A longitudinal study of the effects of chronic maltreatment on children's behavioral and emotional problems☆
Introduction
A number of studies have been conducted over the past few years in the field of child maltreatment with the objective of better understanding the relationships between childhood abuse and/or neglect and the presence of various behavioral and emotional problems. On the whole, the results of these studies present quite compelling evidence that maltreated children are likely to display major behavior problems and marked emotional difficulties (Crouch & Milner, 1993; Egeland, Yates, Appleyard, & van Dulmen, 2002; Johnson et al., 2002, Trickett and McBride-Chang, 1995), and certainly in a much greater proportion than children in normative populations (Jungmeen & Cicchetti, 2003; Lamphear, 1985; Maughan & Cicchetti, 2001). When child victims of abuse and neglect are compared with non-maltreated children, the results obtained using a number of instruments show almost systematically that the maltreated children have a greater degree of behavioral and emotional problems. Maltreated children display significantly more externalizing and internalizing behavior problems (de Paul & Arruabarrena, 1995; Erickson, Egeland, & Pianta, 1989; Shonk & Cicchetti, 2001; Wodarski, Kurtz, Gaudin, & Howing, 1990), more discipline problems at school (Kendall-Tackett & Eckenrode, 1996), and more symptoms of depression (Cerezo and Frias, 1994 Cerezo & Frias, 1994; Toth, Manly, & Cicchetti, 1992). Furthermore, they are more aggressive towards their peers or more socially withdrawn (Hoffman-Plotkin & Twentyman, 1984; Prino & Peyrot, 1994; Shields & Cicchetti, 2001), have fewer social skills (Levendosky, Okun, & Parker, 1995; Rogosch & Cicchetti, 1994) and are more likely to be rejected by their peers or be victims of their aggressivity (Rogosch & Cicchetti, 1994; Shields & Cicchetti, 2001). In addition, work by Shields and Cicchetti (2001) revealed that maltreated children have more problems with the regulation of emotions than non-maltreated children.
Although the many studies that have examined behavior problems in maltreated children have shown a link between experience of abuse and neglect and the presence of behavioral and emotional problems, very little research has focused on the developmental aspects of this relation (Trickett & McBride-Chang, 1995). As a result, many questions have not been clearly answered concerning the relation between dimensions or characteristics of maltreatment, such as the age of the children at the time of the abuse, and the development of behavioral and emotional problems over time. To date, very few longitudinal studies have focused on finding answers to such questions (Trickett & McBride-Chang, 1995) and yet according to Cicchetti (1994; cited in Bolger, Patterson, & Kupersmidt, 1998, p. 1175), “research that charts the sequelae of abuse and neglect across childhood is crucial to a better understanding of the effects of maltreatment on child development.”
In one such longitudinal study, Cicchetti and Rogosch (1997) examined the level of adaptation of school-aged maltreated and non-maltreated children who were evaluated yearly over a period of 3 consecutive years; these authors found that a greater percentage of maltreated children consistently showed a low level of adaptation at all three assessments. Over the 3-year period, the maltreated children exhibited more externalizing and internalizing behavior problems, less prosocial behavior, more symptoms of depression, and more withdrawal behavior than the non-maltreated children, suggesting a continuity in the difficulties experienced by the children who had been abused and neglected. Another 1 year longitudinal study by Lynch and Cicchetti (1998) on the links between child maltreatment, community violence and children's symptomatology also revealed that maltreated children showed more externalizing and internalizing behavior problems than their non-maltreated counterparts. These two studies, therefore, support the findings of cross-sectional studies, that is, maltreated children show significantly more behavioral and emotional problems than non-maltreated children. Moreover, the studies show that the links between maltreatment and these problems appear to last over time, or at least over a certain period of time.
