explained that even something mildly stressful could disrupt Isaiah for an entire day and that he just could not “get himself back together.” This was especially true when there were interpersonal stressors, such as when a peer would make a hurtful comment about him.

Consequences of IPV Exposure and Adversity

IPV and associated adversity can interrupt children’s attainment of core competencies, which suggests that it can differentially impact children across development. In early childhood, children are bound to the caregiving environment where developmental competencies are facilitated by their growing relationships with caregivers, with whom they engage in early emotion socialization—learning to identify and reciprocate emotional expression. With a nurturing relationship, infants and young children feel safe to explore their environment and engage in experiential learning, which helps to facilitate motor and cognitive skills. In a harsh and unpredictable environment, young children may not have a secure bond with a caregiver. The caregiver may be emotionally unavailable or may vacillate between nurturing behavior and behavior that conveys danger or threat. In this type of environment, young children’s brains are adapting to anticipate, prevent, or protect themselves against potential or actual danger, with fewer resources to attain developmental competencies (Dierkhising et al., 2019 ).

This early childhood exposure to adversity can have negative implications for middle childhood, where children are spending more time outside of the home. In middle childhood, children are expected to develop healthy peer and adult relationships, regulate emotions, and engage in behaviors to function effectively in school and other settings. School-age children who are exposed to IPV and associated adversity at home must juggle these new academic and school demands with the demands of the home environment. At home, youth in middle school may be protecting a caregiver or siblings, anticipating and protecting oneself from harsh parenting or maltreatment, or compensating for the lack of basic needs or supportive resources at home. Notably, behaviors that may be adaptive in terms of keeping children safe in a violent home environment, such as hypervigilance and physical defensiveness, are seen as highly problematic in school settings. These children are also at higher risk than their non-exposed peers for repeat victimization and exposure to new forms of adversity that can happen outside of the home given greater opportunities for peer victimization, victimization by non-familial adults, witnessing violence in the community, and engaging in risky behavior that may lead to injury (Dierkhising et al., 2019 ; Finkelhor et al., 2007 ).

Not surprisingly, failed competencies in early and middle childhood can make adolescence particularly challenging. Adolescence defines a period of greater independence when youth are expected to make healthy decisions, avert risk, exhibit effective self-regulation skills, establish a sexual identity, and continue to develop and maintain healthy relationships, including intimate relationships. Youth without the resources to navigate these challenges are more likely to be those who make poorer decisions, engage in risky behavior, appear dysregulated, either struggle to develop a self-identity or embrace an unhealthy identity, and engage in unhealthy relationships, including the potential for intimate partner and sexual violence. Because development is cumulative, with each developmental stage building on previous attainments, perturbations along the way contribute to serious downstream consequences (Dierkhising et al., 2019 ; Ford et al., 2013a ; Grasso et al., 2016a ).

At every stage of development for youth exposed to IPV and adversity are greater risks for developing a host of mental health impairments, with cumulative exposure increasing in a dose–response manner (Finkelhor et al., 2009b ; Grasso, 2020 ). Posttraumatic stress is one of many possible impairments for children that is defined by four symptom clusters tied to the trauma memory. Exposure to IPV, as well as co-occurring violence directed at the child, meets DSM-5 criteria for a PTSD qualifying trauma in that it involves exposure to actual or threatened death or serious injury experienced directly, as a witness, or learning that the event happened to close family member or loved one. Importantly, adversities that commonly co-occur with IPV that do not meet criteria for trauma nonetheless can exacerbate symptoms and impair functioning. Further, it is essential to establish a comprehensive conceptualization of a child’s history of trauma and adversity for understanding symptomatology and guiding and facilitating treatment. Isaiah has a complicated history of exposure. Any one or more of his exposures may be associated with symptoms or impairment and may have implications for his progress in treatment.

From his intake, it appears that Isaiah shows evidence of symptoms from all four of the clusters that make up the PTSD diagnosis. Characteristic of Criterion B “Intrusive Symptoms,” Isaiah reported frequent thoughts and memories about the IPV that interfered with his ability to focus. These elicited psychological distress and physiological reactions. Isaiah would later also endorse intrusive thoughts and nightmares about the sexual assaults he experienced in foster care. Isaiah also drew connections between his sexual assault and the times he witnessed his father, George, sexually assault his mother. He remembered how powerless she was in those moments and how fearful he felt for both of them. It would also be revealed that Isaiah would avoid any thoughts or physical sensations that reminded him of the sexual assaults. This would include seeing himself naked in the shower, as well as times when he would become sexually aroused, which was happening more frequently for him as he entered adolescence. These symptoms fall into Criterion C “Avoidance.”

