Abuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders, the fourth edition, text revision (DSM-IV-TR) under the heading of “Other Conditions That May Be a Focus of Clinical Attention.” Although abuse was initially defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse under a number of different circumstances. Abuse refers to harmful or injurious treatment of another human being that may include physical, sexual, verbal, psychological/emotional, intellectual, or spiritual maltreatment. Abuse may coexist with neglect, which is defined as failure to meet a dependent person’s basic physical and medical needs, emotional deprivation, and/or desertion. Neglect is sometimes described as passive abuse.
The costs of abuse to society run into billions of dollars annually in the United States alone. They include not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors.
Physical abuse refers to striking or beating another person with the hands or an object, but may include assault with a knife, gun, or other weapon. Physical abuse also includes such behaviors as locking someone in a closet or other small space, depriving someone of sleep, and burning, gagging, or tying someone up. Physical abuse of infants or children may include shaking them, dropping them on the floor, or throwing them against the wall or other hard object.
Sexual abuse refers to inappropriate sexual contact between a child or adult and a person who has some kind of family or professional authority over that child or adult. Sexual abuse may include verbal remarks, fondling or kissing, or attempted or completed intercourse. Sexual contact between a child and a biological relative is known as incest, although some therapists extend the term to cover sexual contact between a child and any trusted caregiver, including relatives by marriage. Girls are more likely than boys to be abused sexually. According to a conservative estimate, 38% of girls and 16% of boys are sexually abused before their eighteenth birthday.
Verbal abuse refers to regular and consistent belittling, name-calling, labeling, or ridicule of a person. It may also include spoken threats. It is one of the most difficult forms of abuse to prove because it does not leave physical scars or other evidence, but it is nonetheless hurtful. Verbal abuse may occur in schools or workplaces as well as in families.
Emotional/psychological abuse covers a variety of behaviors that hurt or injure others even though no physical contact may be involved. In fact, emotional abuse is a stronger predictor than physical abuse of the likelihood of suicide attempts in later life. One form of emotional abuse involves the destruction of someone’s pet or valued possession in order to cause pain. Another abusive behavior is emotional blackmail, such as threatening to commit suicide unless the other person does what is wanted. Other behaviors in this category include the silent treatment, shaming or humiliating people in front of others, or punishing them for receiving an award or honor.
Intellectual/spiritual abuse refers to such behaviors as punishing people for having different intellectual interests or religious beliefs from others in the family, preventing them from attending worship services, ridiculing their opinions, and the like.
Child abuse first attracted national attention in the United States in the 1950s, when a Denver pediatrician named C. Henry Kempe began publishing his findings regarding x-ray evidence of intentional injuries to small children. Kempe’s research was followed by numerous investigations of other signs of child abuse and neglect, including learning disorders, malnutrition, failure to thrive, conduct disorders, emotional retardation, and sexually transmitted diseases in very young children.
Experts believe that child abuse in the United States is still significantly underreported. In 2004, there were an estimated 1,490 child deaths from abuse or neglect in the United States, indicating a rate of two children for every 100,000 in the population. In recent years, the rate of maltreatment and child abuse appears to have decreased and was reported in 2004 to be 11.9 children for every thousand in the United States. The forms of abuse included neglect, physical abuse, sexual abuse, and emotional or psychological abuse. Of the children who survive abuse, an estimated 20% have permanent physical injury. Children with birth defects, developmental delays, or chronic illnesses are at higher risk of being abused by parents or other caregivers.
The women’s movement of the 1970s led not only to greater recognition of domestic violence and other forms of abuse of adults, but also to research into the factors in the wider society that perpetuate abusive attitudes and behaviors. Women are more likely than men to be the targets of abuse in adult life, and one in four women will experience domestic violence in her lifetime.
Domestic violence refers to the physical, emotional, and sexual abuse of a spouse or domestic partner. Early research into the problem of wife battering focused on middleclass couples, but it has since been recognized that spouse abuse occurs among couples of any socioeconomic status. In addition, domestic violence also occurs among gay and lesbian couples. It is estimated that four million women in the United States are involved in abusive marriages or relationships;moreover, a significant percentage of female murder victims are killed by their spouses or partners rather than by strangers.
Domestic violence illustrates the tendency of abusive people to attack anyone they perceive as vulnerable: most men who batter women also abuse their children; some battered women abuse their children; and abusive humans are frequently cruel to animals.
