What is child maltreatment?
Childhood maltreatment, trauma, and adversity come in many forms and no term covers all of them. Some terms you may have heard of are “developmental trauma disorder,” “complex trauma,” “chronic stress,” “child traumatic stress,” and more.
A general definition for childhood maltreatment is: “Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act which presents an imminent risk of serious harm” .
Types of child maltreatment: 
- Physical abuse is a “non-accidental physical injury” that can range from minor bruising to fatal harm inflicted by a parent, caregiver, or other person who holds responsibility for the child.
- Neglect is a failure by a parent or other caregiver to provide for a child’s basic needs, including:
- Physical neglect (e.g., failure to provide necessary food or shelter, lack of appropriate supervision)
- Medical neglect (e.g., failure to provide necessary medical or mental health treatment)
- Educational neglect (e.g., failure to educate a child or attend to special education needs)
- Emotional neglect (e.g., inattention to a child’s emotional needs, failure to provide psychological care, permitting the child to use alcohol or other drugs)
- Sexual abuse may be classified as sexual activities by a parent or other caregiver such as fondling a child’s genitals, penetration, incest, rape, sodomy, indecent exposure, and exploitation through prostitution or the production of pornographic materials.
- Emotional or psychological abuse are patterns of behavior that impair a child’s emotional development or self-worth. This may include constant criticism, threats, rejection, and withholding love, support, or guidance.
- Abandonment occurs when “the parent’s identity or whereabouts are unknown, the child has been left alone in circumstances where the child suffers serious harm, and/or the parent has failed to maintain contact with the child or provide reasonable support for a specified period of time.”
Note: The Child Abuse Prevention and Treatment Act (CAPTA) recognizes that culture, poverty, lack of knowledge, religious beliefs and other factors can contribute to neglect. To be considered child abuse, it is critical that parents or caregivers are not utilizing available resources to provide for the child, and that this jeopardizes the child’s health and safety.
Adverse Childhood Experiences (ACEs): 
Adverse childhood experiences (ACEs) refer to overlapping sets of traumatic and adverse childhood experiences and home environment factors that substantially increase a child’s risk for serious, lifelong medical and mental illnesses.
- Wanting to further investigate ACEs, a research project titled the Adverse Childhood Experiences Study was conducted by the Centers for Disease Control and Prevention and the Kaiser Permanente’s Health Appraisal Clinic in San Diego.
- The ACE Study found that adverse childhood experiences, such as abuse and neglect and household dysfunction, lead to an impact on child development and further lead to long-term consequences. Long-term consequences may include:
- Major depression, suicide, and posttraumatic stress disorder
- Drug and alcohol abuse
- Heart disease
- Intergenerational transmission of abuse
- Criminal behavior
- Parenting problems
Studies have found that child maltreatment is much more frequent than most people realize:
- The Adverse Childhood Experiences (ACE) study of 17,337 adults found that:
- 11% of adults reported having been emotionally abused in childhood,
- 28% reported physical abuse,
- and 21% reported sexual abuse .
- ACEs tend to occur together: 60% of the adversity-exposed youth reported multiple childhood adversities  .
- The National Child Traumatic Stress Network (NCTSN) core data set of 10,991 children and adolescents also found high rates of self-reported trauma exposure:
- 48.7% reported experiencing traumatic loss, bereavement, and/or separation
- 45.1% reported domestic violence within the home
- 36.4% reported an impaired caregiver
- 31.4% reported emotional abuse
- 26.8% reported neglect
- 26.2% reported physical abuse
- 20.1% reported sexual abuse
- Over 40% of the sample reported four or more types of trauma and adversity  .
- Studies have also shown that ACEs take a cumulative toll. There is stepwise increase in risk as the number of ACEs experienced increases. Studies show a large jump in the percentage of people experiencing a given negative outcome around three or four ACEs. ACEs predict the first onset of all psychological disorders studied    .
- This link between childhood adversities and the onset of psychological disorders is found in children, teenagers, young adults, and older adults around the world .
- ACEs also have a significant impact on social dysfunction: Those with cumulative ACEs are at risk of lower educational and occupational attainment, shortened lifespan, and higher rates of HIV, teen pregnancy, and maternal depression .