Relatedly, Isaiah felt a lot of guilt around what happened and blamed himself for not being able to protect himself during the assaults. This theme dovetailed with his blaming himself for not being able to protect his mother from George and Joseph. In effect, Isaiah felt a sense of incompetence and guilt. These symptoms are part of Criterion D “Negative Alterations in Cognitions and Mood.” Other symptoms in this cluster that Isaiah endorsed included experiencing negative emotions that “would not go away” and trouble experiencing positive emotions. He also felt detached from other people and had exaggerated negative expectations of others. He claimed not to trust anyone.

Finally, Isaiah was experiencing symptoms in Cluster E “Alterations in Arousal and Reactivity,” which included feeling chronically irritable and quick to anger and like he was always on “high alert”—looking out for danger when there wasn’t any. This symptom cluster directly relates to the incident Isaiah had in school when the teacher put his hand on Isaiah’s shoulder. What the teacher did not know was that Isaiah was experiencing intrusive thoughts that were triggered by another youth in the classroom who resembled the boy who had sexually assaulted him. In putting his head down, it appeared to the teacher that Isaiah was noncompliant and unwilling to engage in class. The teacher did not know about Isaiah’s history and had never received training in trauma-informed care or how to identify traumatic stress symptoms. Naturally, the teacher took a more punitive perspective.

Not surprisingly, the teacher touching Isaiah’s shoulder triggered an aggressive reaction from Isaiah. Isaiah was very worked up and it took a long time for Isaiah to calm down. The school resource officer had to partially restrain him. Isaiah’s difficulty re-regulating himself is certainly characteristic of PTSD, but also may reflect severe disruption in core self-regulatory capacities that is characteristic of the proposed developmental trauma disorder or complex PTSD. This presentation has been described as “PTSD with extra caffeine.” Youth who present with this type of profound impairment are those who have experienced poly-victimization across developmental periods and more complex forms of interpersonal trauma. Here, too, this knowledge is important for treatment planning for Isaiah and has implications for the work he will do in session.

Tips for Clinical Assessment and Case Conceptualization

The extension of Isaiah’s story in the previous section illustrated key components of symptom assessment and case conceptualization with children exposed to IPV. First, similar to assessing the trauma history, psychologists should strive to obtain symptom information from multiple sources and via multiple methods. Children and parents are often discordant on symptom reports, with parents tending to report more overt symptoms and children better at reporting internalizing symptoms.

Second, psychologists should try not to pigeonhole the child’s impairment to posttraumatic stress. A common error is to assume children exposed to trauma will only present with PTSD. IPV and trauma-exposed children can present with a range of symptoms and impairments. Psychologists should assess for posttraumatic stress, but also conduct a comprehensive evaluation of other symptoms and impairment using validated tools—ideally those that have been evaluated on the population they are working with.

When assessing PTSD symptoms, psychologists should allow the child to endorse symptoms as being associated with any one or more of the traumatic experiences captured in their trauma history. They should not require that symptoms be specific to an “index trauma” or the perceived “worst event,” as this makes it possible to miss symptoms that might be differentially associated with the child’s trauma exposures.

Isaiah’s Treatment Planning

The psychologist diagnoses Isaiah with PTSD and comorbid ADHD, by history, and oppositional defiant disorder (ODD). To address symptoms of PTSD he recommends that Isaiah receive Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), an evidence-based intervention with two phases that focus on (1) providing psychoeducation and establishing emotion regulation and cognitive coping skills, and (2) trauma narrative development to facilitate therapeutic exposure and trauma memory processing (Cohen et al., 2018 ). Because Isaiah has had numerous traumatic events his trauma narrative may require multiple sections and may take longer to develop. The psychologist will establish measurable treatment goals and will employ validated methods to monitor Isaiah’s symptoms across the course of treatment to demonstrate treatment effectiveness.

During the trauma narrative phase, themes may emerge that will necessitate cognitive-behavioral strategies for challenging unhealthy beliefs about self, others, and the world that stem from his traumatic experiences. For Isaiah, this may include self-blame and guilt having to do with being a victim of sexual assault and witnessing the physical and sexual victimization of his mother. It may also require processing around his own sexuality as an emerging adolescent, distinguishing it from the sexual assault memory, and becoming less reactive to his body and bodily sensations. Another theme that might emerge may pertain to Isaiah’s perception of men and what this means for his own identity as a young man. So far, his experience has been with men who respond to interpersonal problems with aggression and violence. However, there may be opportunities for Isaiah’s relationship with Joseph to evolve in a positive direction if Sandra and Joseph resume their relationship and Joseph makes progress in his own treatment. Another theme might involve Isaiah’s biased perception of others as untrustworthy and having malintent. If he can accept that he has this bias, he can identify when it is activated and correct it to help facilitate his ability to build and maintain interpersonal relationships.

