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J Am Acad Child Adolesc Psychiatry. Author manuscript; available in PMC 2019 July 09.
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Published in final edited form as:

J Am Acad Child Adolesc Psychiatry. 2018 September ; 57(9): 637–644. doi:10.1016/j.jaac.2018.06.007.

Child Abuse and Neglect

Charles H. Zeanah, MD and
Tulane University School of Medicine, New Orleans, LA.

Kathryn L. Humphreys, PhD, EdM

Tulane University School of Medicine, New Orleans, LA.

Vanderbilt University, Nashville, TN.

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Abstract
Physical, sexual, and emotional abuse and various forms of neglect of children are associated with
substantially increased risk for concurrent and subsequent psychopathology and are among the
common problems encountered by clinicians in many clinical settings. Such cases pose additional
challenges for clinicians because of the many complex family and system forces that engulf these
children and their families. Assessing maltreated children generally requires more time than
evaluations of children who have not experienced maltreatment. Young children, who experience
the highest rates of maltreatment, present especially complex assessments because they are so
dependent upon their caregiving environments. Treatment of psychopathology associated with
maltreatment, which is often multimodal, requires addressing a variety of external factors that may
perpetuate or exacerbate symptoms and impaired functioning. We suggest that the more clinicians
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understand the different cultures of the legal and child protective services systems will help them
advocate more effectively for maltreated children’s bests interests so that the complexity of their
problems is matched by the comprehensiveness of our efforts to minimize their suffering, enhance
their development, and promote their competence.

Keywords
child abuse; child neglect; child maltreatment; child protective services; legal system

Maria, a 12-year-old bilingual undocumented immigrant, disclosed to her school counselor

that her stepfather sexually abused her for several years. After an investigation by child
protective services (CPS), she was placed in foster care because her mother initially denied
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that any abuse had occurred. Following this, the stepfather disappeared. Maria was referred
by CPS to receive an evaluation for depressed mood.

James, an 8-year-old boy, was flagged by his teacher for cuts and bruising on his forehead.
He reported that his father (a single parent) smashed his head into a glass table because he

Correspondence to Charles H. Zeanah, MD, 1430 Tulane Avenue #8055, New Orleans, LA 70112; czeanah@tulane.edu.
The authors are grateful for the families that have allowed them to work with and learn from them, as well as the excellent colleagues,
mentors, and students who have shared their insights. Special thanks to the faculty, trainees, and staff of the Tulane Parenting
Education Program. The authors also wish to thank Madeleine Landrieu, JD, Loyola University of New Orleans, and Peter Digre,
MSW, MPA, DMin, Consultant, for helpful contributions to this article.
 Zeanah and Humphreys Page 2

had not cleaned his room. The school reported his injuries to CPS who placed him in foster
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care after investigating. James’s father was arrested. James and his father were referred for
assessment and treatment as indicated.

Jacqueline, a 22-month-old girl, was found wandering by a police officer several houses
away from her home. After Jacqueline waited 30 minutes outside her home with the police,
her mother arrived. She was combative towards the police and had a long history of
substance-related arrests. Jacqueline was taken into custody and placed with nonrelative
foster parents since no relatives were identified by CPS. Her mother was referred to
substance abuse intervention and to a parenting intervention. Jacqueline was also referred for
evaluation of her status.

Maltreatment of children, comprising various types of abuse and neglect, is a major public
health challenge and one of the most powerful risk factors for concurrent and subsequent
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psychopathology, later health morbidity, and compromised development. In severe cases of

maltreatment, children are often placed in foster care, and as a group are at particularly at
high risk for negative mental health consequences. Halfon and colleagues1 found that foster
children represented less than 4% of Medicaid eligible children in California but accounted
for 41% of all users of mental health services. Costs of the maltreatment that occurred in the
United States in 2008 was estimated to be $124 billion, with a per victim lifetime cost
estimated to be $210,012 for nonfatal and $1,272,900 for fatal maltreatment.2

Clinicians working with children who have experienced maltreatment will be more effective
when their approach extends beyond a focus on symptom patterns and functional
impairment. In order to do so, they must become knowledgeable about the systems in which
maltreated children are entwined. Specifically, the child protection system and the legal
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system each play an important role in the physical placement and well-being of children
who have experienced abuse and neglect. Clinicians may be asked and should be willing to
provide input regarding visits, transitions, custody, and related issues. In addition, work in
this arena is a potent elicitor of countertransference,3 and having trusted colleagues with
whom to review perceptions and plans is essential.

