Child Abuse and Neglect: Are Cases Increasing or Decreasing After 50+ Years of Paediatric Attention?

After more than 5 decades of attention to child abuse and neglect or more generically, child maltreatment, in the peer reviewed literature, the question remains, “have we made a dent in the number of children who are abused or neglected?” In order, to construct an answer that is straightforward question, we need to start with clear definitions and trustworthy statistics so that we can be clear about what cases we are measuring and what trends we are comparing. Towards that end, there are two authoritative publically available data sources that provide clear definitions of the different forms of child maltreatment and which provide rigorously collected data on these forms of child maltreatment. They are:

The periodically conducted National Incidence Studies authorized by the US Congress that uses a different approach than counting reports and investigations of potential abuse as in Child Maltreatment 2014. The National Incidence Studies use a complex sampling technique of sentinel organizations such as children's hospital and child care facilities from a nationally representative sampling of counties. Most recently, the 4th National Incidence Study (NIS-4) was released in 2010 and reports on two data collection periods from 2005 and 2006 [2].

Child Maltreatment 2014
Scope: Child Maltreatment 2014 is the 25th edition of the annual Child Maltreatment series relies on data that states provide through the National Child Abuse and Neglect Data System (NCANDS). NCANDS established in 1988 is a voluntary national data collection and analysis program to make available state child abuse and neglect information.
Data collection: Data have been collected every year since 1991 and NCANDS now annually collects maltreatment data from child protective services agencies in the 50 states, the District of Columbia, and the Commonwealth of Puerto Rico. National and state statistics for child maltreatment are derived from the data collected by child protective services agencies and reported to NCANDS. The data are analyzed, disseminated, and released in an annual report. The 2014 national statistics were based upon receiving data from the 50 states, the District of Columbia and the Commonwealth of Puerto Rico (commonly referred to as the 52 states). Case-level data were received from all 52 states. The data are submitted voluntarily by the 50 states, the District of Columbia, and the Commonwealth of Puerto Rico.

Children included in Child Maltreatment 2014:
All 50 states, the District of Columbia, and the U.S. Territories have child abuse and neglect reporting laws that mandate certain professionals and institutions to report suspected maltreatment to a child protective services (CPS) agency.
Each state has its own definitions of child abuse and neglect that are based on standards set by federal law. Federal legislation provides a foundation for states by identifying a set of acts or behaviors that define child abuse and neglect.
The Child Abuse Prevention and Treatment Act (CAPTA), (42 U.S.C. §5101), as amended by the CAPTA Reauthorization Act of 2010, retained the existing definition of child abuse and neglect, and the definition at a minimum included: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.

NIS-4
Scope: The National Incidence Study (NIS) is mandated by the U.S. Congress (Public Law 108-36), and is a periodic research effort to assess the incidence of child abuse and neglect in the United States. Its design assumes that victims of child maltreatment who are investigated by child protected services (CPS) represent only the "tip of the iceberg." NIS estimates include children investigated by CPS and children who are identified by "sentinels", professionals in a wide range of agencies. Children investigated by CPS and identified by sentinels during the same period are evaluated against standardized definitions of abuse and neglect. To ensure that a given child is counted only once in the study, the data is unduplicated.
Data collection: Data is gathered in a nationally representative sample of 122 counties. A mix of geographic regions and of urban and rural areas is used. CPS agencies were asked to supply data during the referenced period. Other types of agencies, such as public schools, public health departments, public housing departments, licensed day care centers, juvenile probation departments, voluntary social services and mental health agencies, were asked to serve as sentinels. Shelters for runaway and homeless youths and victims of domestic violence were also asked to serve. The data collection period was September 4 through December 3, 2005 and February 4 through May 3, 2006.

Children included in NIS-4 estimates are:
Children who experienced physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect, educational neglect or any abuse, neglect or maltreatment.

Definitions
There are many forms of child maltreatment and in recent years the field has expanded its reach to address other forms of child victimization to include human trafficking and use of the minors in child pornography.
For the purposes of this review, the focus will be upon three types of abuse, namely, physical abuse, sexual abuse and neglect. At a most basic level of description, physical abuse occurs when the child is found to have an injury caused by the child's caregiver; sexual abuse occurs when a child is involved in sexual activities by the caregiver; and, neglect occurs when a child's basic needs are not met by the caregiver. More technical definitions are required for data collection so that cases can be included and excluded so that the statistics generated are valid and reliable and these definitions from the two reports described above are listed in Table 2.

Type of Maltreatment Child Maltreatment 2014 NIS-4 (using harm standard)
Physical Abuse Type of maltreatment that refers to physical acts that caused or could have caused physical injury to a child.
Physical abuse includes shaking, throwing, purposefully dropping a child; hitting; pushing, grabbing, dragging or pulling; punching or kicking; and other physical abuse.

Sexual Abuse
A type of maltreatment that refers to the involvement of the child in sexual activity to provide sexual gratification or financial benefit to the perpetrator, including contacts for sexual purposes, molestation, statutory rape, prostitution, pornography, exposure, incest, or other sexually exploitative activities.
Sexual abuse subsumes a range of behaviors, including intrusion, child's prostitution or involvement in pornography, genital molestation, exposure or voyeurism, providing sexually explicit materials, failure to supervise the child's voluntary sexual activities, attempted or threatened sexual abuse with physical contact, and unspecified sexual abuse. Educational neglect. Children are included in this category when their parent (or parent-substitute) knowingly permits their chronic truancy an average of at least 5 days per month; exhibits a pattern of keeping the child home without legitimate reason; fails to register or enroll a school-age child in school in violation of state law; or refuses to allow or provide needed attention for a diagnosed educational problem, learning disorder, or other special education need.

