CHILD ABUSE Child abuse is the physical, sexual or emotional maltreatment or neglect of a child or children.

[1]In the United States, the Centers for Disease Control and Prevention (CDC) and the Department for Children And Families (DCF) define child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.[2] Child abuse can occur in a child's home, or in the organizations, schools or communities the child interacts with. There are four major categories of child abuse: neglect,physical abuse, psychological or emotional abuse, and sexual abuse. In Western countries, preventing child abuse is considered a high priority, and detailed laws and policies exist to address this issue. Different jurisdictions have developed their own definitions of what constitutes child abuse for the purposes of removing a child from his/her family and/or prosecuting a criminal charge. According to the Journal of Child Abuse and Neglect, child abuse 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, an act or failure to act which presents an imminent risk of serious harm".[3] However, Douglas J. Besharov, the first Director of the U.S. Center on Child Abuse and Neglect, states "the existing laws are often vague and overly broad"[4] and there is a "lack of consensus among professionals and Child Protective Services (CPS) personnel about what the terms abuse and neglect mean".[5] Susan Orr, former head of the United States Childrens Bureau U.S. Department of Health and Services- Administration for Children and Families, 2001-2007, states that "much that is now defined as child abuse and neglect does not merit governmental interference"

Until quite recently, children had very few rights in regard to protection from violence by their parents, and still continue to do so in many parts of the world. Historically, fathers had virtually unlimited rights in regard to their children and how they chose to discipline them. In many cultures, such as in Ancient Rome, a father could legally kill his children; many cultures have also allowed fathers to sell their children into slavery. Child sacrifice was also a common practice.[7] Today,corporal punishment of children by their parents remains legal in most countries, but in Western countries that still allow the practice there are strict limits on what is permitted. The first country to outlaw parental corporal punishment was Sweden (parents' right to spank their own children was first removed in 1966,[8] and it was explicitly prohibited by law from July 1979).

Child abuse can take several forms:[9] The four main types are physical, sexual, psychological, and neglect.[10] According to the 2010 Child Maltreatment Report (NCANDS), a yearly Federal report based on submission by state Child Protective Services (CPS) Agencies, as in prior years, neglect was the most common form of maltreatment. The cases were substantiated as follows:

neglect 78.3%, physical abuse 17.6%, sexual abuse 9.2%, and psychological maltreatment 8.1%.),[11] According to Richard Wexler, the Director of National Coalition of Child Protection Reform, of those labeled substantiated or indicated by protective workers, relatively few are the kind that leap to mind when we hear the words child abuse. By far the largest category was neglect. Often, these are cases in which the primary problem is family poverty.[12]

Physical abuse involves physical aggression directed at a child by an adult. Most nations with child-abuse laws consider the deliberate infliction of serious injuries, or actions that place the child at obvious risk of serious injury or death, to be illegal. Bruises, scratches, burns, broken bones, lacerations, as well as repeated "mishaps," and rough treatment that could cause physical injury, can be physical abuse.[13] Multiple injuries or fractures at different stages of healing can raise suspicion of abuse. Physical abuse can come in many forms, although the distinction between child discipline and abuse is often poorly defined. However, the Human Rights Committee of theUnited Nations has stated that the prohibition of degrading treatment or punishment extends to corporal punishment of children. [14]Since 1979, 29 countries around the world (at 2010) have outlawed domestic corporal punishment of children.[15] In Europe, 22 countries have banned the practice. Cultural norms about what constitutes abuse vary widely: among professionals as well as the wider public, people do not agree on what behaviors constitute abuse.[16] Some professionals claim that cultural norms that sanction physical punishment are one of the causes of child abuse, and have undertaken campaigns to redefine such norms.[17][18][19] Psychologist Alice Miller, noted for her books on child abuse, took the view that humiliations, spankings and beatings, slaps in the face, etc. are all forms of abuse, because they injure the integrity and dignity of a child, even if their consequences are not visible right away.[20]

Child sexual abuse (CSA) is a form of child abuse in which an adult or older adolescent abuses a child for sexual stimulation.[21]Sexual abuse refers to the participation of a child in a sexual act aimed toward the physical gratification or the financial profit of the person committing the act.[13][22] Forms of CSA include asking or pressuring a child to engage in sexual activities (regardless of the outcome), indecent exposure of the genitals to a child, displaying pornography to a child, actual sexual contact with a child, physical contact with the child's genitals, viewing of the child's genitalia without physical contact, or using a child to produce child pornography.[21][23][24] Selling the sexual services of children may be viewed and treated as child abuse with services offered to the child rather than simple incarceration.[25] Effects of child sexual abuse include guilt and self-blame, flashbacks, nightmares, insomnia, fear of things associated with the abuse (including objects, smells, places, doctor's visits, etc.), selfesteem issues, sexual dysfunction, chronic pain, addiction, self-injury,suicidal ideation, somatic complaints, depression,[26] post-traumatic stress disorder,[27] anxiety,[28] other mental illnesses includingborderline personality disorder[29] and dissociative identity

