The full length version of this article (including tables) was
originally published in the peer reviewed journal, Child Abuse
and Neglect, Vol. 18, No. 9, pp. 705-714, 1994. For the complete
article, please see the Pioneer
Publishing Order Form in our resources section.
The Worst Combinations of Child
Abuse and Neglect
Philip G. Ney, MA, MD, FRCP (C), FRANZCP,
Clinical Professor, Department of Family Practice, Faculty of
Medicine, University of B.C.
Tak Fung, PhD, Biostatistician, Academic
Computing Service, University of Calgary
Adele Rose Wickett, BSN, Research Assistant
to Dr. Philip G. Ney
Abstract
We have studied the impact of various kinds of abuse and neglect
on the child's perception of himself and his future. We
found, when considering physical abuse, physical neglect, verbal
abuse, emotional neglect, and sexual abuse, that less than 5%
of these mistreatments occurred in isolation. Since the
vast majority of mistreated children are subject to more than
one kind of abuse or neglect, it was important to delineate which
combinations have the greatest effect. We found that a combination
of physical neglect, physical abuse, and verbal abuse had the
greatest impact on children, affecting such things as their enjoyment
of living and hopes for the future. An early age of onset
for verbal abuse and emotional neglect was significantly associated
with greater severity and frequency of mistreatment. Neglect
appears to be a precursor to abuse in many cases.
Introduction
Although there is a great deal of literature on the mistreatment
of children, there is almost nothing on combinations of various
types of abuse and neglect. Most writing in this area is
about one form or another, as if different abuse or neglect incidents
occurred singly. Clinicians know this is not the case.
Clinically, it appears that physical, verbal or sexual abuse seldom
occur without some component of other mistreatment. Various
forms of abuse are frequently combined with either physical or
emotional neglect.
Although a number of papers have described the impact of abuse
or neglect on children, there appear to be no articles which consider
the impact of a combination of types of mistreatment, or describe
which combination has the greatest impact. Much of the difficulty
arises from the fact that most researchers study either sexual
abuse or physical abuse. Few instruments provide an opportunity
for the subject to indicate how much of which kind of abuse has
affected him/her. In addition, most measures are categorical,
providing little opportunity for individuals to indicate whether
they have been abused in what they consider slight or minimal
ways.
We hypothesize that: (1) various types of mistreatment seldom
occur singly; (2) some combinations are worse than others; and
(3) the order of onset is important. These three hypotheses
were supported by the data, although components of this research
still need further clarification. In less than 5% of our
subjects did any type of abuse or neglect occur singly.
The worst combination of any three types of maltreatment indicates
that physical neglect, physical abuse, and verbal abuse have the
greatest impact on the child's perception of his present and future
life. We also found that if neglect precedes abuse, the
deleterious impact of abuse appears to be more extensive.
Most articles tend to lump "physical and/or sexual abuse"
together (Hibbard, Brack, Rauch, & Orr, 1988; Cavaiola, Schiff,
1989), and some lump abuse and neglect together (Pless, Sibald,
Smith, & Russell, 1987; Powers & Eckenrode, 1988; Alperstein,
Rappaport, & Flanigan, 1988). However, Marshall, Puls
& Davidson (1988) examined 382 children in a paediatric clinic
and found 51% of those suspected of maltreatment presented with
sexual abuse, 34% with physical abuse and 15% nor neglect.
Rosenthal (1988), in his study of the state registry file, differentiated
those who were physically abused from those who were sexually
abused and found a modest same sex perpetrator/victim pattern
for physical abuse. Merrick (1989) did an epidemiological
study form the records of Danish forensic officers and found,
of the 901 children who were registered, 164 were physically or
emotionally abused or neglected, 737 were sexually abuse.
Pieterse & Van Urk (1989) differentiated between emotional
maltreatment, physical abuse and sexual abuse.
A number of authors have noted that some children may be abused
in more than one way. Hobbs & Wynne (1990) state that
16.9% of 769 physically abused children were also sexually abused
and that 13.6% of 949 sexually abused children were also physically
abused. This sample of 130 children was composed of 77 girls
and 53 boys. Riggs, Alario, & McHorney (1990) studied
600 adolescents in high school grades 9 to 12 and found 13% of
them were maltreated. 5.2% suffered physical abuse, 5.4% suffered
sexual abuse and 2.7% suffered both. A study of the southwest
natives of the U.S. (Lujan, DeBruyn, May, & Bird, 1989) found
that 65% of 53 children targeted for investigation suffered both
abuse and neglect. Research in New Zealand demonstrated
an overlap of different types of abuse and neglect (Ney, 1987).
A number of studies have shown there are distinctive symptoms
determined by the effect of one type of abuse or another.
Although both sexually abused and physically abused groups of
children demonstrate dissociative symptoms, the sexually abused
children show higher rate of inappropriate sexual behaviour (Claussen
& Crittenden, 1991; Swett, Surrey, & Cohen, 1990; Deblinger,
McLeer, Atkins, Ralphe, & Foa, 1989). Ney, Moore, McPhee
& Trought (1986) discovered that different types of abuse
or neglect result in different patterns of self-blame, anger,
and pessimism. Green (1988) found that physically abused
children had difficulty in experiencing and modulating aggressive
impulses while sexually abused children had difficulty integrating
sexual feelings. The physically abused child had greater
risk for cognitive and CNS impairment. Both had problems
of depression and low self esteem, and a striking similarity in
the tendency to re-enact their victimization.
Various populations have been studied to determine the relative
preponderance of different kinds of abuse or neglect.
Powers, Eckenrode & Jaklitsch (1990) studied 233 adolescent
runaway youth, fifteen to sixteen years, and found that 60% were
physically abused, 40% emotionally abused, 47% neglected and 21%
sexually abused. On the other hand, Ludwig & Anderson
(1989), who studied chemically dependent women in the criminal
justice system, found that 19.7% were sexually abused and 27%
were physically and /or sexually abused. Among multiple
personality disorder patients (Ross, Norton, & Wozney, 1989).
79.2% were sexually abused and 74.9% were physically abused.
Method
These data come from a long-term research project which has followed
167 children and adolescents from seven to 18 years of age.
Eleven children were selected from a private psychiatry practice,
107 from the Arbutus Society Adolescent Unit in Victoria, B. C.,
23 from the Calgary Young Offenders Centre, and 26 from a Victoria
high school. Each child was interviewed, or, if older, asked
to complete the Child Experience Questionnaire himself.
The answers involved checking the appropriate selection on a list,
or drawing a mark across a 9 cm Visual Analog Scale (VAS); For
example: My enjoyment of living is: very low (9 cm line)
very high.
Questions touched on the child's feelings of enjoyment, purpose
in life, future expectations, chances of having a happy marriage
and being a good parent, perspectives on world problems and nuclear
way, and reflections on his/her childhood. For each of five
types of mistreatment, the child was asked to indicate the nature,
severity and frequency of abuse, and by whom (s)he was victimized,
as well as the age of onset and duration of mistreatment.
The five types of mistreatment were: physical abuse (choked, burned,
punched, broken bones, etc.), physical neglect (lack of food,
lack of shelter, inadequate hygiene, etc.), verbal abuse (threatened,
blamed, shamed, cursed, etc.), emotional neglect (lack of verbal
affection, no encouragement, lack of intellectual stimulation,
etc.), and sexual abuse (expose, forced intercourse, incest, use
for pornography, etc.).
In addition, the child estimated the effect on him/her, whose
fault it way, how abnormal it was, and the reasons (s)he was treated
like this. The questionnaire concludes with a few questions
the parents' marriage (Do they love? Do they fight?
Are they split up? etc.) Results were analyzed at the Academic
Computing Centre of the University of Calgary, with the visual
analog scales being coded into 9-point numerical scales.
For many of the children, similar questionnaires were completed
by their parents, and by trained staff observers.
Results
Physical and verbal abuse were the most frequently noted types,
both in their severe and milder forms. Sexual abuse was
the least frequent.
Associated types of Mistreatment
Table 1 shows the various correlations between the types (e.g.,
physical and verbal abuse) are likely to be associated.
Sexual abuse is frequently associated with physical neglect.
Emotional neglect is significantly correlated with verbal abuse.
In most types of mistreatment, a higher frequency correlates with
greater severity.
How Different Kinds of Mistreatment Affect a Child's Outlook
Table 2 indicates the effect on the child's perception of his/her
present and future life of the five types of mistreatment.
All forms seem to have a significant impact and reduce the chances
of "developing into the person I could have been".