One of the dimensions of maltreatment that has received little attention, but is essential to the understanding of the impact of maltreatment on the development of behavioral and emotional problems is chronicity. The importance of defining chronicity is clear as a significant proportion of cases of abuse and neglect are long lasting (Cicchetti & Barnett, 1991). Furthermore, an exploration of chronicity leads to a better understanding of the cumulative effects of chronic stressors on child development (Shaw, Vondra, Hommerding, & Keenan, 1994).
Chronicity is generally defined as a persisting situation of abuse and neglect. This implies that the abuse inflicted on the child takes place over a relatively long period of time. Despite sustained intervention by child protective services, families where maltreatment is a chronic problem require continuous follow-ups. In contrast, some maltreating families respond to child protective interventions by significantly improving the situation such that the health and safety of the child is no longer jeopardized. These cases are often referred to as transitory maltreatment. A comparison of children in situations of persisting maltreatment and those where the situation of neglect and abuse has improved considerably would shed more light on the impact of maltreatment on child behavioral and emotional outcome.
Among the few studies that have examined the chronic dimension of maltreatment (Bolger & Patterson, 2001; Bolger et al., 1998; Manly, Cicchetti, & Barnett, 1994), one found a direct link between chronicity and behavior problems (Manly et al., 1994). The social skills and behavior problems of 235 underprivileged children aged 5 and 11 years old (145 maltreated and 90 non-maltreated) were assessed while attending a summer camp program. Chronicity was measured according to the total number of months during which the family of the child had received child protection services; the greater the number of months of intervention, the more the situation was deemed chronic. The findings showed that after controlling for the presence and absence of maltreatment, chronicity was linked to problems of aggressive behavior as evaluated by the children's peers. The longer the maltreatment of a child had persisted, as suggested by the length of intervention, the more likely it was for peers to view the child as being aggressive and instigators of conflict.
Two other longitudinal studies carried out recently by Bolger and coworkers (Bolger & Patterson, 2001; Bolger et al., 1998) are relevant to an examination of the links between the chronic dimension of maltreatment and child behavioral and emotional outcome. In their first study, Bolger et al. (1998) found a relationship between various dimensions of maltreatment, including chronicity, and the quality of child peer relationships and self-esteem. Their sample was made up of 214 school-aged children (107 maltreated and 107 non-maltreated) who were assessed over 5 consecutive years. Chronicity was determined based on each child's CPS file: the beginning of maltreatment and the moment it ceased were determined with as much accuracy as possible and the span of time between the two was the measure of chronicity. In their studies, chronicity ranged from 1 to 14 years. The results of their first study showed that chronicity predicted the level of a child's popularity among peers, no matter what type of abuse was involved or the level of severity of the abuse. Chronicity was also associated with problems of self-esteem. In a second study using the same sample of children, Bolger and Patterson (2001) found a link between the various dimensions of maltreatment, including chronicity, and aggressive behaviors, rejection by peers and social withdrawal. The results of the second study revealed that chronicity of maltreatment was associated with a greater risk of rejection by peers and this held true repeatedly over a number of years, from childhood to mid-adolescence. Chronicity was also associated with higher levels of aggressive behavior, whether reported by peers, teachers, or the children themselves (results which support the findings of Manly et al., 1994). The authors state that these links appear to be already well established by school age and continue to be a factor at least until the beginning of adolescence, thus suggesting continuity in the relations between maltreatment and the presence of behavioral and emotional problems.
However, because in the studies discussed above the authors did not concomitantly and repeatedly assess both the maltreatment situation and the children's problems, their results do not shed light on what happens with the problems of maltreated children once maltreatment ceases or diminishes. This leaves several pertinent questions unanswered, such as: “When maltreatment ceases, or at least diminishes, do child behavior problems decrease or disappear?” Only studies that use a longitudinal and prospective approach in their examination of both child maltreatment and the presence of behavioral and emotional problems will be able to provide answers to that type of question.
