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This section provides a review of the common problems associated with maltreatment in the first 3 years of life. In particular, it highlights health, cognitive, emotional, social, and psychopathological outcomes of young maltreated children. Each section starts with a bulleted list of key findings. When possible, known long-term problems are presented.
These fast facts highlight key issues related to the occurrence of developmental problems for maltreated children younger than the age of 3:
Differences in rates are most likely caused by variations in methods used to document developmental delays. Information from numerous studies offers evidence that medical problems and growth delays may be not only outcomes of but also risk factors for maltreatment. In particular, physical injuries (both minor and serious), low birth weight, growth delays, and abnormalities in brain functioning are hypothesized outcomes of abuse and neglect (Beniot, 1993; Block, Kreb, American Academy of Pediatrics Committee on Child Abuse and Neglect, & American Academy of Pediatrics Committee on Nutrition, 2005; Crittenden, 1987; Zelenko, Lock, Kraemer, & Steiner, 2000). However, research indicates that children with medical problems and motor delays are at increased risk of being maltreated — primarily neglected (Famularo, Fenton, & Kinscherff, 1992; Miller, Fox, & Garcia-Beckwith, 1999; Sullivan & Knutson, 1998, 2000; Wu et al., 2004).
Recent research on the brain structure and brain functioning of maltreated infants may be able to explain how all these physical, social, and emotional problems are interrelated. Research using brain imaging data revealed that children who were maltreated during infancy and early childhood had noticeable differences in overall brain size; the same study found that the duration of maltreatment was associated with greater differences in brain structure (De Bellis et al., 1999). These differences in size and structure of the brain may affect the body's ability to grow, plan, and regulate stress. In other studies of the brain, children exposed to neglect and sexual abuse variously have demonstrated variations in cortisol levels, which affect reactions to stress (King, Mandansky, King, Fletcher, & Brewer, 2001; for a review, see Gunnar & Donzella, 2002).
Neuroscientists currently studying brain development and functioning are working to better understand the pathways by which stress and abuse impact overall brain structure and functioning.
The occurrence of developmental problems for maltreated children younger than the age of 3 is summarized in these prevalence data:
Differences in rates most likely occur as a result of the type of cognitive assessment used (e.g., screener versus full battery); determination of mild, moderate, or severe forms of the delay; and type and severity of maltreatment in the study population. Nevertheless, these rates of cognitive and language delays in young maltreated children exceed those found in the general population (Simpson, Colpe, & Greenspan, 2003). In one study, abused preschoolers scored on average 20 points lower than nonabused preschoolers on the Stanford-Binet Intelligence Scales and the Peabody Picture Vocabulary Test (Hoffman-Plotkin & Twentyman, 1984). The majority of research also suggests that children who are physically abused or neglected have higher rates of cognitive language delays than those who experience other types of maltreatment (i.e., sexual and emotional abuse). Available studies of sexually abused children, although based on small samples, suggest that these children perform significantly lower on verbal and performance subtests than their nonmaltreated peers (Porter, Lawson, & Bigler, 2005). Despite lower scores on cognitive tests, sexually abused children still tend to have scores for verbal, performance and full-scale IQs that are in the normal range (Jones, Trudinger, & Crawford, 2004; Porter et al., 2005).
Although some studies demonstrated that, after controlling for socioeconomic status (SES), there were no differences in cognitive functioning between maltreated and nonmaltreated groups (e.g. Samet, 1997), most studies have found that maltreatment affects cognitive functioning, even after controlling for the influence of low SES (Beers & De Bellis, 2002; Yasik, 1998). Pears and Fisher (2005) compared the cognitive abilities of maltreated preschool children in foster care with a group of nonmaltreated preschoolers, all with similar SES backgrounds, and found that maltreated children exhibited significantly lower scores on visuospatial, language, and general cognitive functioning than nonmaltreated peers. Neglected and emotionally abused preschoolers performed much worse in visuospatial, language, memory, and executive functioning tasks than children who were physically or sexually abused.