SCOPE OF THE PROBLEM

In Federal Fiscal Year 2016, approximately 676,000 children in the United States were
confirmed as victims of abuse and neglect by child protective service (CPS) systems, an
incidence of 0.91%; a much greater number (approximately 3.5 million children) were
referred for potential maltreatment.4 Younger children are more likely to be maltreated and
are more likely to die from abuse and neglect. American Indian/Alaskan Native (1.42%) and
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African American (1.39%) children experience the highest rates of maltreatment.

Nevertheless, underreporting of child maltreatment is widely recognized as a problem,5 and
adult retrospective reports of maltreatment are substantially higher6,7 than substantiated rates
of maltreatment in official records. Failure of true cases to be identified by legal authorities,
in addition to the challenges of measurement, infantile amnesia, recall bias in retrospective
reports, and differing definitions for maltreatment, make ascertaining true prevalence rates
challenging.

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For the past several years, roughly 250,000 to 275,000 children are taken into foster care
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each year and a total of 400,000 to 500,000 children are in foster care at any time in the
United States.8 Thus, the majority of child victims who have maltreatment substantiated are
maintained with their families and provided with access to services designed to prevent
removal. These cases are often referred to as family services, “in home” services, family
preservation, or similar terms.

CLASSIFICATION
Types of maltreatment are shown in Table 1.9 Each of the major headings subsumes many
specific types within the broad type. Although neglect is by far the most prevalent type of
maltreatment identified by CPS,4 the important point is that co-occurrence of different types
is the rule rather than the exception. In fact, in a recent study of more than 2,200 maltreated
school-aged children and adolescents, a minority of children experienced only a single type
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of maltreatment10: only 1% of sexually abused children, 4% of physically abused children,

10% of emotionally maltreated children, and 25% of neglected children had no co-
occurrence with one or more other types of maltreatment.10

ADVERSE EFFECTS
Maltreatment is associated with compromises in development across virtually every domain
(eg, cognitive, language, socioemotional, and neurobiological development.)11 Mental health
problems are among the most salient sequelae of child abuse and neglect. For example,
using data from the National Survey of Child and Adolescent Well Being, Burns et al.12
reported that nearly half (48%) of 3,803 children (2 14 years old) who had completed child
welfare investigations had clinically significant emotional or behavioral problems. A study
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of more than 1,000 children 5 to 9 years old who were recruited from pediatric practices
determined that those children who had been maltreated were nearly three times more likely
to be diagnosed with an internalizing or externalizing disorder.13 Population estimates
attribute that the proportion of childhood psychiatric disorders due to experiences of
adversity, including abuse and neglect, is approximately 45%,7 suggesting that there may be
no single greater environmental predictor of mental health difficulties than experiences of
maltreatment.

Developmental psychopathologists have highlighted the importance of considering both

multifinality and equifinality in the course of adverse experiences and psychopathology.14
Although many children who have experienced severe neglect in early life develop a
psychiatric disorder in childhood and adolescence, a greater proportion do not.15,16 For
some disorders, there is an explicit requirement for the role of environmental circumstances
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in order to meet diagnostic criteria (eg, trauma is required for posttraumatic stress disorder
[PTSD], and inadequate care is a necessary criterion for reactive attachment disorder). For
other disorders, although experiences of stress are known risk factors, such experiences are
not required for diagnosis (eg, major depressive disorder). Furthermore, even diverse forms
of maltreatment that are thought to have different consequences for brain development17
may result in risk for the same forms of psychopathology18 (eg, both abuse and neglect are
associated with increased risk for externalizing psychopathology). Taken together, we

