Adverse Childhood Experiences (ACEs) and Child Maltreatment

Important:  If you have been subjected to any type of abuse, going through this material may be challenging for you.  There are some key points to remember.  It can be helpful to work through past abuse and if you need assistance or a referral, do not hesitate to ask. What happened to you is not your fault.  If you have been abused and decide to forgive the abuser it does not mean that what they did was okay, but that you are working to move forward. Each individual has a choice as to whether they continue the cycle of the behavior or make a decision to do things differently.

Adverse Childhood Experiences (ACEs) is the term used to describe all types of abuse, neglect, and other potentially traumatic experiences that occur to people under the age of 18.

Adverse Childhood Experiences have been linked to

• risky health behaviors,
• chronic health conditions,
• low life potential, and
• early death.

As the number of ACEs increases, so does the risk for these outcomes.

The presence of ACEs does not mean that a child will experience poor outcomes. However, children’s positive experiences or protective factors can prevent children from experiencing adversity and can protect against many of the negative health and life outcomes even after adversity has occurred.

It is important to address the conditions that put children and families at risk of ACEs so that we can prevent ACEs before they happen.

Child maltreatment is a considerable social and public health problem in the United States. Unfortunately, data underestimates the number of children impacted by maltreatment due to underreporting and focus on a single data source. Research into the consequences of child maltreatment has identified various acute and severe negative outcomes such as death, injury, and traumatic brain injury. Research has also uncovered many negative long-term developmental outcomes: academic problems, anxiety, conduct disorder, childhood aggression, delinquency, depression, increased risk for suicide, high-risk sexual behavior, interpersonal problems, poor physical health, posttraumatic stress disorder, risky health behaviors, substance abuse, and youth violence. These substantial short- and long-term consequences make prevention, early identification, and intervention imperative. So many cases of child abuse go undetected or unreported. Again, when people do not speak up, other people get hurt – and sometimes even killed. Infants and children are at risk. In many cases, they do not know what constitutes inappropriate treatment and are powerless to do anything about it.  Innocent children are dependent on others to protect them.

Do I Have to Be a “Mandated Reporter” in order to Report?

NO, “mandated reporters” have a legal responsibility to report suspicion, but every citizen should be vigilant about looking for signs of possible abuse/neglect.  Children in these situations are often powerless to help themselves.  Although it is not a legal responsibility for a non-mandated reporter, you would not feel good to hear that a child’s situation that you were aware of ended in harm or even death when it might have been prevented.  People often hesitate for various reasons that will be addressed in this chapter, however, remember that a report is not an accusation, but a request for an investigation to rule out abuse or neglect.  Sometimes parents or caregivers are simply lacking resources or supports that would make the situation safe for a child.

Who Are Mandated Reporters? Individuals in certain occupations are mandated by law to report situations where there is reasonable suspicion. If, for example, you are a teacher, a health care provider, a counselor, or a law enforcement officer and you see something suspicious, you are required by law to report it.  You may have doubts or don’t want to take the time to report. Later on, if the child is seriously hurt or killed and it comes out that you did not report your suspicions, you can be held legally liable. However, as noted above, anyone can report and should report when they see something that could help a child who may be in a harmful situation.

Child Abuse and Neglect

Children under the age of 18 may be exposed to abuse and neglect by a parent, caregiver, or another person in a custodial role (e.g., clergy, coach, teacher). There are four common types of child abuse and neglect.

• Physical abuse is the intentional use of physical force that can result in physical Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activity.
• Emotional/Psychological abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name calling, shaming, rejection, manipulation, withholding love.
• Neglect is the failure to meet a child’s basic physical and emotional needs such as housing, food, clothing, education, access to medical care, and failure to provide a safe and loving environment.

Child abuse and neglect result from the interaction of a number of individual, family, societal, and environmental factors. Child abuse and neglect are not inevitable—safe, stable, and nurturing relationships and environments are key for prevention. Preventing child abuse and neglect can also prevent other forms of violence, as various types of violence are interrelated and share many risk and protective factors, consequences, and effective prevention tactics. Using a public health approach, we can prevent child maltreatment before it starts.