Eigsti and Cicchetti (2004) also looked at language development among maltreated and nonmaltreated children while controlling for SES. The language skills of 5-year-old children who had been maltreated before the age of 2 years (mostly neglect and physical abuse) were compared with nonmaltreated peers, all of whom had similar SES and demographic characteristics (e.g., age, gender, ethnicity, maternal education, financial assistance). Results indicated that both the maltreated and nonmaltreated groups demonstrated delays in expressive communication (i.e., words children are able to articulate) skills. Specifically, those in the maltreated group showed a 16-month delay in their use of syntax whereas those in the nonmaltreated group displayed a 13-month delay. However, maltreated children performed significantly worse than nonmaltreated children with respect to expressive syntax. The receptive vocabulary (i.e., words children are able to understand) of the maltreated group was in the low-average range whereas the nonmaltreated group performance was in the average range. Taken together, maltreatment may further impair the development of cognitive and language skill after controlling for the effects of SES.
As young maltreated children mature they begin to experience problems in school, maltreated children are less inclined to engage in autonomous academic exploration and require external motivation before they can initiate and engage in an educational task (Koenig, Cicchetti, & Rogosch, 2000; Toth & Cicchetti, 1996). They also exhibit poor work habits and receive lower grades in math and English during the elementary years (Rowe & Eckenrode, 1999). Maltreated children in foster care are more likely to receive special education services (Goerge, VanVoorhis, Grant, Casey, & Robinson, 1992) and are more likely than their nonmaltreated peers to be held back (Shonk & Cicchetti, 2001). Research has found that maltreated children are more likely to be retained in kindergarten and first grade than their nonmaltreated peers (Rowe & Eckenrode, 1999), although some of these effects may be attributed to disruptions in schooling that result from involvement with Child Welfare Services.
In brief, a large portion of maltreated infants, toddlers, and preschoolers may exhibit cognitive delays as well as problems with expressive and receptive communication, which is especially salient among young children with histories of physical abuse and neglect. The cognitive abilities of maltreated children are lower than nonmaltreated children from low socioeconomic backgrounds and drastically lower than their nonmaltreated middle-class peers. Cognitive and language delays become more apparent when children reach school age and those delays then negatively affect academic achievement.
These examples highlight common problems seen in maltreated children younger than the age of 3:
When infants do not experience responsive relationships; do not see adaptive regulation being modeled; are met with threats or criticism during emotional events; and are exposed to violence, intense anger, and fear, then social-emotional development may be thwarted (see Edwards et al., 2005; Howes, Cicchetti, Toth, & Rogosch, 2000; Shipman & Zeman, 2001).
Other studies demonstrate that varying types of abuse result in different abilities to recognize emotions. Having a history of neglect is a factor that has been related to a child's poor discrimination of all emotions (Edwards et al, 2005; Pollak et al., 2000) and to atypical emotional response such as less remorse or more fear (Smetana, Daddis et al., 1999). However, children with a history of being physically abused show specific problems associated with discriminating anger: they are as accurate as nonmaltreated children with respect to anger detection but have a tendency to guess that someone is angry during times of ambiguity (Pollak, Vardi, Bechner, & Curtain, 2005). These findings are similar to other studies showing that physically abused children are more likely to interpret ambiguous emotional stimuli and social transgression as being angry and intentional (Dodge, Pettit, Bates, & Valente, 1995; Weiss, Dodge, Bates, & Pettit, 1992).
In addition to the emotional problems discussed above, the ramifications of child maltreatment extend further to the social domain. Studies found that maltreated preschoolers characterized parents as being more negative than did nonmaltreated preschoolers (Toth, Cicchetti, Macfie, & Emde, 1997; Toth, Cicchetti, Macfie, Maughan, & Vanmeenen, 2000). Research has also shown that maltreated infants, toddlers, and preschoolers evidence avoidant, anxious, and atypical attachment relationships (Carlson, 1998; Cicchetti & Barnett, 1991). The underlying principle of these insecure attachment relationships is mistrust and, in some cases, fear of the mother-attachment figure. In other words, these children have difficulty trusting the primary caregiver to protect, comfort, or support them. Studies indicate that children who have experienced abuse or neglect have higher rates of disorganized (insecure) attachments (61%-86%), than their nonmaltreated peers (27%-36%), (Barnett et al., 1999; Cicchetti & Barnett, 1991).