Elder abuse has also become a subject of national concern in the last two decades. As older adults live longer, many become dependent for years on adult caregivers, who may be either their own adult children or nursing home personnel. Care of the elderly can be extremely stressful, especially if the older adult has dementia. Elder abuse may include physical hitting or slapping; withholding food or medications; tying them to a chair or bed; neglecting to bathe them or help them to the toilet; taking their personal possessions, including money or property; and restricting or cutting off their contacts with friends and relatives.
Abusive professional relationships
Adults can also be abused by sexually exploitative doctors, therapists, clergy, and other helping professionals. Although instances of this type of abuse were dismissed prior to the 1980s as consensual participation in sexual activity, most professionals now recognize that these cases actually reflect the practitioner’s abuse of social and educational power. About 85% of sexual abuse cases in the professions involve male practitioners and female clients; another 12% involve male practitioners and male clients; and the remaining 3% involve female practitioners and either male or female clients. Ironically, many of these abusive relationships hurt women who sought professional help in order to deal with the effects of childhood abuse.
Stalking, or the repeated pursuit or surveillance of another person by physical or electronic means, is now defined as a crime in all 50 states. Many cases of stalking are extensions of domestic violence, in that the stalker (usually a male) attempts to track down a wife or girlfriend who left him. However, stalkers may also be casual acquaintances, workplace colleagues, or even total strangers. Stalking may include a number of abusive behaviors, including forced entry into a person’s home, destruction of cars or other personal property, anonymous letters to a person’s friends or employer, or repeated phone calls, letters, or e-mails. About 80% of stalking cases reported to police involve men stalking women.
Workplace bullying is, like stalking, increasingly recognized as interpersonal abuse. It should not be confused with sexual harassment or racial discrimination. Workplace bullying refers to verbal abuse of other workers, interfering with their work, withholding equipment or other resources they need to do their job, or invading their personal space, including touching them in a controlling manner. Half of all work-place bullies are women, and the majority (81%) are bosses or supervisors.
The causes of interpersonal abuse are complex and overlapping. Some of the most important factors are:
- early learning experiences: This factor is sometimes described as the “life cycle” of abuse. Many abusive parents were themselves abused as children and have learned to see hurtful behavior as normal childrearing. At the other end of the life cycle, some adults who abuse their elderly parent are paying back the parent for abusing them in their early years.
- ignorance of developmental timetables: Some parents have unrealistic expectations of children in terms of the appropriate age for toilet training, feeding themselves, and similar milestones; they may attack their children for not meeting these expectations.
- economic stress: Many caregivers cannot afford part-time day care for children or dependent elderly parents, which would relieve some of their emotional strain. Even middle-class families can be financially stressed if they find themselves responsible for the costs of caring for elderly parents before their own children are financially independent.
- lack of social support or social resources: Caregivers who have the support of an extended family, religious group, or close friends and neighbors are less likely to lose their self-control under stress.
- substance abuse: Alcohol and mood-altering drugs do not cause abuse directly, but they weaken or remove a person’s inhibitions against violence toward others. In addition, the cost of a drug habit often gives a person with a substance addiction another reason for resenting the needs of the dependent person. A majority of workplace bullies are substance addicts.
- mental disorders: Depression, personality disorders, dissociative disorders, and anxiety disorders can all affect parents’ ability to care for their children appropriately. A small percentage of abusive parents or spouses are psychotic.
- belief systems: Many men still think that they have a “right” to a relationship with a woman; and many people regard parents’ rights over children as absolute.
- the role of bystanders: Research in the social sciences has shown that one factor that encourages abusers to continue their hurtful behavior is discovering that people who know about or suspect the abuse are reluctant to get involved. In most cases, bystanders are afraid of possible physical, social, or legal consequences for reporting abuse. The result, however, is that many abusers come to see themselves as invulnerable.
Abuse affects all dimensions of human development and existence.
Physical and neurobiological
In addition to such direct results of trauma as broken bones or ruptured internal organs, physically abused children often display retarded physical growth and poor coordination. Malnutrition may slow the development of the brain as well as produce such dietary deficiency diseases as rickets. In both children and adults, repeated trauma produces changes in the neuro-chemistry of the brain that affect memory formation. Instead of memories being formed in the normal way, which allows them to be modified by later experiences and integrated into a person’s ongoing life, traumatic memories are stored as chaotic fragments of emotion and sensation that are sealed off from ordinary consciousness. These traumatic memories may then erupt from time to time in the form of flashbacks.