Statistics Child Maltreatment 2014
In Child Maltreatment 2014, we read that approximately 3.6 million reports of possible child maltreatment involving 6.6 million children were referred to child protective services across the nation [1].
Reports are received and initially screened in or out for investigation. Of the 3.6 million, 2.2 were screened in and were investigated resulting in 702,000 children determined to be, or "substantiated, " as victims of abuse or neglect. Figure 1 provides a flow diagram that graphically displays the process for reports and children.
Over the past two decades looking at the cases reported to child protective services data, Dr. David Finkelhor and colleagues have studied the trends that emerge from the annual reports of substantiated cases (those children determined to have been maltreated after the cases is investigated) [3]. Figure 2 displays the trend lines for over two decades of annual reports that are publically available from 1990 thru 2013. Clearly, the graph demonstrates that there is a decreasing trend of substantiated cases of child maltreatment in the US between 1990 thru 2013. Specifically, substantiated cases of sexual abuse have declined by 64%, physical abuse has declined by 55% and neglect has declined by 13% [3].

4th National Incidence Study (NIS-4)
The NIS-4, which uses a different methodology to determine the incidence of child abuse and neglect, estimated that in 2006, 1,256,000 children were maltreated from all forms of abuse and neglect. The NIS-4 uses the metaphor of an iceberg to conceptualize the number of cases reported to CPS as the part of the iceberg visible above the water line, but that a portion of the iceberg, perhaps even larger than what we see above the water line, lies below the water line. These "below the water line" cases would be cases of abuse and neglect that are not reported but which nonetheless have occurred, many of which are known to someone, likely a professional, in the community (Figure 3) [2].  Table 3 below compares the NIS-4 data using the Harm standard to the NIS-3 and NIS-2. (The Harm standard represents the more serious cases and is likely the most comparable to the types of cases that would be identified by substantiation in the cases reported to child protective services data sources such as Child Maltreatment 2014).
ns The difference between this and the NIS-4 incidence rate is neither significant nor marginal (p>.10).
Note: Estimated totals are rounded to the nearest 100. Examining the NIS-4 data and the comparisons with the previously reported NIS-3 from Table 2, there is a statistically marginal trend towards a decrease of all maltreatment cases moving from approximately 1.6 million cases to approximately 1.3 million. A similar marginal trend is seen with physical abuse moving from approximately 382 thousand cases to 323 thousand. Sexual abuse comparisons reached statistical significance moving from approximately 218 thousand to approximately 135 thousand cases. Physical neglect cases did not have a statistically significant decreasing trend although the number of cases when from approximately 339 thousand cases to 295 thousand in the NIS-4. So, bottom line would be there is a trend towards decreasing incidence of physical and sexual abuse and no decrease in the incidence of neglect.

Discussion
Reflecting back on the original question, "is child abuse and neglect decreasing?" it would appear that the two different types of data sources briefly described above would support the notion that after 50+ years of pediatric attention, that in deed the incidence of child physical abuse and child sexual abuse are declining. Child neglect is less clear and if there is a decrease it is decreasing much less than the trend being seen with physical and sexual abuse cases.
Like any discussion of data, a number of issues immediately arise. Is the decrease in substantiated cases in fact a decrease in the incidence of child maltreatment or are there other factors in play such as making it more difficult to substantiate a case or some other investigatory process rather than an actual decrease in actual children being victimized. Once again Dr. Finkelhor and colleagues have considered these important questions and looking specifically at cases of substantiated child sexual abuse, they have developed a useful graphic that captures a host of possible factors that may account for the decreasing trend in substantiated sexual abuse cases. Figure 4 displays these possibilities ranging from an actual decrease in the incidence of abuse to fewer cases reaching investigation [4].
Examining these factors in more detail, Jones and Finkelhor [4] argue that the actual incidence of child sexual abuse may be declining since during the decades of the 1990s, there were parallel declines in similar social problems such as violent crime, female victimization and rape victimization and trends in sexual abuse might well be expected to track similarly with these forms of investigations as well.
Jones and Finkelhor [4] also consider the possibility of the reported decline in child sexual abuse resulting from changes in attitudes, policies, and standards around reporting and investigating. They recognize that certain events may have made investigators more cautious in making a finding of child sexual abuse owing to a backlash against what might be perceived as an over-zealous advocacy for the validation of the claims of sexual abuse. Looking at detailed state patterns of substantiation, these investigations concluded that changes in attitude and policy might account for some of the declining trend but "these changes do not represent the whole picture" [4]. Finally Jones and Finkelhor [4] call for a balanced and questioning approach since the trend in decreased substantiation of child sexual abuse reports demonstrates "the reasons for the decline is less clear" [4]. Therefore, additional evaluation, tracking and research are essential to parse out the underlying root causes for the decreased substantiation of child sexual abuse cases and the final result will likely be a combination of actual decreases in cases along with some contribution from changed attitudes and standards related to investigations.
Taking both data sources that were examined in this commentary each which uses different methodologies, one using the counting of reported cases that are substantiated and the other using a complex surveying approach not limited to child protective services reported cases, it does appear that the incidence of the number of cases of sexual abuse may be actually decreasing since both data sources have found strong statistical indicators of a decreasing trend. The trend in physical abuse is less clear but does seem to be decreasing as well. With regard to neglect, more analysis will be necessary since the trend in the reported cases was relatively small over the several decade periods and the comparison between NIS-4 and NIS-3 did not reach statistical significance.