Impact of Child Maltreatment

There is a well-recognized relationship between child maltreatment and a variety of negative emotional, developmental, and health consequences.  However, relatively new evidence also indicates that childhood trauma can actually alter the physiology of a child’s brain, which may lead to significant negative impacts on the child’s neurological development and mental health, and thus the child’s social, emotional/behavioral, cognitive, and physical/developmental domains.  These effects can diminish a child's relational competence and lead to the development of behavioral problems, which together can diminish the child’s capacity to maintain effective interpersonal relationships, progress academically and vocationally, and become a productive member of his or her community.  Furthermore, psychotropic medications may be inappropriately used to treat these effects.

Neurological Development

To understand how maltreatment can affect a child's neurological development, it is important to first understand that the brain is organized into and develops within four distinct regions.  These regions range from least to most complex, and each region develops, organizes, and becomes fully functional at different stages of a child's development.

One of the more critical functions of the lower, or "micro-level," brain regions is the creation of neural networks that facilitate simultaneous communication across the regions.  Impairment of these neural networks can result in a myriad of dysfunctions that extend from the lower regions to the higher, or "macro-level," regions.  Thus, brain development in the higher regions that control functions like perception, reasoning, emotion, and problem-solving is dependent on development in the lower regions.

Many of the micro-level brain processes, including the critical development of neural networks, are dependent on an optimal level of activation, which in part comes from the environment or experience of the child.  When the child has adverse experiences, such as loss, threat, neglect, or abuse, the brain’s developmental processes can be disrupted in the micro-level areas and the neural connections can wither.  This, in turn, can have a cascading negative effect on the macro-level regions of the brain.  Depending on the degree and duration of the adverse experience, these effects can be significant and hamper the child’s functioning well into adulthood.

Early childhood, during which neurons are organized to form the complex workings of the brain, is a critical time for brain development.  This development includes essential neurological processes that establish patterns of behavioral and emotional functioning during subsequent stages of life.  Since a child's early experiences and environment can significantly affect the development of specific areas of the brain, the impact of neglect and the impact of abuse on a child's brain can seriously affect his or her ability to regulate emotions and become emotionally connected with others in the future.

Impact of Neglect

Whether it is a lack of emotional or physical nurturance, neglect can negatively affect the child's neurological development.  If a caregiver is depressed, chronically stressed, inconsistent, or absent, this can adversely affect the brain’s neural networks that help the child to regulate stress and benefit from healthy, nurturing support.  Essentially, these early experiences between the caregiver and child create a template for the child’s brain, setting up associations that help determine the child’s balance between resilience and vulnerability.  Bonding and healthy caregiver/child interaction are critical in ensuring normal brain development; thus, the negative impact of neglect on the developing brain, beginning in the lower regions and expanding into the higher regions, can significantly impede a child’s ability to develop socially and emotionally, and to meet developmental milestones.

For example, one of an infant's primary tasks is to determine how to have his or her needs met.  Infants constantly assess whether their cries for comfort and food are answered or ignored.  When infants feel safe and secure and their needs for food and soothing are met, their brains are free to explore, focus on the objects and people in the world around them, and develop socially and cognitively.  If, however, responses to them are inconsistent or harsh, infants will concentrate their energy and brainwork on survival or ensuring that their needs are met.  As a result, it becomes increasingly difficult for them to interact with surrounding people and objects, as their mental and emotional resources are focused on other tasks and their brains shut out the stimulation needed to develop healthy cognitive and social skills.

Impact of Abuse

Abuse, like neglect, can severely affect a child's neurological development.  While mild or moderate levels of stress for a child within a supportive and nurturing environment can promote adaptive coping skills, abuse or severe neglect can expose children to chronic and abnormal levels of stress, which in turn can lead to elevated levels of cortisol, a stress hormone.  These levels can become toxic and stunt the tissue growth of the hippocampus, an area of the brain that affects the child’s ability to respond to future stress, regulate emotion, and retain memory.

Heightened stress can also impede the development of the prefrontal cortex, a part of the brain that controls critical functions like focusing, planning, self-regulation, and decision-making.  All of these functions are essential for children to successfully navigate their way later in life, academically, in relationships, and in the workplace. 

Mental Health

Children who have been maltreated, particularly those who have experienced complex trauma, may experience higher rates of mental health issues and more mental health diagnoses than other children.  Some of the most common diagnoses of maltreated children include:

  • Post-traumatic stress disorder (PTSD)
  • Attention deficit/hyperactivity disorder (ADHD)
  • Major depressive disorder (MDD)
  • Conduct disorder (CD)/oppositional defiant disorder (ODD)

Since many of the children entering the child welfare system meet the diagnostic criteria for mental health disorders before they enter foster care, it is important that child welfare agencies promote mental health screening and assessment early in the child’s involvement with the system.  It is equally important to remember that there is currently no single diagnosis for the full range of issues that can be experienced by children affected by complex trauma.  Behavioral health specialists may instead use one or several mental health diagnoses in an attempt to categorize the array of difficulties shown by many traumatized children.  However, traditional mental health treatments may not aid traumatized children to better control behaviors and improve social relationships.

For example, in a comprehensive analysis of trauma-informed assessments administered to children who entered foster care in Illinois between 2005 and 2011, the researchers found that it was possible for children to have a mental illness and, at the same time, display trauma symptoms.  The primary concern identified was that children did not receive trauma-focused treatment when they were either misdiagnosed with a mental illness or did not meet the criteria for PTSD.  In both cases, the critical need to effectively address the trauma symptoms was neglected.