disorder,[29] propensity to re-victimization in adulthood,[30] bulimia nervosa,[31] physical injury to the child, among other problems.[32] In the United States, approximately 15% to 25% of women and 5% to 15% of men were sexually abused when they were children.[33][34][35][36][37] Most sexual abuse offenders are acquainted with their victims; approximately 30% are relatives of the child, most often brothers, fathers, mothers, uncles or cousins; around 60% are other acquaintances such as friends of the family, babysitters, or neighbours; strangers are the offenders in approximately 10% of child sexual abuse cases.[33] In over one-third of cases, the perpetrator is also a minor.[38] In a 1999 news story, BBC reported, "Close-knit family life in India masks an alarming amount of sexual abuse of children and teenage girls by family members, a new report suggests. Delhi organisation RAHI said 76% of respondents to its survey had been abused when they were children - 40% of those by a family member."[39]

Emotional abuse is defined as the production of psychological and social deficits in the growth of a child as a result of behavior such as loud yelling, coarse and rude attitude, inattention, harsh criticism, and denigration of the child's personality.[13] Other examples include name-calling, ridicule, degradation, destruction of personal belongings, torture or killing of a pet, excessive criticism, inappropriate or excessive demands, withholding communication, and routine labeling or humiliation.[40] Victims of emotional abuse may react by distancing themselves from the abuser, internalizing the abusive words, or fighting back byinsulting the abuser. Emotional abuse can result in abnormal or disrupted attachment development, a tendency for victims to blame themselves (self-blame) for the abuse, learned helplessness, and overly passive behavior.[4 Child neglect is the failure of a parent or other person with responsibility for the child to provide needed food, clothing, shelter, medical care, or supervision to the degree that the child's health, safety, and well-being are threatened with harm. Neglect is also a lack of attention from the people surrounding a child, and the non-provision of the relevant and adequate necessities for the child's survival, which would be a lacking in attention, love, and nurture.[41] Some of the observable signs in a neglected child include: the child is frequently absent from school, begs or steals food or money, lacks needed medical and dental care, is consistently dirty, lacks sufficient clothing for the weather.[42] Neglected children may experience delays in physical and psychosocial development, possibly resulting in psychopathology and impaired neuropsychological functions includingexecutive function, attention, processing speed, language, memory and social skills.[43]Researchers investigating maltreated children have repeatedly found that neglected children in foster and adoptive populations manifest different emotional and behavioral reactions to regain lost or secure relationships and are frequently reported to have disorganized attachments and a need to control their environment. Such children are not likely to view caregivers as being a source of safety, and instead typically show an increase in aggressive and hyperactive behaviors which

may disrupt healthy or secure attachment with their adopted parents. These children have apparently learned to adapt to an abusive and inconsistent caregiver by becoming cautiously selfreliant, and are often described as glib, manipulative and disingenuous in their interactions with others as they move through childhood.[44] Children who are victims of neglect have a more difficult time forming and maintaining relationships, such as romantic or friendship, later in life due to the lack of attachment they had in their earlier stages of life.

Child labour refers to the employment of children in any work that deprives children of their childhood, interferes with their ability to attend regular school, or is mentally, physically, socially or morally dangerous and harmful.[45] This practice is considered a form of exploitation and abuse of children by many international organizations.[46][47] Child labor refers to those occupations which infringe the development of children (due to the nature of the job and/or the lack of appropriate regulation) and does not include age appropriate and properly supervised jobs in which minors may participate. According to ILO, globally, around 215 million children work, many full-time. Many of these children do not go to school, do not receive proper nutrition or care, and have little or no time to play. More than half of them are exposed to the worst forms of child labour, such as child prostitution, drug trafficking, armed conflicts and other hazardous environments.[48]

Child trafficking is the recruitment, transportation, transfer, harbouring or receipt of children for the purpose of exploitation.[49] Children are trafficked for purposes such as of commercial sexual exploitation, bonded labour, camel jockeying, child domestic labour, drug couriering, child soldiering, illegal adoptions, begging.[50][51][52]It is difficult to obtain reliable estimates concerning the number of children trafficked each year, primarily due to the covert and criminal nature of the practice.[53][54] The International Labour Organizationestimates that 1.2 million children are trafficked each year.[55]

Female genital mutilation (FGM) is defined by the World Health Organization (WHO) as "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons."[56] It is practiced mainly in 28 countries in western, eastern, and north-eastern Africa, particularly Egypt and Ethiopia, and in parts of Asia and the Middle East.[57]FGM is most often carried out on young girls aged between infancy and 15 years.[58] The consequences of FGM include physical, emotional and sexual problems, and include serious risks during childbirth.[59][60] In Western countries this practice is illegal and considered a form of child abuse.[61][62]

A child marriage is a marriage whereby minors are given in matrimony - often before puberty. Child marriages are common in many parts of the world, especially in parts of Asia and Africa.