However, attachment relationships may vary across the lifespan (Cicchetti & Barnett, 1991), which raises questions about the long-term effect of attachment relationships. Studies of high-risk groups have shown that attachment relationships can change over time (Vondra, Hommerding, & Shaw, 1999; Weinfield, Sroufe, & Egeland, 2000). Weinfield, Sroufe, and Egeland (2000) found that for a sample of high-risk adults in which 41% had been maltreated as children only 38.6%-50% continued to evidence signs of insecure attachment relationships into early adulthood. The preponderance of insecurely attached adults in this sample was related to a variety of stressful life events. Transitions from a pattern of insecure attachment relationships as infants to secure attachment relationships as adults did sometimes occur and were related to improvements in family functioning. Barnett et al. (1999) found that, for maltreated infants, disorganized attachment was quite stable between 12 and 24 months, with 87.5% of maltreated infants demonstrating attachment continuity. Taken together, it appears that maltreatment places infants at risk for developing tenuous relationships with their caregivers and that these insecure attachment relationships have a tendency to persist, especially when negative parental characteristics and stressful life circumstances remain unchanged.
Research has also found that maltreated preschoolers exhibit not only poor relationships with the primary attachment figure but also poor relationships with peers. Studies indicate that maltreated children show less empathy during times of peer distress than nonmaltreated children (Howe & Parke, 2001; Klimes-Dougan & Kistner, 1990; Main & George, 1985). In other cases, maltreated children were found to cause conflict and distress in their peers (Klimes-Dougan & Kistner, 1990). Maltreated preschoolers have difficulty controlling their behavior in social situations and have problems initiating social interactions (Darwish et al., 2001; Howe & Parke, 2001; Maughan & Cicchetti, 2002). Neglected children, in particular, evidence withdrawn behavior and often play by themselves (Crittenden, 1992). Other studies indicate that abused and neglected children engage in more aggressive behavior than children of typical development, with physically abused children committing more aggressive acts than neglected children (Connor, Steingard, Cunningham, Anderson, & Melloni, 2004; Crittenden, 1992; Herrenkohl, & Russo, 2001). Sexually abused children (when compared with neglected, physically abused, and nonmaltreated children) also display problems in peer interaction and play and tend to include more sexually themed behaviors and more sexual exploration (Friedrich, 1993; Friedrich et al., 2001). Not surprisingly, teachers and children report that maltreated children are least liked and have fewer friends than nonmaltreated children (Cicchetti & Lynch, 1995; Rogosch, Cicchetti, & Aber, 1995).
In summary, maltreated children demonstrate deficits in emotional competence. Although children who have been physically abused tend to overidentify and overexpress anger, neglected children have trouble recognizing all emotions and show atypical emotional responses. This disturbed emotional development negatively affects peer relationships. Not surprisingly, the quality of relationships that are established within the family is also compromised. Maltreated infants, toddlers, and preschoolers show higher rates of insecure and disorganized attachment. These poor attachments — which are thought to be the foundation of other important social competencies — are fairly stable, especially if negative family circumstances persist.
Many of the problems described in this section have been touched on in earlier sections (e.g., social-emotional problems) but this section specifically addresses diagnosable mental health difficulties in very young children. The occurrence of developmental problems for maltreated children younger than the age of 3 is summarized in these prevalence data:
Research has estimated that 10% to 61% of maltreated children have mental health problems (Leslie et al., 2005a; Reams, 1999). Undoubtedly, differences in maltreatment status, duration, and severity as well as the way psychopathology was measured account for some discrepancies in prevalence. Maltreated boys display higher rates of aggression than maltreated girls whereas maltreated girls displayed higher rates of internalizing problems (e.g., depression, anxiety, somatic, etc.) than maltreated boys (Black et al., 2002; Fontanella et al., 2000; Heflinger et al., 2000; Litrownik, Newton, & Landsverk, 2005). Maltreatment that includes witnessing or experiencing painful events has been related to PTSD (Reams, 1999), hypervigilance (Frankel et al., 2000; Pollak, Vardi, Bechner, & Curtin, 2000; Pollak et al., 2005), and clinical levels of dissociation (Macfie, Cicchetti, & Toth, 2001a, 2001b).
