In 2007, according to the NCANDS annual report of reported child maltreatment cases in the United States, an estimated 2.9 million referrals alleging child abuse or neglect were reported and accepted by the state and local child protection agencies (USDHHS, 2009). Of these cases, approximately 906,000 children were identified as actual victims of child abuse and neglect. Childhood neglect was responsible for 60% of the cases, physical abuse equated 20%, sexual abuse accounted for 10%, and the remaining 5% were emotional maltreatment cases. Data reveal that infants and children age birth to three years old are the most common victims of maltreatment, and females are slightly more likely to be abused than males (USDHHS, 2009). In addition, race and ethnicity studies showed the highest rates in Pacific Islanders (21.4 per 1000 children), American Indian or Alaska Natives (21.3 per 1000), African Americans (20.4 per 1000 children), and whites (11.0 per 1000 children). In 2003, an estimated 1500 child fatalities were the result of maltreatment, a rate of 2 deaths per 100,000 U.S. children. Documentation of specific cases remains difficult to quantify because of various reporting criteria and definitions among states, as well as underreporting.

Of the documented NCANDS cases in 2007, approximately 57% of the victims received some sort of services following the assessment and investigation (USDHHS, 2009). Services included in-home and foster care services. Child victims of multiple types of maltreatment were more likely to receive treatment than those with physical abuse alone.

In 2007, NCANDS reported approximately 80% of the perpetrators were parents, 16% were other family members or unmarried partners of parents, and the remaining 4% were “others” (USDHHS, 2009). Women were more common perpetrators than men (58% to 42%, respectively) and were generally younger than male perpetrators. For sexual assault, approximately 76% of the perpetrators were friends or neighbors, with the remaining 30% being family members (only 3% of these were parents).

Over the past few decades, several child maltreatment models (Cowen, 1999 and De Paul and Guibert, 2008) have presented the multiple facets involved in the intentional harm and maltreatment issue, including the model that examines the complex nature of the interactions between the parent and the child, the stressors within and outside the family, and the broader social and cultural system (Howze & Kotch, 1984). This model expanded on earlier models to include familial, social, and cultural aspects, as well as the impact of these relationships with stress, social support systems, and child maltreatment. These authors recognized that stress in the maladaptive abusive family may be situational, acute, or chronic. Milner (1993) worked to develop a physical child abuse risk assessment tool that could be used to assess demographic, social, cognitive/affective, and behavioral risk factors. He based his work on Belsky’s (1980, 1993) organizational model that described four ecological levels found in other models of child abuse: (1) the ontogenic level (individual factors in the child), (2) the microsystem (refers to family factors), (3) the ecosystem (reflecting the community), and (4) the macrosystem (identified as the culture). Belsky (1993) emphasized that his model and assessment tool helps predict the risk of maltreatment behaviors, but not actually maltreatment. Additional models and theories are developing, which have similar concepts. Milner (1993) has refined his own work to include sociocultural, family system, and learning paradigms and sublevels of understanding of each concept, including such details as understanding the social information processing in the abusive parent. The review of literature reveals a complex etiology for child abuse and neglect.

Experts in child maltreatment have identified a dynamic interrelationship of three types of characteristics that must exist for child abuse to evolve (Belsky, 1980 and Milner, 1993). These three characteristics involve the parent or adult (perpetrator), the child (victim), and the environmental context. The interaction of all three groups is deemed necessary for predicting high risk for abuse.

Emotional abuse is defined as a maladaptive parent-child interaction. In emotional neglect, there is a failure to meet the affection, attention, and nurturing needs of the child (Hockenbery, Wilson, Winkelstein, et al., 2002). An additional form of emotional abuse occurs when the adult purposely attempts to destroy or hamper the child’s self-esteem (Nester, 1998). This form of abuse is seen when a parent rejects, isolates, terrorizes, or verbally assaults the child. Frequently in emotional abuse, inappropriate expectations or demands are placed on the child. For example, toilet training may be expected too early. A child may also be expected to carry out more adult functions, such as childcare for siblings, cooking, and cleaning. A parent may place a heavy emotional burden on the child or have adult expectations that result in a reversal of the child-adult roles.