These marriages are typically arranged and often forced; as young children are generally not capable of giving valid consent to enter into marriage, child marriages are often considered by default to be forced marriages. Marriages under the age of majority have a great potential to constitute a form of child abuse.[63] In many countries there are no adequate laws to criminalize these practices, and even where there are laws, they are often unenforced.[64]

Customary beliefs in witchcraft are common in many parts of the world, even among the educated. This is especially the case in parts of Africa.[65] Witchcraft accusations against children in Africa have received increasing international attention in the first decade of the 21st century. Children who are specifically at risk of such accusations include orphans, streetchildren, albinos, disabled children, children who are unusually gifted, children who were born prematurely or in unusual positions, and twins. [66] Being accused of witchcraft in Africa is very dangerous, as a witch is culturally understood to be the symbol of evil, and the cause of all ills. Consequently, those accused of being a witch are ostracized and subjected to punishment, torture and even murdered.[67][68] Recent reports by UNICEF, UNHCR, Save The Children and Human Rights Watch[69][70][71][72] have highlighted the violence and abuse towards children accused of witchcraft in Africa.

David Finkelhor tracked Child Maltreatment Report (NCANDS) data from 1990 to 2010. He states that sexual abuse had declined 62% from 1992 to 2009. The long-term trend for physical abuse was also down by 56% since 1992. The decline in sexual abuse adds to an already substantial positive long-term trend. He states: "It is unfortunate that information about the trends in child maltreatment are not better publicized and more widely known. The long-term decline in sexual and physical abuse may have important implications for public policy."[73] In 2010, there were 74,100,000 US children ages 0 17.[74] NCANDS estimated that there were 695,000 unique children with substantiated maltreatment (78.3% were for neglect); which means that in 2010, less than 1% of the U.S. child population had a substantiated or indicated finding of any form of maltreatment.[11] According to the 2010 NCANDS, 17.6% of substantiated/indicated outcomes were for physical abuse (less than 0.2% of US children) and 9.2% of substantiated/indicated outcomes were for sexual abuse (less than 0.1% of US children).[75] Finkelhor's data from his 2010 study confirm these numbers.[73] According to the (American) National Committee to Prevent Child Abuse, in 1997 neglect represented 54% of confirmed cases of child abuse, physical abuse 22%, sexual abuse 8%, emotional maltreatment 4%, and other forms of maltreatment 12%.[76] A UNICEF report on child wellbeing stated that the United States and the United Kingdom ranked lowest among industrial nations with respect to the wellbeing of children. It also found that child neglect and child abuse were far more common in single-parent families than in families where both parents are present.[77]

In the USA, neglect is defined as the failure to meet the basic needs of children including housing, clothing, food and access to medical care. Researchers found over 91,000 cases of neglect in one year (from October 2005 to 30 September 2006) using information from a database of cases verified by protective services agencies.[2] Neglect could also take the form of financial abuse by not buying the child adequate materials for survival.[78] The U.S. Department of Health and Human Services reports that for each year between 2000 and 2005, "female parents acting alone" were most likely to be perpetrators of child abuse.[79] For FFY 2011, United States reported 676,569 victims of child abuse and neglect.[80] Race and ethnicity of victims in 2011: 43.9% of all victims were White, 21.5% were African American, and 22.1% were Hispanic.[80] According to Manas Akmatov, "A median of 83, 64 and 43% of children in the African region experienced psychological, and moderate and severe physical abuse, respectively. A considerably lower percentage of children in transitional countries experienced these forms of abuse (56, 46 and 9%, respectively)."[81] In 2010, there were 74,100,000 US children ages 0 17 according to the US Census Bureau.[74] The 3.3 million annual (hotline) referrals effects on average 1 out of 10 U.S. families with children (There are 32,200,000 U.S. families with children under 18 according to the 2010 U.S. Census).[82] From the 3.3 million hotline calls (2010), there were less than 475,000 substantiated cases (2010 NCANDS: 436,321 substantiated+24,976 indicated=461,297 total) resulting in about 15% of hotline calls substantiated/indicated, of which 78.3% were for neglect.[11][83] According to NCANDS 2010, there were 695,000 unique children with substantiated maltreatment (78.3% were for neglect); which means that in 2010, less than 1% of the U.S. child population had a substantiated or indicated finding of any form of maltreatment.[11]According to the 2010 NCANDS, 17.6% of substantiated/indicated outcomes were for physical abuse (less than 0.2% of US children) and 9.2% of substantiated/indicated outcomes were for sexual abuse (less than 0.1% of US children).[11] Finkelhors data from his 2010 study confirms these numbers. .[73] Some argue that even many "substantiated reports involve only minor or insignificant matters, which most reasonable people would not truly consider abuse or neglect".[84]