Acts of Commission (Child Abuse)

Words or overt actions that cause harm, potential harm, or threat of harm

Acts of commission are deliberate and intentional; however, harm to a child might not be the intended consequence. Intention only applies to caregiver acts—not the consequences of those acts. For example, a caregiver might intend to hit a child as punishment (i.e., hitting the child is not accidental or unintentional), but not intend to cause the child to have a concussion. The following types of maltreatment involve acts of commission:

• Physical abuse
• Sexual abuse
• Psychological abuse

Acts of Omission (Child Neglect)

Failure to provide needs or to protect from harm or potential harm

Acts of omission are the failure to provide for a child’s basic physical, emotional, or educational needs or to protect a child from harm or potential harm. Like acts of commission, harm to a child might not be the intended consequence. The following types of maltreatment involve acts of omission:

• Physical neglect
• Emotional neglect
• Medical and dental neglect
• Educational neglect
• Inadequate supervision
• Exposure to violent environments

Why Is a Consistent Definition Important?

A consistent definition is needed to monitor the incidence of child abuse and neglect and to examine trends over time. In addition, a clear and consistent definition helps determine the magnitude of child abuse and neglect and allows comparison of the problem across jurisdictions.

Caregiver – A caregiver is a person, or people, who at the time of the maltreatment is in a permanent (primary caregiver) or temporary (substitute caregiver) custodial role. In a custodial role, the person is responsible for care and control of the child and for the child’s overall health and welfare.

Harm – Any acute disruption caused by the threatened or actual acts of commission or omission to a child’s physical or emotional health. Disruptions can affect the child’s physical, cognitive, or emotional development.

Threat of harm occurs when a parent or caregiver expresses an intention or gives signs or warnings through the use of words, gestures, or weapons to communicate the likelihood of inflicting harm to the child. Threat of harm can be explicit or implicit. Explicit threats would include such acts as pointing a gun at the child or raising a hand as if to strike the child. Implicit threats would include such acts as kicking holes in walls or breaking down doors.

Disruption of physical health includes, but is not exclusive to, physical injuries, avoidable illnesses, and inadequate nutrition.

Physical injuries are physical harm, including death, occurring to the body from exposure to thermal, mechanical, electrical, or chemical energy interacting with the body in amounts or rates that exceed the threshold of physiological tolerance, or from the absence of such essentials as oxygen or heat. Physical injuries can include physical marks, burns, lacerations, contusions, abrasions, broken bones, internal injuries, organ damage, poisoning, asphyxiation, or death because of physical injuries sustained. Avoidable illnesses are those illnesses that are preventable or induced as a result of denial of medical care, withholding of medication, or failure to immunize against typical childhood diseases. Examples include sexually transmitted disease, Munchausen’s Syndrome by Proxy, Pediatric Condition Falsification, and deliberate failure to immunize against a vaccine-preventable disease. Inadequate nutrition is defined as a failure by the caregiver to provide nutrition that is adequate for growth and physical development. Examples include hunger, malnutrition, and failure to thrive due to poor nutrition. Note that discrepancies in the definition of caregiver often occur in state laws.

Disruption of emotional health can include anxiety problems, disruption of social functioning, impaired relationships, depression and depressive symptoms, eating disorders, posttraumatic stress (including posttraumatic stress disorder [PTSD), externalizing behaviors (e.g., aggression), lack of education, school failure, delinquency, or substance abuse.

Harm can be immediate (e.g., broken bones) or delayed (e.g., depression, PTSD).

DEFINITIONS OF ACTS OF COMMISSION (CHILD ABUSE)

Physical Abuse – Physical abuse is defined as the intentional use of physical force against a child that results in, or has the potential to result in, physical injury. Physical abuse includes physical acts ranging from those which do not leave a physical mark on the child to physical acts which cause permanent disability, disfigurement, or death. Physical abuse can result from discipline or physical punishment. Physical acts can include hitting, kicking, punching, beating, stabbing, biting, pushing, shoving, throwing, pulling, dragging, dropping, shaking, strangling/choking, smothering, burning, scalding, and poisoning.

