CHAPTER 27
Maltreatment
Maltreatment of children and adolescents became widely recognised in
the USA in the 1960s and since then has been uncovered throughout
the world wherever systematic enquiry has taken place. Most definitions
incorporate two elements: (1) evidence of behaviour towards the child,
which is likely to be damaging; and (2) evidence of harm to the child
resulting from this. Note that intention is not part of the definition; some
parents may feel they love their children dearly but nonetheless may harm
them, albeit unwittingly. Sometimes maltreatment is easy to recognise,
for example, a girl with scalded buttocks with a parent who confesses to
dipping her in a boiling bath to teach her a lesson. At other times it is
far harder, for example, a neglected boy who has conduct disorder and
whose parents are of low intelligence. How much avoidable harm has been
done, or would he have turned out this way even if well looked after?
Information is far from precise on how much neglect is required to cause
specific, measurable damage.
Abuse and neglect cases can be some of the most disturbing and heart-
wrenching experiences in child and adolescent psychiatry, sometimes
evoking horror and a wish to rescue the victim immediately. Therefore
it is important to keep a sense of perspective on how good the evidence
is that abuse is indeed happening, and to have a sympathetic team for
emotional support to stop one becoming overwhelmed by, or cut off from,
what is seen.
Types of maltreatment include:
Physical abuseNon-accidental injury: head injuries, fractures, burns and
scalds, bruises. Munchausen syndrome by proxy (factitious illness by
proxy). Non-organic failure to thrive and psychosocial short stature.
NeglectLack of: physical and medical care, supervision, emotional close-
ness, stimulation.
Emotional abuseHostility, deprivation of attention, threats to abandon,
inappropriate demands.
Sexual abusePenetrative, non-penetrative; intrafamilial, extrafamilial; of
girls, of boys.
Child and Adolescent Psychiatry, Third Edition. Robert Goodman and Stephen Scott.
©c2012 Robert Goodman and Stephen Scott. Published 2012 by John Wiley & Sons, Ltd.
210