Sexual exploitation can range from noncontact indecent exposure to fondling and genital contact to actual adult-child sexual intercourse (National Clearinghouse on Child Abuse and Neglect, 2004). The Child Abuse and Prevention Act states sexual abuse is the “use of persuasion or coercion of any child to engage in sexually explicit conduct, or the producing of visual depiction of such conduct, or rape, molestation, prostitution, or incest with children.” A child does not have the knowledge, emotional maturity, or social skills necessary to enter into a sexual relationship of any nature on an equal basis with an adult. Therefore, it is legally concluded a child cannot be held responsible for a sexual relationship with an adult.

There are two primary forms of sexual abuse. The first is when an adult initially pressures a child into a nonsexual liaison based on a long-term trusted relationship. As the relationship grows, the child eventually participates in the sexual activity to maintain the rewards, attention, approval, or recognition provided by the adult who essentially uses the child to meet his or her unfulfilled needs. The second type of sexual abuse is the forced relationship in which the offender intimidates the child by threatening harm or actually harming the child or someone else the child cares about. The adult has no emotional investment in the child but rather uses the victim to meet short-term sexual needs. Authorities believe most offenders do not actually desire to harm the child; however, a few of the perpetrators seem to obtain vicarious pleasure from harming the child (Hockenbery, et al., 2002).

Child neglect is defined as the failure to provide adequate care. Neglect is considered an act of omission and accounts for over half of the reported child maltreatment (Cowen, 1999, Helfer, 1990 and Hockenbery et al., 2002). Situations of neglect may include inadequate supervision, which may lead to accidents and injury. Overall lack of attention to food, shelter, and medical needs are also considered neglect and can quickly endanger the well-being of a child. In addition, the lack of providing education at both the grade school and high school levels is deemed neglect. Many of these factors are closely related to poverty, single parenthood, and unemployment, leading to a multifaceted social problem. The 1974 Child Abuse Prevention and Treatment Act deemed neglect a form of abuse and required medical attention. Although reporting has improved, actual cases of neglect remain high.

Neglect can result in malnutrition, poor dental care, and a generally poor health status. Children left unattended are at a high risk for injury. Over 75% of neglect victims were reported to have a serious injury or illness within three years of documented neglect (Green & Kilili, 1998). Neglected children can be extremely passive, withdrawn, undisciplined, or disabled (Cowen, 1997). More extreme neglect can lead to Failure to Thrive Syndrome (FTT). Manifestations of FTT include withdrawn effect, decreased and aggressive social interactions, and fewer positive play behaviors such as offering, sharing, accepting, and following (Peterson & Urquiza, 1993). Additionally, the child may experience impaired or delayed growth, delayed language development, and maturational and behavioral difficulties in achieving developmental milestones (Schmitt & Mauro, 1989). It is not uncommon for a child with FTT to die from secondary metabolic defects or other illnesses. Their deaths may also be the result of intentional or un-intentional trauma and neglect. The differential diagnosis of FTT may include a wide range of possible organic conditions (inborn metabolic disorders, congenital viral infections, chromosomal syndromes) and external factors including criminal acts.

Forensic pathologists determine if a child’s death is natural or unnatural. If abuse and neglect are the determined cause or contribute to the cause of death, criminal charges can be filed. Because there are important consequences, the diagnosis must be confirmed. This may be difficult when there may be several underlying causes such as organic FTT, cystic fibrosis, abuse, and neglect. A detailed forensic investigation is required.

Sibling abuse, when one sibling abuses another, is among the most overlooked forms of child abuse. Sibling abuse takes the form of physical, sexual, and emotional abuse and has devastating consequences to victims. Sibling abuse victims often suffer long-term social and psychological disturbances and propagate cycles of family violence. Numerous familial and environmental factors have been identified as predicted risk factors for sibling abuse (Walton-Moss et al., 2005). Forensic investigation of suspicious circumstances concerning child injury, behavior, or death is paramount to facilitate the elimination of historical cultural neglect of child abuse cases and to initiate prevention strategies to help eradicate sibling abuse in society.