Sexual Abuse – Any completed or attempted (non-completed) sexual act, sexual contact with, or exploitation (i.e., noncontact sexual interaction) of a child by a caregiver. Sexual acts include contact involving penetration, however slight, between the mouth, penis, vulva, or anus of the child and another individual. Sexual acts also include penetration, however slight, of the anal or genital opening by a hand, finger, or other object. Genital on genital contact includes:  • Penis to vulva         • Penis to anus  • Penis to penis. Mouth on genital contact includes: • Mouth to penis • Mouth to anus • Mouth to vulva. Sexual acts can be performed by the caregiver on the child or by the child on the caregiver. A caregiver can also force or coerce a child to commit a sexual act on another individual (child or adult).

Abusive sexual contact includes intentional touching, either directly or through the clothing, of the following:  • Genitalia (penis or vulva)  • Anus  • Groin  • Breast  • Inner thigh  • Buttocks.

Abusive sexual contact does not have to involve penetration of any of the above. Abusive sexual contact can be performed by the caregiver on the child or by the child on the caregiver. Abusive sexual contact can also occur between the child and another individual (adult or child) through force or coercion by a caregiver. Abusive sexual contact does not include touching required for the normal care or attention to the child’s daily needs.

Noncontact Sexual Abuse does not include physical contact of a sexual nature between the caregiver and the child. Noncontact sexual abuse can include the following:

1. Acts which expose a child to sexual activity (e.g., pornography; voyeurism of the child by an adult; intentional exposure of a child to exhibitionism);
2. Filming of a child in a sexual manner (e.g., depiction, either photographic or cinematic, of a child in a sexual act);
3. Sexual harassment of a child (e.g., quid pro quo; creating a hostile environment because of comments or attention of a sexual nature by a caregiver to a child);
4. Prostitution of a child (e.g., employing, using, persuading, inducing, enticing, encouraging, allowing, or permitting a child to engage in or assist any other person to engage in, prostitution, or sexual trafficking. Sexual trafficking is defined as the act of transporting children for forced sexual activity such as prostitution or sexual slavery.

Psychological (Emotional) Abuse

Intentional caregiver behavior (i.e., act of commission) that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs. Psychological abuse can be continual (e.g., chronic and pervasive) or episodic (e.g., triggered by a specific context or situation: caregiver substance use/abuse).

Psychologically abusive behaviors may include blaming, belittling, degrading, intimidating, terrorizing, isolating, restraining, confining, corrupting, exploiting, spurning (rejecting), or otherwise behaving in a manner that is harmful, potentially harmful, or insensitive to the child’s developmental needs, or can potentially damage the child psychologically or emotionally. Terrorizing includes caregiver behavior that is life-threatening; makes a child feel unsafe (e.g., situations that are likely to physically hurt, kill, or abandon the child); sets unrealistic expectations of the child with threat of loss, harm, or danger if expectations are not met; and threatens or perpetrates violence against a child or a child’s loved ones or objects (including toys, pets, or other

possessions). For example, placing a child in unpredictable or chaotic circumstances would be considered terrorizing as would be placing a child in a situation reasonably considered dangerous by either the child or another adult. Psychological isolation occurs when a caregiver forbids, prevents, or minimizes a child’s contact with others.

DEFINITIONS OF ACTS OF OMISSION (CHILD NEGLECT)

Failure to Provide – Failure by a caregiver to meet a child’s basic physical, emotional, medical/dental, or educational needs—or combination thereof. Failure to provide includes the following:

Physical Neglect – Caregiver fails to provide adequate nutrition, hygiene, or shelter; or, caregiver fails to provide clothing that is adequately clean, appropriate size, or adequate for the weather. Several examples follow:

• Nutrition: A 9-year-old child makes dinner several times per week because the caregiver(s) are sleeping, away, or otherwise unavailable; a child misses or is denied meals on numerous occasions over time; a child is diagnosed as being severely malnourished.
• Hygiene: Child is dirty, smells bad, or has unwashed hair. Child’s living situation is unsanitary; dirty dishes and spoiled food are left on the kitchen table and counter.
• Shelter: Living arrangements for the child and family are unstable for two weeks or more; the residence is infested with roaches or vermin; residence in unheated or inadequately heated because caregivers have failed to ensure heat available.
• Clothing: The child always wears clothing that is too small; the child is not given a warm coat and gloves when the weather is cold.