Maltreatment occurring during the first few years of life may have enduring adverse influences on adult psychological health. Research has linked maltreatment in early childhood to adolescent and adult antisocial behaviors. In particular, recent studies indicate that physical abuse and neglect are positively related to aggression, arrests for violent crimes, and major and minor theft (Caspi et al., 2002; Jaffee et al., 2005; McCord, 1983; Moe, King, & Bailly, 2004; Widom, 1989; Widom, Weiler, & Cottler, 1999). Because these studies are mainly based on retrospective self-reports, these findings can be questioned. However, research using substantiated reports of abuse and prospective longitudinal designs provides more evidence that maltreatment in the early years is related to antisocial behavior (Jaffee et al., 2005; Koenig, Cicchetti, & Rogosch, 2004). In a lab-based study, Koenig et al. (2004) found that physically abused children engaged in more stealing than nonmaltreated children whereas neglected children displayed more cheating and less adherence to rules during a game situation. Egeland, Yates, Appleyard, and van Dulmen (2002), using a longitudinal design, found that 79% of children who had been maltreated in infancy and preschool exhibited clinically problematic externalizing behavior during adolescence, with 50% of these children meeting criteria for conduct disorder (see Keiley, Howe, Dodge, Bates, & Pettit, 2001). Moreover, they found that a child's resulting inability to trust and use parents for regulatory assistance was one consequence of maltreatment that led to antisocial behavior.
Other studies have found that early maltreatment is related to increased problems of internalizing in middle childhood and adolescence (Appleyard, Egeland, van Dulmen, & Sroufe, 2005; Dubowitz et al. 2005; Keiley et al., 2001; Manly, Kim, Rogosch, & Cicchetti, 2001). Appleyard and colleagues (2005) showed early childhood risk (e.g., maltreatment before the age of 64 months, low SES, life stress, interpersonal violence, and family disruption) to predict internalizing problems at age 16. Additionally, the relationship between early childhood risk and internalizing problems at age 16 continued to be significant after the effects of middle childhood risks were removed, signifying that early childhood maltreatment and related risks directly affect adolescent functioning.
In brief, maltreated children are more likely to demonstrate both externalizing and internalizing behaviors. Although externalizing problems are more common than internalizing behaviors, the differences may be artificial because young children rarely report their internal states and internal disturbances are not easily observable. Nevertheless, maltreated boys show more problems with aggression than girls whereas girls show more withdrawn, sad behaviors than boys. These gender differences may point to genetic predispositions, distinct socialization experiences, differences in maltreatment histories, or some combination. Maltreatment, especially that which includes experiencing abuse and witnessing violence, is also linked with PTSD and pathological rates of dissociation in preschoolers. Early maltreatment also relates to psychological dysfunction and antisocial behavior later in life.
Maltreatment at an early age is related to poor developmental outcomes (Bolger, Patterson, & Kupersmidt, 1998; Keiley et al., 2001; Manly et al., 2001; McGee & Wolfe, 1994). Specifically, many maltreated infants, toddlers, and preschoolers present with physical, cognitive, socioemotional, relational, and psychological difficulties. These problems are not unlike those for children living in poverty; generally speaking, maltreated children have similar medical and health concerns, are less ready for school, have maladaptive coping styles, and experience problematic peer relationships. However, rates of these problems are higher and the dysfunctions are more severe among maltreated children.
Several reasons explain why maltreatment at an early age, in particular, has a lasting negative effect. First, maltreatment that begins at an early age often spans a longer duration than maltreatment that begins when children are older (Bolger et al., 1998; Bolger & Patterson, 2001; English, Upadhyaya et al., 2005). The longer duration alone does not, however, fully account for the lasting negative effects. Maltreatment during the first 5 years of life occurs during a period of rapid development (Cicchetti & Toth, 2000; Shonkoff & Phillips, 2000). For example, brain development, rapid physical growth, locomotor skills, object knowledge, language skills, emotion comprehension and regulation, attachment formation, emerging self-concept and self-esteem, initiative, behavioral control, and burgeoning social skills are among the developmental accomplishments of early childhood. Harsh parenting, including maltreatment during the earliest years, hinders normal development by retarding or prohibiting the progress toward appropriate milestones. Because the developments that occur during this period provide the foundation for subsequent cognitive and social-emotional developments (Cicchetti, 1991; Cicchetti & Rizley, 1981), their impairment can have particularly far-reaching effects (Cicchetti & Tucker, 1994; Sameroff, 1993; Sroufe & Rutter, 1984).