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understand that maltreatment is associated with dramatically increased risk for

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psychopathology, but that several individual (eg, genetics, temperament) and external factors
(eg, consistent and attentive caregivers) may be protective and/or promote resilience in
children who have experienced significant adversity.19 In addition, there is no one-to-one
mapping between the severity or type of maltreatment experience and subsequent
neurobiological or behavioral consequence. In fact, nearly all psychiatric disorders common
in childhood and adolescence (eg, internalizing disorders, externalizing disorders, trauma
and stress-related disorders, neurodevelopmental disorders [eg, attention deficit/
hyperactivity disorder], and substance use disorders) have been linked to experiences of
maltreatment, such that abuse and neglect may play either an etiological role and/or worsen
the presentation and course of the disorder. Impairments in functioning, including academic
problems, delinquency, and difficulties in social relationships are also associated with
maltreatment.
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Recent attempts to clarify the potential mechanisms underlying increased risk for
psychopathology following maltreatment have examined the processes and constructs that
represent intermediate phenotypes (eg, Research Domain Criteria).20 This approach often
focused on the processing and response to emotional content, including rewards, threats, as
well as alterations in executive function, among individuals with histories of neglect.21
These processes are theoretically linked to disorders (eg, threat processing to anxiety
disorder and reduced reward sensitivity to depression) and may be useful targets in
developing interventions to prevent or treat psychopathology following onset. McCrory and
Viding22 have proposed the theory of latent vulnerability, positing that targeting intermediate
phenotypes provides a means of altering risk trajectories following maltreatment but before
psychiatric disorders emerge.
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In addition to attempts to characterize mechanism, it is important to consider how

development might moderate the presentation of symptoms. For example, PTSD presents
somewhat differently in preschool age children compared to adolescents,23 and recent
adaptations to the DSM have begun to define developmental differences.24

For young children (age 5 years and younger), alternative diagnostic criteria for a number of
disorders of early childhood are provided by DC:0–5.25 Although new and incompletely
validated, the criteria for disorders in DC:0–5 were empirically derived in an effort to
identify the manifestations of psychopathology in young children. In addition, the approach
outlined provides an emphasis on characterizing the relational context of child behavior
problems. Furthermore, there is an impetus to identify and treat these children at the
youngest possible ages, in order to improve long-term outcomes and reduce the risk for
intergenerational transmission of maltreatment.26
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SYSTEMS ISSUES
In our experience, clinical effectiveness is enhanced greatly if clinicians are knowledgeable
about and engage with child protection and legal systems when needed. These systems are
best thought of as distinct cultures, each with its own language, values, and priorities.

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Understanding how they differ from the values and priorities of the clinical enterprise is an
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important asset when evaluating and treating maltreated children.

Child Protection System

CPS generally includes distinct divisions responsible for hotline receipt of allegations,
investigations of alleged maltreatment, services to families who have a substantiated finding
of maltreatment where children are not removed, children placed in foster care, and adopted
children following termination of parental rights. It is important to understand which of
these divisions is involved with the child, because the roles of the professionals in each are
quite different.

CPS is based either at the state or county level. Foster care may be provided by CPS and/or
contracted with private entities—some systems (eg, Florida’s Community Based Care) are
entirely privatized, meaning that foster care and related services are outsourced to local
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community agencies. When agencies are contracted to provide foster care, understanding
their relationship to CPS staff is critical. Staff within CPS are hierarchically arranged; for
example, frontline case workers report to supervisors who report to managers who report to
directors. Identifying how best to access information and implement leverage within these
hierarchies is key to useful collaboration.

Key events in child welfare in the United States are noted in Table 2.27,28 As directed by the
Federal government, child welfare systems in the United States were originally focused on
children’s physical safety. There is increasing emphasis on permanency in child welfare
systems,29 because many children seemed to be languishing in foster care, which was
intended to be a temporary intervention. Throughout the past 100 years, the proverbial
pendulum has swung back and forth between a primary emphasis on protecting children and
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another on preserving families. Still, as Table 2 indicates, there has been a steady broadening
of scope of what we mean by child protection over time.