Cognitive and emotional
Abused children develop distorted patterns of cognition (knowing) because they are stressed emotionally by abuse. As adults, they may experience cognitive distortions that make it hard for them to distinguish between normal occurrences and abnormal ones, or between important matters and relatively trivial ones. They often misinterpret other people’s behavior and refuse to trust them. Emotional distortions include such patterns as being unable to handle strong feelings, or being unusually tolerant of behavior from others that most people would protest.
Social and educational
The cognitive and emotional aftereffects of abuse have a powerful impact on adult educational, social, and occupational functioning. Children who are abused are often in physical and emotional pain at school; they cannot concentrate on schoolwork, and consequently fall behind in their grades. They often find it hard to make or keep friends, and may be victimized by bullies or become bullies themselves. In adult life, abuse survivors are at risk of repeating childhood patterns through forming relationships with abusive spouses, employers, or professionals. Even though survivors may consciously want to avoid further abuse, they are often unconsciously attracted to people who remind them of their family of origin. Abused adults are also likely to fail to complete their educations, or they accept employment that is significantly below their actual level of ability.
Treatment of the aftereffects of abuse must be tailored to the needs of the specific individual, but usually involves a variety of long-term considerations that may include legal concerns, geographical relocation, and housing or employment as well as immediate medical or psychiatric care.
Medical and psychiatric
In addition to requiring immediate treatment for physical injuries, abused children and adults often need long-term psychotherapy in order to recover from specific mental disorders and to learn new ways of dealing with distorted thoughts and feelings. This approach to therapy is known as cognitive restructuring. Specific mental disorders that have been linked to childhood abuse include major depression, bulimia nervosa, social phobia, Munchausen syndrome by proxy, generalized anxiety disorder, post-traumatic stress disorder, borderline personality disorder, dissociative amnesia, and dissociative identity disorder. Abused adults may develop post-traumatic stress disorder, major depression, or substance abuse disorders. At present, researchers are focusing on genetic factors as a partial explanation of the fact that some people appear to react more intensely than others to being abused.
Cognitive restructuring —An approach to psychotherapy that focuses on helping patients examine distorted patterns of perceiving and thinking in order to change their emotional responses to people and situations.
Dementia —A group of symptoms (syndrome) associated with a progressive loss of memory and other intellectual functions that is serious enough to interfere with a person’s ability to perform the tasks of daily life. Dementia impairs memory, alters personality, leads to deterioration in personal grooming, impairs reasoning ability, and causes disorientation.
Flashback —The reemergence of a traumatic memory as a vivid recollection of sounds, images, and sensations associated with the trauma. Those having the flashbacks typically feel as if they are reliving the event.
Incest —Unlawful sexual contact between people who are biologically related. Many therapists, however, use the term to refer to inappropriate sexual contact between any members of a family, including stepparents and stepsiblings.
Stalking —The intentional pursuit or surveillance of another person, usually with the intent of forcing that person into a dating or marriage relationship. Stalking is now punishable as a crime in all 50 states.
Medical professionals and, increasingly, religious professionals, are required by law to report child abuse to law enforcement officials, usually a child protection agency. Physicians are granted immunity from lawsuits for making such reports.
Adults in abusive situations may encounter a variety of responses from law enforcement or the criminal justice system. In general, cases of spouse abuse, stalking, and sexual abuse by professionals are taken more seriously than they were two or three decades ago. Many communities now require police officers to arrest aggressors in domestic violence situations, and a growing number of small towns as well as cities have shelters for family members fleeing violent households. All major medical, educational, and legal professional societies, as well as mainstream religious bodies, have adopted strict codes of ethics, and have procedures in place for reporting cases of abuse by their members.
Prevention of abuse requires long-term social changes in attitudes toward violence, gender roles, and the relationship of the family to other institutions. Research in the structure and function of the brain may help to develop more effective treatments for the aftereffects of abuse and possibly new approaches to help break the intergenerational cycle of abuse. At present, preventive measures include protective removal of children or elders from abusive households, legal penalties for abusive spouses and professionals, and education of the public about the nature and causes of abuse.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., Text rev. Washington, D.C.: American Psychiatric Association, 2000.
Baumeister, Roy F., PhD. Evil: Inside Human Violence and Cruelty. New York: W. H. Freeman and Company, 1999.