While research suggests better outcomes for children whose caregivers are engaged in TF-CBT and participate in parallel sessions, including a conjoint session where patients share the trauma narrative, Isaiah’s caregiving is complicated. His foster mother has only known him for a short period of time and it is not feasible for Sandra to attend sessions. Given these barriers, the psychologist intends to include Isaiah’s foster parent in brief weekly check-ins to convey Isaiah’s progress in therapy, reinforce strategies for managing unwanted behavior at home, and coach her on supporting Isaiah’s processing of trauma, which not only occurs in session, but can happen at home when children share thoughts and feelings with a caregiver. This tends to happen more frequently during the trauma narrative development. The psychologist also plans to explain to Isaiah’s foster mother that it is common for children to show a temporary increase in disruptive behavior during the trauma narrative development phase because the trauma memory and emotional triggers are more salient. She may then decide to share this with the school so that they can anticipate the increase in behavior and make plans to provide extra support during this time.

The psychologist also plans to make an effort to connect with Sandra, Isaiah’s mother, to update her on Isaiah’s progress and discuss ways in which she can support Isaiah’s continued recovery and growth. The psychologist anticipates that he will also need to work with Sandra on identifying and addressing issues that may arise when Isaiah is reunified with the family, especially if she and Joseph get back together. A key objective in this case will be to explore and perhaps redefine Isaiah’s relationship with Joseph. The psychologist will leave open the possibility that Isaiah can receive additional sessions after the trauma narrative is complete to address some of these emerging issues. Of course, this will depend on the timing of reunification and whether or not Sandra and Joseph reunite.

Tips for Treatment Planning

This final extension of Isaiah’s story illustrated key components of treatment planning with children exposed to IPV and presenting with PTSD symptoms. First, psychologists should integrate the information obtained during the assessment and conceptualization phase to formulate treatment goals with the child (e.g., symptom reduction, improved functioning) and establish methods for measuring progress, including the use of validated instruments for monitoring symptom change.

Second, treatment goals should be matched to an evidence-based intervention that has been shown to be effective with the population they are working with. Psychologists should consider all of the sociocontextual factors that may play a role in the child’s successful engagement in treatment and capacity to benefit from treatment modalities. For trauma-specific treatment, psychologists should give careful thought to which traumatic experiences may become the focus of the trauma narrative or retelling and how their formulation of the child’s trauma history will be incorporated in the child’s cognitive processing (e.g., emergent themes and unhealthy cognitions).

Third, psychologists should always consider options for engaging caregivers in the child’s treatment when it is appropriate to do so, as this will help to support the child’s progress in their home environment. Finally, psychologists should anticipate potential setbacks or new issues that may emerge because of changes in the child’s living situation or family circumstances and make a plan to address these.

Concluding Thoughts

This article introduced Isaiah, a 13-year-old boy with an extensive history of IPV exposure, adversity, and trauma. Along the way, we learned about unique circumstances of IPV that influence assessment, case conceptualization, and treatment planning. This was illustrated in Isaiah’s story, which involved co-occurring adversity including sexual assault, multiple perpetrators, adverse impacts of the COVID-19 pandemic, changes in caregiving, and symptom manifestations that impacted his functioning at school. We observed how Isaiah’s complicated trauma history influenced his engagement in treatment and emergent themes and unhealthy cognitions that served to maintain symptoms and dysfunction. There are several key takeaways: (1) IPV is complex and often co-occurs with other forms of victimization, trauma, and deprivation; (2) assessment of the trauma history should be carefully orchestrated and comprehensive, with information acquired from multiple sources; (3) clinical assessment should focus on both broad-based and trauma-specific symptoms, with information obtained from multiple sources and via multiple methods; (4) case conceptualization and treatment planning should incorporate the child’s trauma history, co-occurring adversities, and other sociocontextual factors that may influence treatment engagement and response, including anticipated setbacks or upcoming changes to the child’s living situation or circumstances.

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Grasso, D.J. A Trauma-Informed Approach to Assessment, Case Conceptualization, and Treatment Planning for Youth Exposed to Intimate Partner Violence. J Health Serv Psychol 48 , 3–11 (2022). https://doi.org/10.1007/s42843-021-00053-2

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David Powlison

Recovering from child abuse: help and healing for victims (part 1).

September 6, 2009

This is part 1 of a 2 part series: Part 2

When a vulnerable child experiences physical, emotional, and/or sexual abuse the hurt and the scars go deep. In this article, experienced counselor David Powlison directly addresses child abuse victims by acknowledging their suffering, giving them concrete ways to express their painful experience to God, and encouraging the healing process through small steps of faith. Listen in as Dr. Powlison brings God’s comfort and hope to those who have been abused.