In cases in which there are substantiated reports of maltreatment but parental rights are not
immediately terminated, the emphasis has been focused on time-limited opportunities for
parents to rehabilitate and resume unencumbered care of their children. Much more recently,
child well-being has been made an explicit Federal priority.30 This provides more impetus
for mental health services, although well-being remains a newer and less well integrated
emphasis in many settings.

In virtually every case, reunification of children with the parents from whom they have been
removed is the goal for CPS. Furthermore, reunification hinges on demonstration of minimal
safety and caregiving effectiveness, which typically falls far below the standard approach in
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clinical treatment. Often, continuing treatment after children are returned to parents is
necessary to address a child’s symptoms and functional impairment and/or to assist with
family stabilization.

Legal System
Courts concerned with child protection are called juvenile court, family court, dependency
court, or something similar in different states. Larger jurisdictions may have full-time judges

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in these courts, but in smaller jurisdictions, judges may oversee child protection cases as
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only one of many other roles. Judges are “triers of fact” and make the ultimate decisions
regarding most phases of child protection and child custody. There are differences in state-
level laws and within individual judges about how to interpret and implement the law.
Judges’ perspectives derive from the United States Constitution, especially the due process
clause of the 14th Amendment, which has been used to limit government interference in
family life. As an initial assumption from a legal perspective, parents are presumed by courts
to have their children’s best interest guiding their parenting behavior. Thus, the thrust of
most laws pertaining to governmental intervention restricts it to instances in which the
child’s physical safety is endangered. Furthermore, at the earliest indication that parents can
be minimally safe, many judges are inclined to return children and eliminate the state’s
involvement in the family’s life. This inclination runs counter to clinical efforts to delay
return until it is clear that parents are sufficiently rehabilitated so that risk of recidivism is
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minimized.

Nevertheless, courts in all 50 states are required to consider whether their decisions about
placement of children, services provided to them, and custody are in the child’s “best
interest.”31 Although the best interests of the child are considered, they do not trump
parental rights in cases in which those conflict. Mental health professionals may be called as
experts to testify about what is in children’s best interest, providing an opportunity to
address current and future needs of the child.

ASSESSMENT
Safety, permanence, and well-being of the child also should inform psychiatric assessments
of maltreated children. The most important initial question to address is ensuring that
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children are physically and psychology safe in their current placements. Second,
understanding the timeline and whether the current placement is short-term or long-term and
what CPS plans for the child may affect treatment strategies. Finally, child well-being,
which encompasses psychiatric symptoms and functional impairment, as well as adequacy
of the caregiving environment, form the crux of the assessment.

Assessment of children involved with CPS is complicated by the need for information from
multiple sources. Having CPS records available at the time of the evaluation is important.
Speaking to the case worker before or during the evaluation provides important
supplemental information that may be unavailable from the records, such as information
about the legal status and timeline of the case, for example. If the child is in foster care,
meeting with foster parents is essential, but biological parents also will provide important
history when that is possible. Observing interactions of children with their foster parents as
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well as with their biological parents will often reveal important differences in children’s
behavior. For young children (less than 5 years old), this is essential.

PTSD deserves special mention. It is clearly important to assess for PTSD symptomatology
in every child with a history of maltreatment and exposure to violence. In our experience,
PTSD may be both over- and underdiagnosed in these children. That is, not every
symptomatic child assessed after exposure to a trauma has signs or symptoms of PTSD—

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many disorders can result from trauma, although there is some evidence that PTSD serves a
gateway function to new-onset disorders following traumatic exposure.32 Regarding
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underdiagnosis, PTSD in children can be challenging to identify, especially if children

present with re-experiencing and hyperarousal in the form of aggressive behavior.
Systematic inquiry about exposure to possible traumatic exposures is key, as well as
assessing triggers of challenging behaviors.