A child abuse fatality occurs when a child's death is the result of abuse or neglect, or when abuse and/or neglect are contributing factors to a child's death. In the United States, 1,730 children died in 2008 due to factors related to abuse; this is a rate of 2 per 100,000 U.S. children.[85] Family situations which place children at risk include moving, unemployment, having non-family members living in the household. A number of policies and programs have been put in place in the U.S. to try to better understand and to prevent child abuse fatalities, including: safe-haven

laws, child fatality review teams, training for investigators, shaken baby syndrome prevention programs, and child abuse death laws which mandate harsher sentencing for taking the life of a child.[86] Child abuse is a complex phenomenon with multiple causes.[87] Understanding the causes of abuse is crucial to addressing the problem of child abuse.[88] Parents who physically abuse their spouses are more likely than others to physically abuse their children.[89] However, it is impossible to know whether marital strife is a cause of child abuse, or if both the marital strife and the abuse are caused by tendencies in the abuser.[89] This commonly used term refers to the process of parents' setting expectations for their child that are clearly beyond the child's capability. When parents' expectations are particularly deviant (e.g., preschool children who are expected to be totally responsible for self-care or provision of nurturance to parents) the resulting frustration caused by the child's non-compliance is believed to function as a contributory if not necessary cause of child abuse.[90] Children resulting from unintended pregnancies are more likely to be abused or neglected.[91][92] Neglect is by far the most common form of child abuse, accounting for more than 78% of all cases.[93] In addition, unintended pregnancies are more likely than intended pregnancies to be associated with abusive relationships,[94] and there is an increased risk of physical violence during pregnancy.[95]They also result in poorer maternal mental health,[95] and lower mother-child relationship quality.[95] A study on child abuse sought to determine: the forms of child abuse perpetrated on children with disabilities; the extent of child abuse; and the causes of child abuse of children with disabilities. A questionnaire on child abuse was adapted and used to collect data in this study. Participants comprised a sample of 31 pupils with disabilities (15 children with vision impairment and 16 children with hearing impairment) selected from special schools in Botswana. The study found that the majority of participants were involved in doing domestic chores. They were also sexually, physically and emotionally abused by their teachers. This study showed that children with disabilities were vulnerable to child abuse in their schools.[96] Substance abuse can be a major contributing factor to child abuse. One U.S. study found that parents with documented substance abuse, most commonly alcohol, cocaine, and heroin, were much more likely to mistreat their children, and were also much more likely to reject courtordered services and treatments.[97] Another study found that over two-thirds of cases of child maltreatment involved parents with substance abuse problems. This study specifically found relationships between alcohol and physical abuse, and between cocaine and sexual abuse.[98] Although the abuse survivor does not always realise the abuse is wrong, the internal confusion can lead to chaos. Inner anger turns to outer frustration. Once aged 17/18, drink and drugs are used to numb the hurt feelings, nightmares and daytime flashbacks. Acquisitive crimes to pay for the chemicals are inevitable if the survivor is unable to find employment.[99] A 2010 article in the BBC reports that thousands of African children have been abandoned, tortured and murdered because they are believed to be witches.[100]