You have been victimized by a terrible wrong. During your childhood, the time you were most vulnerable, instead of being protected, helped, and comforted you were abused. Most likely you were abused by someone who should have been trustworthy—a family member, a teacher, a neighbor, a coach, a pastor, a friend. Instead of being protected you were violated. You were treated with malice. Someone used, misused, and took advantage of you. Now you are wondering if recovery is possible.

The simple answer to that question is yes, recovery is possible. But you already know you can’t just snap your fingers and make everything all better. And you know that pat answers won’t help you. But here are two important truths to keep in mind: You are not alone, and there is hope.

Your recovery will be a process of learning and remembering those two truths, not just once, but over and over. Think about how bread gets made. It must be kneaded so that the yeast goes through the whole loaf. These two truths must be kneaded into who you are until they work through every part of you. The working of these truths into the deepest part of you takes time. The damage you suffered may have been done in one or more terrible moments; the healing and the restoration unfolds at a human pace. It unfolds at your pace. It unfolds as part of your story, and it unfolds over time.

There are three broad categories of child abuse: verbal abuse, physical abuse, and sexual abuse. If you were verbally abused, someone whose words should have been helpful and kind instead demeaned you and assaulted you. If you were physically abused, someone (perhaps a parent or another authority figure) attacked you and hurt you. If you were sexually abused, someone used you and violated an intimate part of who you are.

However you were abused, what happened to you was evil—you were sinned against. And now you are suffering. God is mindful of your suffering, and he hears your cries. He heard the cry of a child dying of thirst in the desert (Genesis 21:17–18); he heard the cries of the Israelites suffering as slaves (Exodus 2:23–24); and he hears you. God has much to say to those who have experienced evil at the hands of others. So he has much to say to you.

Your Identity is Bigger Than Your Abuse

Abuse feels like an experience that has stamped you and has the final word on your identity. But the truth is that God gives you a different identity. No matter what terrible atrocities happened to you, they are not your identity. Your identity as God’s child is far deeper than the abuse you suffered.

When you come to God through trusting in Jesus, he gives you a new identity. You become part of the family of God. You are his dearly loved child. Listen to what the apostle John says about your identity, “How great is the love the Father has lavished on us, that we should be called children of God! And that is what we are!” (1 John 3:1). You have a perfect Father in heaven who loves you and wants to fill your life with the good gift of himself (Luke 11:13).

Because you are God’s child, you are not alone in a nightmare of pointless suffering. It’s true that “the heart knows its own bitterness” (Proverbs 14:10), and even your dearest friend can’t fully understand the terror, the aloneness, the pain, and the horror you experienced. But Jesus does understand, and he is with you.

Jesus experienced every form of suffering when he was in the world. “He was despised and rejected by men; a man of sorrows, and acquainted with grief” (Isaiah 53:3). He was betrayed and tortured. He is well acquainted with your grief, and he will never leave you (John 14:18).

Your Story is Bigger Than Your Abuse

Experiencing Jesus’ presence and love will give you the courage to see that the story of your life is bigger than your suffering. What happened to you is not the last word on who you are and where your life is going. It’s a significant part of your story, but it’s not the most significant part of your story. It’s only one part of the new story of your life that Jesus is writing.

Think about Joseph in the Bible (Genesis 37; 39–45). Abuse and betrayal were also a big part of his story. When he was a teenager, he was sold into slavery by his brothers and became a slave in Egypt. Then he was falsely accused of rape by his master’s wife and thrown into prison. After several years in prison, he was released and put in charge of all of Egypt. At the end of the story, Joseph meets his brothers again and instead of taking revenge says, “As for you, you meant evil against me, but God meant it for good, to bring it about that many people should be kept alive, as they are today” (Genesis 50:20 ESV). God used the terrible betrayal that Joseph suffered to put him into a position where he could save his family from famine.

Joseph did not minimize what happened to him. He acknowledged that his brothers did “evil” to him. But he had a wider perspective. The meaning of his story was bigger than the evil he suffered. God was at work bringing good out of extreme betrayal. God is also at work in your life. Abuse is not the last word on your life story. God has a purpose for you.

Redeeming Your Story

The abuse you suffered is part of the stage upon which your life choices will now take place. It’s out of the choices you are facing right now that great good can come. That doesn’t mean that you will forget the evil done to you. Martin Luther King never forgot the evils of racism. It was the reason he started a movement that changed our country. Candy Lightner did not forget that her thirteen year old daughter was killed by a drunk driver. Her daughter’s death became the impetus for forming MADD (Mothers Against Drunk Driving), an organization that works to stop drunk driving.