Special Issues in Early Childhood

Because the majority of maltreatment cases onset in children less than 5 years old, and
because of the developmental vulnerability of the early years, there has been increasing
recognition of the importance of bringing insights from developmental science to bear on
practice in child welfare.33 This rationale derives from a convergence of neuroscience
documenting the effects of experience on the developing brain, child development data about
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the centrality of relationships in promoting adaptive relationships, and economic data about
the return on investment of early intervention.34

From a clinical perspective, we know that young children may be markedly symptomatic
with one caregiver and asymptomatic with another caregiver.35 This is especially likely in
the context of young children seen with foster parents and biological parents. In addition to
the usual history and developmentally modified mental status examination, a relationship
assessment between the young child and all important caregivers is recommended for young
children who have been maltreated.36 Importantly, AACAPPractice Parameters on
assessments of infants and toddlers37 recommends that assessments of young children
should typically involve three to five sessions—evaluating young maltreated children will be
among the more complex assessments conducted. Formal methods for assessing
relationships in young children are available,38,39 but attending to observed interactions and
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parents’ perceptions of their children in order to understand the relationship are

recommended. In addition, Axis II of the DC:0–525 pro-vides guidelines for comprehensive
characterization of the relational context of young children. Although derived from a large
body of evidence regarding the importance of primary caregiving relationships and co-
parenting for young children’s development, the specific DC:0–5 guidelines about the
relational context of young children await explicit validation.

We have argued that foster care is a different intervention for younger children (especially
less than 3 years old but generally up to age 5 years) than for older children.40,41 This
derives from our understanding that the quality of the young child’s attachment relationships
is a foundational component of young children’s socioemotional development and an
important predictor of subsequent psychosocial functioning, especially within high-risk
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groups.42,43 Furthermore, young children develop and sustain attachments through

substantial contact with caregiving adults.44 This means that for young children in foster
care, foster parents must function as primary attachment figures for them. The vital role of
foster parents is too often under recognized, not only by CPS and the courts, but even by
mental health professionals. Recognizing its importance has obvious implications for young
children and their relationships with foster parents.

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Reports from childcare and preschool teachers are especially valuable to include in the
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assessment, because they provide data about the child’s functioning outside of the family
context. This is important for determining which behaviors are pervasive and which are
context specific. Given the sometimes contentious relationships between foster and
biological parents, teachers can provide a perspective from more objective observers and
also from professionals who likely have a keen appreciation of age typical and age-atypical
behaviors.

Because of the high rates of cognitive, motor, and language delays in young maltreated
children,45,46 referrals for developmental assessments to address suspected or apparent
language and/or motor delays are often indicated.

INTERVENTIONS
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One component of treatment of maltreated children is virtually identical to treatment of

nonmaltreated children—psychotherapy and/or medication as determined by a thorough
assessment. Of course, given that maltreated children are at the extreme of the risk
continuum, there are compelling reasons to apply evidenced-based interventions to treat
their symptoms and impaired functioning.47 These treatments are key elements of the
therapeutic arsenal for the complex pictures of comorbidity with which maltreated children
often present, even though most of the interventions, including medication, have not been
studied systematically in maltreated children. Fortunately, there are many evidence-based
treatments available for infants through adolescents who have experienced maltreatment (eg,
trauma-focused cognitive-behavioral therapy; parent–child interaction therapy; child–parent
psychotherapy).

Overuse and misuse of psychotropic medication among foster children has become an
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increasing concern.48 Reviewing Medicaid data from one month in 2004 in Texas, for
example, Zito et al.49 found that among foster children prescribed psychotropic medication,
41% took three different classes of medication, and 16% took four different classes. Care
should be taken about using multiple classes of psychotropic medication in foster children,
given the lack of evidence supporting the safety and efficacy of combined pharmacotherapy,
particularly for three or more medications. Reduced access to and investment in evidenced-
based psychotherapy may contribute to unwarranted psychotropic medication use.