Beers, Mark H., MD. “Chapter 41: Behavior Disorders in Dementia.” The Merck Manual of Geriatrics, Mark H. Beers, MD, and Robert Berkow, MD, eds. Whitehouse Station, NJ: Merck Research Laboratories, 2000.
“Child Abuse and Neglect.” Section 19, Chapter 264 in The Merck Manual of Diagnosis and Therapy, Mark H. Beers, MD, and Robert Berkow, MD, eds. Whitehouse Station, NJ: Merck Research Laboratories, 1999.
Herman, Judith, MD. Trauma and Recovery. 2nd ed., revised. New York: Basic Books, 1997.
Marcantonio, Edward, MD. “Dementia.” Chapter 40 in The Merck Manual of Geriatrics, Mark H. Beers, MD, and Robert Berkow, MD, eds. Whitehouse Station, NJ: Merck Research Laboratories, 2000.
Morris, Virginia. How to Care for Aging Parents. New York: Workman Publishing, 1996.
Rutter, Peter, MD. Sex in the Forbidden Zone: When Men in Power—Therapists, Doctors, Clergy, Teachers, and Others—Betray Women’s Trust. New York: Jeremy P. Tarcher, 1989.
Stout, Martha, PhD. The Myth of Sanity: Tales of Multiple Personality in Everyday Life. New York: Penguin Books, 2001.
Walker, Lenore E., PhD. The Battered Woman. New York: Harper & Row, 1979.
Weitzman, Susan, PhD. “Not to People Like Us”: Hidden Abuse in Upscale Marriages. New York: Basic Books, 2000.
Carter, Ann. “Abuse of Older Adults.” Clinical Reference Systems Annual (2000): 12.
Gibb, Brandon E., and others. “Childhood Maltreatment and College Students’ Current Suicidal Ideation: A Test of the Hopelessness Theory.” Suicide and Life-Threatening Behavior 31 (2001): 405–15.
Lieb, Roselind. “Parental Psychopathology, Parenting Styles, and the Risk of Social Phobia in Offspring: A Prospective-Longitudinal Community Study.” Journal of the American Medical Association 284 (December 13, 2000): 2855.
Plunkett, A., and others. “Suicide Risk Following Child Sexual Abuse.” Ambulatory Pediatrics 1 (September-October 2001): 262–66.
Redford, Jennifer. “Are Sexual Abuse and Bulimia Linked?” Physician Assistant 25 (March 2001): 21.
Steiger, Howard, and others. “Association of Serotonin and Cortisol Indices with Childhood Abuse in Bulimia Nervosa.” Archives of General Psychiatry 58 (September 2001): 837.
Strayhorn, Joseph M., Jr. “Self-Control: Theory and Research.” Journal of the American Academy of Child and Adolescent Psychiatry 41 (January 2002): 7–16.
Van der Kolk, Bessel. “The Body Keeps the Score: Memory and the Evolving Psychobiology of PTSD.” Harvard Review of Psychiatry 1 (1994): 253–65.
American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. Telephone: (202) 966-7300. Fax: (202) 966-2891. <http://www.aacap.org>.
C. Henry Kempe National Center for the Prevention and Treatment of Child Abuse and Neglect. 1205 Oneida Street, Denver, CO 80220. Telephone: (303) 321-3963.
National Coalition Against Domestic Violence. 1120 Lincoln Street, Suite 1603, Denver, CO, 80203, Telephone: (303) 839-1852, Fax: (303) 831-9251, TTY: (303) 839-1681. <http://www.ncadv.org>.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. Telephone: (301) 443-4513. <http://www.nimh.nih.gov>.
Campaign Against Workplace Bullying. P. O. Box 1886, Benicia, CA 94510. <http://www.bullybusters.org>.
Child Welfare Information Gateway. “Child Abuse and Neglect Fatalities: Statistics and Interventions.” 2006. <http://www.childwelfare.gov/pubs/factsheets/fatality.pdf>.
National Library of Medicine. National Institutes of Health. “Domestic Violence.” <http://www.nlm.nih.gov/medlineplus/domesticviolence.html>.
U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Mal-treatment 2004 (Washington, D.C.: U.S. Government Printing Office, 2006). <http://www.acf.hhs.gov/programs/cb/pubs/cm04/cm04.pdf>.
Rebecca Frey, PhD
Emily Jane Willingham, PhD