You also can choose how to respond to the evil that was done to you. You can grow in gratitude, joy, purpose, and the ability to help others and live your life with courage and conscious intent. A few years ago I counseled a thirty-five year old woman named Joann. She had suffered terrible physical and sexual abuse at the hands of many male relatives from the age of three to fourteen. She was finally rescued by a social worker and placed in foster care. When I met her she was married, had two children, and had become a social worker herself who counseled abused children.

Joann hadn’t forgotten her suffering and was still working through its effects, but her life story was about more than her abuse. She was creating a loving home for her husband and children and reaching out to others who were suffering as she had. Her suffering wasn’t forgotten, it was redeemed.

The gospel of John closes with this verse, “And there are also many other things which Jesus did, which if they were written in detail, I suppose that even the world itself would not contain the books that would be written” (John 21:25). Your life is one of those books that John was talking about. You’re continuing the story of what “Jesus did.” It’s a story where terrible evils happened to you, but Jesus showed up and did something—he redeemed you and is still redeeming you so that you can love, forgive, and do good to those around you. Your story is not only about the pain of betrayal, it’s about Jesus taking what others meant for evil and redeeming it for a good purpose.

Practical Strategies for Change

Perhaps when you think about your new identity as God’s child and read about Joann, you desire to move forward too. But you feel stuck. Here are some ways that those who have been abused as children sometimes struggle as adults:

• Trusting others : It can feel impossible to trust anyone after your trust has been shattered by your childhood experiences.
• Having a healthy sexual relationship with your spouse : If you were sexually abused, sex for you has been maimed and twisted by darkness.
• Being filled with bitterness : How do you avoid being filled with bitterness when terrible evils have occurred? How can you learn to forgive such a great wrong?
• Disciplining your own children : How do you learn to discipline your children in love when you were attacked by your own parents?
• Dealing with any conflict or confrontation : How do you confront a problem with family, friends, or co-workers when anger and confrontation was brutally distorted in your life?

You might have even more things to add to this list. Is God able to work in these areas in your life and change your automatic responses to people and situations? Yes he is. God can and will change you, not all at once, but gradually over your lifetime. I have seen God do this many times in those I’ve counseled. Change begins as you face what happened to you with God in view.

Facing Your Abuse

Facing your abuse might be the last thing you want to do. Many who have suffered through child abuse are terrified of their memories. They have only two ways to deal with their past—either they cover it over with denial and busyness or they get stuck in memories that are a black hole of terror and fear.

Perhaps you are working hard to stay in denial and keep your memories locked away. Doing this is a little like having a lion in your bedroom closet. You can try to keep the lion of your past abuse caged in all different ways, some positive (working hard, exercising, achieving, keeping busy, etc.) and some not so positive (you might use sex, food, alcohol, or drugs to numb yourself). But, in the end the lion is too strong for whatever doors you have erected, and your mind is flooded with memories. You relive your abuse and are again filled with the fear, rage, and anguish you experienced as a young child. But there is a third way. You can learn to hear God’s promises and to pour out your heart to God about your troubles in a purposeful way. The Psalms, the prayer book of God’s people for thousands of years, will help you do this. There is no Psalm that portrays the explicit experience of being sinned against through child abuse, but there are many that capture the experience of being abused, misused, used, and betrayed by others. Start with Psalms 55, 56, and 57 and make them into your own personal liturgy. You can rewrite these Psalms and turn them into prayers that will express your heart to God and God’s heart to you.

Use Psalms 55, 56 and 57 to Express Your Experience

Read through these three psalms and notice how they express the experience of what abuse is like. Psalm 55 was written out of the fire and darkness of being betrayed by someone close, someone who should have been trustworthy. In the middle of the Psalm, David says that he wasn’t attacked by an overt enemy, it was “my companion and my familiar friend” (Psalm 55:13). That closeness made the betrayal even worse. Perhaps you felt that way also.

Psalm 56 is about someone who feels imprisoned by people who hate him. He’s trapped. He’s tied down. He’s feels like he is locked in a closet. People want to kill him, hurt him, and torture him. And they have all the power; he has none. Does this describe some of your experience?

Psalm 57 is about having a predator after you. David wrote it when he was hiding from his enemy in a cave. Those who wanted to kill him were waiting outside with an army. You might remember feeling the same way.

As you read, notice that these psalms are about more than the experience of betrayal, powerlessness, and fear. In the middle of the darkness of molestation, the darkness of violence, and the darkness of hurt is the cry of faith. David is turning to his living, all powerful God and expecting help and deliverance. He has hope. He has someone good and powerful to talk to. The same is true for you. The reality that your God hears you, helps you, and defends you will let you open the closet door of your abuse, come out of the silence, the aloneness, and the stuck-ness, and start to talk it out with God.