What is different about treatment of maltreated children is that symptom reductions through
evidenced-based treatments is rarely sufficient. Comprehensive and multimodal treatments
are required, and often over long durations. Myriad factors beyond maltreatment are likely to
cause or exacerbate symptoms in maltreated children (eg, maladaptive family interactions,
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quality of placements, stress of visits, separation inherent in foster placements, separations

from siblings, and court and CPS decisions). These challenging stressors require additional
clinical efforts to help the child navigate the aftermath of maltreatment.

CASE INTERVENTIONS
Maria had a 5-day inpatient hospitalization for depression with suicidal intent, and
completed 4 months of trauma focused cognitive-behavioral therapy (TF-CBT). During this

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time, her mother received several months of therapy focused on Maria’s stepfather’s
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controlling relationship with her and how this contributed to her failure to protect Maria. She
accepted that the abuse had occurred and indicated that initially her fear of the police and
CPS had led her to deny her daughter’s allegations. In addition, the clinical team intervened
to address a conflicted relationship between Maria’s family and CPS. Six additional months
of family therapy were directed at a role-reversed mother–daughter relationship and the
mother’s failure to protect Maria from the stepfather. In the midst of these multifaceted
intervention efforts, Maria was successfully returned to her mother’s care, and treatment
continued for another 9 months after her return home.

James was treated with 4 months of TF-CBT. His father was enrolled in a 4-month skill-
building group therapy for parents (Effective Black Parenting). Following this, James’s
father was seen for grief counseling about the loss of James’s mother to cancer 2 years
earlier. James and his older and younger sister were seen with their father for family therapy,
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which focused on the father’s sensitivity to rejection and angry outbursts. James was
returned home after 12 months in foster care.

Jacqueline was overly active, aggressive, and socially indiscriminate when she entered her
foster placement. Immediate work with her foster parents focused on restricting her contact
with unfamiliar adults and establishing a reward-oriented behavior management plan. The
foster mother was coached in using the PRIDE skills (labeled praise, reflections, imitations,
descriptions, and enthusiasm) from parent–child interaction therapy. Her symptoms
gradually dissipated, and she was able to attend childcare without difficulty. Her biological
mother tested positive for substances, did not enroll in an intervention program, and after
several months stopped attending scheduled visits with Jacqueline. When Jacqueline was 34
months old, her maternal aunt appeared and requested that she be placed with her. Following
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a hearing on the matter, including expert testimony about best interest, the judge denied the
aunt’s request. Jacqueline was adopted by her foster parents after a termination of parental
rights trial.

Disclosure:
Dr. Zeanah has received funding from the John D. and Catherine T. MacArthur Foundation Research Network on
“Early Experience and Brain Development” (Charles A. Nelson, PhD, Chair), the National Institute of Mental
Health (NIMH; 1R01MH091363, Nelson), the Substance Abuse and Mental Health Services Administration
(SAMHSA; 1U79SM080030-01, Lieberman), the Palix Foundation, the Lumos Foundation, and the Irving Harris
Foundation (Zeanah). He has received royalties from Guilford Press and Harvard University Press and honoraria for
speaking engagements to professional audiences. Dr. Humphreys has received support from NIMH
(F32MH107129), the Brain and Behavior Research Foundation (formerly NARSAD) Young Investigator Award
23819, the Klingenstein Third Generation Foundation Fellowship, and the Jacobs Foundation Early Career
Research Fellowship.
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Key Messages
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• Child maltreatment—physical, sexual, and emotional abuse, as well as

various forms of neglect—leads to increased risk for psychopathology across
development, including internalizing disorders, externalizing disorders,
trauma and stress related disorders, neurodevelopmental disorders (eg,
attention-deficit/hyperactivity disorder), and substance use disorders, as well
as academic problems, delinquency, and difficulties in social relationships.

• Maltreatment is associated with a substantial proportion of the psychiatric

morbidity that presents to clinical settings for children and adolescents, so
that affected children are overrepresented in these settings.