Unemployment and financial difficulties are associated with increased rates of child abuse.[101] In 2009 CBS News reported that child abuse in the United States had increased during the economic recession. It gave the example of a father who had never been the primary caretaker of the children. Now that the father was in that role, the children began to come in with injuries.[102] Child-abuse cases go through screeners like Belisle to an "assessment" worker, the job Belisle used to handle. Eventually they reach the various social workers and services (counseling, referral to day care centers and Alcoholics Anonymous in local neighborhoods). Having been abused as a child seems to lead to a repetition with one's own children. Beyond that, the causes of child abuse seem to be deep-rooted anger and frustration and an intolerable sense of physical or emotional inadequacy. Anger most of all. "They don't know how to control it," says Belisle's co-worker Anna Ferzoco.[103] A 1988 study of child murders in the US found that children are 100 times more often killed by a "non-biological parent (e.g. step-parent, co-habitee or boyfriend/girlfriend of a biological parent)" than by a biological parent.[104] An evolutionary psychology explanation for this is that using resources in order to take care of another person's biological child is likely not a good strategy for increasingreproductive success.[104] More generally, stepchildren have a much higher risk of being abused which is sometimes referred to as theCinderella effect. The Cinderella Effect attempts to explain the observation that parents are more likely to kill their stepchildren than their biological children using evolutionary logic - as described by Daly and Wilson: "research concerning animal social behaviour provide a rationale for expecting parents to be discriminative in their care and affection, and more specifically, to discriminate in favour of their own young".[105] Psychologists conducted a study in the United States in 2010 which examined over 200 regular church attendees from eleven different denominations of Christianity, most of whom were educated, upper-middle class White Americans, found that extrinsic religious orientation was associated with a greater risk of physical child abuse. Those with a more extrinsic religious orientation who also adhered to greater social conformity were particularly more likely to share characteristics with physically abusive subjects. Subjects who adhered to Biblical literalism exhibited a higher potential of physical child abuse. Those who had a more intrinsic religious orientation were not found to be at a greater risk of child abuse, although they sometimes exhibited greater social conformity or a greater propensity for holding literal interpretations of the Bible. Approximately 85% of the study's subjects were parents.[106]

Child abuse is an international phenomenon. Poverty and substance abuse are common widespread international issues, and no matter the location, show a similar trend in the correlation to child abuse. Although these issues can likely contribute to child maltreatment, differences in cultural perspectives play a significant role in the treatment of children. In certain nations, the battle

for equality within the sexes plays a large part in a childs upbringing. During the Soviet period, there were conflicts regarding the traditional housewife versus the emphasis on equality within the sexes. Some women felt a considerable amount of pressure to carry out their motherly duties, obtaining an authoritarian parenting style, acting dominating and emotionally distant towards her children while overly involved in her own career.[107] Many were encouraged to use more firm and direct disciplinary methods, as well as be overbearing and overprotective of their children.[107] Now that this Communist Era has ended, there are many positive changes being put into play. While there is a new openness and acceptance regarding parenting styles and close relationships with children, child abuse still remains a serious concern. Although it is now more publicly recognized, it has certainly not ceased to exist. While controlling parenting may be less of a concern, financial difficulty, unemployment, and substance abuse still remain to be dominating factors in child abuse throughout Eastern Europe.[107] A study conducted by members from several Baltic and Eastern European countries, together with specialists from the United States, examined the causes of child abuse in the countries of Latvia, Lithuania, Macedonia and Moldova. In these countries, respectively, 33%, 42%, 18% and 43% of children reported at least one type of child abuse.[108] According to their findings, there was a series of correlations between the potential risk factors of parental employment status, alcohol abuse, and family size within the abuse ratings.[107] In three of the four countries, parental substance abuse was considerably correlated with the presence of child abuse, and although it was a lower percentage, still showed a relationship in the fourth country (Moldova).[107] Each country also showed a connection between the father not working outside of the home and either emotional or physical child abuse.[107] These cultural differences can be studied from many perspectives. Most importantly, overall parental behavior is genuinely different in various countries. Many may view child abuse, both emotional and physical, as socially acceptable. Each culture has their own "range of acceptability," and what one may view as offensive, others may seem as tolerable. Behaviors that are normal to some may be viewed as abusive to others, all depending on the societal norms of that particular country.[107] Asian parenting perspectives, specifically, hold different ideals from American culture. Many have described their traditions as includingphysical and emotional closeness that ensures a lifelong bond between parent and child, as well as establishing parental authority and child obedience through harsh discipline.[109] Balancing disciplinary responsibilities within parenting is common in many Asian cultures, including China, Japan, Singapore, Vietnam and Korea.[109] To some cultures, forceful parenting may be seen as abuse, but in other societies such as these, the use of force is looked at as a reflection of parental devotion.[109] The differences in these cultural beliefs demonstrate the importance of examining all crosscultural perspectives when studying the concept of child abuse. As of 2006, between 25,000 and 50,000 children in Kinshasa, Democratic Republic of the Congo, had been accused of witchcraft and abandoned.[110] In Malawi it is also common practice

to accuse children of witchcraft and many children have been abandoned, abused and even killed as a result.[111] In the Nigerian states of Akwa Ibom and Cross River about 15,000 children were branded as witches.[112]