Not every young maltreated child, however, will exhibit problematic behavior and compromised functioning. Research suggests the some maltreated children show academic, emotional, and behavioral resiliency (Lansford et al., 2006; McGloin & Widom, 2001). Successful adaptation in the face of abuse and neglect is more likely, however, when maltreatment is isolated from other risk factors or when children possess or are surrounded by protective factors (Lansford et al., 2006). Nonetheless, research has shown that young maltreated children typically face numerous additional factors known to negatively influence child functioning, factors such as low cognitive stimulation, poor parental education, parental psychopathology, low SES, inadequate social support, poor nutrition, insufficient health care, and preexisting disabilities (Kotch, Browne, Dufort, & Winsor, 1999; Palusci, et al., 2005; Sullivan & Knutson, 1998; Wu et al., 2004). These cumulating risk factors further complicate the development of cognitive and socioemotional functioning in maltreated children (Appleyard et al., 2005; Greenberg, Speltz, Dekyen, & Jones, 2001; Rutter, 1979).
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Research on maladaptive functioning and resiliency of maltreated children has contributed to the field of early intervention (Kinard,1998). This research offers evidence of individual and situational protective factors that facilitate child development (Cicchetti & Rogosch, 1997; Haskett, Nears, Ward, McPherson, 2006; Lynskey & Fergusson, 1997). Intervention programs provide positive therapeutic and developmentally enriching experiences that attempt to ameliorate negative effects of maltreatment. It is believed, however, that interventions that occur as early as possible — before developmental delays and behavioral and relational dysfunction become further entrenched — offer the greatest potential for fostering maltreated children's healthy development (Shonkoff & Phillips, 2000).
Under Part C of the Individuals With Disabilities Education Act (IDEA) of 1990, children needing services are to be identified, evaluated, and served, especially those children who are typically underrepresented (e.g., minority, low-income, inner city, Indian and rural populations) through an interagency, coordinated, multidisciplinary system of early intervention services. Each State's early intervention system must include child find and public awareness activities that are coordinated and collaborated with all other child find efforts in the State. Part C recognizes the need for early referral and short timelines for evaluation as development occurs at a more rapid rate during the first three years of life than at any other age.
Children are to be evaluated to determine whether they are eligible for Part C services; however, eligibility requirements vary from state to state. Eligibility for Part C services entitles children to services as deemed necessary in the evaluation and documented in the Individualized Family Service Plan (IFSP) that is developed by Part C service providers and parents at the time the time of enrollment. Physical therapy, occupational therapy, speech and language therapy, and services provided by a developmental specialist, are among the most common Part C services used.
In 2003, the federal government amended the Child Abuse Prevention and Treatment Act (CAPTA) of 1974 through the Keeping Children and Families Safe Act of 2003, which requires states to have provisions and procedures in place for the referral of children younger than the age of 3 years with substantiated maltreatment to Part C. CAPTA does not specifically require that every child younger than the age of 3 who is involved in a substantiated case of child abuse or neglect must be referred to Part C services. States have the discretion to refer every such child younger than the age of 3 for early intervention services or to first use a screening process to determine whether a referral is needed.(2)
Although this vehicle shows promise for better providing intervention services to maltreated infants and toddlers who have documented delays, there is evidence to suggest that Part C and other early intervention programs are underused (Horwitz, Owens, & Simms, 2000; Robinson & Rosenberg, 2004). This underuse is associated with (a) the failure of child welfare professionals to recognize potential developmental problems (which results in low referral rates) and (b) low intervention participation (and high attrition) among parents and guardians (Giardino, Hudson, & Marsh, 2003; Hurlburt et al., 2004).
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2. Part C of the Individuals With Disabilities Education Act (IDEA) of 1990, which was reauthorized on December 3, 2004, by the IDEA Improvement Act of 2004, contains a provision very similar to the one in CAPTA. The conference report accompanying the IDEA legislation indicates that the conferees did not intend the IDEA provision to require every child under the age of 3 who is involved in a substantiated case of child abuse or neglect to receive an evaluation. Rather, the intention was that such children be screened to determine whether a referral to early intervention services is warranted (House Report No. 108-779, 2004).
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