Emotional Neglect

Caregiver ignores the child, or denies emotional responsiveness or adequate access to mental health care (e.g., caregiver does not respond to infant cries or older child’s attempt to interact).

Medical/Dental Neglect

Caregiver fails to provide adequate access to medical, vision, or dental care for the child. Examples include the following: • Caregiver does not administer prescribed medications; • Caregiver refuses to take the child for needed medical attention or seek timely medical attention.

Educational Neglect

Caregiver fails to provide access to adequate education. Examples include:

• Caregiver allows child to miss 25 or more school days in one academic year without excuse;
• Caregiver does not enroll the child in school (if not home schooled); caregiver encourages a child (under 16 years of age) to drop out of school.

Failure to Supervise – Failure by the caregiver to ensure a child’s safety within and outside the home given the child’s emotional and developmental needs.

Inadequate Supervision   

Failure by the caregiver to ensure that the child engages in safe activities and uses appropriate safety devices, to ensure that the child is not exposed to unnecessary hazards; or to ensure appropriate supervision by an adequate substitute caregiver. Inadequate supervision (sometimes called “supervisional neglect”) includes occasions when a caregiver knowingly fails to protect a child from

maltreatment perpetrated by a substitute caregiver. Under such conditions, the primary caregiver’s behavior would be considered neglectful only if the maltreatment was recognized and allowed to occur. Regardless of the primary caregiver’s knowledge of the maltreatment, the substitute caregiver’s behavior would be considered maltreatment.

Exposure to Violent Environments 

Caregiver intentionally fails to take available measures to protect the child from pervasive violence within the home, neighborhood, or community. For example, a caregiver who sells illicit drugs out of the child’s home exposes the child to a violent environment; or, a school bus driver (temporary caregiver) who allows a student to be routinely victimized by another student while riding the bus without taking steps to intervene (e.g., notifying school administrators) also exposes a child to a violent environment. Exposure of a child to violence between caregivers in the home may also qualify as exposure to a violent environment, particularly if the caregivers do not take available measures to protect the child from exposure. But, in instances where the caregiver is being victimized by a partner, and alternatives to protect the child are not available, or the caregiver is unaware of alternatives, the caregiver is not maltreating the child.1

• Sudden change in behavior
• Withdrawn, signs of depression, anxiety
• Learning difficulties with no known cause
• Not wanting to go home
• Not wanting to be around parent, guardian, sibling
• Attempts to run away
• Parents may keep child overly neat and clean to cover abuse
• Not allowed to have friends over

1. Signs and Symptoms of Physical Abuse

• Injuries that do not match explanation
• Marks that appear to be from a hand or an object
• Injuries that are healing at different times
• Untreated medical issues
• Fear of adults, a parent or guardian
• Abuse of animals or pets
• Wearing long clothing inappropriate for weather
• Avoidance of physical contact
• Withdrawing from friends and family
• Parent describes child in a negative way
• History of abuse in family
• Use of physical punishment

2. Signs and Symptoms of Neglect

• Poor hygiene
• Lack of medical, mental or dental care
• Frequently miss school
• Steal money or food
• Eat an unusual amount or hide food
• Need new or weather-appropriate clothing
• Say they are home alone a lot

3. Signs and Symptoms of Sexual Abuse

• Note – Sexual abuse can be very difficult to detect
• Have trouble sitting or walking
• Overly modest or overly open about nudity/sexuality
• Nightmares
• Bed wetting
• Lack of appetite
• Demonstrates inappropriate knowledge of sex
• Fear or hesitation around parent, guardian or sibling
• Get attached to strangers quickly
• Discomfort or markings around the genitals
• Sexually abuses other children
• Pregnancy or STI
• Tries to run away
• May try to tell indirectly

4. Signs and Symptoms of Emotional Abuse

• Constantly worry they are doing something wrong
• Distant from parent or caregiver
• Delays in learning, emotional development or speech
• Poor academic performance
• Attention seeking
• Behavior inappropriate for age
• Depression
• Low self-esteem
• Headaches or stomach issues with no known causes
• Lack interest in activities or friends