There are strong associations between exposure to child abuse in all its forms and higher rates of many chronic conditions. In the United States, the strongest evidence comes from the Adverse Childhood Experiences (ACE's) series of studies which show correlations between exposure to abuse or neglect and higher rates in adulthood of chronic conditions, high-risk health behaviors and shortened lifespan.[113] A recent publication, Hidden Costs in Health Care: The Economic Impact of Violence and Abuse,[114] makes the case that such exposure represents a serious and costly public-health issue that should be addressed by the healthcare system. A big concern with researchers is the degree to which maltreated children grow up to be maltreating adults or if they exhibit social signs of abuse or neglect. Studies show that 90 percent of maltreating adults were maltreated as children in their life. When children were two, studies show that 16 percent of 267 high-risk mothers mistreated their own children, to different effects.[115] The first two years of a child's life is when parents invest the least in their children. Almost 7 million American infants go to child care services, like day care, and a majority of that care is poor. Serious consequences occur when young children are maltreated, including developmental issues.[116] 16 percent of those 267 high risk mothers mistreat their two year old children in different ways. 55 percent of the children experienced physical abuse, 55 percent experienced neglect, 43 percent experienced hostile and rejecting parenting, and 43 percent experienced unavailable parenting.[115]

Children who have a history of neglect or physical abuse are at risk of developing psychiatric problems,[117][118] or a disorganized attachment style.[119][120][121] Disorganized attachment is associated with a number of developmental problems, including dissociativesymptoms,[122] as well as anxiety, depressive, and acting out symptoms.[123][124] A study by Dante Cicchetti found that 80% of abused and maltreated infants exhibited symptoms of disorganized attachment.[125][126] When some of these children become parents, especially if they suffer from posttraumatic stress disorder (PTSD), dissociative symptoms, and other sequelae of child abuse, they may encounter difficulty when faced with their infant and young children's needs and normative distress, which may in turn lead to adverse consequences for their child's social-emotional development.[127][128] Despite these potential difficulties, psychosocial intervention can be effective, at least in some cases, in changing the ways maltreated parents think about their young children.[129] Victims of childhood abuse, it is claimed, also suffer from different types of physical health problems later in life. Some reportedly suffer from some type of chronic head, abdominal, pelvic, or muscular pain with no identifiable reason.[130] Even though the majority of childhood abuse victims know or believe that their abuse is, or can be, the cause of different health problems in their adult life, for the great majority their abuse was not directly associated with those problems, indicating that sufferers were most likely diagnosed with other possible causes for their health

problems, instead of their childhood abuse.[130] One long-term study found that up to 80% of abused people had at least one psychiatric disorder at age 21, with problems including depression, anxiety, eating disorders, and suicide attempts.[131] One Canadian hospital found that between 36% and 76% of women mental health outpatients had been abused, as had 58% of women and 23% of men schizophrenic inpatients.[132] In the case of 23 of the 27 illnesses listed in the questionnaire of a French INSEE survey, some statistically significant correlations were found between repeated illness and family traumas encountered by the child before the age of 18 years. According to Georges Menahem, the French sociologist who found out these correlations by studying health inequalities, these relationships show that inequalities in illness and suffering are not only social. Health inequality also has its origins in the family, where it is associated with the degrees of lasting affective problems (lack of affection, parental discord, the prolonged absence of a parent, or a serious illness affecting either the mother or father) that individuals report having experienced in childhood.

Children who are physically abused are likely to receive bone fractures, particularly rib fractures,[134] and may have a higher risk of developing cancer.[135] Children who experience child abuse & neglect are 59% more likely to be arrested as juveniles, 28% more likely to be arrested as adults, and 30% more likely to commit violent crime.[136] The immediate physical effects of abuse or neglect can be relatively minor (bruises or cuts) or severe (broken bones, hemorrhage, or even death). In some cases the physical effects are temporary; however, the pain and suffering they cause a child should not be discounted. Meanwhile, the long-term impact of child abuse and neglect on physical health is just beginning to be explored. The long-term effects can be:

Shaken baby syndrome. Shaking a baby is a common form of child abuse that often results in permanent neurological damage (80% of cases) or death (30% of cases).[137]Damage results from intracranial hypertension (increased pressure in the skull) after bleeding in the brain, damage to the spinal cord and neck, and rib or bone fractures (Institute of Neurological Disorders and Stroke, 2007). Impaired brain development. Child abuse and neglect have been shown, in some cases, to cause important regions of the brain to fail to form or grow properly, resulting in impaired development (De Bellis & Thomas, 2003). These alterations in brain maturation have longterm consequences for cognitive, language, and academic abilities (Watts-English, Fortson, Gibler, Hooper, & De Bellis, 2006). NSCAW found more than three-quarters of foster children between 1 and 2 years of age to be at medium to high risk for problems with brain development, as opposed to less than half of children in a control sample (ACF/OPRE, 2004a). Poor physical health. Several studies have shown a relationship between various forms of household dysfunction (including childhood abuse) and poor health (Flaherty et al., 2006; Felitti, 2002). Adults who experienced abuse or neglect during childhood are more likely to

suffer from physical ailments such as allergies, arthritis, asthma, bronchitis, high blood pressure, and ulcers (Springer, Sheridan, Kuo, & Carnes, 2007).[138] On the other hand, there are some children who are raised in child abuse, but who manage to do unexpectedly well later in life regarding the preconditions. Such children have been termed dandelion children, as inspired from the way that dandelions seem to prosper irrespective of soil, sun, drought, or rain.[139] Such children (or currently grown-ups) are of high interest in finding factors that mitigate the effects of child abuse.