Child welfare agencies must focus on developing effective trauma-based screenings and assessments to capture trauma history and symptoms in children whom they serve, rather than relying solely on mental health screening and diagnoses to pinpoint behavioral and mental health needs.  To be effective in this task, the relationship between trauma and mental health, and how decisions about treatment are affected by this interplay, must be understood.  Otherwise, a traumatized child's condition may be treated in isolation, thereby ignoring the disarray of the traumatized child’s condition as a whole. 

Relational Competence

Relational competence refers to a child’s ability to engage in beneficial caregiver and peer relationships, and navigate other social interactions.  Trauma-affected and vulnerable children frequently have difficulty forming and sustaining relationships.  This may be due to the absence of an early nurturing relationship with their primary caregiver.  Nurturing relationships provide the context within which a child learns about reciprocal relationships.  Also, in early adolescence, the neurological development of the brain areas most crucial to successfully forming interpersonal relationships may be hindered by traumatic stressors.

If, however, children in the child welfare system are able to form and sustain supportive relationships with peers and adults, and other protective and coping factors are strengthened, their ability to cope with trauma can be greatly enhanced.  Child welfare agencies should strive, through effective trauma-based screenings and assessments and trauma-informed systems, to strengthen the child’s capacity to successfully build meaningful relationships with others, including the child’s caregivers, by emphasizing the development and employment of critical interpersonal skills like cooperation, seeing another’s perspective, boundaries, and empathy.

While this skill-building is taking place, agencies, caregivers, and others must continually strive to enhance the child’s protective and coping factors by surrounding the child with caring, supportive adults; listening to the child; keeping the child’s world as predictable as possible; and ensuring that the child has a secure attachment relationship.  The goal is not only to enhance the child’s self-esteem, but to make the child feel as psychologically and physically safe as possible.

Behavioral Problems

The National Survey of Child and Adolescent Well-Being (NASCAW) study showed that behavioral problems warranting mental health or behavioral services are common in children who have been maltreated or traumatized.  Many of these children lack sufficient ability to regulate their emotions or impulsivity and may also have difficulty describing their feelings.  They may be unable to articulate their wishes and desires in a socially acceptable way, and may manifest behavioral problems externally through bullying, fighting, or opposition; or internally through withdrawal, anxiety, or fear in the face of non-threatening events, or crying easily.

Caregivers of traumatized children with behavioral issues in the child welfare system frequently have difficulty coping with these children in the home.  They do not understand why a child fails to respond to their affection, support, and structure with improved behaviors.  The caregiver may eventually ask for the removal of a child with behavioral problems, particularly if the child is defiant and aggressive.  This may further compound the child’s social and emotional difficulties, and make permanency even more elusive.

Psychotropic Medications

The use of psychotropic medications for children has risen over the past 10-15 years, although there is currently no definitive, comprehensive information that shows the prevalence of psychotropic medication use among children in the child welfare system.  However, published studies do indicate that there are higher rates of psychotropic medication use among children involved in child welfare than in the general population; older children, males, and children in residential or group settings are the most likely to have psychotropic medications prescribed.

Unfortunately, the full effect of these medications on a child's growth, development, and maturing neurological system remains unknown.  What is known is that psychotropic medications can have a variety of side effects, including lethargy, withdrawal, weight gain, poor appetite, irritability, and sleep disturbances.  They can also cause hallucinations, intrusive thoughts, and paranoia.

There are growing concerns that some children in foster care are prescribed too many psychotropic medications, that their dosages exceed approved recommendations, and that they are being prescribed psychotropic medication at too young an age.  There has, in fact, been a dramatic rise over the past 20 years in the use of antipsychotic medications with foster children.  A seven-state study found that the rate of antipsychotic medication use among foster children was almost nine times that of other Medicaid-covered children, even though foster children made up only three percent of the population of children on Medicaid.  An additional concern is that because there is no clear diagnostic label for complex trauma, a default to a mental health diagnosis is resulting in the inappropriate over-use of psychotropic medication for traumatized children.

Despite these concerns, the high rates of psychotropic medication use among children in foster care may indicate, at least in part, the high level of emotional and behavioral needs of this population.  Psychotropic medication may be necessary to effectively treat children or adolescents struggling with a mental illness, and can be helpful when children are so overwhelmed by their own behavior that their symptoms cannot be managed in other ways.  However, if untreated emotional trauma underlies the presenting symptoms, use of medication as a primary treatment may be ineffective or even exacerbate existing problems, and the stabilization needed to effectively support growth and healing will not occur.

Pending Developments in Psychotropic Medication

Some States have made attempts to regulate, at least to some extent, the use of psychotropic medication for behavior and mood management among foster children, encouraging caregivers to become more skilled in dealing with children’s challenging behaviors. Agencies are promoting more effective, evidence-based treatments for these children, coupled with trauma-focused training and education for staff and foster parents about caring for and managing behaviors of children with significant emotional and behavioral needs. The issues surrounding psychotropic medication use for children in foster care are being addressed through several Federal initiatives outlined in the ACYF Information Memorandum, Promoting the Safe, Appropriate, and Effective Use of Psychotropic Medication for Children in Foster Case (ACYF-IM-12-03).