- Developmental models also postulate that resilience against ACEs decreases as the amount of ACEs increase .
The ACE Studies also show that child maltreatment is costly: 
Each first-time case of child maltreatment costs the United States economy approximately 1.8 million dollars in total expenditures over their lifetime.
- Child abuse costs approximately $30,000 to $200,000 per case over their lifetime. Child abuse leads to further dysfunction, including:
- Teen pregnancy (costs approximately $120,000 to $138,000),
- High school dropouts (costs approximately $250,000 to $450,000),
- Illegal drug abuse (costs approximately $250,000 to $740,000), and
- Alcohol abuse (costs approximately $230,000 to $690,000).
Monetary costs do not include the human suffering borne by victims and their families and the intergenerational transmission of childhood adversity born by future society.
Eradication of ACEs would result in substantial decreases in the onset of psychiatric illness among across the lifespan: 
|Type of Disorder||Childhood Onset||Adolescent Onset||Adult Onset|
* Too few new onset cases available to assess.
- Indeed, ACEs are the most preventable case of serious mental illness .
- Psychological/emotional abuse is particularly difficult to study because it does not leave physical evidence like other forms of child maltreatment, making it more difficult to prosecute.
Prevalence across studies vary considerably depending on their definitions of child maltreatment and methodology.
Self-report from victims and parents: 
- 5-35% of children experienced severe physical abuse per reviews from the United States, the United Kingdom, New Zealand, Finland, and Italy
- 3% of children in the United States experience severe psychological abuse
Official statistics from the United States police and child protection agencies: 
- 78% of children in the United States were investigated in 2006
- 21% of children in the United States had substantiated cases of maltreatment in 2006. These were composed of:
- 60% neglect
- 10% physical abuse
- 12% multiple forms of maltreatment
- 11% psychological abuse/unknown
- 10% sexual abuse
Additional psychopathology linked to child maltreatment can be found here.
Who is at risk?
- Women: Women have a higher risk of being sexually abused than do men, although rates of other types of maltreatment are similar for both sexes in high-income countries. In low-income countries, women are at higher risk for infanticide, sexual abuse, and neglect, whereas men seem to be at greater risk of harsh physical punishment.
- Disabled populations: The National Criminal Justice Reference Service defines disabled individuals as those who have “limited interaction between their bodies and their physical, emotional, and mental health, and the physical and social environment in which they live.”
- In the US, 9% of all children are maltreated but 31% of disabled children are maltreated—although whether the disability increases the risk or results from maltreatment (such as Fetal Alcohol Syndrome) is not clear .
- Younger children: The highest amount of maltreatment involves younger children. Additionally, maltreatment has greater negative effects for younger children as compared to older children  .
- Children ages 0-3 have the highest exposure to maltreatment, followed by children ages 4-6, children ages 7-9, children ages 10-12, adolescents aged 13-15, and finally adolescents aged 16-17.
- The most common type of maltreatment experienced is neglect at 67%, followed by physical abuse at 16% and sexual abuse at 8%.
- Previous victims: Child maltreatment victims are 2-7% more likely to experience maltreatment again as compared to children who have not been victimized .
- Likewise, having zero ACEs significantly protects against child and adult mental illness. Positive childhood experiences can also offset negative childhood experiences.
Developmental Trauma Disorder 
After exposure to maltreatment, individuals may develop Developmental Trauma Disorder. The criteria for Developmental Trauma Disorder are as follows:
1. Multiple or chronic exposure to one or more forms of developmentally adverse interpersonal trauma (e.g., abandonment, betrayal, physical assaults, sexual assaults, threats to bodily integrity, coercive practices, emotional abuse, witnessing violence and death).