Another limitation of these studies is the way chronicity is defined, usually by the number of months (or years) over which a family receives services (Manly et al., 1994). This can only be an approximation of the actual duration of maltreatment, since services may cease for administrative reasons (or other reasons) and the maltreatment may well continue. In spite of their limitations, these studies do underline the importance of considering the chronic aspect of maltreatment when examining behavior problems in maltreated children.
In any discussion of the concept of chronicity of maltreatment, it is crucial to differentiate between the duration of services provided by child protection agencies and the actual situation of the maltreated children. We, therefore, believe that in addition to the number of months or years of CPS intervention other criteria must be included in order to arrive at a definition of chronicity. For that reason, in the present study we have included the level of potential abuse by the mother as an additional criterion. Since all of the children in the current sample were maltreated at the start of the study and all mothers were at least one of the perpetrators in the alleged reports of maltreatment, we believe that the use of this measure, in addition to the information contained in the CPS files, could result in a more precise assessment of chronicity. The fact that we used a longitudinal and prospective (as opposed to retrospective) research strategy, in which both the maltreatment situation and the children's behavior problems were assessed on a number of occasions, should serve to overcome some of the limitations of past studies and more accurately identify the nature of the links between chronic maltreatment and behavioral outcome.
The present study was designed to explore the relationship between maltreatment and child behavior problems across childhood. Its main originality, in addition to the new method of measuring chronicity, lies in the fact that it compares two groups of maltreated children. Our objective was to answer the following questions: (1) Do chronically maltreated children display greater behavior problems than children in family situations that involve transitory maltreatment? (2) Are there differences in the type of problems displayed (externalizing problems, internalizing problems, etc.) by the children, depending on which group they are in? (3) Do the children's problems increase or decrease over time, depending on which group they are in? (4) Are chronically maltreated children more likely to display a clinical level of behavior problems than children in maltreatment situations characterized as transitory?
More specifically, we put forward the following hypotheses: (1) Chronically maltreated children will exhibit more behavior problems than children whose maltreatment was transitory; (2) The children in both groups will display the same types of problem; only the degree of the problems will differ; (3) The level of behavior problems will decrease for the children in the Transitory group and remain stable or increase for those in the Chronic group; (4) The chronically maltreated children will be more likely to display a clinical level of behavior problems compared to their peers living in situations that involve transitory maltreatment.
Section snippets
Participants
A sub-sample of 49 maltreated preschoolers and school-aged children and their mothers who completed all three evaluations were selected from a larger sample (93 maltreating families). The participants in this larger sample were initially evaluated as part of a broader longitudinal study on the impact of an intervention program called the Personal, Family and Community Help Program (PFCHP; Éthier, Couture, Lacharité, & Gagnier, 1995). The PFCHP, developed from an ecological framework, is a
Preliminary analyses
Table 1 shows the comparison of socio-demographic variables between the mothers and children of the CH and the TR groups. The groups were not statistically different except for the type of family (single or dual-parent family). Since the type of family was not found to be correlated with children's behavior problems at each assessment time, we did not consider this variable further.
Chronicity and behavior problems
Table 2 shows the means (and standard deviations) for the scores obtained by the children on the CBCL for the
Discussion
Overall, the results of the present study suggest that chronicity of maltreatment is an important variable that must be considered in studies examining the links between maltreatment and child behavioral and emotional outcomes. In this study, the chronically maltreated children showed, after 6 years, a greater proportion of emotional problems than their peers in transitory maltreatment situations. They were also more likely to exhibit a level of problems considered to be extremely elevated,
Acknowledgements
The authors would like to thank the Child Protection Services of the Mauricie-Centre du Québec sector for their help during the recruitment and follow-up of the families. Our thanks also go to Renèle Désaulniers (research project coordinator), to the GREDEF's graduate students for their invaluable assistance during data collection, to Tristan Milot who worked on the statistical analyses, as well as to the families who took part in the study.
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The present study was funded by the Fonds québécois de la recherche sur la société et la culture (FQRSC).