• Racial and ethnic disparities are apparent. African American and American
Indian children have the highest rates of maltreatment, and clinicians should
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be alert for structural racism affecting decision making.

• More effective care will be provided to maltreated children in need of

treatment when clinicians are knowledgeable about the legal and child
protection systems, each of which has its own priorities, values, and
languages and differs from those of clinical work.

• Assessments of children presenting for evaluation of problems related to

maltreatment, especially if they are involved with legal and child protective
systems, are necessarily complex and likely require more time than
evaluations of children who have not experienced maltreatment.

• Treatment of symptoms and disorders related tomaltreatment should be

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multimodal and often needs to address external factors that may contribute to
their perpetuation and exacerbation.

• Young children, who comprise the majority of maltreatment cases, require

careful evaluation of the child’s caregiving contexts, which often includes
multiple caregivers, so that both assessments and treatment are
comprehensive.
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TABLE 1

Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) Modified Maltreatment Classification System

100 Physical Abuse When a caregiver or responsible adult inflicts physical injury upon a child by other than accidental means. Injury does not include culturally sanctioned
physical alterations such as circumcision and ear piercing.
200 Sexual Abuse When any sexual contact or attempt at sexual contact occurs between a caregiver or other responsible adult and a child, for purposes of the caregiver’s sexual
gratification or financial benefit. In cases of sexual abuse, caregiver or responsible adult refers to any family member or friend who has a relationship with the
child, or is in a position of authority over the child (eg, baby-sitter).
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300 Physical Neglect/Failure to A caregiver or responsible adult fails to exercise a minimum degree of care in meeting the child’s physical needs (food, clothing, shelter, hygiene, medical/
Provide dental care).
400 Physical Neglect/Lack of A caregiver or responsible adult does not take adequate precautions to ensure a child’s safety in and out of the home, given the child’s particular emotional and
Supervision developmental needs. This includes adequate supervision, safe environments and adequate substitute care.
500 Emotional Maltreatment A caregiver persistently or extremely thwarts a child’s basic emotional needs. This also includes parental acts that are harmful because they are insensitive to
the child’s developmental level, including psychological safety and security, acceptance and self-esteem, and age-appropriate autonomy.

Note: Adapted from9. Severity ratings 1–5 are included for each type of maltreatment.

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TABLE 2

Selected Key Developments in American Child Welfare

Year Event Result

1909 First White House Conference on Children Articulated principles of child welfare, including preference for care in families; most child protection handled by
nongovernmental entities at this time
1935 The Social Security Act of 1935 Authorized the first federal grants for child welfare services; these were first federal grants that led states to establish child
welfare agencies and to develop local programs to deliver child welfare services
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1962 Kempe and colleagues publish Battered Child Syndrome Led to much greater attention and government-directed child protection efforts
1974 Child Abuse Prevention and Treatment Act (CAPTA; Public Mandated that states establish procedures to investigate suspected incidents of child maltreatment, and provided funding to
Law 93–247) prevent, identify, and treat child maltreatment
1978 Indian Child Welfare Act (ICWA) Designed to reduce inappropriate removal of Indian children from their homes, ICWA provides that only tribal courts can
decide abuse and neglect cases involving children whose permanent residence is a reservation, and the tribe has the right to
intervene in cases involving children living outside reservations
1980 Adoption Assistance and Child Welfare Act of 1980 (Public Focused on family preservation efforts to help children out of foster care by providing services to prevent the need for removal
Law 96–272).
1997 Adoption and Safe Families Act (ASFA) (Public Law 105–89). Shift from reunification efforts to time-limited opportunities for parents to rehabilitate before enacting permanent plans for
children
2011 Extension of Child and Family Services Programs (Public Law Focuses on proper use of psychotropic medications and addressing and coordinating services to address trauma
112–34)
2012 Administration on Children and Families Memorandum on Child well-being brought on par with safety and permanency as major goals of American Child Welfare practice
Promoting Social and Emotional Well-Being for Children and
Youth Receiving Child Welfare Services

Note: Adapted from references27 and28.

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