2. Subjective Experience (e.g., rage, betrayal, fear, resignation, defeat, shame).
B. Triggered pattern of repeated dysregulation in response to trauma cues:
1. Dysregulation (high or low) in presence of cues. Changes persist and do not return to baseline. Dysregulation is not reduced in intensity by conscious awareness. Examples of dysregulation may include:
- Somatic symptoms (e.g, physiological, motoric, medical)
- Affective symptoms (e.g, mood disturbance)
- Behavioral symptoms (e.g., re-enactment, cutting)
- Cognitive symptoms (e.g., confusion, dissociation, depersonalization)
- Relational symptoms (e.g., clinging, oppositional, distrustful, compliant)
- Self-attribution symptoms (e.g., self-hate and blame)
C. Persistently altered attributions and expectancies:
1. Negative self-attribution
2. Distrust protective caretaker
3. Loss of expectancy of protection by others
4. Loss of trust in social agencies to protect
5. Lack of recourse to social justice/retribution
6. Inevitability of future victimization
D. Functional Impairment
Child maltreatment resources:
- Child Help National Child Abuse Hotline: 1-800-4-A-CHILD
- Offers crisis intervention, information, literature, and referrals to thousands of emergency, social service, and support resources.
- Support is offered in 170 languages.
- K. National Society for the Prevention of Cruelty to Children:
- Childline – 0800 1111
- International Child Helpline:
- As of May 2014, the International Child Helpline has a network of 179 helplines in 124 countries.
- Find a helpline in your country: http://www.childhelplineinternational.org/where-we-work/
- To report child abuse in the United States, see: https://www.childwelfare.gov/pubs/reslist/rl_dsp.cfm?rs_id=5&rate_chno=W-00082
Books about traumatized individuals:
There are many excellent books written for traumatized adults, including those traumatized in childhood. Listed below are a few:
- Boon, S., Steele, K., & van der Hart, O. (2011). Coping with Trauma-Related Dissociation: Skills Training for Patients and Therapists. New York, New York: Norton.
- Lewis, L., Kelly, K., & Allen, J.G. (2004). Restoring hope and trust: An illustrated guide to mastering trauma. Baltimore, Maryland: Sidran Institute Press.
- Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York, New York: Guilford Press.
- Williams, M.B. & Poijula, S. (2002). The PTSD Workbook: Simple, effective techniques for overcoming traumatic stress symptoms. Oakland, California: New Harbinger Publications.
Books about treating traumatized children:
- Cohen, J.,A. Mannarino, A.P., & Deblinger, (2006). Treating Trauma and Traumatic Grief in Children and Adolescents. New York: Guilford Press.
- Cohen, J.,A. Mannarino, A.P., & Deblinger, (2012). Trauma-Focused CBT for Children and Adolescents: Treatment Applications. New York: Guilford Press.
 Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C. H., Perry, B. D., … & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood. European Archives of Psychiatry and Clinical Neuroscience, 256(3), 174-186.
 McLaughlin, K. A., Green, J. G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., & Kessler, R. C. (2012). Childhood adversities and first onset of psychiatric disorders in a national sample of US adolescents. Archives of General Psychiatry, 69(11), 1151-1160.
 Kessler, R. C., Green, J. G., Gruber, M. J., Sampson, N. A., Bromet, E., Cuitan, M., … & Zaslavsky, A. M. (2010). Screening for serious mental illness in the general population with the K6 screening scale: Results from the WHO World Mental Health (WMH) survey initiative. International Journal of Methods in Psychiatric Research, 19(S1), 4-22.
 Office on Child Abuse and Neglect, Children’s Bureau. (2003). The role of educators in preventing and responding to child abuse and neglect. Retrieved from https://www.childwelfare.gov/pubs/usermanuals/educator/
 Administration for Children and Families Children’s Bureau, Department of Health and Human Services (2015). Child maltreatment 2006. Retrieved from http://archive.acf.hhs.gov/programs/cb/pubs/cm06/cm06.pdf
 Pynoos, R. S., Steinberg, A. M., Layne, C. M., Liang, L., Vivrette, R. L., Briggs, E. C., & … Fairbank, J. A. (2014). Modeling constellations of trauma exposure in the National Child Traumatic Stress Network Core Data Set. Psychological Trauma: Theory, Research, Practice, And Policy, 6(Suppl 1), S9-S17.
 Administration for Children and Families Children’s Bureau, Department of Health and Human Services (2014). Child maltreatment 2012. Retrieved from http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf