# data[].attributes.body
Poor growth or weight gain or being overweight

Poor hygiene

Lack of clothing or supplies to meet physical needs

Taking food or money without permission

Hiding food for later

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

# data[].attributes.attachment_link.readable_text
Any intentional harm or mistreatment to a child under 18 years old is considered child abuse. Child abuse takes many forms, which often occur at the same time.

Physical abuse. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person.

Sexual abuse. Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child, including sex trafficking.

Emotional abuse. Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault - such as continually belittling or berating a child - as well as isolating, ignoring or rejecting a child.

Medical abuse. Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care.

Neglect. Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care.

In many cases, child abuse is done by someone the child knows and trusts - often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

A child who's being abused may feel guilty, ashamed or confused. The child may be afraid to tell anyone about the abuse, especially if the abuser is a parent, other relative or family friend. That's why it's vital to watch for red flags, such as:

Specific signs and symptoms depend on the type of abuse and can vary. Keep in mind that warning signs are just that - warning signs. The presence of warning signs doesn't necessarily mean that a child is being abused.

Physical abuse signs and symptoms

Unexplained injuries, such as bruises, broken bones (fractures) or burns

Injuries that don't match the given explanation

Injuries that aren't compatible with the child's developmental ability

Sexual abuse signs and symptoms

Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Genital or anal pain, bleeding, or injury

Statements by the child that he or she was sexually abused

Inappropriate sexual behavior with other children

Emotional abuse signs and symptoms

Neglect signs and symptoms

Poor growth

Excessive weight with medical complications that are not being adequately addressed

Poor personal cleanliness

Lack of clothing or supplies to meet physical needs

Hoarding or stealing food

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

Parental behavior

Sometimes a parent's demeanor or behavior sends red flags about child abuse. Warning signs include a parent who:

Shows little concern for the child

Appears unable to recognize physical or emotional distress in the child

Blames the child for the problems

Consistently belittles or berates the child, and describes the child with negative terms, such as "worthless" or "evil"

Expects the child to provide attention and care to the parent and seems jealous of other family members getting attention from the child

Uses harsh physical discipline

Demands an inappropriate level of physical or academic performance

Severely limits the child's contact with others

Offers conflicting or unconvincing explanations for a child's injuries or no explanation at all

Repeatedly brings the child for medical evaluations or requests medical tests, such as X-rays and lab tests, for concerns not seen during the health care provider's examination

Physical punishment

Child health experts condemn the use of violence in any form, but some people still use physical punishment, such as spanking, to discipline their children. While parents and caregivers often use physical punishment with the intention of helping their children or making their behavior better, research shows that spanking is linked with worse, not better, behavior. It's also linked to mental health problems, difficult relationships with parents, lower self-esteem and lower academic performance.

Any physical punishment may leave emotional scars. Parental behaviors that cause pain, physical injury or emotional trauma - even when done in the name of discipline - could be child abuse.

If you're concerned that your child or another child has been abused, seek help immediately. Depending on the situation, contact the child's health care provider, a local child welfare agency, the police department or a 24-hour hotline for advice. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline at 1-800-422-4453.

If the child needs immediate medical attention, call 911 or your local emergency number.

In the United States, keep in mind that health care professionals and many other people, such as teachers and social workers, are legally required to report all suspected cases of child abuse to the appropriate local child welfare agency.

Some children overcome the physical and psychological effects of child abuse, particularly those with strong social support and resiliency skills who can adapt and cope with bad experiences. For many others, however, child abuse may result in physical, behavioral, emotional or mental health issues - even years later.

Here are some examples.

Physical issues

Premature death

Physical disabilities

Learning disabilities

Substance abuse

Health problems, such as heart disease, diabetes, chronic lung disease and cancer

Emotional issues

Low self-esteem

Difficulty establishing or maintaining relationships

Challenges with intimacy and trust

An unhealthy view of parenthood

Inability to cope with stress and frustrations

An acceptance that violence is a normal part of relationships

You can take important steps to protect your child from exploitation and child abuse, as well as prevent child abuse in your neighborhood or community. The goal is to provide safe, stable, nurturing relationships for children.

Here's how you can help keep children safe:

Offer your child love and attention. Nurture and listen to your child and be involved in your child's life to develop trust and good communication. Encourage your child to tell you if there's a problem. A supportive family environment and social networks can help improve your child's feelings of self-esteem and self-worth.

Don't respond in anger. If you feel overwhelmed or out of control, take a break. Don't take out your anger on your child. Talk with your health care provider or a therapist about ways you can learn to cope with stress and better interact with your child.

Think supervision. Don't leave a young child home alone. In public, keep a close eye on your child. Volunteer at school and for activities to get to know the adults who spend time with your child. When old enough to go out without supervision, encourage your child to stay away from strangers and to hang out with friends rather than be alone. Make it a rule that your child tells you where he or she is at all times. Find out who's supervising your child - for example, at a sleepover.

Know your child's caregivers. Check references for babysitters and other caregivers. Make irregular, but frequent, unannounced visits to observe what's happening. Don't allow substitutes for your usual child care provider if you don't know the substitute.

Emphasize when to say no. Make sure your child understands that he or she doesn't have to do anything that seems scary or uncomfortable. Encourage your child to leave a threatening or frightening situation immediately and seek help from a trusted adult. If something happens, encourage your child to talk to you or another trusted adult about what happened. Assure your child that it's OK to talk and that he or she won't get in trouble.

Teach your child how to stay safe online. Put the computer in a common area of your home, not the child's bedroom. Use the parental controls to restrict the types of websites your child can visit. Check your child's privacy settings on social networking sites. Consider it a red flag if your child is secretive about online activities.

Cover online ground rules, such as not sharing personal information; not responding to inappropriate, hurtful or frightening messages; and not arranging to meet an online contact in person without your permission. Tell your child to let you know if an unknown person makes contact through a social networking site. Report online harassment or inappropriate senders to your service provider and local authorities, if necessary.

Reach out. Meet the families in your neighborhood, including parents and children. Develop a network of supportive family and friends. If a friend or neighbor seems to be struggling, offer to babysit or help in another way. Consider joining a parent support group so that you have an appropriate place to vent your frustrations.

If you worry that you might abuse your child

If you're concerned that you might abuse your child, seek help immediately. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453).

Or you can start by talking with your family health care provider. Your provider may offer a referral to a parent education class, counseling or a support group for parents to help you learn appropriate ways to deal with your anger. If you're misusing alcohol or drugs, ask your health care provider about treatment options.

If you were abused as a child, get counseling to ensure you don't continue the abuse cycle or teach those destructive behaviors to your child.

Remember, child abuse is preventable - and often a symptom of a problem that may be treatable. Ask for help today.

AskMayoExpert. Child abuse. Mayo Clinic; 2021.

Overview of child maltreatment (child abuse). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment#. Accessed Jan. 12, 2022.

Trauma and child abuse resource center: Frequently asked questions. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/FAQ.aspx#question1. Accessed Jan. 12, 2022.

Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html. Accessed Jan. 12, 2022.

Preventing adverse childhood experiences (ACEs): Leveraging the best available evidence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/82316. Accessed Jan. 12, 2022.

Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/11493. Accessed Jan. 12, 2022.

Violence prevention: Risk and protective factors. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed Jan. 12, 2022.

Long-term consequences of child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/. Accessed Jan. 12, 2022.

How to report child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/topics/responding/reporting/how/. Accessed Jan. 12, 2022.

Keeping children safe online. U.S. Department of Justice. https://www.justice.gov/coronavirus/keeping-children-safe-online. Accessed Jan. 13, 2022.

Other conditions that may be a focus of clinical attention: Abuse and neglect. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 13, 2022.

Boos SC. Physical child abuse: Recognition. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Child neglect: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Health Education & Content Services (Patient Education). Talking to your child about safe and unsafe touch. Mayo Clinic; 2021.

Handling child abuse disclosures. Childhelp. https://www.childhelp.org/what-is-child-abuse/handling-child-abuse-disclosures/. Accessed Jan. 14, 2022.

Zeanah CH, et al. Child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; doi:10.1016/j.jaac.2018.06.007.

Cohen JA, et al. Trauma-focused cognitive behavioral therapy for children and families. Child and Adolescent Psychiatric Clinics of North America. 2022; doi:10.1016/j.chc.2021.05.001.

Child-parent psychotherapy. Youth.gov. https://youth.gov/content/child%25E2%2580%2593parent-psychotherapy. Accessed Jan. 14, 2022.

Sege RD, et al. Effective discipline to raise healthy children. Pediatrics. 2018; doi:10.1542/peds.2018-3112.

Derauf DC (expert opinion). Mayo Clinic. Jan. 28, 2022.

# data[].attributes.attachment_link.title
Learn the signs of child abuse and how to get help-Child abuse - Symptoms & causes - Mayo Clinic

# data[].attributes.attachment_link.description
Child abuse includes physical, sexual, emotional and medical abuse, as well as neglect. Learn about signs, risk factors, how to get help and prevention.

# data[].attributes.body
Delayed or inappropriate emotional development

Loss of self-confidence or self-esteem

Social withdrawal or a loss of interest or enthusiasm

Depression

Avoidance of certain situations, such as refusing to go to school or ride the bus

Desperately seeks affection

A decrease in school performance or loss of interest in school

Loss of previously acquired developmental skills

# data[].attributes.attachment_link.readable_text
Any intentional harm or mistreatment to a child under 18 years old is considered child abuse. Child abuse takes many forms, which often occur at the same time.

Physical abuse. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person.

Sexual abuse. Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child, including sex trafficking.

Emotional abuse. Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault - such as continually belittling or berating a child - as well as isolating, ignoring or rejecting a child.

Medical abuse. Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care.

Neglect. Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care.

In many cases, child abuse is done by someone the child knows and trusts - often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

A child who's being abused may feel guilty, ashamed or confused. The child may be afraid to tell anyone about the abuse, especially if the abuser is a parent, other relative or family friend. That's why it's vital to watch for red flags, such as:

Specific signs and symptoms depend on the type of abuse and can vary. Keep in mind that warning signs are just that - warning signs. The presence of warning signs doesn't necessarily mean that a child is being abused.

Physical abuse signs and symptoms

Unexplained injuries, such as bruises, broken bones (fractures) or burns

Injuries that don't match the given explanation

Injuries that aren't compatible with the child's developmental ability

Sexual abuse signs and symptoms

Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Genital or anal pain, bleeding, or injury

Statements by the child that he or she was sexually abused

Inappropriate sexual behavior with other children

Emotional abuse signs and symptoms

Neglect signs and symptoms

Poor growth

Excessive weight with medical complications that are not being adequately addressed

Poor personal cleanliness

Lack of clothing or supplies to meet physical needs

Hoarding or stealing food

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

Parental behavior

Sometimes a parent's demeanor or behavior sends red flags about child abuse. Warning signs include a parent who:

Shows little concern for the child

Appears unable to recognize physical or emotional distress in the child

Blames the child for the problems

Consistently belittles or berates the child, and describes the child with negative terms, such as "worthless" or "evil"

Expects the child to provide attention and care to the parent and seems jealous of other family members getting attention from the child

Uses harsh physical discipline

Demands an inappropriate level of physical or academic performance

Severely limits the child's contact with others

Offers conflicting or unconvincing explanations for a child's injuries or no explanation at all

Repeatedly brings the child for medical evaluations or requests medical tests, such as X-rays and lab tests, for concerns not seen during the health care provider's examination

Physical punishment

Child health experts condemn the use of violence in any form, but some people still use physical punishment, such as spanking, to discipline their children. While parents and caregivers often use physical punishment with the intention of helping their children or making their behavior better, research shows that spanking is linked with worse, not better, behavior. It's also linked to mental health problems, difficult relationships with parents, lower self-esteem and lower academic performance.

Any physical punishment may leave emotional scars. Parental behaviors that cause pain, physical injury or emotional trauma - even when done in the name of discipline - could be child abuse.

If you're concerned that your child or another child has been abused, seek help immediately. Depending on the situation, contact the child's health care provider, a local child welfare agency, the police department or a 24-hour hotline for advice. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline at 1-800-422-4453.

If the child needs immediate medical attention, call 911 or your local emergency number.

In the United States, keep in mind that health care professionals and many other people, such as teachers and social workers, are legally required to report all suspected cases of child abuse to the appropriate local child welfare agency.

Some children overcome the physical and psychological effects of child abuse, particularly those with strong social support and resiliency skills who can adapt and cope with bad experiences. For many others, however, child abuse may result in physical, behavioral, emotional or mental health issues - even years later.

Here are some examples.

Physical issues

Premature death

Physical disabilities

Learning disabilities

Substance abuse

Health problems, such as heart disease, diabetes, chronic lung disease and cancer

Emotional issues

Low self-esteem

Difficulty establishing or maintaining relationships

Challenges with intimacy and trust

An unhealthy view of parenthood

Inability to cope with stress and frustrations

An acceptance that violence is a normal part of relationships

You can take important steps to protect your child from exploitation and child abuse, as well as prevent child abuse in your neighborhood or community. The goal is to provide safe, stable, nurturing relationships for children.

Here's how you can help keep children safe:

Offer your child love and attention. Nurture and listen to your child and be involved in your child's life to develop trust and good communication. Encourage your child to tell you if there's a problem. A supportive family environment and social networks can help improve your child's feelings of self-esteem and self-worth.

Don't respond in anger. If you feel overwhelmed or out of control, take a break. Don't take out your anger on your child. Talk with your health care provider or a therapist about ways you can learn to cope with stress and better interact with your child.

Think supervision. Don't leave a young child home alone. In public, keep a close eye on your child. Volunteer at school and for activities to get to know the adults who spend time with your child. When old enough to go out without supervision, encourage your child to stay away from strangers and to hang out with friends rather than be alone. Make it a rule that your child tells you where he or she is at all times. Find out who's supervising your child - for example, at a sleepover.

Know your child's caregivers. Check references for babysitters and other caregivers. Make irregular, but frequent, unannounced visits to observe what's happening. Don't allow substitutes for your usual child care provider if you don't know the substitute.

Emphasize when to say no. Make sure your child understands that he or she doesn't have to do anything that seems scary or uncomfortable. Encourage your child to leave a threatening or frightening situation immediately and seek help from a trusted adult. If something happens, encourage your child to talk to you or another trusted adult about what happened. Assure your child that it's OK to talk and that he or she won't get in trouble.

Teach your child how to stay safe online. Put the computer in a common area of your home, not the child's bedroom. Use the parental controls to restrict the types of websites your child can visit. Check your child's privacy settings on social networking sites. Consider it a red flag if your child is secretive about online activities.

Cover online ground rules, such as not sharing personal information; not responding to inappropriate, hurtful or frightening messages; and not arranging to meet an online contact in person without your permission. Tell your child to let you know if an unknown person makes contact through a social networking site. Report online harassment or inappropriate senders to your service provider and local authorities, if necessary.

Reach out. Meet the families in your neighborhood, including parents and children. Develop a network of supportive family and friends. If a friend or neighbor seems to be struggling, offer to babysit or help in another way. Consider joining a parent support group so that you have an appropriate place to vent your frustrations.

If you worry that you might abuse your child

If you're concerned that you might abuse your child, seek help immediately. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453).

Or you can start by talking with your family health care provider. Your provider may offer a referral to a parent education class, counseling or a support group for parents to help you learn appropriate ways to deal with your anger. If you're misusing alcohol or drugs, ask your health care provider about treatment options.

If you were abused as a child, get counseling to ensure you don't continue the abuse cycle or teach those destructive behaviors to your child.

Remember, child abuse is preventable - and often a symptom of a problem that may be treatable. Ask for help today.

AskMayoExpert. Child abuse. Mayo Clinic; 2021.

Overview of child maltreatment (child abuse). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment#. Accessed Jan. 12, 2022.

Trauma and child abuse resource center: Frequently asked questions. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/FAQ.aspx#question1. Accessed Jan. 12, 2022.

Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html. Accessed Jan. 12, 2022.

Preventing adverse childhood experiences (ACEs): Leveraging the best available evidence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/82316. Accessed Jan. 12, 2022.

Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/11493. Accessed Jan. 12, 2022.

Violence prevention: Risk and protective factors. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed Jan. 12, 2022.

Long-term consequences of child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/. Accessed Jan. 12, 2022.

How to report child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/topics/responding/reporting/how/. Accessed Jan. 12, 2022.

Keeping children safe online. U.S. Department of Justice. https://www.justice.gov/coronavirus/keeping-children-safe-online. Accessed Jan. 13, 2022.

Other conditions that may be a focus of clinical attention: Abuse and neglect. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 13, 2022.

Boos SC. Physical child abuse: Recognition. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Child neglect: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Health Education & Content Services (Patient Education). Talking to your child about safe and unsafe touch. Mayo Clinic; 2021.

Handling child abuse disclosures. Childhelp. https://www.childhelp.org/what-is-child-abuse/handling-child-abuse-disclosures/. Accessed Jan. 14, 2022.

Zeanah CH, et al. Child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; doi:10.1016/j.jaac.2018.06.007.

Cohen JA, et al. Trauma-focused cognitive behavioral therapy for children and families. Child and Adolescent Psychiatric Clinics of North America. 2022; doi:10.1016/j.chc.2021.05.001.

Child-parent psychotherapy. Youth.gov. https://youth.gov/content/child%25E2%2580%2593parent-psychotherapy. Accessed Jan. 14, 2022.

Sege RD, et al. Effective discipline to raise healthy children. Pediatrics. 2018; doi:10.1542/peds.2018-3112.

Derauf DC (expert opinion). Mayo Clinic. Jan. 28, 2022.

# data[].attributes.attachment_link.title
Learn the signs of child abuse and how to get help-Child abuse - Symptoms & causes - Mayo Clinic

# data[].attributes.attachment_link.description
Child abuse includes physical, sexual, emotional and medical abuse, as well as neglect. Learn about signs, risk factors, how to get help and prevention.

# data[].attributes.body
Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Blood in the child's underwear

Statements that he or she was sexually abused

Inappropriate sexual contact with other children

# data[].attributes.attachment_link.readable_text
Any intentional harm or mistreatment to a child under 18 years old is considered child abuse. Child abuse takes many forms, which often occur at the same time.

Physical abuse. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person.

Sexual abuse. Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child, including sex trafficking.

Emotional abuse. Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault - such as continually belittling or berating a child - as well as isolating, ignoring or rejecting a child.

Medical abuse. Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care.

Neglect. Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care.

In many cases, child abuse is done by someone the child knows and trusts - often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

A child who's being abused may feel guilty, ashamed or confused. The child may be afraid to tell anyone about the abuse, especially if the abuser is a parent, other relative or family friend. That's why it's vital to watch for red flags, such as:

Specific signs and symptoms depend on the type of abuse and can vary. Keep in mind that warning signs are just that - warning signs. The presence of warning signs doesn't necessarily mean that a child is being abused.

Physical abuse signs and symptoms

Unexplained injuries, such as bruises, broken bones (fractures) or burns

Injuries that don't match the given explanation

Injuries that aren't compatible with the child's developmental ability

Sexual abuse signs and symptoms

Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Genital or anal pain, bleeding, or injury

Statements by the child that he or she was sexually abused

Inappropriate sexual behavior with other children

Emotional abuse signs and symptoms

Neglect signs and symptoms

Poor growth

Excessive weight with medical complications that are not being adequately addressed

Poor personal cleanliness

Lack of clothing or supplies to meet physical needs

Hoarding or stealing food

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

Parental behavior

Sometimes a parent's demeanor or behavior sends red flags about child abuse. Warning signs include a parent who:

Shows little concern for the child

Appears unable to recognize physical or emotional distress in the child

Blames the child for the problems

Consistently belittles or berates the child, and describes the child with negative terms, such as "worthless" or "evil"

Expects the child to provide attention and care to the parent and seems jealous of other family members getting attention from the child

Uses harsh physical discipline

Demands an inappropriate level of physical or academic performance

Severely limits the child's contact with others

Offers conflicting or unconvincing explanations for a child's injuries or no explanation at all

Repeatedly brings the child for medical evaluations or requests medical tests, such as X-rays and lab tests, for concerns not seen during the health care provider's examination

Physical punishment

Child health experts condemn the use of violence in any form, but some people still use physical punishment, such as spanking, to discipline their children. While parents and caregivers often use physical punishment with the intention of helping their children or making their behavior better, research shows that spanking is linked with worse, not better, behavior. It's also linked to mental health problems, difficult relationships with parents, lower self-esteem and lower academic performance.

Any physical punishment may leave emotional scars. Parental behaviors that cause pain, physical injury or emotional trauma - even when done in the name of discipline - could be child abuse.

If you're concerned that your child or another child has been abused, seek help immediately. Depending on the situation, contact the child's health care provider, a local child welfare agency, the police department or a 24-hour hotline for advice. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline at 1-800-422-4453.

If the child needs immediate medical attention, call 911 or your local emergency number.

In the United States, keep in mind that health care professionals and many other people, such as teachers and social workers, are legally required to report all suspected cases of child abuse to the appropriate local child welfare agency.

Some children overcome the physical and psychological effects of child abuse, particularly those with strong social support and resiliency skills who can adapt and cope with bad experiences. For many others, however, child abuse may result in physical, behavioral, emotional or mental health issues - even years later.

Here are some examples.

Physical issues

Premature death

Physical disabilities

Learning disabilities

Substance abuse

Health problems, such as heart disease, diabetes, chronic lung disease and cancer

Emotional issues

Low self-esteem

Difficulty establishing or maintaining relationships

Challenges with intimacy and trust

An unhealthy view of parenthood

Inability to cope with stress and frustrations

An acceptance that violence is a normal part of relationships

You can take important steps to protect your child from exploitation and child abuse, as well as prevent child abuse in your neighborhood or community. The goal is to provide safe, stable, nurturing relationships for children.

Here's how you can help keep children safe:

Offer your child love and attention. Nurture and listen to your child and be involved in your child's life to develop trust and good communication. Encourage your child to tell you if there's a problem. A supportive family environment and social networks can help improve your child's feelings of self-esteem and self-worth.

Don't respond in anger. If you feel overwhelmed or out of control, take a break. Don't take out your anger on your child. Talk with your health care provider or a therapist about ways you can learn to cope with stress and better interact with your child.

Think supervision. Don't leave a young child home alone. In public, keep a close eye on your child. Volunteer at school and for activities to get to know the adults who spend time with your child. When old enough to go out without supervision, encourage your child to stay away from strangers and to hang out with friends rather than be alone. Make it a rule that your child tells you where he or she is at all times. Find out who's supervising your child - for example, at a sleepover.

Know your child's caregivers. Check references for babysitters and other caregivers. Make irregular, but frequent, unannounced visits to observe what's happening. Don't allow substitutes for your usual child care provider if you don't know the substitute.

Emphasize when to say no. Make sure your child understands that he or she doesn't have to do anything that seems scary or uncomfortable. Encourage your child to leave a threatening or frightening situation immediately and seek help from a trusted adult. If something happens, encourage your child to talk to you or another trusted adult about what happened. Assure your child that it's OK to talk and that he or she won't get in trouble.

Teach your child how to stay safe online. Put the computer in a common area of your home, not the child's bedroom. Use the parental controls to restrict the types of websites your child can visit. Check your child's privacy settings on social networking sites. Consider it a red flag if your child is secretive about online activities.

Cover online ground rules, such as not sharing personal information; not responding to inappropriate, hurtful or frightening messages; and not arranging to meet an online contact in person without your permission. Tell your child to let you know if an unknown person makes contact through a social networking site. Report online harassment or inappropriate senders to your service provider and local authorities, if necessary.

Reach out. Meet the families in your neighborhood, including parents and children. Develop a network of supportive family and friends. If a friend or neighbor seems to be struggling, offer to babysit or help in another way. Consider joining a parent support group so that you have an appropriate place to vent your frustrations.

If you worry that you might abuse your child

If you're concerned that you might abuse your child, seek help immediately. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453).

Or you can start by talking with your family health care provider. Your provider may offer a referral to a parent education class, counseling or a support group for parents to help you learn appropriate ways to deal with your anger. If you're misusing alcohol or drugs, ask your health care provider about treatment options.

If you were abused as a child, get counseling to ensure you don't continue the abuse cycle or teach those destructive behaviors to your child.

Remember, child abuse is preventable - and often a symptom of a problem that may be treatable. Ask for help today.

AskMayoExpert. Child abuse. Mayo Clinic; 2021.

Overview of child maltreatment (child abuse). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment#. Accessed Jan. 12, 2022.

Trauma and child abuse resource center: Frequently asked questions. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/FAQ.aspx#question1. Accessed Jan. 12, 2022.

Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html. Accessed Jan. 12, 2022.

Preventing adverse childhood experiences (ACEs): Leveraging the best available evidence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/82316. Accessed Jan. 12, 2022.

Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/11493. Accessed Jan. 12, 2022.

Violence prevention: Risk and protective factors. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed Jan. 12, 2022.

Long-term consequences of child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/. Accessed Jan. 12, 2022.

How to report child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/topics/responding/reporting/how/. Accessed Jan. 12, 2022.

Keeping children safe online. U.S. Department of Justice. https://www.justice.gov/coronavirus/keeping-children-safe-online. Accessed Jan. 13, 2022.

Other conditions that may be a focus of clinical attention: Abuse and neglect. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 13, 2022.

Boos SC. Physical child abuse: Recognition. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Child neglect: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Health Education & Content Services (Patient Education). Talking to your child about safe and unsafe touch. Mayo Clinic; 2021.

Handling child abuse disclosures. Childhelp. https://www.childhelp.org/what-is-child-abuse/handling-child-abuse-disclosures/. Accessed Jan. 14, 2022.

Zeanah CH, et al. Child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; doi:10.1016/j.jaac.2018.06.007.

Cohen JA, et al. Trauma-focused cognitive behavioral therapy for children and families. Child and Adolescent Psychiatric Clinics of North America. 2022; doi:10.1016/j.chc.2021.05.001.

Child-parent psychotherapy. Youth.gov. https://youth.gov/content/child%25E2%2580%2593parent-psychotherapy. Accessed Jan. 14, 2022.

Sege RD, et al. Effective discipline to raise healthy children. Pediatrics. 2018; doi:10.1542/peds.2018-3112.

Derauf DC (expert opinion). Mayo Clinic. Jan. 28, 2022.

# data[].attributes.attachment_link.title
Learn the signs of child abuse and how to get help-Child abuse - Symptoms & causes - Mayo Clinic

# data[].attributes.attachment_link.description
Child abuse includes physical, sexual, emotional and medical abuse, as well as neglect. Learn about signs, risk factors, how to get help and prevention.

# data[].attributes.body
Sexual Abuse
Physical Abuse
Emotional Abuse
Neglect

# data[].attributes.body
Unexplained injuries, such as bruises, fractures or burns

Injuries that don't match the given explanation

# data[].attributes.attachment_link.readable_text
Any intentional harm or mistreatment to a child under 18 years old is considered child abuse. Child abuse takes many forms, which often occur at the same time.

Physical abuse. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person.

Sexual abuse. Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child, including sex trafficking.

Emotional abuse. Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault - such as continually belittling or berating a child - as well as isolating, ignoring or rejecting a child.

Medical abuse. Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care.

Neglect. Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care.

In many cases, child abuse is done by someone the child knows and trusts - often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

A child who's being abused may feel guilty, ashamed or confused. The child may be afraid to tell anyone about the abuse, especially if the abuser is a parent, other relative or family friend. That's why it's vital to watch for red flags, such as:

Specific signs and symptoms depend on the type of abuse and can vary. Keep in mind that warning signs are just that - warning signs. The presence of warning signs doesn't necessarily mean that a child is being abused.

Physical abuse signs and symptoms

Unexplained injuries, such as bruises, broken bones (fractures) or burns

Injuries that don't match the given explanation

Injuries that aren't compatible with the child's developmental ability

Sexual abuse signs and symptoms

Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Genital or anal pain, bleeding, or injury

Statements by the child that he or she was sexually abused

Inappropriate sexual behavior with other children

Emotional abuse signs and symptoms

Neglect signs and symptoms

Poor growth

Excessive weight with medical complications that are not being adequately addressed

Poor personal cleanliness

Lack of clothing or supplies to meet physical needs

Hoarding or stealing food

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

Parental behavior

Sometimes a parent's demeanor or behavior sends red flags about child abuse. Warning signs include a parent who:

Shows little concern for the child

Appears unable to recognize physical or emotional distress in the child

Blames the child for the problems

Consistently belittles or berates the child, and describes the child with negative terms, such as "worthless" or "evil"

Expects the child to provide attention and care to the parent and seems jealous of other family members getting attention from the child

Uses harsh physical discipline

Demands an inappropriate level of physical or academic performance

Severely limits the child's contact with others

Offers conflicting or unconvincing explanations for a child's injuries or no explanation at all

Repeatedly brings the child for medical evaluations or requests medical tests, such as X-rays and lab tests, for concerns not seen during the health care provider's examination

Physical punishment

Child health experts condemn the use of violence in any form, but some people still use physical punishment, such as spanking, to discipline their children. While parents and caregivers often use physical punishment with the intention of helping their children or making their behavior better, research shows that spanking is linked with worse, not better, behavior. It's also linked to mental health problems, difficult relationships with parents, lower self-esteem and lower academic performance.

Any physical punishment may leave emotional scars. Parental behaviors that cause pain, physical injury or emotional trauma - even when done in the name of discipline - could be child abuse.

If you're concerned that your child or another child has been abused, seek help immediately. Depending on the situation, contact the child's health care provider, a local child welfare agency, the police department or a 24-hour hotline for advice. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline at 1-800-422-4453.

If the child needs immediate medical attention, call 911 or your local emergency number.

In the United States, keep in mind that health care professionals and many other people, such as teachers and social workers, are legally required to report all suspected cases of child abuse to the appropriate local child welfare agency.

Some children overcome the physical and psychological effects of child abuse, particularly those with strong social support and resiliency skills who can adapt and cope with bad experiences. For many others, however, child abuse may result in physical, behavioral, emotional or mental health issues - even years later.

Here are some examples.

Physical issues

Premature death

Physical disabilities

Learning disabilities

Substance abuse

Health problems, such as heart disease, diabetes, chronic lung disease and cancer

Emotional issues

Low self-esteem

Difficulty establishing or maintaining relationships

Challenges with intimacy and trust

An unhealthy view of parenthood

Inability to cope with stress and frustrations

An acceptance that violence is a normal part of relationships

You can take important steps to protect your child from exploitation and child abuse, as well as prevent child abuse in your neighborhood or community. The goal is to provide safe, stable, nurturing relationships for children.

Here's how you can help keep children safe:

Offer your child love and attention. Nurture and listen to your child and be involved in your child's life to develop trust and good communication. Encourage your child to tell you if there's a problem. A supportive family environment and social networks can help improve your child's feelings of self-esteem and self-worth.

Don't respond in anger. If you feel overwhelmed or out of control, take a break. Don't take out your anger on your child. Talk with your health care provider or a therapist about ways you can learn to cope with stress and better interact with your child.

Think supervision. Don't leave a young child home alone. In public, keep a close eye on your child. Volunteer at school and for activities to get to know the adults who spend time with your child. When old enough to go out without supervision, encourage your child to stay away from strangers and to hang out with friends rather than be alone. Make it a rule that your child tells you where he or she is at all times. Find out who's supervising your child - for example, at a sleepover.

Know your child's caregivers. Check references for babysitters and other caregivers. Make irregular, but frequent, unannounced visits to observe what's happening. Don't allow substitutes for your usual child care provider if you don't know the substitute.

Emphasize when to say no. Make sure your child understands that he or she doesn't have to do anything that seems scary or uncomfortable. Encourage your child to leave a threatening or frightening situation immediately and seek help from a trusted adult. If something happens, encourage your child to talk to you or another trusted adult about what happened. Assure your child that it's OK to talk and that he or she won't get in trouble.

Teach your child how to stay safe online. Put the computer in a common area of your home, not the child's bedroom. Use the parental controls to restrict the types of websites your child can visit. Check your child's privacy settings on social networking sites. Consider it a red flag if your child is secretive about online activities.

Cover online ground rules, such as not sharing personal information; not responding to inappropriate, hurtful or frightening messages; and not arranging to meet an online contact in person without your permission. Tell your child to let you know if an unknown person makes contact through a social networking site. Report online harassment or inappropriate senders to your service provider and local authorities, if necessary.

Reach out. Meet the families in your neighborhood, including parents and children. Develop a network of supportive family and friends. If a friend or neighbor seems to be struggling, offer to babysit or help in another way. Consider joining a parent support group so that you have an appropriate place to vent your frustrations.

If you worry that you might abuse your child

If you're concerned that you might abuse your child, seek help immediately. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453).

Or you can start by talking with your family health care provider. Your provider may offer a referral to a parent education class, counseling or a support group for parents to help you learn appropriate ways to deal with your anger. If you're misusing alcohol or drugs, ask your health care provider about treatment options.

If you were abused as a child, get counseling to ensure you don't continue the abuse cycle or teach those destructive behaviors to your child.

Remember, child abuse is preventable - and often a symptom of a problem that may be treatable. Ask for help today.

AskMayoExpert. Child abuse. Mayo Clinic; 2021.

Overview of child maltreatment (child abuse). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment#. Accessed Jan. 12, 2022.

Trauma and child abuse resource center: Frequently asked questions. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/FAQ.aspx#question1. Accessed Jan. 12, 2022.

Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html. Accessed Jan. 12, 2022.

Preventing adverse childhood experiences (ACEs): Leveraging the best available evidence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/82316. Accessed Jan. 12, 2022.

Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/11493. Accessed Jan. 12, 2022.

Violence prevention: Risk and protective factors. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed Jan. 12, 2022.

Long-term consequences of child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/. Accessed Jan. 12, 2022.

How to report child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/topics/responding/reporting/how/. Accessed Jan. 12, 2022.

Keeping children safe online. U.S. Department of Justice. https://www.justice.gov/coronavirus/keeping-children-safe-online. Accessed Jan. 13, 2022.

Other conditions that may be a focus of clinical attention: Abuse and neglect. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 13, 2022.

Boos SC. Physical child abuse: Recognition. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Child neglect: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Health Education & Content Services (Patient Education). Talking to your child about safe and unsafe touch. Mayo Clinic; 2021.

Handling child abuse disclosures. Childhelp. https://www.childhelp.org/what-is-child-abuse/handling-child-abuse-disclosures/. Accessed Jan. 14, 2022.

Zeanah CH, et al. Child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; doi:10.1016/j.jaac.2018.06.007.

Cohen JA, et al. Trauma-focused cognitive behavioral therapy for children and families. Child and Adolescent Psychiatric Clinics of North America. 2022; doi:10.1016/j.chc.2021.05.001.

Child-parent psychotherapy. Youth.gov. https://youth.gov/content/child%25E2%2580%2593parent-psychotherapy. Accessed Jan. 14, 2022.

Sege RD, et al. Effective discipline to raise healthy children. Pediatrics. 2018; doi:10.1542/peds.2018-3112.

Derauf DC (expert opinion). Mayo Clinic. Jan. 28, 2022.

# data[].attributes.attachment_link.title
Learn the signs of child abuse and how to get help-Child abuse - Symptoms & causes - Mayo Clinic

# data[].attributes.attachment_link.description
Child abuse includes physical, sexual, emotional and medical abuse, as well as neglect. Learn about signs, risk factors, how to get help and prevention.

# data[].attributes.headline
Consequences of children that experience abuse often...

# data[].attributes.subject
Consequences of children that experience abuse often...

# data[].attributes.body
Withdrawal from friends or usual activities

Changes in behavior — such as aggression, anger, hostility or hyperactivity — or changes in school performance

Depression, anxiety or unusual fears, or a sudden loss of self-confidence

An apparent lack of supervision

Frequent absences from school

Reluctance to leave school activities, as if he or she doesn't want to go home

Attempts at running away

Rebellious or defiant behavior

Self-harm or attempts at suicide

# data[].attributes.attachment_link.readable_text
Any intentional harm or mistreatment to a child under 18 years old is considered child abuse. Child abuse takes many forms, which often occur at the same time.

Physical abuse. Physical child abuse occurs when a child is purposely physically injured or put at risk of harm by another person.

Sexual abuse. Child sexual abuse is any sexual activity with a child. This can involve sexual contact, such as intentional sexual touching, oral-genital contact or intercourse. This can also involve noncontact sexual abuse of a child, such as exposing a child to sexual activity or pornography; observing or filming a child in a sexual manner; sexual harassment of a child; or prostitution of a child, including sex trafficking.

Emotional abuse. Emotional child abuse means injuring a child's self-esteem or emotional well-being. It includes verbal and emotional assault - such as continually belittling or berating a child - as well as isolating, ignoring or rejecting a child.

Medical abuse. Medical child abuse occurs when someone gives false information about illness in a child that requires medical attention, putting the child at risk of injury and unnecessary medical care.

Neglect. Child neglect is failure to provide adequate food, clothing, shelter, clean living conditions, affection, supervision, education, or dental or medical care.

In many cases, child abuse is done by someone the child knows and trusts - often a parent or other relative. If you suspect child abuse, report the abuse to the proper authorities.

A child who's being abused may feel guilty, ashamed or confused. The child may be afraid to tell anyone about the abuse, especially if the abuser is a parent, other relative or family friend. That's why it's vital to watch for red flags, such as:

Specific signs and symptoms depend on the type of abuse and can vary. Keep in mind that warning signs are just that - warning signs. The presence of warning signs doesn't necessarily mean that a child is being abused.

Physical abuse signs and symptoms

Unexplained injuries, such as bruises, broken bones (fractures) or burns

Injuries that don't match the given explanation

Injuries that aren't compatible with the child's developmental ability

Sexual abuse signs and symptoms

Sexual behavior or knowledge that's inappropriate for the child's age

Pregnancy or a sexually transmitted infection

Genital or anal pain, bleeding, or injury

Statements by the child that he or she was sexually abused

Inappropriate sexual behavior with other children

Emotional abuse signs and symptoms

Neglect signs and symptoms

Poor growth

Excessive weight with medical complications that are not being adequately addressed

Poor personal cleanliness

Lack of clothing or supplies to meet physical needs

Hoarding or stealing food

Poor record of school attendance

Lack of appropriate attention for medical, dental or psychological problems or lack of necessary follow-up care

Parental behavior

Sometimes a parent's demeanor or behavior sends red flags about child abuse. Warning signs include a parent who:

Shows little concern for the child

Appears unable to recognize physical or emotional distress in the child

Blames the child for the problems

Consistently belittles or berates the child, and describes the child with negative terms, such as "worthless" or "evil"

Expects the child to provide attention and care to the parent and seems jealous of other family members getting attention from the child

Uses harsh physical discipline

Demands an inappropriate level of physical or academic performance

Severely limits the child's contact with others

Offers conflicting or unconvincing explanations for a child's injuries or no explanation at all

Repeatedly brings the child for medical evaluations or requests medical tests, such as X-rays and lab tests, for concerns not seen during the health care provider's examination

Physical punishment

Child health experts condemn the use of violence in any form, but some people still use physical punishment, such as spanking, to discipline their children. While parents and caregivers often use physical punishment with the intention of helping their children or making their behavior better, research shows that spanking is linked with worse, not better, behavior. It's also linked to mental health problems, difficult relationships with parents, lower self-esteem and lower academic performance.

Any physical punishment may leave emotional scars. Parental behaviors that cause pain, physical injury or emotional trauma - even when done in the name of discipline - could be child abuse.

If you're concerned that your child or another child has been abused, seek help immediately. Depending on the situation, contact the child's health care provider, a local child welfare agency, the police department or a 24-hour hotline for advice. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline at 1-800-422-4453.

If the child needs immediate medical attention, call 911 or your local emergency number.

In the United States, keep in mind that health care professionals and many other people, such as teachers and social workers, are legally required to report all suspected cases of child abuse to the appropriate local child welfare agency.

Some children overcome the physical and psychological effects of child abuse, particularly those with strong social support and resiliency skills who can adapt and cope with bad experiences. For many others, however, child abuse may result in physical, behavioral, emotional or mental health issues - even years later.

Here are some examples.

Physical issues

Premature death

Physical disabilities

Learning disabilities

Substance abuse

Health problems, such as heart disease, diabetes, chronic lung disease and cancer

Emotional issues

Low self-esteem

Difficulty establishing or maintaining relationships

Challenges with intimacy and trust

An unhealthy view of parenthood

Inability to cope with stress and frustrations

An acceptance that violence is a normal part of relationships

You can take important steps to protect your child from exploitation and child abuse, as well as prevent child abuse in your neighborhood or community. The goal is to provide safe, stable, nurturing relationships for children.

Here's how you can help keep children safe:

Offer your child love and attention. Nurture and listen to your child and be involved in your child's life to develop trust and good communication. Encourage your child to tell you if there's a problem. A supportive family environment and social networks can help improve your child's feelings of self-esteem and self-worth.

Don't respond in anger. If you feel overwhelmed or out of control, take a break. Don't take out your anger on your child. Talk with your health care provider or a therapist about ways you can learn to cope with stress and better interact with your child.

Think supervision. Don't leave a young child home alone. In public, keep a close eye on your child. Volunteer at school and for activities to get to know the adults who spend time with your child. When old enough to go out without supervision, encourage your child to stay away from strangers and to hang out with friends rather than be alone. Make it a rule that your child tells you where he or she is at all times. Find out who's supervising your child - for example, at a sleepover.

Know your child's caregivers. Check references for babysitters and other caregivers. Make irregular, but frequent, unannounced visits to observe what's happening. Don't allow substitutes for your usual child care provider if you don't know the substitute.

Emphasize when to say no. Make sure your child understands that he or she doesn't have to do anything that seems scary or uncomfortable. Encourage your child to leave a threatening or frightening situation immediately and seek help from a trusted adult. If something happens, encourage your child to talk to you or another trusted adult about what happened. Assure your child that it's OK to talk and that he or she won't get in trouble.

Teach your child how to stay safe online. Put the computer in a common area of your home, not the child's bedroom. Use the parental controls to restrict the types of websites your child can visit. Check your child's privacy settings on social networking sites. Consider it a red flag if your child is secretive about online activities.

Cover online ground rules, such as not sharing personal information; not responding to inappropriate, hurtful or frightening messages; and not arranging to meet an online contact in person without your permission. Tell your child to let you know if an unknown person makes contact through a social networking site. Report online harassment or inappropriate senders to your service provider and local authorities, if necessary.

Reach out. Meet the families in your neighborhood, including parents and children. Develop a network of supportive family and friends. If a friend or neighbor seems to be struggling, offer to babysit or help in another way. Consider joining a parent support group so that you have an appropriate place to vent your frustrations.

If you worry that you might abuse your child

If you're concerned that you might abuse your child, seek help immediately. In the United States, you can get information and assistance by calling or texting the Childhelp National Child Abuse Hotline: 1-800-4-A-CHILD (1-800-422-4453).

Or you can start by talking with your family health care provider. Your provider may offer a referral to a parent education class, counseling or a support group for parents to help you learn appropriate ways to deal with your anger. If you're misusing alcohol or drugs, ask your health care provider about treatment options.

If you were abused as a child, get counseling to ensure you don't continue the abuse cycle or teach those destructive behaviors to your child.

Remember, child abuse is preventable - and often a symptom of a problem that may be treatable. Ask for help today.

AskMayoExpert. Child abuse. Mayo Clinic; 2021.

Overview of child maltreatment (child abuse). Merck Manual Professional Version. https://www.merckmanuals.com/professional/pediatrics/child-maltreatment/overview-of-child-maltreatment#. Accessed Jan. 12, 2022.

Trauma and child abuse resource center: Frequently asked questions. American Academy of Child and Adolescent Psychiatry. https://www.aacap.org/aacap/Families_and_Youth/Resource_Centers/Child_Abuse_Resource_Center/FAQ.aspx#question1. Accessed Jan. 12, 2022.

Preventing child abuse and neglect. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/fastfact.html. Accessed Jan. 12, 2022.

Preventing adverse childhood experiences (ACEs): Leveraging the best available evidence. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/82316. Accessed Jan. 12, 2022.

Child maltreatment surveillance: Uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention. https://stacks.cdc.gov/view/cdc/11493. Accessed Jan. 12, 2022.

Violence prevention: Risk and protective factors. Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/childabuseandneglect/riskprotectivefactors.html. Accessed Jan. 12, 2022.

Long-term consequences of child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/pubs/factsheets/long-term-consequences/. Accessed Jan. 12, 2022.

How to report child abuse and neglect. Child Welfare Information Gateway. https://www.childwelfare.gov/topics/responding/reporting/how/. Accessed Jan. 12, 2022.

Keeping children safe online. U.S. Department of Justice. https://www.justice.gov/coronavirus/keeping-children-safe-online. Accessed Jan. 13, 2022.

Other conditions that may be a focus of clinical attention: Abuse and neglect. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. https://dsm.psychiatryonline.org. Accessed Jan. 13, 2022.

Boos SC. Physical child abuse: Recognition. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Child neglect: Evaluation and management. https://www.uptodate.com/contents/search. Accessed Jan. 12, 2022.

Health Education & Content Services (Patient Education). Talking to your child about safe and unsafe touch. Mayo Clinic; 2021.

Handling child abuse disclosures. Childhelp. https://www.childhelp.org/what-is-child-abuse/handling-child-abuse-disclosures/. Accessed Jan. 14, 2022.

Zeanah CH, et al. Child abuse and neglect. Journal of the American Academy of Child & Adolescent Psychiatry. 2018; doi:10.1016/j.jaac.2018.06.007.

Cohen JA, et al. Trauma-focused cognitive behavioral therapy for children and families. Child and Adolescent Psychiatric Clinics of North America. 2022; doi:10.1016/j.chc.2021.05.001.

Child-parent psychotherapy. Youth.gov. https://youth.gov/content/child%25E2%2580%2593parent-psychotherapy. Accessed Jan. 14, 2022.

Sege RD, et al. Effective discipline to raise healthy children. Pediatrics. 2018; doi:10.1542/peds.2018-3112.

Derauf DC (expert opinion). Mayo Clinic. Jan. 28, 2022.

# data[].attributes.attachment_link.title
Learn the signs of child abuse and how to get help-Child abuse - Symptoms & causes - Mayo Clinic

# data[].attributes.attachment_link.description
Child abuse includes physical, sexual, emotional and medical abuse, as well as neglect. Learn about signs, risk factors, how to get help and prevention.

# data[].attributes.headline
Long-term consequences of child physical abuse

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Long-term consequences of child physical abuse

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"Significant connection were also observed with post-traumatic stress disorder (PTSD) and panic disorder diagnoses"

An "increased risk of developing bulimia for those that experienced more severe and repeated physical abuse"

"Significant increase in the risk of alcohol abuse problems"

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Rosana E. Norman,

Munkhtsetseg Byambaa,

Rumna De,

Alexander Butchart,

James Scott,

Theo Vos

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Abstract

Conclusions

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.

Please see later in the article for the Editors' Summary

Citation: Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T (2012) The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 9(11): e1001349. https://doi.org/10.1371/journal.pmed.1001349

Academic Editor: Mark Tomlinson, Stellenbosch University, South Africa

Received: March 20, 2012; Accepted: October 17, 2012; Published: November 27, 2012

Copyright: © 2012 Norman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was supported by a University of Queensland Start-up-Grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Alexander Butchart is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ACE, Adverse Childhood Experiences; BMI, body mass index; CI, confidence interval; DSM, Diagnostic and Statistical Manual of Mental Disorders; HSV2, herpes simplex virus type 2; OR, odds ratio; PTSD, post-traumatic stress disorder; STI, sexually transmitted infection; WHO, World Health Organization

Introduction

Child maltreatment is defined as all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation of children that results in actual or potential harm to a child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power [1]. Four types of maltreatment are commonly recognised: sexual abuse, physical abuse, emotional abuse (also referred to as psychological abuse), and neglect ( Table 1).

There is a great deal of uncertainty around estimates of the frequency and severity of child maltreatment worldwide. Furthermore, much violence against children remains largely hidden and unreported because of fear and stigma and the societal acceptance of this type of violence [2]. Globally, prevalence of reported child sexual abuse varies from 2% to 62%, with some of this variation explained by a number of methodological factors including definition of abuse, method of data collection, and type of sample assessed [3]. In high-income countries, the annual prevalence of physical abuse ranges from 4% to 16%, and approximately 10% of children are neglected or emotionally abused [4]. Eighty percent of this maltreatment is perpetrated by parents or parental guardians [4], and poverty, mental health problems, low educational achievement, alcohol and drug misuse, having been maltreated oneself as a child, and family breakdown or violence between other family members are all important risk factors for parents abusing their children [5].

There is growing recognition that different forms of interpersonal violence have a large public health impact [6]. In children, the consequences of violence can vary widely. Physical injuries and, in extreme cases, death are direct consequences. World Health Organization (WHO) estimates of child homicide suggest that infants and very young children are at greatest risk, with rates for the 0- to 4-y age group about double those for 5- to 14-y-olds as a result of their dependency and vulnerability [5]. However, in the majority of non-fatal cases, the direct physical injury causes less morbidity to the child than the long-term impact of the violence on the child's neurological, cognitive, and emotional development and overall health [5].

Child maltreatment is a major public health problem, yet a lack of understanding of its serious lifelong consequences and of the cost and burden on society has hampered investment in prevention policies and programs. In order to effectively respond to the problem, the WHO 2006 report on prevention of child maltreatment [5] recommended expanding the scientific evidence base for the magnitude, consequences, and preventability of child maltreatment.

The relationship between child sexual abuse and adverse psychological consequences in adults is well established [7]-[9], and in the WHO comparative risk assessment study, Andrews and colleagues [3] carried out a systematic review and meta-analysis summarising the evidence of a relationship between child sexual abuse and subsequent mental disorders. This review is currently being updated in the new iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study, aiming to provide global estimates of attributable burden for 1990 to 2010 [10], but other forms of child maltreatment have been omitted.

Exposure to non-sexual child maltreatment, namely, physical abuse, emotional abuse, and neglect, is associated with increased risk of a wide range of psychological and behavioural problems, including depression, alcohol abuse, anxiety, and suicidal behaviour, and with increased risk of HIV and herpes simplex virus type 2 (HSV2) infection [11]-[14]. However, the long-term health consequences of these other forms of child maltreatment have not been systematically examined. To address these omissions, clarify the present state of empirical research, and enable the quantification of the health impacts of child neglect, physical abuse, and emotional abuse at the population level using burden of disease and comparative risk assessment methodology, we conducted a systematic review of the scientific literature and quantitative meta-analyses. To the best of our knowledge, this is the first meta-analysis to summarise the evidence for associations between individual types of non-sexual child maltreatment and outcomes related to mental and physical health.

Methods

General recommendations from the PRISMA 2009 revision [15], with regard to processing and reporting of results, were taken into account ( Text S1). The meta-analysis conforms to the guidelines outlined by the Meta-analysis of Observational Studies in Epidemiology recommendations [16]. Methods and inclusion criteria were specified in advance and documented in a review protocol ( Text S2).

Inclusion and Exclusion Criteria

This systematic review and meta-analysis incorporated retrospective and prospective cohort, cross-sectional, and case-control studies meeting the following inclusion criteria: (1) the study reported original, empirical research published in a peer-reviewed journal, (2) the study considered non-sexual child maltreatment as a potential risk factor for loss of health, and (3) the related health outcomes or behavioural risk factors were among those listed in the Global Burden of Diseases, Injuries, and Risk Factors Study [10]. Studies reporting exposure only to combined types of abuse were excluded. Included studies reported odds ratios (ORs) and confidence intervals (CIs) comparing those exposed and not exposed by type of abuse or, alternatively, provided the information from which effect sizes and confidence intervals could be calculated ( Text S2).

Search Strategy

Three electronic databases (Medline, EMBASE, and PsycINFO up to 26 June 2012) were searched using full text and Medical Subject Headings (MeSH) terms to identify studies reporting an association between non-sexual child maltreatment and health outcomes ( Text S2). Truncation of terms was used to capture variation in terminology. The search was not restricted to the English language, nor restricted by any other means. Searches were conducted using synonyms and combinations of the following search terms: "maltreatment", "physical abuse", "psychological abuse", and "emotional abuse", and automatic explosion of the terms "child abuse" and "child neglect". The search was also not restricted to any particular health outcome. Instead, the broader terms "risk", "adverse effect", "consequences", "harm", and "association" were used to encompass all studies that investigated any adverse outcome of non-sexual child maltreatment. In addition, reference lists of selected studies were screened for any other relevant study, and additional studies were also identified through contact with study authors. Articles in languages other than English were translated.

Data Collection and Quality Assessment

Statistical Analyses

Weighted summary measures were computed using MetaXL, version 1.2 [18], a tool for meta-analysis in Microsoft Excel, with ORs chosen as the principal summary measure. Heterogeneity was quantitatively assessed using the Cochran's Q and I 2 statistics to evaluate whether the pooled studies represent a homogeneous distribution of effect sizes. Evidence of publication bias was investigated by means of funnel plots using the standard error on the y-axis [19].

To address the effects of important study characteristics and explore heterogeneity, we additionally conducted several pre-specified subgroup analyses (depending on data availability) by the following: gender of participants in the sample, geographic location (high income versus low-to-middle income), type of sample (population-based versus non-representative samples), measurement of abuse (self-reported versus official records), assessment of health outcome (structured clinical interview versus self-reported), prospective versus retrospective assessment of abuse and neglect, and appropriate adjustment versus no or inadequate adjustment for confounders.

Results

Out of 285 articles assessed for eligibility, 124 studies provided evidence of a relationship between non-sexual child maltreatment and various health outcomes for use in subsequent meta-analyses ( Figure 1). The majority ( n = 112) were from Western Europe, North America, Australia, and New Zealand. Data from low- and middle-income countries were sparse. Only 16 studies used a prospective cohort design that followed abused or neglected children over time to identify later health outcomes ( Table 3). The remaining studies included cohort, cross-sectional, and case-control studies that measured the maltreatment retrospectively, usually by self-report in adolescence or adulthood. Most of the studies included in our meta-analysis presented data from regional or nationally representative samples ( Table 3). The results of primary meta-analyses are presented in Tables 4- 6, with Figures S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11, S12, S13, S14, S15, S16, S17, S18, S19, S20, S21, S22, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, S33, S34, S35, S36, S37, S38, S39, S40, S41, S42 showing the forest plots of these meta-analyses. Details of subgroup analyses are presented in Tables S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11.

Mental Disorders

Physically abused (OR = 1.54; 95% CI 1.16-2.04), emotionally abused (OR = 3.06; 95% CI 2.43-3.85), and neglected (OR = 2.11; 95% CI 1.61-2.77) individuals were found to have a higher risk of developing depressive disorders than non-abused individuals ( Table 4; Figures S1, S2, S3). The test for heterogeneity was highly significant, with p<0.01 for both abuse types and neglect. Funnel plots indicate the possibility of publication bias for physical abuse, as it appears that some smaller, less precise studies have a greater effect size than the larger studies, and there are no smaller studies to the left (negative) side of the graph, suggesting that some negative studies may never have been published ( Figure S4).

Physical abuse (OR = 1.51; 95% CI 1.27-1.79), emotional abuse (OR = 3.21; 95% CI 2.05-5.03), and neglect (OR = 1.82; 95% CI 1.51-2.20) were associated with a significantly increased risk of anxiety disorders ( Figures S5, S6, S7, S8). For physical abuse, significant associations were also observed with post-traumatic stress disorder (PTSD) and panic disorder diagnoses ( Table S2). A dose-response relationship was observed with physical abuse but not with emotional abuse and neglect [22], with anxiety disorders more likely with frequent physical abuse than with abuse that occurred only sometimes in childhood ( Table S2). Physical abuse, emotional abuse, and neglect were also associated with an almost 3-fold increased risk of developing eating disorders ( Figures S9, S10, S11, S12), and physical abuse was associated with a 5-fold increased risk of developing bulimia nervosa meeting Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria. Most of the evidence came from retrospective studies, and only one prospective study [23] reported a strong association with neglect in childhood ( Table S3). A dose-response relationship was also observed, with bulimia nervosa more likely with more severe and repeated physical abuse [24] ( Table S3).

Physical abuse and neglect were also associated with a doubling of the odds of childhood behavioural and conduct disorders ( Figures S13, S14, S15). With respect to physical abuse, higher odds of developing conduct and childhood behavioural disorders were observed in prospective than in retrospective studies, but differences were not statistically significant. Studies with non-representative samples had significantly increased effect size for the association between physical abuse and childhood behavioural problems and conduct disorder (OR = 5.98; 95% CI 2.73-13.10) compared with population-based studies (OR = 2.02; 95% CI 1.58-2.58) ( Table S4).

Although primary analyses suggest an increased risk of drug use associated with physical abuse (OR = 1.92; 95% CI 1.67-2.20), emotional abuse (OR = 1.41; 95% CI 1.11-1.79), and neglect (OR = 1.36; 95% CI 1.21-1.54) ( Figures S20, S21, S22, S23), there was only borderline significance in prospective studies, with a stronger consistent association observed in retrospective studies, albeit with overlapping confidence intervals ( Table S6). A dose-response relationship between emotional abuse and neglect and drug use was not consistently seen.

Physically abused (OR = 3.00; 95% CI 2.07-4.33), emotionally abused (OR = 3.08; 95% CI 2.42-3.93), and neglected (OR = 1.85; 95% CI 1.25-2.73) individuals had a significantly increased risk of suicidal behaviour compared with non-abused individuals ( Table 4). These significant associations continued in subgroup analyses by type of suicidal behaviour, with physically abused (OR = 3.40; 95% CI 2.17-5.32), emotionally abused (OR = 3.37; 95% CI 2.44-4.67), and neglected (OR = 1.95; 95% CI 1.13-3.37) individuals at a significantly increased risk of suicide attempt ( Figures S24, S25, S26, S27) and suicide ideation ( Table S7). There were no prospective studies investigating non-sexual child maltreatment and suicide attempt or ideation. Only one prospective study [25] was found investigating the association between self-inflicted injuries and exposure to physical abuse and neglect. Six studies [13],[26]-[30] presented the results by gender for physical abuse and suicide attempt and ideation, but no statistically significant differences were observed. One study showed that exposure to frequent childhood neglect was more strongly associated with suicidal behaviour than exposure to neglect that occurred sometimes [13] ( Table S7).

Sexually Transmitted Infections and Risky Sexual Behaviour

Chronic Diseases, Lifestyle Risk Factors, and Other Physical Health Outcomes

With regard to obesity, a significantly increased risk was observed for physical (OR = 1.32; 95% CI 1.06-1.64) and emotional abuse (OR = 1.24; 95% CI 1.13-1.36) but not for neglect (OR = 1.07; 95% CI 0.97-1.19) in the primary analysis ( Figures S32, S33, S34, S35). Subgroup analysis by assessment of outcome indicated that neglect was associated with a higher risk of developing self-reported obesity, but there was no association with obesity defined by waist circumference or body mass index (BMI) measurements ( Table S9). In the subgroup analysis by ascertainment of exposure to physical abuse, there was a strong association with obesity in one prospective study, but the magnitude of the effect was reduced in retrospective studies ( Table S9). A dose-response relationship between physical and emotional abuse and obesity has been observed [31] ( Table S9).

Physical (OR = 1.78; 95% CI 1.26-2.52) ( Figure S36) and emotional abuse (OR = 1.65; 95% CI 1.46-1.87) ( Figure S37) were associated with a significantly increased risk of current smoking, but the association was not significant for neglect in childhood (OR = 1.20; 95% CI 0.98-1.48). One study showed a dose response, with smoking more likely with physical abuse that occurred 3-5 times than with abuse that occurred 1-2 times, but this relationship did not continue into those who had been abused more than six times compared with those who had been abused 3-5 times [32] ( Table S10).

Discussion

To the best of our knowledge, this article presents the first systematic review and meta-analysis of published studies assessing the association between non-sexual child maltreatment and mental and physical health outcomes. We identified 124 studies that examined the association between physical abuse, emotional abuse, and neglect in childhood and various health outcomes.

Does Non-Sexual Child Maltreatment Cause Adverse Health Outcomes?

Evidence for a causal relationship between non-sexual child maltreatment and health outcomes was evaluated within the Bradford Hill framework on the grounds of the following important criteria: strength and consistency of the association, the temporal relationship of the association, evidence of a biological gradient or dose-response relationship, biological plausibility, and consideration of alternate explanations [34] ( Table S12).

Temporality

Both prospective and retrospective studies consistently showed an association between exposure to child physical abuse, emotional abuse, and neglect and adverse health outcomes. The availability of prospective studies provides conclusive evidence of a temporal relationship between exposure to non-sexual child maltreatment and the later development of mental health outcomes, drug use, and STIs and risky sexual behaviour, as in these studies abuse and neglect preceded the onset of health problems in adulthood.

However, only 16 studies were prospective, while the majority of the studies were cross-sectional and relied on adult retrospective report of abuse and neglect in childhood. By definition, these studies cannot prove a temporal relationship between exposure to child maltreatment and the onset of health outcomes. Furthermore, retrospective, self-reported information regarding abuse in childhood may be subject to recall bias, where those with adjustment problems may be more prone to recall or disclose exposure to abuse and neglect. In many cases participants were asked to report on events that would have occurred many years before, and the issue of potentially unreliable recall threatens the validity of the published literature on child maltreatment. At least with respect to child sexual abuse, evidence suggests moderate to good consistency of reports over time [35]. It has also been suggested that biases are probably towards under-reporting rather than over-reporting of abuse [36]. Nevertheless, given that retrospective reports were often the only measure of abuse available, particularly with regard to emotional abuse, we accepted these within the context of the limitations stated.

Consistency of the Association

As shown in the forest plots of the effects by study, there was strong consistency and agreement in the estimated effect measures across studies, particularly for neglect and physical abuse, although we suspect publication bias for some of the outcomes. Risk estimates were comparable across different types of samples, for both non-representative and representative populations ( Tables S1, S2, S3, S4 and S6, S7, S8). The findings persisted across different study designs, samples, and geographic regions investigated. It can be concluded that there is a highly consistent association between child physical abuse, emotional abuse, and neglect and adverse mental health outcomes, drug use, and STIs and risky sexual behaviour. We did not observe evidence of strong consistent associations for alcohol problems, chronic diseases, or lifestyle risk factors.

Dose-Response Relationship

We found evidence of a dose-response relationship between adverse health outcomes and non-sexual child maltreatment, such that those experiencing more severe abuse or neglect were at greater risk of developing mental disorders than those experiencing less severe maltreatment [39]. In the Chapman et al. [40] study, increasing severity of childhood adversity corresponded with poorer mental health outcomes. Consistent dose-response relationships with repeated, frequent, or severe abuse have been reported for mental disorders and physical abuse [13],[24],[41] and emotional abuse and neglect [13],[22]. Furthermore, there is evidence to suggest that experiencing multiple types of maltreatment may carry more severe consequences, with those exposed to multiple types of abuse at increased odds of developing mental disorders [42],[43], and the risk increases with the magnitude of multiple abuse [44]. Dose-response relationships with repeated frequent or severe abuse have also been reported for STIs and physical and emotional abuse [13], obesity and emotional and physical abuse [31], and smoking and physical abuse [32].

Plausibility

With respect to biological plausibility, animal models of mental disorders do not exist, making it particularly difficult to understand the underlying biological mechanisms. Progress in understanding has to be made by association and inference rather than experimental data [3]. There are nevertheless several potential mechanisms that may explain the observed association between abuse and neglect in childhood and increased risk of mental health problems. Neurobiological development can be physiologically altered by maltreatment during a child's early years, which can in turn negatively affect a child's physical, cognitive, emotional, and social growth, leading to psychological, behavioural, and learning problems that persist throughout the life course [45],[46]. Moreover, cumulative trauma may further increase risk [47], and some victims of abuse may try to manage the subsequent distress through the use of alcohol, prescription medication, tobacco, or other drugs.

Consideration of Alternate Explanations

It is important to note that the role of genes, environment, and gene-environment interactions in the causation of mental disorders is not well understood. Twin studies provide one of the best ways to examine the interplay between genetic and environmental influences [3], but to the best of our knowledge, these are only available for child sexual abuse. The relationship between abuse and neglect in childhood and subsequent health effects is complex. Although childhood abuse and neglect does result in adverse health outcomes, these outcomes are not independent of broader socioeconomic contexts. Lifestyle factors, access to health care, and neighbourhood characteristics may act as mediators between child abuse and neglect and long-term health consequences [49]-[51]. Exposure to child maltreatment often co-occurs within the context of other family dysfunction, social deprivation, and other environmental stressors that are also associated with mental disorders. Child maltreatment may be a marker of other family problems that together lead to the development of mental disorders. In addition, findings from many studies do not take into account the likely contribution of hereditary influences on the predisposition to mental disorders. Children of depressed parents may be at greater risk of depression through both exposure to maltreatment by their parents and genetic predisposition [43]. Hence, some of the effect of child abuse and neglect on mental disorders may still be explained by confounding. However, the effect of abuse on mental disorders remained significant in the majority of studies included in these meta-analyses after controlling for these co-occurring factors.

Assessment of Causality

In summary, there was robust evidence of significant associations between exposure to non-sexual child maltreatment and increased likelihood of a range of mental disorders, suicide attempts, drug use, STIs, and risky sexual behaviour. An increase in the likelihood of alcohol problem use was not consistently seen. There is weak to limited evidence suggesting a relationship between non-sexual child maltreatment and certain physical disorders and risk factors ( Table 8), but more research is required to confirm these relationships.

Study Limitations

Although these findings and conclusions seem to be relatively consistent and robust, they should be interpreted in light of a number of limitations of our analysis.

This meta-analysis may be subject to publication bias because non-significant findings are less likely to be published [52]. This problem is increased when statistical models are employed because often only significant estimates are reported in many studies. This may result in the association between child abuse and neglect and outcomes being overstated, particularly for depressive disorders and anxiety, where publication bias may have played a role. For some of the other conditions there were too few studies to make conclusions with respect to publication bias.

Measurement bias with respect to health outcomes and the questionable reliability of self-reported data may also have affected the results. We dealt with this issue in the meta-analysis by adjusting the quality score and performing subgroup analyses. For mental disorders, studies using well-validated and standardised diagnostic instruments were assigned a higher quality score than studies using self-report symptom scales.

Another limitation of meta-analyses of observational studies is that, since individuals cannot be randomly allocated to case groups, the influence of confounding variables cannot be fully evaluated. While most studies presented multivariable adjusted ORs controlling for a range of socio-demographic and study design variables, a few studies presented unadjusted associations between child maltreatment and health outcomes, or adjusted for age and sex only. We again dealt with this issue in our meta-analysis by adjusting the quality score of studies with inadequate control for confounding and by carrying out separate analyses depending on data availability. Some studies also statistically controlled for exposure to other forms of maltreatment by including the different types of abuse in the same model in order to determine the independent contribution of each abuse type. Generally, in studies presenting results from various unadjusted and adjusted models, the association between abuse and physical and mental health outcomes was attenuated when controlling for the effects of mediating variables [61]-[72] and other forms of abuse [73]-[79]. However, findings from a recent prospective cohort study indicate that for some physical health outcomes additional control for socioeconomic status, unhealthy behaviour, smoking, and mental health problems seems to play varying roles in attenuating or intensifying these complex relationships [33]. Furthermore, we cannot exclude that residual confounding or unmeasured potential confounders may still remain. Despite evidence of weak associations between non-sexual child maltreatment and chronic diseases, further studies are needed that ensure adequate adjustment for lifetime confounders, because the attributable burden would be appreciable.

Significant heterogeneity exists in the primary analysis of physical and emotional abuse, even after our attempts to control for study quality in quality effects models, and the heterogeneity remained significant in most of the subgroup analyses. Given this situation, combining the effects may not be justified. With respect to neglect, pooled estimates in primary and subgroup analyses did not show significant heterogeneity for many outcomes.

Recommendations

Inconsistencies in the measurement and definition of child maltreatment highlight the importance of international efforts to standardise studies to enhance the comparability of findings. These include defining the cutoff age for childhood (0-18 y, as specified by the United Nations), and breaking this period into smaller age bands that can reflect age-specific patterns [5]. Researchers should select methodologies and instruments with international comparisons in mind. Identical questionnaires, research designs, and interviewing techniques should ideally be used for surveys in different countries [5]. In reality, however, all survey methods will require at least some adaptation to local conditions, and efforts to ensure comparability should involve choosing definitions of abuse and neglect, and questionnaire items, that represent an advanced level of knowledge [80]. To minimise how participants' subjective perceptions and definitions shape the answers, it is recommended that self-report studies clearly specify the behaviours and experiences being investigated, and that each sub-type of abuse and neglect is explored using multiple behaviourally specific questions, instead of a single-item "label question" [81].

Examples of international efforts to increase comparability across studies include the WHO's establishment of a global adverse childhood experiences research network, and the International Society for Prevention of Child Abuse and Neglect's Child Abuse Screening Tools (ICAST). The WHO network has developed an international version of the Adverse Childhood Experiences (ACE) questionnaire (the ACE International Questionnaire), for administration to people aged 18 y and older, which is currently being validated through trial implementation as part of broader health surveys in several countries [82]. The ICAST initiative has involved the development of three instruments that ask parents about their use of different behaviours for discipline, young adults (18-24 y) about their exposure to child abuse and neglect in childhood, and older children about their own recent experiences of violence [83].

Child maltreatment deserves increased investment in preventive and treatment strategies. Currently, there is a paucity of evidence-based interventions to reduce child maltreatment. Further research is urgently needed to identify programs that reduce the prevalence of child maltreatment, thereby alleviating an important risk factor for later health problems. Evidence-based systemic interventions that improve parenting strategies and family functioning may be more effective and economical than attempting to treat the wide-ranging deleterious health outcomes in adulthood that arise from maltreatment in the early years of life [48],[84].

A broad range of protective factors have been identified that assist in promoting resilience in children exposed to adversity. Self control, problem-solving skills, secure relationships with caregivers, and safe schools and neighbourhoods are known to reduce the risk of adverse consequences in children exposed to trauma [85],[86]. There is mounting evidence that exposure to childhood adversity interacting with particular genetic dispositions such as the short allele of the serotonin transporter gene [87] and genes involved in the regulation of the hypothalamic-pituitary axis [88],[89] can result in problems with stress regulation and increased risk of anxiety and depression. Epigenetic changes have also been postulated as a mechanism by which transgenerational resilience or vulnerability may occur [90]. In spite of the increased knowledge in this field, it remains a challenge to translate this research into interventions at a population level that can reduce the vulnerability of children exposed to maltreatment [91].

Conclusion

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. There is also emerging evidence that neglect in childhood may be as harmful as physical and emotional abuse. Although these conclusions have been drawn before from single empirical studies, in this article they are demonstrated in aggregate quantitative effects, to our knowledge for the first time.

This review contributes to a better understanding and measurement of the non-injury health impacts of child maltreatment globally and enables quantification of the burden attributable to physical and emotional abuse and neglect at the population level using comparative risk assessment methodology [92]. All forms of child maltreatment should be considered as part of the cluster of interpersonal violence risk factors in future global comparative risk assessments. Attributable burden is likely to be substantial, given the high prevalence of these forms of child maltreatment, the strong associations reported in our analysis, and the fact that related health outcomes are among the leading causes of disease burden globally. Despite the magnitude of the problem and increasing awareness of its high social costs, preventing child maltreatment is not a political priority in most countries. It is imperative that epidemiology and public health approaches find their proper place at the forefront of national and international efforts to understand and prevent child maltreatment [93].

Acknowledgments

Sophie Moore is gratefully acknowledged for her contribution to the systematic review. Lars Eriksson and Keryl Michener, University of Queensland Health Sciences Library, are thanked for their assistance in designing the search strategy.

Author Contributions

Conceived and designed the experiments: REN TV. Performed the experiments: REN MB RD. Analyzed the data: REN MB. Wrote the first draft of the manuscript: REN. Contributed to the writing of the manuscript: REN MB RD AB JS TV. ICMJE criteria for authorship read and met: REN MB RD AB JS TV. Agree with manuscript results and conclusions: REN MB RD AB JS TV.

References

17. Wells G, Shea B, O'Connell D, Petersen J, Welch V, et al.. (2012) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute. Available: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 November 2012.

# data[].attributes.attachment_link.title
The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis

# data[].attributes.attachment_link.description
Rosana Norman and colleagues conduct a systematic review and meta-analysis to assess the relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.

# data[].attributes.headline
Long-term consequences of Child neglect, emotional and physical abuse

# data[].attributes.subject
Long-term consequences of Child neglect, emotional and physical abuse

# data[].attributes.body
These children have an "increased risk of a wide range of psychological and behavioural problems, including depression, alcohol abuse, anxiety, and suicidal behaviour, and with increased risk of HIV and herpes simplex virus type 2 (HSV2) infection"

"Higher risk of developing depressive disorders than non-abused individuals "

"Significantly increased risk of anxiety disorders"

"Increased risk of developing eating disorders"

# data[].attributes.attachment_link.readable_text
Rosana E. Norman,

Munkhtsetseg Byambaa,

Rumna De,

Alexander Butchart,

James Scott,

Theo Vos

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Abstract

Conclusions

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence.

Please see later in the article for the Editors' Summary

Citation: Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T (2012) The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis. PLoS Med 9(11): e1001349. https://doi.org/10.1371/journal.pmed.1001349

Academic Editor: Mark Tomlinson, Stellenbosch University, South Africa

Received: March 20, 2012; Accepted: October 17, 2012; Published: November 27, 2012

Copyright: © 2012 Norman et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This work was supported by a University of Queensland Start-up-Grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Alexander Butchart is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: ACE, Adverse Childhood Experiences; BMI, body mass index; CI, confidence interval; DSM, Diagnostic and Statistical Manual of Mental Disorders; HSV2, herpes simplex virus type 2; OR, odds ratio; PTSD, post-traumatic stress disorder; STI, sexually transmitted infection; WHO, World Health Organization

Introduction

Child maltreatment is defined as all forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation of children that results in actual or potential harm to a child's health, survival, development, or dignity in the context of a relationship of responsibility, trust, or power [1]. Four types of maltreatment are commonly recognised: sexual abuse, physical abuse, emotional abuse (also referred to as psychological abuse), and neglect ( Table 1).

There is a great deal of uncertainty around estimates of the frequency and severity of child maltreatment worldwide. Furthermore, much violence against children remains largely hidden and unreported because of fear and stigma and the societal acceptance of this type of violence [2]. Globally, prevalence of reported child sexual abuse varies from 2% to 62%, with some of this variation explained by a number of methodological factors including definition of abuse, method of data collection, and type of sample assessed [3]. In high-income countries, the annual prevalence of physical abuse ranges from 4% to 16%, and approximately 10% of children are neglected or emotionally abused [4]. Eighty percent of this maltreatment is perpetrated by parents or parental guardians [4], and poverty, mental health problems, low educational achievement, alcohol and drug misuse, having been maltreated oneself as a child, and family breakdown or violence between other family members are all important risk factors for parents abusing their children [5].

There is growing recognition that different forms of interpersonal violence have a large public health impact [6]. In children, the consequences of violence can vary widely. Physical injuries and, in extreme cases, death are direct consequences. World Health Organization (WHO) estimates of child homicide suggest that infants and very young children are at greatest risk, with rates for the 0- to 4-y age group about double those for 5- to 14-y-olds as a result of their dependency and vulnerability [5]. However, in the majority of non-fatal cases, the direct physical injury causes less morbidity to the child than the long-term impact of the violence on the child's neurological, cognitive, and emotional development and overall health [5].

Child maltreatment is a major public health problem, yet a lack of understanding of its serious lifelong consequences and of the cost and burden on society has hampered investment in prevention policies and programs. In order to effectively respond to the problem, the WHO 2006 report on prevention of child maltreatment [5] recommended expanding the scientific evidence base for the magnitude, consequences, and preventability of child maltreatment.

The relationship between child sexual abuse and adverse psychological consequences in adults is well established [7]-[9], and in the WHO comparative risk assessment study, Andrews and colleagues [3] carried out a systematic review and meta-analysis summarising the evidence of a relationship between child sexual abuse and subsequent mental disorders. This review is currently being updated in the new iteration of the Global Burden of Diseases, Injuries, and Risk Factors Study, aiming to provide global estimates of attributable burden for 1990 to 2010 [10], but other forms of child maltreatment have been omitted.

Exposure to non-sexual child maltreatment, namely, physical abuse, emotional abuse, and neglect, is associated with increased risk of a wide range of psychological and behavioural problems, including depression, alcohol abuse, anxiety, and suicidal behaviour, and with increased risk of HIV and herpes simplex virus type 2 (HSV2) infection [11]-[14]. However, the long-term health consequences of these other forms of child maltreatment have not been systematically examined. To address these omissions, clarify the present state of empirical research, and enable the quantification of the health impacts of child neglect, physical abuse, and emotional abuse at the population level using burden of disease and comparative risk assessment methodology, we conducted a systematic review of the scientific literature and quantitative meta-analyses. To the best of our knowledge, this is the first meta-analysis to summarise the evidence for associations between individual types of non-sexual child maltreatment and outcomes related to mental and physical health.

Methods

General recommendations from the PRISMA 2009 revision [15], with regard to processing and reporting of results, were taken into account ( Text S1). The meta-analysis conforms to the guidelines outlined by the Meta-analysis of Observational Studies in Epidemiology recommendations [16]. Methods and inclusion criteria were specified in advance and documented in a review protocol ( Text S2).

Inclusion and Exclusion Criteria

This systematic review and meta-analysis incorporated retrospective and prospective cohort, cross-sectional, and case-control studies meeting the following inclusion criteria: (1) the study reported original, empirical research published in a peer-reviewed journal, (2) the study considered non-sexual child maltreatment as a potential risk factor for loss of health, and (3) the related health outcomes or behavioural risk factors were among those listed in the Global Burden of Diseases, Injuries, and Risk Factors Study [10]. Studies reporting exposure only to combined types of abuse were excluded. Included studies reported odds ratios (ORs) and confidence intervals (CIs) comparing those exposed and not exposed by type of abuse or, alternatively, provided the information from which effect sizes and confidence intervals could be calculated ( Text S2).

Search Strategy

Three electronic databases (Medline, EMBASE, and PsycINFO up to 26 June 2012) were searched using full text and Medical Subject Headings (MeSH) terms to identify studies reporting an association between non-sexual child maltreatment and health outcomes ( Text S2). Truncation of terms was used to capture variation in terminology. The search was not restricted to the English language, nor restricted by any other means. Searches were conducted using synonyms and combinations of the following search terms: "maltreatment", "physical abuse", "psychological abuse", and "emotional abuse", and automatic explosion of the terms "child abuse" and "child neglect". The search was also not restricted to any particular health outcome. Instead, the broader terms "risk", "adverse effect", "consequences", "harm", and "association" were used to encompass all studies that investigated any adverse outcome of non-sexual child maltreatment. In addition, reference lists of selected studies were screened for any other relevant study, and additional studies were also identified through contact with study authors. Articles in languages other than English were translated.

Data Collection and Quality Assessment

Statistical Analyses

Weighted summary measures were computed using MetaXL, version 1.2 [18], a tool for meta-analysis in Microsoft Excel, with ORs chosen as the principal summary measure. Heterogeneity was quantitatively assessed using the Cochran's Q and I 2 statistics to evaluate whether the pooled studies represent a homogeneous distribution of effect sizes. Evidence of publication bias was investigated by means of funnel plots using the standard error on the y-axis [19].

To address the effects of important study characteristics and explore heterogeneity, we additionally conducted several pre-specified subgroup analyses (depending on data availability) by the following: gender of participants in the sample, geographic location (high income versus low-to-middle income), type of sample (population-based versus non-representative samples), measurement of abuse (self-reported versus official records), assessment of health outcome (structured clinical interview versus self-reported), prospective versus retrospective assessment of abuse and neglect, and appropriate adjustment versus no or inadequate adjustment for confounders.

Results

Out of 285 articles assessed for eligibility, 124 studies provided evidence of a relationship between non-sexual child maltreatment and various health outcomes for use in subsequent meta-analyses ( Figure 1). The majority ( n = 112) were from Western Europe, North America, Australia, and New Zealand. Data from low- and middle-income countries were sparse. Only 16 studies used a prospective cohort design that followed abused or neglected children over time to identify later health outcomes ( Table 3). The remaining studies included cohort, cross-sectional, and case-control studies that measured the maltreatment retrospectively, usually by self-report in adolescence or adulthood. Most of the studies included in our meta-analysis presented data from regional or nationally representative samples ( Table 3). The results of primary meta-analyses are presented in Tables 4- 6, with Figures S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11, S12, S13, S14, S15, S16, S17, S18, S19, S20, S21, S22, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, S33, S34, S35, S36, S37, S38, S39, S40, S41, S42 showing the forest plots of these meta-analyses. Details of subgroup analyses are presented in Tables S1, S2, S3, S4, S5, S6, S7, S8, S9, S10, S11.

Mental Disorders

Physically abused (OR = 1.54; 95% CI 1.16-2.04), emotionally abused (OR = 3.06; 95% CI 2.43-3.85), and neglected (OR = 2.11; 95% CI 1.61-2.77) individuals were found to have a higher risk of developing depressive disorders than non-abused individuals ( Table 4; Figures S1, S2, S3). The test for heterogeneity was highly significant, with p<0.01 for both abuse types and neglect. Funnel plots indicate the possibility of publication bias for physical abuse, as it appears that some smaller, less precise studies have a greater effect size than the larger studies, and there are no smaller studies to the left (negative) side of the graph, suggesting that some negative studies may never have been published ( Figure S4).

Physical abuse (OR = 1.51; 95% CI 1.27-1.79), emotional abuse (OR = 3.21; 95% CI 2.05-5.03), and neglect (OR = 1.82; 95% CI 1.51-2.20) were associated with a significantly increased risk of anxiety disorders ( Figures S5, S6, S7, S8). For physical abuse, significant associations were also observed with post-traumatic stress disorder (PTSD) and panic disorder diagnoses ( Table S2). A dose-response relationship was observed with physical abuse but not with emotional abuse and neglect [22], with anxiety disorders more likely with frequent physical abuse than with abuse that occurred only sometimes in childhood ( Table S2). Physical abuse, emotional abuse, and neglect were also associated with an almost 3-fold increased risk of developing eating disorders ( Figures S9, S10, S11, S12), and physical abuse was associated with a 5-fold increased risk of developing bulimia nervosa meeting Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria. Most of the evidence came from retrospective studies, and only one prospective study [23] reported a strong association with neglect in childhood ( Table S3). A dose-response relationship was also observed, with bulimia nervosa more likely with more severe and repeated physical abuse [24] ( Table S3).

Physical abuse and neglect were also associated with a doubling of the odds of childhood behavioural and conduct disorders ( Figures S13, S14, S15). With respect to physical abuse, higher odds of developing conduct and childhood behavioural disorders were observed in prospective than in retrospective studies, but differences were not statistically significant. Studies with non-representative samples had significantly increased effect size for the association between physical abuse and childhood behavioural problems and conduct disorder (OR = 5.98; 95% CI 2.73-13.10) compared with population-based studies (OR = 2.02; 95% CI 1.58-2.58) ( Table S4).

Although primary analyses suggest an increased risk of drug use associated with physical abuse (OR = 1.92; 95% CI 1.67-2.20), emotional abuse (OR = 1.41; 95% CI 1.11-1.79), and neglect (OR = 1.36; 95% CI 1.21-1.54) ( Figures S20, S21, S22, S23), there was only borderline significance in prospective studies, with a stronger consistent association observed in retrospective studies, albeit with overlapping confidence intervals ( Table S6). A dose-response relationship between emotional abuse and neglect and drug use was not consistently seen.

Physically abused (OR = 3.00; 95% CI 2.07-4.33), emotionally abused (OR = 3.08; 95% CI 2.42-3.93), and neglected (OR = 1.85; 95% CI 1.25-2.73) individuals had a significantly increased risk of suicidal behaviour compared with non-abused individuals ( Table 4). These significant associations continued in subgroup analyses by type of suicidal behaviour, with physically abused (OR = 3.40; 95% CI 2.17-5.32), emotionally abused (OR = 3.37; 95% CI 2.44-4.67), and neglected (OR = 1.95; 95% CI 1.13-3.37) individuals at a significantly increased risk of suicide attempt ( Figures S24, S25, S26, S27) and suicide ideation ( Table S7). There were no prospective studies investigating non-sexual child maltreatment and suicide attempt or ideation. Only one prospective study [25] was found investigating the association between self-inflicted injuries and exposure to physical abuse and neglect. Six studies [13],[26]-[30] presented the results by gender for physical abuse and suicide attempt and ideation, but no statistically significant differences were observed. One study showed that exposure to frequent childhood neglect was more strongly associated with suicidal behaviour than exposure to neglect that occurred sometimes [13] ( Table S7).

Sexually Transmitted Infections and Risky Sexual Behaviour

Chronic Diseases, Lifestyle Risk Factors, and Other Physical Health Outcomes

With regard to obesity, a significantly increased risk was observed for physical (OR = 1.32; 95% CI 1.06-1.64) and emotional abuse (OR = 1.24; 95% CI 1.13-1.36) but not for neglect (OR = 1.07; 95% CI 0.97-1.19) in the primary analysis ( Figures S32, S33, S34, S35). Subgroup analysis by assessment of outcome indicated that neglect was associated with a higher risk of developing self-reported obesity, but there was no association with obesity defined by waist circumference or body mass index (BMI) measurements ( Table S9). In the subgroup analysis by ascertainment of exposure to physical abuse, there was a strong association with obesity in one prospective study, but the magnitude of the effect was reduced in retrospective studies ( Table S9). A dose-response relationship between physical and emotional abuse and obesity has been observed [31] ( Table S9).

Physical (OR = 1.78; 95% CI 1.26-2.52) ( Figure S36) and emotional abuse (OR = 1.65; 95% CI 1.46-1.87) ( Figure S37) were associated with a significantly increased risk of current smoking, but the association was not significant for neglect in childhood (OR = 1.20; 95% CI 0.98-1.48). One study showed a dose response, with smoking more likely with physical abuse that occurred 3-5 times than with abuse that occurred 1-2 times, but this relationship did not continue into those who had been abused more than six times compared with those who had been abused 3-5 times [32] ( Table S10).

Discussion

To the best of our knowledge, this article presents the first systematic review and meta-analysis of published studies assessing the association between non-sexual child maltreatment and mental and physical health outcomes. We identified 124 studies that examined the association between physical abuse, emotional abuse, and neglect in childhood and various health outcomes.

Does Non-Sexual Child Maltreatment Cause Adverse Health Outcomes?

Evidence for a causal relationship between non-sexual child maltreatment and health outcomes was evaluated within the Bradford Hill framework on the grounds of the following important criteria: strength and consistency of the association, the temporal relationship of the association, evidence of a biological gradient or dose-response relationship, biological plausibility, and consideration of alternate explanations [34] ( Table S12).

Temporality

Both prospective and retrospective studies consistently showed an association between exposure to child physical abuse, emotional abuse, and neglect and adverse health outcomes. The availability of prospective studies provides conclusive evidence of a temporal relationship between exposure to non-sexual child maltreatment and the later development of mental health outcomes, drug use, and STIs and risky sexual behaviour, as in these studies abuse and neglect preceded the onset of health problems in adulthood.

However, only 16 studies were prospective, while the majority of the studies were cross-sectional and relied on adult retrospective report of abuse and neglect in childhood. By definition, these studies cannot prove a temporal relationship between exposure to child maltreatment and the onset of health outcomes. Furthermore, retrospective, self-reported information regarding abuse in childhood may be subject to recall bias, where those with adjustment problems may be more prone to recall or disclose exposure to abuse and neglect. In many cases participants were asked to report on events that would have occurred many years before, and the issue of potentially unreliable recall threatens the validity of the published literature on child maltreatment. At least with respect to child sexual abuse, evidence suggests moderate to good consistency of reports over time [35]. It has also been suggested that biases are probably towards under-reporting rather than over-reporting of abuse [36]. Nevertheless, given that retrospective reports were often the only measure of abuse available, particularly with regard to emotional abuse, we accepted these within the context of the limitations stated.

Consistency of the Association

As shown in the forest plots of the effects by study, there was strong consistency and agreement in the estimated effect measures across studies, particularly for neglect and physical abuse, although we suspect publication bias for some of the outcomes. Risk estimates were comparable across different types of samples, for both non-representative and representative populations ( Tables S1, S2, S3, S4 and S6, S7, S8). The findings persisted across different study designs, samples, and geographic regions investigated. It can be concluded that there is a highly consistent association between child physical abuse, emotional abuse, and neglect and adverse mental health outcomes, drug use, and STIs and risky sexual behaviour. We did not observe evidence of strong consistent associations for alcohol problems, chronic diseases, or lifestyle risk factors.

Dose-Response Relationship

We found evidence of a dose-response relationship between adverse health outcomes and non-sexual child maltreatment, such that those experiencing more severe abuse or neglect were at greater risk of developing mental disorders than those experiencing less severe maltreatment [39]. In the Chapman et al. [40] study, increasing severity of childhood adversity corresponded with poorer mental health outcomes. Consistent dose-response relationships with repeated, frequent, or severe abuse have been reported for mental disorders and physical abuse [13],[24],[41] and emotional abuse and neglect [13],[22]. Furthermore, there is evidence to suggest that experiencing multiple types of maltreatment may carry more severe consequences, with those exposed to multiple types of abuse at increased odds of developing mental disorders [42],[43], and the risk increases with the magnitude of multiple abuse [44]. Dose-response relationships with repeated frequent or severe abuse have also been reported for STIs and physical and emotional abuse [13], obesity and emotional and physical abuse [31], and smoking and physical abuse [32].

Plausibility

With respect to biological plausibility, animal models of mental disorders do not exist, making it particularly difficult to understand the underlying biological mechanisms. Progress in understanding has to be made by association and inference rather than experimental data [3]. There are nevertheless several potential mechanisms that may explain the observed association between abuse and neglect in childhood and increased risk of mental health problems. Neurobiological development can be physiologically altered by maltreatment during a child's early years, which can in turn negatively affect a child's physical, cognitive, emotional, and social growth, leading to psychological, behavioural, and learning problems that persist throughout the life course [45],[46]. Moreover, cumulative trauma may further increase risk [47], and some victims of abuse may try to manage the subsequent distress through the use of alcohol, prescription medication, tobacco, or other drugs.

Consideration of Alternate Explanations

It is important to note that the role of genes, environment, and gene-environment interactions in the causation of mental disorders is not well understood. Twin studies provide one of the best ways to examine the interplay between genetic and environmental influences [3], but to the best of our knowledge, these are only available for child sexual abuse. The relationship between abuse and neglect in childhood and subsequent health effects is complex. Although childhood abuse and neglect does result in adverse health outcomes, these outcomes are not independent of broader socioeconomic contexts. Lifestyle factors, access to health care, and neighbourhood characteristics may act as mediators between child abuse and neglect and long-term health consequences [49]-[51]. Exposure to child maltreatment often co-occurs within the context of other family dysfunction, social deprivation, and other environmental stressors that are also associated with mental disorders. Child maltreatment may be a marker of other family problems that together lead to the development of mental disorders. In addition, findings from many studies do not take into account the likely contribution of hereditary influences on the predisposition to mental disorders. Children of depressed parents may be at greater risk of depression through both exposure to maltreatment by their parents and genetic predisposition [43]. Hence, some of the effect of child abuse and neglect on mental disorders may still be explained by confounding. However, the effect of abuse on mental disorders remained significant in the majority of studies included in these meta-analyses after controlling for these co-occurring factors.

Assessment of Causality

In summary, there was robust evidence of significant associations between exposure to non-sexual child maltreatment and increased likelihood of a range of mental disorders, suicide attempts, drug use, STIs, and risky sexual behaviour. An increase in the likelihood of alcohol problem use was not consistently seen. There is weak to limited evidence suggesting a relationship between non-sexual child maltreatment and certain physical disorders and risk factors ( Table 8), but more research is required to confirm these relationships.

Study Limitations

Although these findings and conclusions seem to be relatively consistent and robust, they should be interpreted in light of a number of limitations of our analysis.

This meta-analysis may be subject to publication bias because non-significant findings are less likely to be published [52]. This problem is increased when statistical models are employed because often only significant estimates are reported in many studies. This may result in the association between child abuse and neglect and outcomes being overstated, particularly for depressive disorders and anxiety, where publication bias may have played a role. For some of the other conditions there were too few studies to make conclusions with respect to publication bias.

Measurement bias with respect to health outcomes and the questionable reliability of self-reported data may also have affected the results. We dealt with this issue in the meta-analysis by adjusting the quality score and performing subgroup analyses. For mental disorders, studies using well-validated and standardised diagnostic instruments were assigned a higher quality score than studies using self-report symptom scales.

Another limitation of meta-analyses of observational studies is that, since individuals cannot be randomly allocated to case groups, the influence of confounding variables cannot be fully evaluated. While most studies presented multivariable adjusted ORs controlling for a range of socio-demographic and study design variables, a few studies presented unadjusted associations between child maltreatment and health outcomes, or adjusted for age and sex only. We again dealt with this issue in our meta-analysis by adjusting the quality score of studies with inadequate control for confounding and by carrying out separate analyses depending on data availability. Some studies also statistically controlled for exposure to other forms of maltreatment by including the different types of abuse in the same model in order to determine the independent contribution of each abuse type. Generally, in studies presenting results from various unadjusted and adjusted models, the association between abuse and physical and mental health outcomes was attenuated when controlling for the effects of mediating variables [61]-[72] and other forms of abuse [73]-[79]. However, findings from a recent prospective cohort study indicate that for some physical health outcomes additional control for socioeconomic status, unhealthy behaviour, smoking, and mental health problems seems to play varying roles in attenuating or intensifying these complex relationships [33]. Furthermore, we cannot exclude that residual confounding or unmeasured potential confounders may still remain. Despite evidence of weak associations between non-sexual child maltreatment and chronic diseases, further studies are needed that ensure adequate adjustment for lifetime confounders, because the attributable burden would be appreciable.

Significant heterogeneity exists in the primary analysis of physical and emotional abuse, even after our attempts to control for study quality in quality effects models, and the heterogeneity remained significant in most of the subgroup analyses. Given this situation, combining the effects may not be justified. With respect to neglect, pooled estimates in primary and subgroup analyses did not show significant heterogeneity for many outcomes.

Recommendations

Inconsistencies in the measurement and definition of child maltreatment highlight the importance of international efforts to standardise studies to enhance the comparability of findings. These include defining the cutoff age for childhood (0-18 y, as specified by the United Nations), and breaking this period into smaller age bands that can reflect age-specific patterns [5]. Researchers should select methodologies and instruments with international comparisons in mind. Identical questionnaires, research designs, and interviewing techniques should ideally be used for surveys in different countries [5]. In reality, however, all survey methods will require at least some adaptation to local conditions, and efforts to ensure comparability should involve choosing definitions of abuse and neglect, and questionnaire items, that represent an advanced level of knowledge [80]. To minimise how participants' subjective perceptions and definitions shape the answers, it is recommended that self-report studies clearly specify the behaviours and experiences being investigated, and that each sub-type of abuse and neglect is explored using multiple behaviourally specific questions, instead of a single-item "label question" [81].

Examples of international efforts to increase comparability across studies include the WHO's establishment of a global adverse childhood experiences research network, and the International Society for Prevention of Child Abuse and Neglect's Child Abuse Screening Tools (ICAST). The WHO network has developed an international version of the Adverse Childhood Experiences (ACE) questionnaire (the ACE International Questionnaire), for administration to people aged 18 y and older, which is currently being validated through trial implementation as part of broader health surveys in several countries [82]. The ICAST initiative has involved the development of three instruments that ask parents about their use of different behaviours for discipline, young adults (18-24 y) about their exposure to child abuse and neglect in childhood, and older children about their own recent experiences of violence [83].

Child maltreatment deserves increased investment in preventive and treatment strategies. Currently, there is a paucity of evidence-based interventions to reduce child maltreatment. Further research is urgently needed to identify programs that reduce the prevalence of child maltreatment, thereby alleviating an important risk factor for later health problems. Evidence-based systemic interventions that improve parenting strategies and family functioning may be more effective and economical than attempting to treat the wide-ranging deleterious health outcomes in adulthood that arise from maltreatment in the early years of life [48],[84].

A broad range of protective factors have been identified that assist in promoting resilience in children exposed to adversity. Self control, problem-solving skills, secure relationships with caregivers, and safe schools and neighbourhoods are known to reduce the risk of adverse consequences in children exposed to trauma [85],[86]. There is mounting evidence that exposure to childhood adversity interacting with particular genetic dispositions such as the short allele of the serotonin transporter gene [87] and genes involved in the regulation of the hypothalamic-pituitary axis [88],[89] can result in problems with stress regulation and increased risk of anxiety and depression. Epigenetic changes have also been postulated as a mechanism by which transgenerational resilience or vulnerability may occur [90]. In spite of the increased knowledge in this field, it remains a challenge to translate this research into interventions at a population level that can reduce the vulnerability of children exposed to maltreatment [91].

Conclusion

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. There is also emerging evidence that neglect in childhood may be as harmful as physical and emotional abuse. Although these conclusions have been drawn before from single empirical studies, in this article they are demonstrated in aggregate quantitative effects, to our knowledge for the first time.

This review contributes to a better understanding and measurement of the non-injury health impacts of child maltreatment globally and enables quantification of the burden attributable to physical and emotional abuse and neglect at the population level using comparative risk assessment methodology [92]. All forms of child maltreatment should be considered as part of the cluster of interpersonal violence risk factors in future global comparative risk assessments. Attributable burden is likely to be substantial, given the high prevalence of these forms of child maltreatment, the strong associations reported in our analysis, and the fact that related health outcomes are among the leading causes of disease burden globally. Despite the magnitude of the problem and increasing awareness of its high social costs, preventing child maltreatment is not a political priority in most countries. It is imperative that epidemiology and public health approaches find their proper place at the forefront of national and international efforts to understand and prevent child maltreatment [93].

Acknowledgments

Sophie Moore is gratefully acknowledged for her contribution to the systematic review. Lars Eriksson and Keryl Michener, University of Queensland Health Sciences Library, are thanked for their assistance in designing the search strategy.

Author Contributions

Conceived and designed the experiments: REN TV. Performed the experiments: REN MB RD. Analyzed the data: REN MB. Wrote the first draft of the manuscript: REN. Contributed to the writing of the manuscript: REN MB RD AB JS TV. ICMJE criteria for authorship read and met: REN MB RD AB JS TV. Agree with manuscript results and conclusions: REN MB RD AB JS TV.

References

17. Wells G, Shea B, O'Connell D, Petersen J, Welch V, et al.. (2012) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. Ottawa: Ottawa Hospital Research Institute. Available: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 November 2012.

# data[].attributes.attachment_link.title
The Long-Term Health Consequences of Child Physical Abuse, Emotional Abuse, and Neglect: A Systematic Review and Meta-Analysis

# data[].attributes.attachment_link.description
Rosana Norman and colleagues conduct a systematic review and meta-analysis to assess the relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.

# data[].attributes.headline
Long-term consequences of Child sexual abuse are...

# data[].attributes.subject
Long-term consequences of Child sexual abuse are...

# data[].attributes.body
"More likely to exhibit symptoms of depression, anxiety, dissociation, PTSD, as well as behavioral problems such as aggression, delinquent behaviors, and school problems."

"Higher risk of depression and alcohol and drug abuse"

"Significantly earlier ages of first consensual intercourse, which was associated with increased sexually transmitted infections and risky behaviors"

"Results indicate that over 53% of sexually abused females reported at least one domestic violence experience compared to 24% of comparison females"

# data[].attributes.body
"Any recent act or failure to act on the part
of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act or failure to act that presents an imminent risk of serious harm."

# data[].attributes.body
Rejecting
Isolating
Terrorizing
Ignoring
Corrupting
Verbally Assaulting
Overpressuring

# data[].attributes.body
"Child sexual abuse is a form of child abuse that includes sexual activity with a minor. A child cannot consent to any form of sexual activity, period. When a predator engages with a child this way, they are committing a crime that can have lasting effects on the victim for years. Child sexual abuse does not need to include physical contact between a perpetrator and a child."

Non-physical sexual abuse...

exposing or flashing

showing pornography

exposing a child to sexual acts

making them masturbate

forcing a child to make, view or share child abuse images or videos

making, viewing or distributing child abuse images or videos

forcing a child to take part in sexual activities or conversations online or through a smartphone

http://www.ncdsv.org/publications_childsexabuse.html

# data[].attributes.attachment_link.readable_text
When a perpetrator intentionally harms a minor physically, psychologically, sexually, or by acts of neglect, the crime is known as child abuse. This page focuses specifically on child sexual abuse and the warning signs that this crime may be occurring.

What is child sexual abuse?

Child sexual abuse is a form of child abuse that includes sexual activity with a minor. A child cannot consent to any form of sexual activity, period. When a perpetrator engages with a child this way, they are committing a crime that can have lasting effects on the victim for years. Child sexual abuse does not need to include physical contact between a perpetrator and a child. Some forms of child sexual abuse include (but are not limited to):

Exhibitionism, or exposing oneself to a minor

Fondling

Intercourse

Masturbation in the presence of a minor or forcing the minor to masturbate

Obscene conversations, phone calls, text messages, or digital interaction

Producing, owning, or sharing pornographic images or movies of children

Sex of any kind with a minor, including vaginal, oral, or anal

Sex trafficking

Any other contact of a sexual nature that involves a minor.

What do perpetrators of child sexual abuse look like?

The majority of perpetrators are someone the child or family knows. As many as 93 percent of victims under the age of 18 know the abuser. A perpetrator does not have to be an adult to harm a child. They can have any relationship to the child including an older sibling or playmate, family member, a teacher, a coach or instructor, a caretaker, or the parent of another child. According to 1 in 6, "[Child] sexual abuse is the result of abusive behavior that takes advantage of a child's vulnerability and is in no way related to the sexual orientation of the abusive person."

Abusers can manipulate victims to stay quiet about the sexual abuse using a number of different tactics. Often an abuser will use their position of power over the victim to coerce or intimidate the child. They might tell the child that the activity is normal or that they enjoyed it. An abuser may make threats if the child refuses to participate or plans to tell another adult. Child sexual abuse is not only a physical violation; it is a violation of trust and/or authority.

How can I protect my child from sexual abuse?

A big part of protecting your child is about creating a dialogue. Read more to learn about creating this dialogue and keeping your child safe.

What are the warning signs?

Child sexual abuse isn't always easy to spot and some survivors may not exhibit obvious warning signs. The perpetrator could be someone you've known a long time or trust, which may make it even harder to notice. Consider some of the following common warning signs:

Physical signs:

Bleeding, bruises, or swelling in genital area

Bloody, torn, or stained underclothes

Difficulty walking or sitting

Frequent urinary or yeast infections

Pain, itching, or burning in genital area

Behavioral signs:

Changes in hygiene, such as refusing to bathe or bathing excessively

Develops phobias

Exhibits signs of depression or post-traumatic stress disorder

Expresses suicidal thoughts, especially in adolescents

Has trouble in school, such as absences or drops in grades

Inappropriate sexual knowledge or behaviors

Nightmares or bed-wetting

Overly protective and concerned for siblings, or assumes a caretaker role

Returns to regressive behaviors, such as thumb sucking

Runs away from home or school

Shrinks away or seems threatened by physical contact

Where can I get help?

If you want to talk to someone anonymously, call the National Child Abuse Hotline at 800.4.A.CHILD (422-4453), any time 24/7.

Learn more about being an adult survivor of childhood sexual abuse.

To speak with someone who is trained to help, call the National Sexual Assault Hotline at 800.656.HOPE (4673) or chat online at online.rainn.org.

Want to learn more about healing after child sexual abuse? Access RAINN's eight-week learning series "Redefining Resilience" with topics such as understanding trauma, moving past shame, managing memories, and more.

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warning signs of sexual abuse in children

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how to tell if a child is being molested

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how to tell if a child is being sexually abused

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signs that a child has been molested by another child

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When a perpetrator intentionally harms a minor physically, psychologically, sexually, or by acts of neglect, the crime is known as child abuse.

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"Physical child abuse is physical injury inflicted upon the child with cruel and/or malicious intent. Physical abuse can be the result of punching, beating, kicking, biting, burning, shaking, or otherwise harming a child physically."

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Physical child abuse: Next to child neglect, physical abuse is the second most frequently reported form of child abuse, accounting for 25% of all cases of child abuse.

Physical child abuse is physical injury inflicted upon the child with cruel and/or malicious intent. Physical abuse can be the result of punching, beating, kicking, biting, burning, shaking, or otherwise harming a child physically.

The parent or caretaker who abused the child may not have intended to hurt the child, but rather the child's injury may have resulted from overly harsh discipline or physical punishment. There is, in this regard, a substantial debate going on about certain forms physical discipline such as spanking and slapping and their relationship to more orthodox forms of physical abuse.

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Physical child abuse: Next to child neglect, physical abuse is the second most frequently reported form of child abuse, accounting for 25% of all cases of child abuse. Physical child abuse is physical injury inflicted upon the child with cruel and/or malicious intent.

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Sexual Abuse
Physical Abuse
Emotional Abuse
Neglect

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"[T]he role of [the abuser] has a significant effect on reproduction of new abusers and continuation of victimization of people in the society.

"This preliminary study shows that a remarkable number of patients with history of abuse in their childhood tend to behave as abusers in adulthood. As mentioned, it seems that evil is re-produced in each new generation."