The murder of a child by his or her sibling is categorized as siblicide. From Doug Mock’s animal research on killing of siblings, one can hypothesize sibling abuse occurs as a result of a deficiency in the family or parental structure that will cause children to exhibit abusive behaviors toward siblings to gain more resources. However, not enough is known about sibling abuse to draw firm conclusions. Despite the lack of attention that sibling abuse receives from parents and society at large, it can have detrimental long-term effects in children and can result in premature death in some cases (Smith & Smith, 2001).

Statistical information reveals that child abuse committed by siblings is a prevalent social problem previously ignored. In a Canadian study (2001), siblings were perpetrators of 28% of sexual offenses and 24% of physical assaults in child victims less than 12 years of age (Johnson & Au Coin, 2003). Research results are particularly shocking when examining incidences of sexual abuse. The National Society for the Prevention of Cruelty to Children indicates siblings are twice as likely to be abused by brothers than by fathers or stepfathers (Spenser, 2000). Incidences of sibling abuse differs somewhat from adult abusers. Unlike parental child abuse where the most vulnerable age for maltreatment is 12 months to 5 years, children of any age can be targets of sibling abuse. Younger children have a higher mortality rate whether the perpetrator is an adult or a sibling.

Physical and emotional neglect is commonly associated with parental child abuse, whereas phenomena such as bullying are more often related to sibling abuse. Dominance and control appear to be a common link among most types of child abuse and are especially apparent in different forms of sibling abuse.

Sibling abuse is often mistaken as “sibling rivalry,” a seemingly harmless and playful interaction, which parents tend to ignore or join in with the supposed playfulness. However, survivors of this type of abuse report their parent’s reaction to sibling violence as one of nonchalance, denial, or blame (Wiehe, 1997). Parents commonly trivialize the event or do not believe such reports, and they often accuse victims of deserving or enabling maltreatment. For example, when a child is verbally degraded, the parent may see retaliatory self-defense as the initial cause of the child being teased. Unfortunately, if parents do not address sibling abuse, they are essentially condoning abusive behaviors.

Teasing is a common form of emotional abuse. Emotional abuse has been found to be the most destructive force among all types of abuse with the most damaging long-term effects (Keltner et al., 2001 and Wiehe, 1997). Teasing and other forms of emotional abuse often accompany physical and sexual abuse. According to Wiehe, 7% of his sample indicated emotional abuse alone, compared to 71% indicated experiencing emotional, physical, and sexual abuse.

It may be difficult to distinguish abuse from playful interaction between siblings, parents, or other adults or children. Social interaction that revolves around negative verbal communications directed at a child can be considered emotionally abusive. This differs from joking because emotional abuse is conducted at the victim’s expense (Wiehe, 1991). Fear and intimidation are often used against victims as a means of control and dominance. Older siblings may be able to inflict more emotional damage because they are often idolized by the younger siblings and have developed more hurtful behaviors (Simonelli, Mullis, Elliott et al., 2002). Victims often internalize hurtful comments, which produce feelings of low self-worth. Conversely, some victims externalize emotional abuse, which manifests itself as negative behaviors (Hart & Brassard, 1987).

A prime example of the integration of emotional abuse with other forms of sibling abuse is bullying. Bullying is primarily emotional but can also lead to physical intimidation and violence. Bullying is emotional intimidation perpetrated by a person who is stronger than or in a position of power over the victim. The bully child often has high dominance needs, lacks empathy, and has a positive view of aggression. Bullying can take on many forms and often occurs between peers or siblings (Nansel, Overpeck, Pilla, Ruan, Simons-Morton, & Scheidt, 2001).

Research reveals children involved in sibling bullying are more likely bullies or victims at school (Duncan, 1999). According to Duncan, 53% of 210 college freshmen reported bully victimization during their childhood. Yet society continues to underestimate the potential emotional damage of bullying. Research statistics indicated 22% of participants who were bullied were pushed, hit, or shoved, and 81% reported being “beaten up” (Duncan, 1999). Bully victimization has been linked to psychological difficulties such as depression, anxiety, and low self-esteem.

A multibillion-dollar industry, human trafficking generally is a hidden problem. Periodically, a few cases appear in the mainstream media. It is important to understand the breadth of the problem as an individual and public health issue and to know how to identify and effectively intervene in these cases.