A support-group structure is needed to reinforce parenting skills and closely monitor the child's well-being. Visiting home nurse or social-worker visits are also required to observe and evaluate the progress of the child and his/her caretaking situation. The support-group structure and visiting home nurse or social-worker visits are not mutually exclusive. Many studies have demonstrated that the two measures must be coupled together for the best possible outcome.[140] Children's school programs regarding "good touch...bad touch" can provide children with a forum in which to role-play and learn to avoid potentially harmful scenarios. Unintended conception increases the risk of subsequent child abuse, and large family size increases the risk of child neglect.[92] Thus a comprehensive study for the National Academy of Sciences concluded that affordable contraceptive services should form the basis for child abuse prevention.[92][141]"The starting point for effective child abuse programming is pregnancy planning," according to an analysis for US Surgeon General C. Everett Koop.[92][142] April has been designated Child Abuse Prevention Month in the United States since 1983.[143] U.S. President Barack Obama continued that tradition by declaring April 2009 Child Abuse Prevention Month.[144] One way the Federal government of the United States provides funding for child-abuse prevention is through Community-Based Grants for the Prevention of Child Abuse and Neglect (CBCAP).[145]Each year during Child Abuse Prevention Month, often media and commentators take the number of reports to be synonymous with the number of cases of actual child maltreatment; this is obviously not the case.[146] From the 3.3 million hotline calls (2010), there were less than 475,000 substantiated cases (2010 NCANDS: 436,321 substantiated+24,976 indicated=461,297 total), resulting in about 15% of hotline calls substantiated/indicated, of which 78.3% were for neglect.[11][83] Some argue that even many substantiated reports involve only minor or insignificant matters, which most reasonable people would not truly consider abuse or neglect..[84] The 3.3 million annual (hotline) referrals effects on average 1 out of 10 U.S. families with children (There are 32,200,000 U.S. families with children under 18 according to the 2010 U.S. Census) .[82] Unsubstantiated rates of the current magnitude go beyond anything reasonably needed; a high rate of unsubstantiated reports should concern everyone, according to Besharov. He further states each report results in what can be an intrusive and traumatic investigation that is inherently a breach of parental and family privacy. The emotionally charged desire to do something about child abuse, fanned by repeated and often sensational media coverage has led to an understandable, but counterproductive over reaction on the part of the professionals and citizens who report child abuse according to Besharov.[147]

Resources for child-protection services are sometimes limited. According to Hosin (2007), "a considerable number of traumatized abused children do not gain access to protective childprotection strategies."[148] Briere (1992) argues that only when "lower-level violence" of children[clarification needed] ceases to be culturally tolerated will there be changes in the victimization and police protection of children.[149] A number of treatments are available to victims of child abuse.[150] Trauma-focused cognitive behavioral therapy, first developed to treat sexually abused children, is now used for victims of any kind of trauma. It targets trauma-related symptoms in children including post-traumatic stress disorder (PTSD), clinical depression and anxiety. It also includes a component for nonoffending parents. Several studies have found that sexually abused children undergoing TF-CBT improved more than children undergoing certain other therapies. Data on the effects of TF-CBT for children who experienced only non-sexual abuse was not available as of 2006.[150] The purpose of dealing with the thoughts and feelings associated with the trauma is to deal with nightmares, flashbacks and other intrusive experiences that might be spontaneously brought on by any number of discriminative stimuli in the environment or in the individuals brain. This would aid the individual in becoming less fearful of specific stimuli that would arouse debilitating fear, anger, sadness or other negative emotion.In other words, the individual would have some control or mastery over those emotions.[44] Abuse-focused cognitive behavioral therapy was designed for children who have experienced physical abuse. It targets externalizing behaviors and strengthens prosocial behaviors. Offending parents are included in the treatment, to improve parenting skills/practices. It is supported by one randomized study.[150] Rational Cognitive Emotive Behavior Therapy consists of ten distinct but interdependent steps. These steps fall into one of three theoretical orientations (i.e., rational or solution focused, cognitive emotive, and behavioral) and are intended to provide abused children and their adoptive parents with positive behavior change, corrective interpersonal skills, and greater control over themselves and their relationships. They are: 1) determining and normalizing thinking and behaving, 2) evaluating language, 3) shifting attention away from problem talk 4) describing times when the attachment problem isnt happening, 5) focusing on how family members successfully solve problematic attachment behavior; 6) acknowledging unpleasant emotions (i.e., angry, sad, scared) underlying negative interactional patterns, 7) identifying antecedents (controlling conditions) and associated negative cognitive emotive connections in behavior (reciprocal role of thought and emotion in behavioral causation), 8) encouraging previously abused children to experience or own negative thoughts and associated aversive emotional feelings, 9) modeling and rewarding positive behavior change (with themselves and in relationships), and 10) encouraging and rewarding thinking and behaving differently. This type of therapy shifts victims thoughts away from the bad and changes their behavior.[44] Child-parent psychotherapy was designed to improve the child-parent relationship following the experience of domestic violence. It targets trauma-related symptoms in infants, toddlers, and