You are not alone. David wrote these psalms, and he went through an experience similar to yours. You are not alone. Jesus made the psalms the voice of his own experience. Jesus said these words. Jesus felt these things. He’s been there with you. You are not alone.

To make these Psalms into your own prayer, start by getting four different colored markers. You are going to follow four strands through each psalm; strands that will help you express and redefine your experience.

• What happened to you? Take the first marker, and underline all the phrases in each psalm that express the sort of thing that happened to you as a child. You will find phrases like “the stares of the wicked…they bring down suffering upon me…my companion attacks his friends” (Psalm 55:3, 20), “men hotly pursue me; all day long they press their attack…many are attacking me…they conspire, they lurk; they watch my steps’ (Psalm 56:1, 2, 6), “they spread a net for my feet…they dug a pit in my path” (Psalm 57:6).
• What does it feel like? Now take the second marker and underline all the phrases that express how you felt—your anguish, your fear, your terror. Look at phrases like these, “I am distraught…my heart is in anguish within me; the terrors of death assail me; fear and trembling have beset me; horror has overwhelmed me. I said, ‘Oh that I had wings like a dove! I would fly away and be at rest…’ (Psalm 55:2, 4–6), “When I am afraid…my lament…my tears” (Psalm 56:3, 8), “I am in the midst of lions…I was bowed down in my distress” (Psalm 57:4, 6).
• What is said about God? Use the third marker to underline what the psalms say about God and what he is doing. Start with some of these phrases, “the Lord saves me…he hears my voice…He ransoms me unharmed…he will sustain you” (Psalm 55:16–18, 22), “For you have delivered my soul from death, and my feet from stumbling,” (Psalm 56:13), “He sends from heaven and saves me; rebuking those who hotly pursue me…for great is your love reaching to the heavens, your faithfulness reaches to the skies” (Psalm 57:3, 10).
• What does faith say? Use the fourth marker to underline all the phrases that are cries of faith. “Listen to my prayer, O God, do not ignore my plea; hear me and answer me…but I call to God and the Lord saves me…but as for me, I trust in you” (Psalm 55:1, 2, 16, 23), “Be merciful to me, O God…when I am afraid, I will trust in you…in God I trust: I will not be afraid. What can mortal man do to me…Record my lament; list my tears on your scroll…God is for me” (Psalm 56:1, 3, 4, 8, 9), “Have mercy on me, O God, have mercy on me, for in you my soul takes refuge. I will take refuge in the shadow of your wings until the disaster has passed…I cry out to God Most High…My heart is steadfast, O God, my heart is steadfast;” (Psalm 57:1– 2, 7).

This is part one of a two part series: Part 2

This article is adapted from the mini book, Recovering from Child Abuse: Healing and Hope for Victims copyright © 2008 by Christian Counseling & Educational Foundation. Used by permission of New Growth Press and may not be downloaded and/or reproduced without prior written permission of New Growth Press. Recovering from Child Abuse: Healing and Hope for Victims is available for purchase at www.newgrowthpress.com .

Author, Speaker

David Powlison served as CCEF’s executive director (2014-2019), a faculty member, and senior editor of the Journal of Biblical Counseling . He held a PhD from the University of Pennsylvania and an MDiv from Westminster Theological Seminary. David wrote extensively on biblical counseling and on the relationship between faith and psychology. His books Seeing with New Eyes and Speaking Truth in Love probe the implications of Scripture for how to understand people and how to counsel. The Biblical Counseling Movement: History and Context explores the background and development of CCEF’s mission. David is survived by his wife Nan, their three children and spouses, and seven grandchildren.

Related Resources

Recovering from child abuse: Help and healing for victims (Part 2)

Recovering from Child Abuse: Healing and Hope for Victims

Child abuse: A classic case report with literature review

Affiliation.

• 1 Department of Paediatric Dentistry and Orthodontics, University of Nairobi, Kenya.
• PMID: 24963259
• PMCID: PMC4067796
• DOI: 10.4103/0976-237X.132380

Child abuse and neglect are serious global problems and can be in the form of physical, sexual, emotional or just neglect in providing for the child's needs. These factors can leave the child with serious, long-lasting psychological damage. In the present case report, a 12-year-old orphaned boy was physically abused by a close relative who caused actual bodily and emotional trauma to the boy. After satisfactorily managing the trauma and emotional effects to the patient, in addition to the counseling services provided to the caregiver, the patient made a steady recovery. He was also referred to a child support group for social support, and prepare him together with his siblings for placement in a children's home in view of the hostile environment in which they were living.