None of these types of abuse or neglect appear to have significant
correlations with the young person's belief that they have a chance
of having children. Using the average Pearson correlation
coefficient, it appears that physical abuse an verbal abuse had
the greatest impact on children's outlook, followed by emotional
and physical neglect and sexual abuse. It is interesting
to note the effect of physical and verbal abuse on the child's
enjoyment of living. Physical abuse, emotional neglect,
and sexual abuse take their toll in the person's expectation of
a happy marriage.
Worst Combinations
When we combined several types of abuse and neglect into clusters
of two or three, and then measured the effect on the child's outlook,
some interesting patterns developed. It appears that
a combination of physical abuse, physical neglect, and verbal
abuse has the greatest impact. Tables 3 and 4 indicate the
correlations between the various combinations of abuse and neglect
and their effect on the child's outlook. Ranked according
to the average correlation, and beginning with the most devastating
combination, verbal abuse appears 7 times in the top 10, physical
neglect 6 times, physical abuse 5 times, emotional neglect 5 times,
sexual abuse once. Sexual abuse appears 9 times in the rankings
11 - 20, usually in combination with physical or emotional neglect.
The combination of physical neglect, verbal abuse, and sexual
abuse (rank #8) is remarkably associated with a lack of enjoyment
of living. In fact, most of these combinations of mistreatment
appear to severely attack the enjoyment of living in their victims.
None of the types of mistreatment appear to have a significant
correlation with a poor expectation of obtaining a good job.
Table 5 shows the worst combinations of four types of abuse or
neglect. Where the average correlation is calculated, the
first in the rank order is physical abuse, physical neglect, verbal
abuse, and emotional neglect; followed by physical neglect, emotional
neglect, verbal abuse and sexual abuse. Twenty-eight young
people were affected by all five types of mistreatment. The areas
of major impact for this group were in their decreased enjoyment
of living, and in their decreased expectation of being good parents.
Interactions Between Neglect and Abuse
Table 6 indicates correlations between the age of onset and the
extent of mistreatment. (Extent of mistreatment is calculated
as a multiple of the two scores on the scales for frequency and
severity). The greatest extent of emotional neglect and
sexual abuse are most closely correlated with early onset.
Table 7 compares the age of onset of abuse and neglect in children
who experience both. While the neglect is typically experienced
at a younger age than the abuse, this difference is only significant
in the case of sexual abuse.
Table 8 shows that when the onset of neglect precedes abuse,
compared to when the onset of abuse occurs at the same time or
precedes neglect, the mean effect of the neglect is significantly
greater (lower score means greater effect). In this measure
the child is responding to the question, "What effect did
the abuse or neglect have on you?" by making a mark across
the line between the extremes of "ruined my life" and
"no effect".
Discussion
Our study tends to show a higher rate of combinations than found
by others. This is possibly because we used a more sensitive
measuring device which permitted the subjects to rate all five
kinds of abuse or neglect on a continuum. The visual analog
scale gave opportunity, for example, for a subject to indicate
that he was verbally abused moderately, but infrequently.
Our study agrees with others which indicate that combinations
of different types of maltreatment are the rule rather than the
exception. It raises the question fo why there so few studies
on the combinations of types of mistreatment? It may be
that combined variables are hard to study, or that investigators
tend to be attracted to simpler explanations? Whatever the
explanation, it would be useful, in our opinion, to see more work
done in this area.
Claussen & Crittenden (1991), who studied the effects of
physical and psychological maltreatment, noted that psychological
maltreatment would be present in almost all cases of physical
maltreatment. Hard data seem to indicate that psychological
conflicts can arise out of any type of abuse or neglect.
It is possible that psychological mistreatment can occur alone,
and it indeed may be very devastating, but our evidence supports
the hypothesis that the most severe psychological conflicts arise
from neglect. Having been deprived of the necessary ingredients
to their normal development, children never seem to accept the
loss of the childhood that could have been. They keep searching
as adolescents and adults, only to find that those they search
among are usually themselves deprived people who not only cannot
provide them with what they needed as children, but also tend
to abuse them, partly out of their own frustrations in encountering
somebody who they thought would give to them when they were so
hungry.
Example:
Joe was brought for psychiatric evaluation because of violent
altercations with his siblings, alternating with periods of morbid
fascination with death. Over a four-year period, he, together
with his older brother and sister, had been sexually abused by
their mother's bisexual husband. This often occurred while
the mother was having an affair with her husband's lover.
The mother had been sexually abused when she was very young and
was frequently neglected by her mother. She was now physically
and verbally violent toward her own children. Both the sexual
and physical abuse had been preceded by periods of neglect when
the mother was partying. Treatment required a number of hospitalizations.