preschoolers, including PTSD, aggression, defiance, and anxiety. It is supported by two studies of one sample.[150] Other forms of treatment include group therapy, play therapy, and art therapy. Each of these types of treatment can be used to better assist the client, depending on the form of abuse they have experienced. Play therapy and art therapy are ways to get children more comfortable with therapy by working on something that they enjoy (coloring, drawing, painting, etc.). The design of a child's artwork can be a symbolic representation of what they are feeling, relationships with friends or family, and more. Being able to discuss and analyze a child's artwork can allow a professional to get a better insight of the child.[151]

One of the most challenging ethical dilemmas arising from child abuse relates to the parental rights of abusive parents or caretakers with regard to their children, particularly in medical settings.[152] In the United States, the 2008 New Hampshire case of Andrew Bednerdrew attention to this legal and moral conundrum. Bedner, accused of severely injuring his infant daughter, sued for the right to determine whether or not she remain on life support; keeping her alive, which would have prevented a murder charge, created a motive for Bedner to act that conflicted with the apparent interests of his child.[152][153][154] Bioethicists Jacob M. Appel and Thaddeus Mason Pope recently argued, in separate articles, that such cases justify the replacement of the accused parent with an alternative decision-maker.[152][155] Child abuse also poses ethical concerns related to confidentiality, as victims may be physically or psychologically unable to report abuse to authorities. Accordingly, many jurisdictions and professional bodies have made exceptions to standard requirements for confidentiality and legal privileges in instances of child abuse. Medical professionals, including doctors, therapists, and other mental health workers typically owe a duty of confidentiality to their patients and clients, either by law and/or the standards of professional ethics, and cannot disclose personal information without the consent of the individual concerned. This duty conflicts with an ethical obligation to protect children from preventable harm. Accordingly, confidentiality is often waived when these professionals have a good faith suspicion that child abuse or neglect has occurred or is likely to occur and make a report to local child protection authorities. This exception allows professionals to breach confidentiality and make a report even when the child or his/her parent or guardian has specifically instructed to the contrary. Child abuse is also a common exception to Physicianpatient privilege: a medical professional may be called upon to testify in court as to otherwise privileged evidence about suspected child abuse despite the wishes of the child and his/her family.[156]

There are organizations at national, state, and county levels in the United States that provide community leadership in preventing child abuse and neglect. The National Alliance of Children's Trust Funds and Prevent Child Abuse America are two national organizations with member organizations at the state level.

Many investigations into child abuse are handled on the local level by Child Advocacy Centers. Started over 25 years ago at what is now known as the National Children's Advocacy Center[157] in Huntsville, Alabama by District Attorney Robert "Bud" Cramer these multidisciplinary teams have met to coordinate their efforts so that cases of child abuse can be investigated quickly and efficiently, ultimately reducing trauma to the child and garnering better convictions.[158][159] These Child Advocacy Centers (known as CACs) have standards set by the National Children's Alliance.[160] Other organizations focus on specific prevention strategies. The National Center on Shaken Baby Syndrome focuses its efforts on the specific issue of preventing child abuse that is manifested as shaken baby syndrome. Mandated reporter training is a program used to prevent ongoing child abuse. NICHD, also known as the National Institute of Child Health & Human Development is a broad organization, but helps victims of child abuse through one of its branches. Through the Child Development and Behavior (CDB) Branch, NICHD raises awareness efforts by supporting research projects to better understand the short- and long-term impacts of child abuse and neglect. They provide programs and observe National Child Abuse Prevention Month every April since 1984. The Childrens Bureau leads activities for the Month, including the release of updated statistics about child abuse and neglect, candlelight vigils, and fundraisers to support prevention activities and treatment for victims. The Bureau also sponsors a "Blue Ribbon Campaign," in which people wear blue ribbons in memory of children who have died from abuse, or in honor of individuals and organizations that have taken important steps to prevent child abuse and neglect.