Keywords: Etiology; child abuse; child neglect; management.

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• Case Reports

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Child Abuse. Case Study

2016, SCIENTIFIC RESEARCH AND EDUCATION IN THE AIR FORCE

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The thesis concerns two pathways for legal intervention in cases of suspected child abuse at the hands of parents. One pathway is based on social law, where society's utmost tool is child protective custody. The other pathway is criminal law, where the abuse is investigated and enforced as a criminal offence. Sometimes only one of these pathways becomes relevant, sometimes both. The purpose of the thesis is to examine and analyse the regulatory framework and its practical application, and to highlight what the two pathways of intervention can accomplish in relation to the child victim's rights and interests. In the case of child abuse, the (legal) relationship between parents and children - and between children, parents and society - is brought to a head. The study demonstrates that many complex legal issues arise when the person subjecting the child to violence and abuse is the same person who under family law answers for the child's protection, care and representation. It is inter alia noted that the concept "best interests of the child" is interpreted somewhat freely, which can risk overriding the legal rights of the child victim. It is concluded that, in order to secure the child victim's legal protection, the regulation needs many small enhancements, each tailored to the problem conditions.

Jolanta Maćkowicz

The article concentrates on the problem of child abuse in the family, which is most usually manifested by physical and psychical violence. Despite the fact that when abusing the child parents usually do not intend to harm them but rather want to make them act in the desired manner, causing pain or distress and exerting physical or psychic violence may have many negative consequences on the child, both direct and distant in time. Based on the conducted empirical research, the article presents the scale of the problem and its consequences, as well as the parents’ opinions included in the study on violence during child growth and its effects on parents’ behaviour in situations related to child upbringing. It also demonstrates the relationship between child abuse and the manifestation of negative behaviours, directly resulting from violence. From among many forms of negative behaviours which may be related to physical or psychic violence, the study concentrated, among others, on aggression, using dependence agents (alcohol, narcotics, cigarettes, steroids and drugs) and escapes from home. The conducted statistical analyses indicate a very close relationship between the two.

Liceo de Cagayan University Journal

JEZYL C E M P R O N CUTAMORA

Discipline in the Filipino culture is often carried out as a corporal punishment, if carried to the extreme would constitute as an abusive situation. The study sought to make an accurate picture of the abusive situation. Utilizing documentary research, data were gathered and profiling was done by computing the percentages. Results of the study revealed that the greater incidence of child abuse occurs most commonly in female children between the ages 12 – 18 years old, in low socio-economic families and to parents whose highest educational attainment were high school level. These abuses lasted for 1 – 5 years before it was reported to the proper authorities for intervention. Furthermore, the most common perpetrators of the abuses were the male neighbors followed by the female neighbors and the cohabiting husband; adults whom the parent/s entrust the care of their children. The study further revealed that the most common form of abuse was physical abuse in the form of hitting, followed by child-rape, spousal abuse in the presence of the child and verbal assault, respectively. It was concluded that child abuse damages the child not only physically but also psychologically. Furthermore, the parents’ low socio-economic status contributes to the stress and trauma of the child and finally, part of the problem in abuse is the witnesses’ unwillingness to get involved in the earliest possible time. The researcher recommends public education, creation of a crisis intervention program, and undertaking of a parallel study to identify the type of abuse at specific age group, examination of a ten-year data and establishment of the dynamics of abuse. Keywords: child abuse, abused, abuser, profile

helen tesfaye

Child-Parent abuse is a very sensitive and complex issue like that of other types of abuses in the family. Though, it has received very limited attention and recognition from researchers and concerned bodies. In Ethiopia there are no organized data which shows its prevalence. Creating an awareness of the problem is essential to provide an adequate help for the victims or to follow up planed intervention methods. To feel this gap, a phenomenological study was conducted based on the lived experience of 10 parents (6mothers and 4 fathers) who are experiencing CPA in Gulele sub city of Addis Ababa. Data were collected using an in-depth interview with this parents and the researcher’s observation; and it was analyzed simultaneously with interpretative analysis method. The finding of the study shows that some parents have suffered a great deal from the various acts of abuses by their own children. In general, it was identified that the abuses includes verbal, physical, and financial and material exploitations. The verbal abuse includes, constant insults, threatening to harm, humiliation and demeaning reactions. The financial and material exploitation or abuse consists of stealing money or parents’ belongings, demanding the parent to buy things knowing that they can’t afford and selling possessions of theirs or their parents’ and destroying the parents’ belongings. And a serious incident from choking and slapping to the use of weapons resulting grave bodily injuries is included under the physical abuse nature of CPA. Because of this parents are suffering stigma from their neighbors and from the society, physical injuries, emotional and psychological problems. It is found out that the abusive Childs’ addiction (of alcohol, khat and substance abuse); economic dependency or nemployment, past abusive experience of the parent and negative peer influence are the major causes. The parents take reporting the abuse to the police as a last measure after having to deal with it for a long time. All measures the parents took to handle the situation are unsatisfactory to them; because they want ending the abuse not their relationship with their child. Therefore the necessary attention and professional response is indispensable.