In a June 2008 Trafficking in Persons Report, the U.S. government noted it is difficult to precisely determine the magnitude of human trafficking both nationally and globally because of the underground nature of the problem. This report quoted estimates by the United Nations’ International Labor Organization that at any given time, some 12.3 million people are in forced labor or bonded labor, forced child labor, or sexual servitude. It is unclear how many of these persons are children.

Federally sponsored research found roughly 800,000 persons are trafficked across national borders annually; about 80% of transnational victims are women and girls, and up to 50% are minors. Typically, victims are promised a better life through employment, educational opportunities, or marriage. Instead, they find themselves entrenched in modern-day slavery, working as domestics, laborers, sweatshop workers, nail salon employees, or commercial sex workers. Victims generally do not identify themselves because many traffickers use physical, sexual, or emotional abuse to control them, according to a background brief distributed at the September 2008 National Symposium on the Health Needs of Human Trafficking Victims held by the U.S. Department of Health and Human Services. Trafficking victims experience many social and health problems, including sexually transmitted infections (STIs), malnutrition, substance abuse, and mental illness (USDHHS, 2008).

Nurses need to understand that human trafficking touches all communities. As nurses, we are supposed to promote the humane treatment of all human beings. Therefore, we need to be more aware of this issue because human trafficking is not just a public health issue but an ethical moral issue. It is not just the responsibility of the emergency department, forensic nurses, or public health nurses. All nurses must be adept at recognizing and assisting trafficking victims. We all need to be working on this together because it is part of our professional obligation to the public.

Parental drug use can have a devastating impact on children. Although many illegal drugs impact a person’s ability to parent, methamphetamine (also called “meth”) use is now epidemic. Many people who become addicted to meth or other drugs often lose track of their priorities and present as disorganized and increasingly violent, in addition to experiencing many other problems. The silent victims of drug addiction are too often the children. If a caregiver is getting “high” and “crashing” for days at a time, his or her ability to safely parent is compromised.

There has been a lot of attention in the media given to meth abuse and manufacturing because it is such an addictive and dangerous substance. The U.S. Drug Enforcement Agency (U.S. DEA) documents that the use of this substance has been consistently high for many years. According to the U.S. DEA web site, “methamphetamine is one of the most widely abused controlled substances…and availability is high.” Meth is cheaper than most drugs, easily accessible, somewhat easy to manufacture, and creates an intense feeling of euphoria or “high.” Because of this intense feeling and other effects, it is extremely easy for a person to become addicted, sometimes after only one use. The negative effects of meth can be uncomfortable and can include depression, irritability, paranoia, fatigue, and anxiety. A person may binge on meth to avoid these feelings. The tolerance for the drug builds up quickly, which requires a person to use more at a faster rate to get the same high.

Unfortunately, children and youths are often lost in the drug addiction of their parents. The risk of children being neglected or physically and sexually abused is high because their parent/caregiver has lost the ability to attend to their physical and emotional needs. Risks to children include exposure to toxic fumes and the danger of explosions or fires; drugs and drug paraphernalia within easy reach; loaded weapons and booby traps in the home; exposure to sexual abusers and violent drug users, leading to possible physical and sexual abuse of the child; neglect, including lack of food and inappropriate sleeping conditions; exposure to pornography; and a greater risk of becoming an addict.

Some people who are addicted to meth are irritable, become agitated much easier, and their decision-making process is compromised. This can lead to an increased risk for physical and emotional abuse. If a child does something the parent does not want him or her to do, the child could be yelled at and called names. These parents may spank their children to discipline without realizing how hard they spanked; a bruise could be left on the child’s skin. In severe cases of abuse, a parent could become frustrated with an infant’s crying and shake the infant, causing brain damage and death.

U.S. Congress House of Representatives Bill 5842 mandates that exposing a child to meth is child abuse and neglect. (www.legislature.mi.gov/documents/2005-2006/billanalysis/House/htm/2005-HLA-5842-1.htm). More and more children are being taken into protective custody by law enforcement and child welfare caseworks as a result of their exposure to caregiver meth use.