It was complicated by Joe's attachment to his mother's bisexual
lover (that they both insisted was a father-son affection).
As this example demonstrates, there is a tangled web of neglect
and abuse present in many families. The researcher is presented
with confounding variables which affect the child. In addition,
transgenerational transmission of abuse is evident in the repetition
of mistreatment. The grandparents mistreated their daughter
who, in turn, abused her chlidren. Joe is now violent with his
siblings and, if no intervention is successful, will undoubtedly
pass on the abuse to his own future children. This underlines
the necessity of understanding the combinations of abuse and neglect,
as well as its transgenerational aspect (Ney, 1988).
The data in this study raises a number of important issues.
Why should a combination of physical neglect, physical abuse and
verbal abuse have the greatest impact on children? Is it
possible that physical, biologically-based needs, including shelter
and food, are so basic that without them a child feels incredibly
vulnerable? A child could live without attention, but without
basic biological needs being met, it is hard to exist. If,
when hungry or cold, one turns to one's parents, and they attack
both physically and verbally, it must do a great deal of damage.
Physical abuse leaves a child wounded, in pain, fearful, and angry.
This anger cannot find proper expression, because it would mean
attacking the very person that one needs to rely upon, and yet
who is so inadequate at meeting the child's needs. Verbal
abuse creates a poor self-image, so poor, in fact, that the child
can only expect more of what he has already received. Is
it for this reason that children who are hungry look in garbage
dumps and garbage cans when those with better self-image would
seek food and help from rich people? Do such children think, "I'm
such a miserable creature I only deserve garbage" vs. "I
don't deserve to be treated like this; come on, you well-fed rich
people, share a little!"
From our study it appears that various forms of abuse have a
major impact on the child's lack of enjoyment of living.
This may be because so much energy and effort is spent dealing
with mistreatment, surviving, and trying to develop that there
is no time left for enjoyment of life's pleasures. It is
not surprising that some of these children turn to more unusual,
even anti-social forms of excitement. Yet even while they're lacking
enjoyment in living, children do not lack a purpose in life.
While they think their own future is poor, they do not think the
future of the world is necessarily poor, nor do they think their
experience will affect their chance of getting a job.
Unquestionably, these abused and neglected children believe that
the mistreatment they have experienced will diminish their chance
of having a happy marriage, but that it has less impact on their
chance of having children, or being a good parent. It appears
from these data, that mistreated children don't enjoy life, nor
do they think it will get better. However, they have a strong
drive to survive, even a determination to make things better for
their children than they experienced themselves.
The extent of abuse and neglect has a major impact on the way
in which young people expect to die. Those who are more
severely abused expect violent deaths, most particularly, death
by suicide. Data not presented here indicate that young
people who have experienced violence by physical or verbal abuse
are more inclined to expect to die in a violent way. More
extensively mistreated young people do not expect to live as long.
Approximately 10% expect to die before the age of 25. This
corresponds to the other data which indicate that they believe
their future is poor. It may be that mistreated young people
become those who struggle and succeed, but because of their negative
expectations they undermine much of what they hope to achieve,
both for themselves and for their family.
Among the first ten combinations of abuse and neglect, ranked
as correlated with the child's view of his/her future, nine had
a combination of abuse and neglect. This plus other data
yet to be published seems to indicate that a combination of neglect
and various forms of abuse makes the child particularly vulnerable.
We have found that there is a significant association between
the extent of abuse and whether the neglect occurred before or
at approximately the same time or later than the abuse.
It appears that children who are first neglected are more vulnerable
to being abused. Metaphorically speaking, children who are
starving will eat anything, even if it's garbage off the street.
They are hungry for affection, but only look for it in those who
have little to offer but more abuse. This might explain
why, although sexual abuse does not appear to have a prominent
effect on the measures we have used, when in combination with
emotional neglect it is significantly harmful. If this is
the case, it is important for clinicians to understand the effect
of all types of abuse, particularly sexual abuse, in the context
of the neglect which often precedes it.
Neglect appears to increase the tendency and sensitivity to abuse.
Unfortunately, the measurement and study of neglect, which is
less easily identified, needs much more emphasis.
Limitations
Some readers may question our data from their clinical perception
of the impact of sexual abuse. It is possible we were not
measuring the most important variables. It is possible that
adults abused as children are attributing their difficulties to
the more obvious and socially recognized types of abuse.