Franklin Mosley

Child abuse is prevalent in the United States and in every other country in the world. Each segment of society has its own definition and understanding of child abuse. Those understandings and definitions vary greatly. In order to work toward prevention and intervention of child abuse a clear definition must be understood and agreed upon. Criterion of prevention also must include understanding causation. This paper will examine definitions and identify a legal definition of child abuse. Prevention of child abuse and recovery for the abused and the perpetrator will also be an emphasis of this paper.

INTERNATIONAL JOURNAL OF RESEARCH IN COMPUTER APPLICATION & MANAGEMENT

Dr Juhi Garg

Cases of child abuse have increased, in 2014 the number was 8904 that has increased to 14913 in 2015 (POSCO, 2016). World Health Organization (WHO) defines child abuse 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. “There are four types of child abuse: physical abuse; sexual abuse; emotional and psychological abuse; and neglect. The study will help the society to know the impact of child abuse on the victim’s life and how the personality changes and life becomes a miserable journey, where family’s love and support is playing a very important role. Acceptance and love nurture broken personality of the child and the absence of which can have an adverse impact on the psyche of the child. It also has long-term impacts on their intellectual health and in obtaining occupation; this leads them to destructive behavioural patterns and criminality. However, if accepted gracefully by the society they will lead a happy and fulfilling life like any normal individual in many directions like family, job, and service to the society. KEYWORDS child abuse, emotional abuse and physical abuse

ADEFUNKE EKINE

The school and home setting more often than not are expected to be a haven of safety, care and stimulation for the young mind to develop as both are pivotal to the total development of the child. However, the trend of reported cases in the media of outright violence and injustice against the child and more importantly against the girl child by the significant others both at home and in the school has become worrisome. This paper is an attempt to chronicle the rise in violence against children has documented in the media and the overall effect of such on the child's total development. The question is what went wrong with our value system and the protective nature of the African family? Where did we go wrong that everyone now has lost caution to the wind? Could the increase in reporting be due to more awareness by the public and global efforts in domesticating the convention on the rights of the child? The grave consequences of these menace was highlighted in the paper and recommendations were suggested for all stakeholders.

Pravo - teorija i praksa

Milan Pocuca

Domestic violence, regardless of how it is manifested, represents a phenomenon which has recently attracted more and more significant doctrinal and media attention and it is a very complex problem. There are numerous questions about domestic violence to which this paper tried to provide answers. However, it is important to point out that domestic violence is not the only type of violence to which a child can be exposed, or to which he/she can be connected in an indirect or direct way. Bearing in mind that one form of violence predominantly causes and entails the other forms of violence to which a child can be exposed, and even find him/herself in the capacity of being a bully, the authors of the paper considered it important to briefly mention the other forms of violence in which the center of attention can be the child, such as digital violence and violence in schools. The focus of the paper has certainly concerned the position of the child in situations where violence against one ...

INTRAFAMILY SEXUAL ABUSE AND INSTITUTIONAL CARE OF CHILDREN IN EARLY CHILDHOOD: A CASE STUDY (Atena Editora)

Atena Editora

Sexual abuse impacts different spheres of a child's life, generating consequences for physical, psychological, social, affective and cognitive development. This study aims to present the phenomenon of intrafamily sexual abuse and the psychological, social and legal aspects experienced by victims. For that, a case study of two brothers victims of sexual abuse was used. Observation of the children was carried out in the institutional reception environment; projective techniques with social educators, and documentary research of the legal processes of the brothers, o In 2018, the brothers were welcomed after presenting, in an emergency medical consultation, signs of sexual violence and neglect of care. The documents contained in the legal proceedings found intrafamily sexual abuse, neglect of parental care, developmental problems: speech delay and muscle tone; and difficulty in establishing affective bonds and socialization, among other health problems. The storytelling of the educators showed anguish and commitment in the care of the brothers. The observation of the children pointed to the global improvement over the months, the establishment of affective bonds and initial difficulties overcome. It is concluded that the institutional reception promoted an environment of protection and individualized and affective care, allowing the siblings to develop again and to establish an affective bond between themselves and with others. The study reiterates the seriousness of sexual abuse in early childhood, highlights the serious violation of rights, which must be addressed within the scope of public and mental health and social assistance, implementing and expanding public policies aimed at early childhood.