It may have been that we should have only studied those who had
been severely abused or neglected. Yet even those who were
mildly abused or neglected have an appreciation of what impact
it has on them and their perception of the future. It is
possible these measures of the child's self-concept and his anticipation
of the future are less important than other measures of behaviour
or mental illness.
From data in our study of this clinical sample of adults abused
as children, it appears emotional neglect is most closely correlated
with later development of psychiatric illness. This is an
important concept which should be pursued.
References
Alperstein, G., Rappaport, C., Flanigan, J.M. (1988). Health
problems of homeless children in New York City. American Journal
of Public Health, 78, 1232-1233.
Cavaiola, A.A., Schiff, M. (1989). Self-esteem in abused chemically
dependent adolescents. Child Abuse & Neglect, 13, 327-334.
Claussen, A.H., Crittenden, P.M. (1991). Physical and psychological
maltreatment: relations among types of maltreatment. Child Abuse
& Neglect, 15, 5-18.
Deblinger, E., McLeer, S.V., Atkins, M.S., Ralphe, D., Foa, E.
(1989). Post-traumatic stress in sexually abused, physically abused,
and non-abused children. Child Abuse & Neglect, 13, 403-408.
Green, A.H. (1988). Child Maltreatment and its victims: a comparison
of physical and sexual abuse. Psychiatric Clinics of North America,
11, 591-610.
Hibbard, R.A., Brack, C.J., Rauch, S., Orr, D.P. (1988). Abuse,
feelings, and health behaviors in a student population. American
Journal of Diseases of Children, 142, 326-330.
Hobb, C.J., Wynne, J.M. (1990). Sexually abused battered child.
Arch Dis Child, 65, 423-427.
Ludwig, G.B., Anderson, M.D. (1989). Substance abuse in women:
relationship between chemical dependency of women and past reports
of physical and/or sexual abuse. International Journal of Addiction,
13, 449-461.
Lujan, C., DeBruyn, L.M., May, P.A., Bird, M.E. (1989). Profile
of abused and neglected American Indian children in the Southwest.
Child Abuse & Neglect, 13, 449-461.
Marshall, W.N. Jr., Puls, T., Davidson, C. (1988). New child
abuse spectrum in an era of increased awareness. American Journal
of Diseases of Children, 142, 664-667.
Merrick, J. (1989). Child abuse and the lack of care: an epidemiologic
study from the Danish Forensic Officers. Institute of Forensic
Medicine and the Medico-Legal Council during 1970-1979. Ugreskrift
for Laeger, 151, 870-874.
Ney, P.G. (1988). Transgenerational child abuse. Child Psychiatry
and Human Development, 18, 151-168.
Ney, P.G., Moore, C., McPhee, J., Trought, P. (1986). Child abuse:
a study of the child's perspective. Child Abuse & Neglect,
10, 511-518.
Ney, P.G. (1987). Does verbal abuse leave deeper scars: a study
of children and parents. Canadian Journal of Psychiatry, 32, 371-378.
Pieterse, J.J., Van Urk, H. (1989). Maltreatment of children
in the Netherlands: an update after ten years. Child Abuse &
Neglect, 13, 263-269.
Pless, I.B., Sibald, A.D., Smith, M.A., Russell, M.D. (1987).
Reappraisal of the frequency of child abuse seen in paediatric
emergency rooms. Child Abuse & Neglect, 11, 193-200.
Powers, J.L., Eckenrode, J., (1988). Maltreatment of adolescents.
Child Abuse & Neglect, 12, 189-199.
Powers, J.L., Eckenrode, J., Jaklitsch, B. (1990). Maltreatment
among runaway and homeless youth. Child Abuse & Neglect, 14,
87-98.
Riggs, S., Alario, A.J., McHorney, C. (1990). Health risk behaviors
and attempted suicide in adolescents who report prior maltreatment.
Journal of Paediatrics, 116, 815-821.
Rosenthal, J.A. (1988). Patterns of reported child abuse and
neglect. Child Abuse & Neglect, 12, 263-271.
Ross, C.A., Norton, G.R., Wozney, K. (1989). Multiple personality
disorder: an analysis of 236 cases. Canadian Journal of Psychiatry,
34, 413-418.
Swett, C. Jr., Surrey, J., Cohen, C. (1990). Sexual and physical
abuse histories and psychiatric symptoms among male psychiatric
outpatients. American Journal of Psychiatry, 147, 632-636.
